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      Use of standardised patients for healthcare quality research in low- and middle-income countries

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          Abstract

          The use of standardised patients (SPs)—people recruited from the local community to present the same case to multiple providers in a blinded fashion—is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement.

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          Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality.

          J Peabody, J. Luck, P Glassman … (2000)
          Better health care quality is a universal goal, yet measuring quality has proven to be difficult and problematic. A central problem has been isolating physician practices from other effects of the health care system. To validate clinical vignettes as a method for measuring the competence of physicians and the quality of their actual practice. Prospective trial conducted in 1997 comparing 3 methods for measuring the quality of care for 4 common outpatient conditions: (1) structured reports by standardized patients (SPs), trained actors who presented unannounced to physicians' clinics (the gold standard); (2) abstraction of medical records for those same visits; and (3) physicians' responses to clinical vignettes that exactly corresponded to the SPs' presentations. Setting Outpatient primary care clinics at 2 Veterans Affairs medical centers. Ninety-eight (97%) of 101 general internal medicine staff physicians, faculty, and second- and third-year residents consented to be randomized for the study. From this group, 10 physicians at each site were randomly selected for inclusion. A total of 160 quality scores (8 cases x 20 physicians) were generated for each method using identical explicit criteria based on national guidelines and local expert panels. Scores were defined as the percentage of process criteria correctly met and were compared among the 3 methods. The quality of care, as measured by all 3 methods, ranged from 76.2% (SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality using vignettes consistently produced scores closer to the gold standard of SP scores than using chart abstraction. This pattern was robust when the scores were disaggregated by the 4 conditions (P<.001 to <.05), by case complexity (P<.001), by site (P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted, although less dominantly, when we assessed the component domains of the clinical encounter--history, physical examination, diagnosis, and treatment. Vignettes were responsive to expected directions of variation in quality between sites and levels of training. The vignette responses did not appear to be sensitive to physicians' having seen an SP presenting with the same case. Our data indicate that quality of health care can be measured in an outpatient setting by using clinical vignettes. Vignettes appear to be a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice. Vignettes show promise as an inexpensive case-mix adjusted method for measuring the quality of care provided by a group of physicians.
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            Outpatient process quality evaluation and the Hawthorne Effect.

            Kenneth Leonard, Melkiory Masatu (2006)
            We examine the evidence that the behavior of clinicians is impacted by the fact that they are being observed by a research team. Data on the quality of care provided by clinicians in Arusha region of Tanzania show a marked fall in quality over time as new patients are consulted. By conducting detailed interviews with patients who consulted both before and after our research team arrived we are able to show strong evidence of the Hawthorne effect. Patient-reported quality is steady before we arrive, rises significantly (by 13 percentage points) at the moment we arrive and then falls steadily thereafter. We show that quality after we arrive begins to look similar to quality before we arrived between the 10th and 15th consultations. Implications for quality measurement and policy are discussed.
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              Patient knowledge and antibiotic abuse: Evidence from an audit study in China.

              Wei Zhang, Wanchuan Lin, Janet Currie (2011)
              We conduct an audit study in which a pair of simulated patients with identical flu-like complaints visits the same physician. Simulated patient A is instructed to ask a question that showcases his/her knowledge of appropriate antibiotic use, whereas patient B is instructed to say nothing beyond describing his/her symptoms. We find that a patient who displays knowledge of appropriate antibiotics use reduces both antibiotic prescription rates and drug expenditures. Such knowledge also increases physicians' information provision about possible side effects, but has a negative impact on the quality of the physician-patient interactions. Our results suggest that antibiotics abuse in China is not driven by patients actively demanding antibiotics, but is largely a supply-side phenomenon. Copyright © 2011 Elsevier B.V. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Glob Health
                Journal ID (iso-abbrev): BMJ Glob Health
                Journal ID (hwp): bmjgh
                Journal ID (publisher-id): bmjgh
                Title: BMJ Global Health
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2059-7908
                Publication date Collection: 2019
                Publication date (Electronic): 12 September 2019
                Volume: 4
                Issue: 5
                Electronic Location Identifier: e001669
                Affiliations
                [1 ] departmentSchool of Public Health , University of California Berkeley , Berkeley, California, USA
                [2 ] departmentMcCourt School of Public Policy and School of Foreign Service , Georgetown University , Washington, District of Columbia, USA
                [3 ] ACCESS Health International , New York City, New York, USA
                [4 ] departmentDepartment of Anthropology , Johns Hopkins University , Baltimore, Maryland, USA
                [5 ] departmentDepartment of Epidemiology & Biostatistics, and McGill International TB Centre , McGill University , Montreal, Quebec, Canada
                [6 ] Center for Policy Research , Delhi, India
                Author notes
                [Correspondence to ] Dr Madhukar Pai; madhukar.pai@ 123456mcgill.ca
                Author information
                http://orcid.org/0000-0003-3667-4536
                http://orcid.org/0000-0002-5909-3585
                Article
                Publisher ID: bmjgh-2019-001669
                DOI: 10.1136/bmjgh-2019-001669
                PMC ID: 6747906
                PubMed ID: 31565413
                SO-VID: 36727c05-dfcf-4020-b594-22283d7c24fa
                Copyright © © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 26 April 2019
                Date revision received : 28 June 2019
                Date accepted : 20 July 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004828, Grand Challenges Canada;
                Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: BMGF OPP1091843
                Funded by: FundRef http://dx.doi.org/10.13039/100004421, World Bank Group;
                Categories
                Subject: Analysis
                Subject: 1506
                Custom metadata
                special-feature unlocked

                Keywords: standardized patients,quality of care,health care providers
                Data availability:
                Keywords: standardized patients, quality of care, health care providers

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