According to WHO estimates, depression affects more than 300 million people worldwide, yet the condition remains widely underdiagnosed. To find out what happens “behind closed doors”, US researchers sent undercover actors posing as potentially depressed patients to doctor’s offices in New Jersey.
By Alan Schwartz
You have probably heard of “secret shoppers” – people who are hired by market research companies to shop in stores, collect data and give feedback afterwards. But did you know that you can also go undercover in a doctor’s office?
For a study recently published in Diagnosis, researchers from the Institute for Practice and Provider Improvement (I3PI*) sent undercover actors to visit New Jersey doctors to find out how often they were screened for depression. The actors, called “unannounced standardized patients” (USPs), visited the doctors as if they were real patients, while their task was to observe and record how clinical care was delivered.
Clinical guidelines for preventive care recommend that every patient should be screened for depression at each primary care visit. In the study, the actors played four different cases. In two of the cases, the actors were trained to screen positive, which means they should have been referred for further evaluation or treatment.
Doctors who agreed to take part in the study were visited by four USPs, with feedback after the first two. Each actor carried a concealed recorder. Before informing the physician that the visit was a USP, the researchers at I3PI reviewed the recordings of the visit and the physician’s note.
Depression screening rates and insurance claims increased after visits by “fake patients”
In many pre-feedback visits, depression screening was not performed or not communicated to the patient. After feedback, doctors were significantly more likely to perform and document depression screening; in fact, the screening rate increased from 55% to 70%.
The researchers also compared the rate of depression diagnoses in insurance claims of actual patients three months before and after the feedback to those of patients in a similar set of practices that did not participate in the USP visits. Depression claims increased by 40% in the participating practices, while this was not the case in the “control practices”.
Depression is a widespread condition that is substantially underdiagnosed in primary care, despite recommendations for screening at every visit. A 2002 review in the American Journal of Psychiatry by Luoma and colleagues found that 45% of suicide victims had seen a primary care provider within a month of their suicide, which suggests that failure to screen may have severe consequences. In this context, finding new ways of improving depression screening becomes all the more important.
Learn more in the original article here:
Alan Schwartz, Steven Peskin, Alan Spiro & Saul J. Weiner: Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients, 18.03.2020.
*The study was conducted by I3PI, which specializes in using USPs to improve quality and cost of care, in partnership with the American College of Physicians and Horizon Blue Cross Blue Shield of New Jersey. It was funded by the Robert Wood Johnson Foundation. The findings do not represent official statements of any of these organizations.