By Steven R. Peskin, MD, MBA, FACP, Executive Medical Director, Population Health

Doctors and care teams have a new and unlikely ally when it comes to delivering the highest quality care: secret shoppers.

Recent secret shopper research sponsored by Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), its physician partners and The Robert Wood Johnson Foundation offers doctors important takeaways on topics ranging from depression screening to opioid prescribing that they can use to hone their clinical skills.

In the medical field, secret shoppers are trained actors, also known as unannounced standardized patients (USPs), who appear to be real patients to doctors. A research team records the visit and then reviews it along with the doctor’s notes from the patient’s medical record. The findings are reported back to the doctor along with suggestions that can help the doctor improve care.

Across all clinical areas Horizon BCBSNJ prioritized as important for its members, “we saw an 8 percent improvement in adherence to evidence-based clinician behaviors, a remarkable positive change,” said Saul Weiner, MD, co-founder of the Institute for Practice and Provider Performance Improvement (IP3I) who helped lead this project.

“USP-driven quality improvement can be a powerful new tool for reducing preventable hospitalizations, improving medication adherence and increasing evidence-based screening for primary prevention,” added Dr. Weiner.

Here are the five top takeaways  from the findings for physicians:

Takeaway #1: Much can go wrong in universal screening for depression in primary care

Actors were trained to present as depressed, meaning they would test positive on a depression screen at intake. During the study, their depression was often missed, or, if it was identified, the patients didn’t receive treatment or a referral.

Important steps that were overlooked during some exams included: a) no screening procedure was done in the clinic; b) screening was done by a medical assistant, but incorrectly and did not adhere to testing guidelines; c) screening was done correctly, but the positive result was not communicated to the physician; d) a positive screen was sent to the physician, but the physician overlooked it; or e) the physician saw the positive test and discussed it but then did not arrive at a plan.

Secret shopper study impact: With feedback, physicians participating in the study completed all steps correctly 70 percent of the time, an improvement from 42 percent prior to feedback.

Takeaway #2: Effective tobacco cessation counseling takes more than advising patients to quit

Evidence-based recommendations include three components: advising smokers and tobacco users to quit, discussing cessation medications and discussing cessation strategies. Most physicians in the study overlooked one or more of these components when counseling patients.

Secret shopper study impact: After feedback, participating physicians improved their adherence to guidelines from 24 percent to 57 percent.

Takeaway #3: Opioids are not the automatic answer: chronic pain management requires patient education and an alternative treatment plan

The secret shopper research team trained actors who presented with chronic lower back pain to request opioids even while reporting they were not on any pain medication. Evidence-based treatment should include: a) not prescribing the opioids; b) educating patients about the dangers and lack of efficacy of opioids in this setting; c) prescribing non-opioid alternatives, such as NSAIDS; and d) considering or referring the patients to physical therapy or a comparable integrative alternative. The most common oversight was educating patients about the dangers of opioids.

Secret shopper study impact: With feedback, participating physicians improved from 74 percent to 84 percent in terms of following the recommendations.

Takeaway #4: Don’t accept “no thanks” for an answer when it comes to cancer screening

Actors were trained to decline age-appropriate cancer screening when asked, without offering a reason why. In each case, the refusal was based on a common misconception, such as “my mother died of breast cancer despite being screened.” Only about one-third of participating physicians asked patients why they were declining the test, with or without feedback.

Secret shopper study impact: Even though feedback did not have a significant effect on providers’ behaviors, it’s important to keep focused on the best ways to address patient misconceptions about cancer screening.

Takeaway #5: Don’t assume the review of systems is negative

The secret shopper research team trained actors to report a positive review of systems in several areas, such as depressed mood or pain. However, the team often observed that these items were reported as negative in the physician’s note – even though the patients had never been asked about these items.

Secret shopper study impact: With feedback, physicians’ documentation of information they had not elicited dropped by 21 percent.

This innovative research required a new way of thinking from doctors, researchers and Horizon BCBSNJ. And the results have opened new pathways for patients to receive higher quality care. Find out more about the secret shopper research here.