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Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients

Alan Schwartz ORCID logo, Steven Peskin, Alan Spiro and Saul J. Weiner
From the journal Diagnosis



Depression is substantially underdiagnosed in primary care, despite recommendations for screening at every visit. We report a secondary analysis focused on depression of a recently completed study using unannounced standardized patients (USPs) to measure and improve provider behaviors, documentation, and subsequent claims for real patients.


Unannounced standardized patients presented incognito in 217 visits to 59 primary care providers in 22 New Jersey practices. We collected USP checklists, visit audio recordings, and provider notes after visits; provided feedback to practices and providers based on the first two visits per provider; and compared care and documentation behaviors in the visits before and after feedback. We obtained real patient claims from the study practices and a matched comparison group and compared the likelihood of visits including International Classification of Diseases, 10th Revision (ICD-10) codes for depression before and after feedback between the study and comparison groups.


Providers significantly improved in their rate of depression screening following feedback [adjusted odds ratio (AOR), 3.41; 95% confidence interval (CI), 1.52–7.65; p = 0.003]. Sometimes expected behaviors were documented when not performed. The proportion of claims by actual patients with depression-related ICD-10 codes increased significantly more from prefeedback to postfeedback in the study group than in matched control group (interaction AOR, 1.41; 95% CI, 1.32–1.50; p < 0.001).


Using USPs, we found significant performance issues in diagnosis of depression, as well as discrepancies in documentation that may reduce future diagnostic accuracy. Providing feedback based on a small number of USP encounters led to some improvements in clinical performance observed both directly and indirectly via claims.


Support for this project was provided by a grant from the Robert Wood Johnson Foundation to the American College of Physicians and the Institute for Practice and Provider Performance Improvement, Inc. We gratefully acknowledge the assistance of the American College of Physicians and Horizon Blue Cross Blue Shield of New Jersey staff, particularly Kathleen Feeney, Elizabeth Rubin, Cari Miller, and Yan Zhang. However, the findings do not represent official statements of any of these organizations, and any errors are the authors’.

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: Grant from the Robert Wood Johnson Foundation, Funder Id:, Grant Number: 73791 to the American College of Physicians and the Institute for Practice and Provider Performance Improvement, Inc.

  3. Employment or leadership: A. Schwartz, SJW, and A. Spiro conducted this work as employees and board members of the Institute for Practice and Provider Performance Improvement, Inc., with support from the Robert Wood Johnson Foundation and American College of Physicians. A. Spiro was also an employee of Blue Health Intelligence during the period when the parent study was performed. SP is an employee of Horizon Blue Cross Blue Shield of New Jersey, and neither SP nor Horizon was compensated for their participation.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  6. Disclosures: None declared.


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Received: 2019-12-26
Accepted: 2020-02-26
Published Online: 2020-03-18
Published in Print: 2020-08-27

©2020 Walter de Gruyter GmbH, Berlin/Boston

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