In the study by Caplan et al1 in this issue, a partial explanation of a persistent conundrum is offered. Previous research has shown that patients with serious adverse events are likely to be judged as receiving inappropriate or negligent care.2,3 For example, in the recently published Harvard Medical Practice Study,3 negligence was identified in 51% of adverse events that resulted in death but in only 22% of events that led to minimal impairment. Was the care really poor, or did the bad outcomes influence the review process?
This study suggests that the reviewer's knowledge of the outcomes of care clouds the assessment of the process. Physician reviewers were presented with anesthesia cases from closed claims files and asked to review them for appropriateness of care using implicit criteria. Two versions of the same case were offered, identical in every respect except for the seriousness of the outcome.