To the Editor.
— I do not agree that the observations by Brennan et al1 "may represent an important improvement on existing measures of quality," ie, outcome-based measures. My disagreement can be understood by considering a hypothetical premise that illustrates a significant potential bias in the article by Brennan et al.My premise is that academic physician specialists are uncomfortable with outcome-based measures of quality of care because this puts them on equal footing with nonacademic physicians. Further, they prefer the concept of negligence-based quality assurance because this enables academic-based reviewers to insert a subtle bias in favor of teaching hospitals.In the article by Brennan et al, a group of academic-based reviewers (or, at least, physician reviewers selected by academic-based reviewers and likely to be sympathetic to them) reviewed charts of about 50 hospitals. The reviewers were likely to be personally familiar with some of these institutions, while
Morfesis FA. Hospital Events Associated With Adverse Events and Substandard Care. JAMA. 1991;266(21):2983. doi:10.1001/jama.1991.03470210051017