Clinical Peer Review: Burnishing a Tarnished Icon

Hayward and colleagues, in this issue of Annals, show that implicit criteria, widely used in peer review to assess quality of care, are inadequate. Prescriptions for improving peer review are suggested.

Physician groups frequently extol the sanctity of clinical peer review. In this issue of Annals, however, Hayward and colleagues [1] confirm that the way most physicians and review organizations do peer review to assess quality of care is unreliable [2]. Well-trained internists were asked to judge the appropriateness and quality of care on a general medical ward. Raters were taught a structured, implicit criterion approach, in which their perception of the relevant standard of care served as the basis for their judgment. Agreement among reviewers on the existence of most quality problems for single patients was generally poor. This study confirmed that peer review using implicit criteria is useful when judging groups of patients [3]; however, for single patients, it is useful only when care is egregiously bad and the relevant standard is obvious.

The findings would not be so important if the use of implicit criteria for judging the quality and appropriateness of care were not so widespread. Considerable money and energy have been spent in federal, state, and private peer review of the quality of care of individual patients, using implicit criteria and limited explicit criteria [4]. Such programs have created enormous hassle for conscientious doctors and countless heated rhetorical arguments with little evidence that they have substantially improved the quality of care [2-5].

As a member of a state disciplinary board from 1988 to 1992, I read hundreds of peer-review reports from the medical society committees mandated by state law to assess patients' potentially serious complaints. Few used predefined explicit criteria for what constituted a breach in standard of care. Many reports …