Effect of outcome on physician judgments of appropriateness of care

Is a permanent injury more likely to elicit a rating of inappropriate care than a temporary injury? To explore this question, we asked 112 practicing anesthesiologists to judge the appropriateness of care in 21 cases involving adverse anesthetic outcomes. The original outcome in each case was classified as either temporary or permanent. The authors then generated a matching alternate case identical to the original in every respectexcept that a plausible outcome of opposite severity was substituted. The original and alternate cases were randomly divided into two sets and assigned to reviewers who were blind to the intent of the study. The reviewers were asked to rate independently the care in each case as appropriate, less than appropriate, or impossible to judge, based on their personal (implicit) judgment of reasonable and prudent practice. A significant inverse relationship between severity of outcome and judgments of appropriateness of care was observed in 15 (71%) of the 21 matched pairs of cases. Overall, the proportion of ratings for appropriate caredecreasedby 31 percentage points when the outcome was changed from temporary to permanent andincreasedby 28 percentage points when the outcome was changed from permanent to temporary. We conclude that knowledge of the severity of outcome can influence a reviewer's judgment of the appropriateness of care. (JAMA. 1991;265:1957-1960)