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H. Gilbert Welch, MD, MPH
Department of Veterans Affairs White River Junction, Vt

William C. Black, MD
Dartmouth-Hitchcock Medical Center Lebanon, NH

Elliott S. Fisher, MD, MPH
Center for the Evaluative Clinical Sciences Hanover, NH

JAMA. 1995;273(10):772-773.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

To the Editor.

—Dr Salem-Schatz and colleagues have done admirable work investigating the influence of case-mix adjustment on physician profiles.¹ Readers should be aware, however, that case-mix adjustment may make bad apples look good.

It is important to step back and consider the rationale for adjusting physician profiles in general. Adjustment is a mechanism to control for factors that confound the relationship between physician and practice style. Ideally, the intent is to remove the effect of exogenous factors (ie, those in which the physician has no influence). Age and sex adjustment serves as the classic example. On the other hand, it is important not to adjust away endogenous factors (ie, those that the physician can influence). For example, it would be silly to adjust

physician profiles for physician income. In the private sector, at least, one would be adjusting for a factor that is strongly related to what one . . . [Full Text PDF of this Article]

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