In-State vs. Out-of-State Reviewer

Problem:

“When we determine it is necessary to send cases for external peer review, we often struggle with the decision of whether to use in-state or out-of-state physicians.”

Solution:

The most common reason for commissioning external peer review is to manage conflicts of interest and preserve objectivity. The closer in geographic proximity the external reviewer is to the subject physician, the more likely is the potential for bias, whether competitive, relational, perceptive or other. Yet the further away the reviewer, the less aware or sensitive he or she might be to local standards of care. This brings us to the key determining factor: If the care provided was or should have been affected by local standards of care that are perhaps inconsistent with national standards, then a reviewer familiar with those local standards should be considered. In such cases, the use of a more proximate reviewer has to be considered against the opposing risk of bias. If, however, the relevant standards of care are not unique to the local setting, the choice becomes far clearer: A reviewer outside the state without any meaningful knowledge to the subject physician or hospital should be pursued.

Most typically, standards of care are not unique to the local setting.  Therefore, most often, selection of a reviewer who is not familiar with the local physicians, hospital, politics or other factors is the highest integrity approach.

On occasion, we come across hospitals who feel that the reviewer must have membership on their medical staff prior to conducting the review.  Of course, this usually necessitates that the reviewer hold a medical license within the state. This is no longer a commonly pursued strategy.  Given that peer review is not the practice of medicine and that both federal state peer review protections have significantly evolved, in most cases neither medical staff membership nor an in state medical license serve any meaningful purpose.

Generally, the lower the potential for bias, the greater likelihood for high integrity, defensible peer review. There is a time for use of in-state or local reviewers; however, use of out-of-state physicians is most often the highest integrity approach.