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To the Editor: Quality improvement initiatives now help to shape health care.¹ In his Commentary, Dr Berwick² contrasted the evaluation of improvements in clinical evidence (assessing efficacy for new tests, drugs, and procedures) with that of improvements in quality of care. He argued that randomized controlled trials (RCTs) are appropriate for evaluating improvements in the former, but not the latter. He believes that improving quality of care is a matter for social science, in which leadership, organizational history, changing environments, and culture are important. Other quantitative and qualitative research methods are therefore required. I believe that opposition of these 2 types of research—clinical and health services research—is debatable.

RCTs have their limitations, but these limitations affect both clinical and health services research. Even well-designed RCTs take place in a controlled environment, with volunteer patients and volunteer physicians. The extent to which the results of RCTs can be generalized is always . . . [Full Text of this Article]

Pierre Durieux, MD, MPH
pierre.durieux@egp.aphp.fr
Paris Descartes University
Paris, France

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