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Physician Services
Question 1: Are higher volumes of physician services necessary? The answers can be found in examining current regional variation in physician services. [...] Question 2: Are there trade offs between medical care quality, health outcomes, and efficiency? Dartmouth Atlas of Health Care www.dartmouthatlas.org John E. [...] Wennberg, MD MPH Elliot Fisher, MD MPH Jonathan Skinner, PhD Amitabh Chandra, PhD Therese Stukel, PhD . [...] The Role of Growing Physician Capacity in Quality and Efficiency Growth in physician supply: Where do more physicians go? 1979 1999 Source: Goodman. [...] New Engl J Med, 2002 Better Outcomes Inefficient Care 15.08.828.3 FTEs Primary Care Medical SpecialistsTotal Physician FTEs per 1,000 end-of-life Medicare beneficiaries NYU Medical Center Primary Care Medical SpecialistsTotal 3.93.08.9 FTEs Mayo Clinic Source: Goodman, Health Affairs,March/April 2006l.
Variation in the Care of Surgical Conditions
The new Dartmouth Atlas series on variation in the care of surgical conditions, including this report on the treatment of diabetes and peripheral arterial disease, raises new questions regarding surgical management of both common and less frequently occurring medical conditions. This report carefully details the scope of the problem of diabetes and peripheral arterial disease and, as in previous Atlas analyses, emphasizes geographic practice variation in both preventive services and in surgical treatment rates. However, the report also takes a more patient-centered view. The goals of avoiding amputation and retaining the ability to walk are paramount. The best strategies to achieve these goals are the focus of quality improvement groups such as the Vascular Quality Initiative, described in this report. The outcomes data being recorded should go a long way toward producing the kind of widely applicable data upon which patient decision support tools should be based. Patients want to know procedure and facility-based risks and benefits.
Variation in the Care of Surgical Conditions
The new Dartmouth Atlas series on variation in the care of surgical conditions, including this report on the surgical treatment of cerebral aneurysms, raises new questions regarding surgical management of both common and less frequently occurring medical conditions. This report carefully details the prevalence of cerebral aneurysms and, as in previous Atlas analyses, emphasizes geographic practice variation in surgical treatment rates. However, the report also takes a more longitudinal view. The changes over time in which procedure is favored to treat aneurysms are particularly fascinating, driven as they appear to be by a mix of clinical evidence--including emerging long-term results--and physicians' opinions and personal experience.
Health Care Spending, Quality, and Outcomes
The U.S. health care system is broken. Overall life expectancy has improved, but the burden of chronic illness is increasing, and racial and socioeconomic disparities in mortality are widening. Almost 50 million Americans lack health insurance, and coverage for many others is inadequate. The safety and reliability of care in hospitals, surgical centers, nursing homes and physician offices is far from assured. And health care costs--already the highest in the world--are growing at a rate that poses a serious threat to patients, employers and the nation. For two decades, the Dartmouth Atlas Project has examined regional variations in the practice of medicine and in spending for health care, principally in the Medicare population. This policy brief focuses on what we have learned about the relationship between regional differences in spending and the quality of care--and the implications for efforts to reform the U.S. health care system.
Variation in the Care of Surgical Conditions
Despite many years of attention and study, variation in the diagnosis and treatment of prostate cancer persists in the United States. While some progress has been made--for example, screening practices are becoming more risk-based than population-based--new questions have arisen: for example, how best to counsel patients regarding their risk of cancer and the benefits and trade-offs of treatment; how to optimize outcomes related to treatment; and which patients are best treated with active surveillance. While these questions are being answered, clinicians and health systems need to strive to incorporate the best available evidence and shared decision-making into their efforts to detect and treat prostate cancer.
Trends and Regional Variation in Hip, Knee, and Shoulder Replacement
From 2000-01 to 2005-06, rates of hip, knee, and shoulder replacement all rose substantially among Medicare beneficiaries, and there was widespread variation in the use of these procedures across geographic regions and by race. The Dartmouth Atlas Project has detailed similar variation in the use of other elective procedures. One possible interpretation of this variation is that the decision to undergo the procedure may be influenced more by physician judgments than by the preferences and values of the individual patients. Another explanation might be that patients in some geographical areas do not have adequate access to joint replacement. These findings highlight the need for improved physician and patient education and the use of shared decision-making to determine whether a patient should undergo joint replacement.
