Conclusion
The United States has an extraordinarily innovative health care system with the best-trained physicians in the world. This Dartmouth Atlas report shines a light on local health care patterns at teaching hospitals and finds that they vary in technical quality, patient experiences, intensity of treatment, and the use of procedures. These differences in care can be hard to see on the ground, but are clear from the report's epidemiological analyses.
Many factors influence the decision of where to complete residency training. Dartmouth Atlas data can help guide this decision, as it provides information about how hospitals manage patients with chronic illnesses and provide discretionary procedures, both of which are critical aspects of residency training. Physicians who train at institutions with better, more patient-centered and efficient care will be better prepared to lead the transformation of health care when they are in practice. But most health care systems seek and need further improvements in care. Physicians in training can contribute to better health care by learning about improvement strategies in the following areas:
Effective care: There are many clinical situations in which there is a clear best single option for most patients. Examples include immunizations for children, the use of aspirin for patients with myocardial infarctions, and prevention of central line infections through better catheter care. Reducing variation in effective care requires re-engineering care systems through improvements of clinical microsystems. The Institute for Healthcare Improvement (www.ihi.org) has numerous programs to help clinicians and hospitals implement the very best of evidence-based medicine.
Supply-sensitive care: A large proportion of Medicare spending goes toward managing chronic illness. The way chronic illness is managed varies extensively across the country and is often influenced by resource capacity. As our country works to reform health care, an important solution will be the wise investment in future capacity, which should be adjusted for the relative size of the patient population served and not the current level of utilization of resources (since utilization is influenced by availability). In addition, an increased focus on the coordination of care by teams of health care workers within organized systems can reduce utilization to more reasonable levels while producing equal or better health outcomes. One model for improving the organization of care that is currently supported by the Affordable Care Act and the Centers for Medicare and Medicaid Services (CMS) is the Accountable Care Organization (ACO). The ACO is a provider-led organization for which reimbursements are tied to quality metrics and total cost reduction for a defined patient population. Through this model, reimbursements are decoupled from volume and intensity, allowing for increased efficiency and coordinated care. When cost savings are achieved while quality measures are met, the ACO receives a share of the cost savings. [17]
Preference-sensitive care: An important first step in addressing the variation in preference-sensitive care is making hospitals aware of their procedure rates. This alone can help to reduce overuse, as shown by an analysis conducted in Maine regarding hysterectomy rates; after the study, one hospital successfully implemented a quota on the number of procedures performed upon learning that its rates were much higher than the state average. [5] However, this does not ensure that the right patients are receiving the right treatments. As such, comparative effectiveness research should continue to be undertaken to develop evidence in support of treatment efficacy. Outcomes research that incorporates patient perceptions and values will enhance our understanding of suitability and the effects of treatments that matter most to patients. Finally, shared decision-making programs and the development and use of decision aids will ensure that patient preferences are heard and that informed patient choice, rather than physician opinion, dictates the demand for procedures.