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Executive Summary

Executive Summary

For more than 20 years, the Dartmouth Atlas of Health Care has used Medicare data to understand differences in medical care across U.S. hospitals and regions. The Atlas project has uncovered marked variations in resource utilization and health care spending. It has demonstrated that increased utilization and spending do not always lead to higher quality care or better outcomes. It has also shown that many patients receive care that they would not want if they were better informed about the full range of treatment options.

This report is part of a new effort to provide medical students with information about the patterns of care provided by teaching hospitals with residency training programs. Most fourth-year medical students consider the reputation and training curriculum of the institution as well as their own geographical and lifestyle preferences when choosing a residency program. This report offers medical students new ideas and information to help guide their choice. It shines a light on hospital characteristics that are often invisible but are part of the hidden training curriculum that can affect a lifetime of practice. These include how aggressively physicians at each hospital treat chronically ill patients at the end of life, and the frequency with which patients undergo surgery when other treatment options are available. The authors of this report (who are physicians in training) believe that the wise use of health care resources and respect for patient preferences are just as important as learning to work up a patient.

Understanding these patterns of care is particularly important for tomorrow's doctors in order to practice successfully in the new environment created by health care reform. The nation can no longer afford unrestricted growth in health care costs and health care systems that provide low quality and inefficient care. Teaching hospitals vary widely in their performance, and medical students should consider the advantages of training in hospitals that already deliver high-value health care. At the very least, they should be aware of the practice styles of residency programs they are considering ranking highly in the Residency Match.

Differences in patterns of care can be understood through three categories of medical care variation defined at the Geisel School of Medicine at Dartmouth: effective care, supply-sensitive care, and preference-sensitive care. Effective care refers to services that are of proven value and have no significant tradeoffs; the benefits of the services so far outweigh the risks that all suitable patients should receive them. Supply-sensitive care represents services for which the supply of physicians and other resources—such as hospital beds—strongly influences the amount of care delivered. Preference-sensitive care comprises care for conditions for which there is more than one treatment option, each with its own benefits and tradeoffs. For these conditions, patients' preferences should—but often do not—guide decision-making. Variations in the way teaching hospitals utilize supply-sensitive and preference-sensitive services are an important driver of spending differences across the United States. Beyond cost considerations, variation in all of these categories is an important factor in the quality of patient-centered care. This report will help fourth-year medical students to identify the hospitals with exemplary practice patterns and to be aware of training hospitals that have room to improve.

This report uses Dartmouth Atlas data to show the variation in medical care for Medicare beneficiaries among academic medical centers rated by U.S. News and World Report as the best hospitals for clinical excellence in 2012-13 [1] (see Appendix B for more information on this list). The report also includes several other notable teaching hospitals for a total of 23 medical centers reflecting a wide range of practice styles. [2] Together, these hospitals represent approximately 17 percent of all primary residency slots in 2012 [3] and are home to some of the largest and most popular training programs. This web site has additional data for nearly all other U.S. teaching hospitals.

The report is divided into three sections. The first section reports on care provided in the last six months of life, which reflects the way that physicians at different institutions approach end-of-life care for chronically ill patients. The second section describes preference-sensitive care and uses regional surgical procedure rates to demonstrate the inconsistency in the use of different treatment options. The final section presents patient care quality indicators submitted by each hospital to the U.S. Department of Health and Human Services.

Understanding variations in the way care is delivered by these institutions is important because it affects residency training and, thus, the way residents in a given program will practice as physicians. The report demonstrates that hospitals providing higher intensity care are not necessarily providing higher quality or better patient experiences. Hence, training at hospitals with less intensive utilization patterns may better prepare residents to provide higher quality care that respects patient preferences. Medical students and residents can also use this resource to learn and question the practice patterns at academic institutions where they are currently training.


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and data
           Variation in end-of-life care and
the management of chronic illness
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The Dartmouth Atlas of Health Care is based at The Dartmouth Institute for Health Policy and Clinical Practice and is supported by a coalition of funders led by the Robert Wood Johnson Foundation, including the WellPoint Foundation, the United Health Foundation, the California HealthCare Foundation, and the Charles H. Hood Foundation.