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  • Issue Briefs

      • Health Care Spending, Quality and Outcomes, Elliott Fisher, David Goodman, Jonathan Skinner and Kristen Bronner
      • This issue brief focuses on what the Dartmouth Atlas Project has learned about the relationship between regional differences in spending and the quality of care over two decades of research, and the implications for efforts to reform the U.S. health care system.
      • The Policy Implications of Variations in Medicare Spending Growth, Elliott Fisher, Julie Bynum and Jonathan Skinner
      • This brief report reviews variations in spending growth across U.S. regions and the implications of these findings for health policy. It also provides detailed tables on Medicare per capita spending levels and growth rates for all U.S. hospital referral regions and states.
      • An Agenda for Change: Improving Quality and Curbing Health Care Spending, John Wennberg, Shannon Brownlee, Elliott Fisher, Jonathan Skinner and James Weinstein
      • This Dartmouth Atlas white paper makes the case that the United States can extend coverage to the country's uninsured without substantially increasing overall health care costs. The paper argues that the Obama Administration and the Congress can adopt measures that will improve health care quality and patient outcomes, while reducing the growth of health care spending.
  • Topic Briefs

      • The Dartmouth Atlas of Children's Health Care in Northern New England, David Goodman, Nancy Morden, Shawn Ralston, Chiang-Hua Chang, Devin Parker, Shelsey Weinstein and Kristen Bronner
      • The Dartmouth Atlas has produced the first report showing the patterns of care received by nearly the entire population of infants and children in Northern New England for ambulatory physician services, hospitalization, common surgery, imaging, and outpatient prescription fills. Read the report, press release, download data tables, or purchase a hardcover or paperback copy.
      • The Dartmouth Atlas of Medicare Prescription Drug Use, Jeffrey Munson, Nancy Morden, David Goodman, Luca Valle, John Wennberg and Kristen Bronner
      • In its first look at prescription drug use, the Dartmouth Atlas Project shows that the use of both effective and risky drug therapies by Medicare patients varies widely across U.S. regions, offering further evidence that location is a key determinant in the quality and cost of the medical care that patients receive. Read the report, press release, download data tables, or purchase a copy.
      • Trends in Cancer Care Near the End of Life, David Goodman, Nancy Morden, Chiang-Hua Chang, Elliott Fisher and John Wennberg
      • This report finds that the care that elderly patients with cancer receive does not always reflect their own preferences, but the prevailing styles of treatment in the regions and health care systems where they happen to receive cancer treatment. Where patients with advanced cancer live continues to play an important role in the care they receive.
      • Measuring Up? End-of-Life Cancer Care in California, Shannon Brownlee
      • This report on treatment of cancer patients in California as they approach death indicates there is sharp variation in the aggressiveness of care by region and by hospital. Such variation is not explained by differences among patients in terms of age, sex, or race. The report also shows trends in advanced cancer care from 2003–07 to 2010.
      • Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life, David Goodman, Elliott Fisher, John Wennberg, Jonathan Skinner, Scott Chasan-Taber and Kristen Bronner
      • This Dartmouth Atlas brief demonstrates that improvements in care have occurred between 2007 and 2010 for chronically ill Medicare patients in their last six months of life. However, the pace of change varied across regions and hospitals, with some experiencing rapid change while other health systems showed little improvement.
      • End-of-Life Care in California: You Don't Always Get What You Want, Shannon Brownlee
      • Californians frequently do not get the kind of care that they want at the end of their lives. This report documents research on end-of-life care for Medicare beneficiaries, and analyses it in light of what is known about Californian's preferences for care as they approach death. The research found sharp variation that cannot be explained by differences among patients in age, sex, or race.
      • The Revolving Door: A Report on U.S. Hospital Readmissions, The Dartmouth Atlas Project and PerryUndem Research & Communication
      • The Robert Wood Johnson Foundation has released a report showing that one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while patients in the hospital for reasons other than surgery returned at an even higher rate of one in six. The findings are based on new data from the Dartmouth Atlas Project. Click here for data tables.
      • What Kind of Physician Will You Be? Variation in Health Care and Its Importance for Residency Training, Anita Arora and Alicia True
      • When choosing a residency program, medical students typically consider the reputation and training curriculum of the institution, as well as their own geographical and lifestyle preferences. But there's something else they should consider: The way academic medical centers deliver health care differs dramatically from one institution to the next.
      • What Kind of Physician Will You Be? End-of-Life Care and Its Effect on Residency Training, Anita Arora
      • This report was created by a fourth-year student at Dartmouth Medical School in collaboration with the Dartmouth Atlas Project. Her goal was to encourage her fellow students to consider the "hidden" training curriculum when ranking residency training programs -- the style and culture of practice that are reflected in the intensity of the care given to chronically ill patients who are nearing the end of their lives.
      • After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries, David Goodman, Elliott Fisher and Chiang-Hua Chang
      • This report is the first national study looking at how effectively communities and hospitals coordinate care for patients leaving the hospital. It reveals striking variations in 30-day readmission rates and little progress in reducing readmissions and improving care coordination between 2004 and 2009. Readmission rates for some conditions have increased for many regions and at many hospitals, including some of America's most elite academic medical centers.
      • Care About Your Care: Tips for Patients When They Leave the Hospital
      • This article will help you LOOK at the care you get and understand what good care for patients who are leaving the hospital looks like, help you LEARN what you can do to make sure you get the best possible care, and help you LIVE better by taking action to get better care.
      • A New Series of Medicare Expenditure Measures by Hospital Referral Region: 2003-2008, Jonathan Skinner, Daniel Gottlieb and Donald Carmichael
      • This Dartmouth Atlas report presents newly developed measures of Medicare spending based on a larger (20%) sample of claims and compares them to our previous spending measures. These new per capita spending rates are also adjusted for differences across regions in the prices paid by Medicare for similar services -- differences due both to higher costs in some regions, and to higher Medicare payments to hospitals with residency training programs and hospitals that serve a high percentage of low-income patients.
      • Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, David Goodman, Amos Esty, Elliott Fisher and Chiang-Hua Chang
      • Chronically ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but there was an increase in the intensity of care for patients who were hospitalized, according to a new Dartmouth Atlas Project report. This report updates previous findings regarding variations in end-of-life care and documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life.
      • Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses, David Goodman, Elliott Fisher, Chiang-Hua Chang, Nancy Morden, Joseph Jacobson, Kimberly Murray and Susan Miesfeldt
      • Whether Medicare patients with advanced cancer will die while receiving hospice care or in the hospital varies markedly depending on where they live and receive care, according to the Dartmouth Atlas Project's first-ever report on cancer care at the end of life. The report demonstrates no consistent pattern of care or evidence that treatment patterns follow patient preferences, even among the nation's leading academic medical centers.
      • Regional and Racial Variation in Primary Care and the Quality of Care Among Medicare Beneficiaries, David Goodman, Shannon Brownlee, Chiang-Hua Chang and Elliott Fisher
      • This report shows that neither delivering a greater amount of primary care, nor making sure patients routinely see a primary care clinician is, by itself, a guarantee that patients will get recommended care or experience better outcomes. The report also demonstrates that patients' access to and use of primary care, the quality of care overall, and outcomes vary markedly in different locations.
      • Hospital and Physician Capacity Update, David Goodman, Elliott Fisher and Kristen Bronner
      • This report analyzes current hospital and physician capacity as well as trends over a 10-year period, and reveals the irrational distribution of these valuable and expensive health care resources. The report finds similar wide and persistent variations in capacity in 2006 to those that existed in 1996, generally in the same places. Note: The 2006 hospital resource rates in this report include information from psychiatric and rehabilitation facilities. Data in the table were revised to exclude these beds 09/08/09.
      • Regional and Racial Variation in Health Care among Medicare Beneficiaries, Elliott Fisher, David Goodman, Amitabh Chandra and Kristen Bronner
      • This report updates our June 2008 AF4Q report. Included are data for Dartmouth Atlas hospital service areas, as well as data updates through 2006. Updated methods and definitions are also available.
      • Disparities in Health and Health Care among Medicare Beneficiaries, Elliott Fisher, David Goodman, Amitabh Chandra and Kristen Bronner
      • The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program commissioned a special report by the Dartmouth Atlas Project to highlight the uneven quality of health care being delivered across America and the need to improve the quality of care and reduce disparities in health in every community. Aligning Forces for Quality is working to lift the overall quality of health care in targeted communities across America, and provide models for national reform.The report demonstrates that in U.S. health care, it's not only who you are that matters, it's also where you live. The findings highlight the importance of understanding health and health care within a local context - and of efforts to explore and address the underlying causes of disparities within and across regions. Documents available in addition to the report and data include an executive summary, methods and definitions, and frequently asked questions.
      • Effective Care, The Dartmouth Atlas Project
      • The Dartmouth Atlas Project has documented three sources of unwarranted variation in the practice of medicine and the use of medical resources across the United States. The underuse of effective care includes such problems as the failure to give beta-blockers consistently to people who have had heart attacks, or to routinely screen diabetics for early signs of retinal disease. Even hospitals considered among the "best" in the country - including some academic medical centers - fail to take these proven steps.
      • Preference-Sensitive Care, The Dartmouth Atlas Project
      • The Dartmouth Atlas Project has documented three sources of unwarranted variation in the practice of medicine and the use of medical resources across the United States. Misuse of preference-sensitive care refers to situations in which there are significant tradeoffs among the available options, yet often the patient's values and preferences are not taken into account when deciding the course of treatment.
      • Supply-Sensitive Care, The Dartmouth Atlas Project
      • The Dartmouth Atlas Project has documented three sources of unwarranted variation in the practice of medicine and the use of medical resources across the United States. The overuse of supply-sensitive care is particularly apparent in the management of chronic illness, where there is often an over-dependence on hospitals and a lack of the infrastructure necessary to support the management of chronically ill patients in non-inpatient settings. In the absence of medical evidence regarding such questions as when to schedule return visits, when to hospitalize or admit to intensive care, when to refer to a medical specialist, and, for most conditions, when to order a diagnostic or imaging test, the availability of resources tends to govern these decisions.
  • Surgical Variation Studies

      • Variation in the Care of Surgical Conditions: Spinal Stenosis, Brook Martin, Anna Tosteson, Jon Lurie, Sohail Mirza, Phil Goodney, Nino Dzebisashvili, David Goodman and Kristen Bronner
      • The fourth in a series of six surgical reports, this study focuses on lumbar spinal stenosis as an example that helps to summarize the treatment options, epidemiology, and evidence of effectiveness of treatment for back pain, a leading cause of morbidity and disability in the United States. Download the report, press release, or data table, or purchase a printed copy.
      • Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease, Philip Goodney, Nino Dzebisashvili, David Goodman and Kristen Bronner
      • The third in a series of six surgical reports, this study examines the significant racial and regional disparities in the care of patients with diabetes, including both preventive services and surgical interventions. Download the report, press release, or data table, or purchase a printed copy.
      • Variation in the Care of Surgical Conditions: Cerebral Aneurysms, Kimon Bekelis, Philip Goodney, Nino Dzebisashvili, David Goodman and Kristen Bronner
      • The second in a series of six surgical reports, this study addresses the common and potentially dangerous problem of cerebral aneurysms, including the frequency of the condition, the decision about whether to treat unruptured aneurysms, and which treatment to use.
      • Variation in the Care of Surgical Conditions: Obesity, Bradley Reames, Nancy Birkmeyer, Justin Dimick, Philip Goodney, Nino Dzebisashvili, David Goodman and Kristen Bronner
      • This report, the first in a series of six surgical reports, addresses the growing problem of obesity in the United States. Topics include the decision to use bariatric surgery, trends and regional variation in bariatric surgery rates, the quality of surgical care, and patient outcomes.
      • Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota, Shannon Brownlee, John Wennberg, Michael Barry, Elliott Fisher, David Goodman and Julie Bynum
      • For Medicare patients with conditions for which surgery is an option, whether they undergo elective surgery depends largely on where they live and the clinicians they see, according to a report from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making. The study shows wide regional variations in elective surgery for Medicare patients with similar conditions and advocates for shared decision-making between patients and their clinicians.
      • Trends and Regional Variation in Hip, Knee, and Shoulder Replacement, Elliott Fisher, John-Erik Bell, Ivan Tomek, Amos Esty, David Goodman and Kristen Bronner
      • This report shows trends in joint replacement from 2000-2001 to 2005-2006, as well as four to tenfold variations among hospital referral regions. The patterns suggest both overuse and underuse of these procedures.
      • Trends and Regional Variation in Carotid Revascularization, Philip Goodney, Lori Travis, F. Lee Lucas, Elliott Fisher, David Goodman, Kristen Bronner and Amos Esty
      • This report explores the treatment of cerebrovascular atherosclerosis, a condition which can lead to stroke. Changes in rates from 1998 to 2007 and the pattern of variation across regions in each of those years are discussed.
      • Spine Surgery, Dartmouth - CMS - FDA collaborative
      • This report focuses on trends and regional variations in spine surgery, particularly discectomy and laminectomy procedures and spine fusion. Two hospital referral regions with unusual patterns of utilization are also examined.
      • Cardiac Surgery, The Dartmouth Atlas Project
      • This study reports on national trends in coronary revascularization and valve replacement surgery from 1992 to 2003, and regional variations in procedure rates in 2003. Two hospital referral regions with unusual patterns of utilization - Redding, California for coronary bypass and valve replacement surgery, and Elyria, Ohio for coronary angioplasty - are also examined.
      • Trends and Regional Variations in Abdominal Aortic Aneurysm Repair, Dartmouth - CMS - FDA collaborative
      • This report examines the impact of the introduction of endovascular AAA repair on utilization and outcomes. The data are drawn from Medicare discharge records from 1992 through 2003.
  • National Atlas Editions

      • Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008, John Wennberg, Elliott Fisher, David Goodman and Jonathan Skinner
      • This Atlas builds on the analyses presented in the 2006 edition. As before, the focus is on Medicare beneficiaries who had severe chronic illnesses and were in their last two years of life. This edition both updates the earlier analyses to encompass more recent data (through 2005) and expands the scope to include all sectors of care covered by the Medicare program. This Atlas also proposes new ways of thinking about how to achieve better care coordination and reduce the overuse of acute care hospital services. It offers concrete recommendations on the ways different stakeholders can use the new data - from choosing the right provider to reforming the U.S. health care system.
      • The Care of Patients with Severe Chronic Illness: A Report on the Medicare Program, John Wennberg and Elliott Fisher
      • This edition of the Dartmouth Atlas reports on the last two years of life among Medicare enrollees with severe chronic illnesses. Several dimensions of care are examined: per decedent Medicare spending for hospital and physician care; FTE physician, hospital bed, and ICU bed inputs; physician visits; hospitalizations and stays in intensive care; and selected quality measures. The chapters document extensive variation in the amount, as well as the quality, of care given to chronically ill Medicare beneficiaries among states, regions, and from one hospital to another, even within the same region.
      • The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas Project
      • Variations in the intensity of use of hospitals, the striking differences in care at the end of life, and the nearly random patterns of elective surgery all raise questions about the outcomes and value of care - about quality. Is more in fact better? What is the value received for the money spent? What is the cost of poor quality? Patients as well as health services researchers have begun to ask whether more really is better, and whether the "system" really is a system. Until we can answer those questions with any certainty, we will not be able to achieve real quality in American medical care. This edition uses data from 1995 & 1996.
      • The Dartmouth Atlas of Health Care 1998, The Dartmouth Atlas Project
      • The Atlas shows once again that in health care, geography is destiny. The amount of care consumed by Americans is highly dependent on where they live - on the capacity of the health care system where they live, and on the practice styles of local physicians. Variations in the intensity of use of hospitals, the striking differences in the way terminal care is delivered, and the idiosyncratic patterns of elective surgery raise significant questions about the outcomes and value of health care. The fundamental questions posed by the Atlas are Which rate is right? How much is enough? and What is fair? This edition uses data from 1994 & 1995.
      • The Dartmouth Atlas of Health Care 1996, The Dartmouth Atlas Project
      • The existence of large variations in the use of medical care among communities and regions raises a number of important issues. Foremost is the question "Which rate is right?" Another important issue raised by geographic variation concerns fairness. Variation studies provide good evidence that populations in low cost regions are not sicker or in greater medical need than those in high cost regions. A system that rewards high cost areas by continuing to pay their higher costs is by definition economically punishing areas that have fewer resources, use them more efficiently, and are reimbursed less. Is it fair for citizens living in regions with low per capita health care costs to subsidize the greater (and more costly) use of care by people living in high resource and high utilization regions? This edition uses data from 1992 & 1993.
  • Specialty-Specific Editions

      • The Dartmouth Atlas of Musculoskeletal Health Care, James Weinstein and John Birkmeyer
      • Musculoskeletal disease is a major cause of disability, and requires substantial health care expenditure in the United States. However, little is known about the demographics of musculoskeletal health care across our country. As we attempt to refine our treatment of musculoskeletal injury and disease, the variations in treatment patterns that are evident in the delivery of care are important to understand, particularly as this understanding can lead to an improvement in the care of musculoskeletal injuries and disease. This edition uses data from 1996 & 1997.
      • The Dartmouth Atlas of Vascular Health Care, Jack Cronenwett and John Birkmeyer
      • Despite general progress in the field of vascular surgery, little is known about how vascular health care is currently being delivered in the United States. How often are patients undergoing surgery or other procedures in different parts of the country? Which types of specialists are providing vascular health care in different regions? How good are their outcomes? This Atlas helps focus attention on the most important questions and controversies in the field. This edition uses data from 1996 & 1997.
      • The Dartmouth Atlas of Cardiovascular Health Care, David Wennberg and John Birkmeyer
      • The first specialty-specific volume in the Dartmouth Atlas series deals with the most common chronic disease in the U.S. - ischemic heart disease- as well as cardiac conduction disease and valvular heart disease among the Medicare population. This edition uses data from 1996 & 1997.
  • State Editions

      • The Dartmouth Atlas of Health Care in Virginia, The Dartmouth Atlas Project and the Maine Medical Assessment Foundation
      • This Atlas uses the Virginia discharge data set as well as Medicare data to demonstrate again that the way health care resources are distributed and used at the local level depends more on the supply of resources and the practice style of local physicians than on differences in demographic or illness characteristics. This is as true for residents of Virginia as it is for people living elsewhere in the United States. This edition uses data from 1996 & 1997.
      • The Dartmouth Atlas of Health Care in Michigan, John Wennberg and David Wennberg
      • The Michigan atlas is the most extensive study of its kind of medical care in the state. Claims data from Blue Cross Blue Shield of Michigan, as well as Medicare data, was used to analyze the use and supply of health care services in Michigan. This edition uses data from 1996 & 1997.
      • The Dartmouth Atlas of Health Care in Pennsylvania 1998, The Dartmouth Atlas Project and the Maine Medical Assessment Foundation
      • The first state-specific edition of Atlas uses the Pennsylvania discharge data set as well as Medicare data to show that the way health care resources are distributed and used at the local level challenges the conventional wisdom that illness determines the use of medical care, and the assumption that the supply of medical care arises in response to the demand for it. This edition uses data from 1994 & 1995.
  • Regional Editions

  • Health care is highly local, and the analysis of patterns of resource distribution and utilization among hospital referral regions often masks important differences between the communities which, when aggregated, make up the larger region. Moreover, the task of actually addressing the problems of variation is often a local undertaking, one for which more specific - and more local - information is needed. The 2012 regional reports highlight surgical variation at the hospital referral region (HRR) and hospital service area (HSA) level and emphasize the importance of share decision-making, using data from 2008-10. The 1996 regional Atlas volumes focus on HSAs and make clear that there is often as much, and frequently more, variation among the hospital service areas within states and regions than among the larger units of analysis. These editions use data from 1992-93.
      • The East South Central States, The Dartmouth Atlas of Health Care, 1996
      • The West South Central States, The Dartmouth Atlas of Health Care, 1996



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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.