Table of contents
  1. Story
  2. Screen Capture
  3. Spotfire Dashboard
  4. Research Notes
  5. The Dartmouth Atlas of Health Care
    1. Understanding of the Efficiency and Effectiveness of the Health Care System
      1. Tools
      2. Percent of Deaths Occuring in Hospitals, 2010
      3. View Other Data By
      4. View Other Data By Zip Code
    2. Spotlight
      1. Tracking Improvement In The Care Of Chronically Ill Patients: A Dartmouth Atlas Brief On Medicare Beneficaries Near The End Of Life
        1. Introduction
          1. Table. National trends in selected measures of the care of chronically ill patients near the end of life
        2. Overall change in care near the end of life
        3. Change in care near the end of life across academic medical centers
        4. What can we learn from end-of-life care?
        5. References
          1. 1
          2. 2
          3. 3
          4. 4
          5. 5
          6. 6
          7. 7
          8. 8
        6. The Dartmouth Atlas Project
      2. Press Release
        1. New findings show longitudinal change for care provided to chronically ill Medicare patients
        2. Medicare spending per patient during the last two years of life
        3. Deaths occurring in hospitals
        4. Patients seeing 10 or more doctors during the last six months of life
        5. About the Dartmouth Atlas Project
      3. Download the Data
      4. Comments on James D. Reschovsky et al.
        1. Geographic Variation in Fee-for-Service Medicare Beneficiaries’ Medical Costs Is Largely Explained by Disease Burden, Medical Care Research & Review, 2013.
    3. Stay Informed
    4. Other
  6. Data By Region
    1. About Our Regions
      1. Hospital Referral Regions
      2. Hospital Service Areas
      3. Primary Care Service Areas
  7. Data By Hospital
    1. Browse Hospitals
    2. About Our Hospital Data
  8. Data By Topic
    1. Care of Chronic Illness in Last Two Years of Life
    2. Medicare Reimbursements
    3. Hospital Use
    4. Medical Discharges
    5. Surgical Procedures
    6. Post-Acute Care
    7. Quality/Effective Care
    8. Hospital & Physician Capacity
    9. End of Life Care
    10. Primary Care Service Area (PCSA)
  9. Tools
    1. Downloads
      1. Atlas Downloads
        1. Crosswalk files
          1. ZIP code crosswalks
          2. Other crosswalks
        2. Geographic boundary files
        3. Post-discharge events
          1. 2010
          2. 2004 and 2009
          3. 2008
        4. Care of chronically ill patients during the last two years of life
          1. Deaths occurring in 2010
          2. Deaths occurring 2003-07
          3. Deaths occurring 2001-05
        5. Cancer deaths occurring 2003-07
      2. Atlas rate tables
        1. Medicare mortality rates
        2. Selected surgical discharge rates
        3. Selected medical discharge rates
        4. Selected measures of inpatient utilization during the last six months of life
        5. Selected Medicare reimbursement measures
        6. Selected hospital and physician capacity measures
        7. Selected measures of primary care access and quality
        8. Pacemaker insertion
    2. PCSA Downloads
      1. PCSA v 2.1 Data
      2. Populations
        1. ZCTA Level 2008 Population Estimates
        2. PCSA Level 2008 Population Estimates
        3. PCSA Level 2006 Insurance Population Estimates
        4. County Level 2006 Insurance Population Estimates
        5. ZCTA Level 2006 HPSA/MUA Population Estimates
        6. PCSA Level 2006 HPSA/MUA Population Estimates
      3. Clinicians
        1. ZCTA Level 2007 AMA/AOA Physicians
        2. PCSA Level 2007 AMA/AOA Physicians
      4. Utilization
        1. ZCTA Level 2005 Medicare Utilization
        2. PCSA Level 2005 Medicare Utilization
        3. ZCTA Level 2007 CHC-FQHC-RHC Location Data
        4. PCSA Level 2007 CHC-FQHC-RHC Location Data
      5. Crosswalks
        1. ZIP Code to ZCTA 2009
        2. ZIP Code to ZCTA 2008
        3. ZIP Code to ZCTA 2007
        4. ZIP Code to ZCTA 2006
        5. ZCTA to PCSA v2.1
        6. PCSA to County 2000
        7. RUCA to PCSA 2004
      6. GIS Shape Files
        1. ZCTA 2000 Shape File
        2. PCSA 2000 Shape File
      7. Archives
        1. Populations
        2. Clinicians
        3. Crosswalks
    3. Glossary
      1. [AAA] -
      2. [ACS conditions] -
      3. [AF4Q] -
      4. [AMI] -
      5. [Arthroplasty] -
      6. [BETOS codes] -
      7. [CABG] -
      8. [Capitated] -
      9. [CHF] -
      10. [CMG] -
      11. [CMHS file] -
      12. [CMS] -
      13. [Confidence interval] -
      14. [COPD] -
      15. [COTH] -
      16. [CPT codes] -
      17. [DME] -
      18. [DRG] -
      19. [E&M] -
      20. [EOL] -
      21. [ESRD] -
      22. [FQHC] -
      23. [FTE] -
      24. [HCAHPS] -
      25. [HCI index] -
      26. [HEDIS] -
      27. [HMO] -
      28. [HPSA] -
      29. [HRR] -
      30. [HRSA] -
      31. [HSA] -
      32. [IMG] -
      33. [L2Y] -
      34. [L6M] -
      35. [MedPAR file] -
      36. [MUA/MUP] -
      37. [NCQA] -
      38. [Part A] -
      39. [Part B] -
      40. [Part D] -
      41. [PCI] -
      42. [PCSA] -
      43. [Revascularization] -
      44. [RHC] -
      45. [RUCA] -
      46. [RVU] -
      47. [SNF] -
      48. [TURP for BPH] -
      49. [UPIN] -
      50. [ZCTA] -
    4. FAQ
      1. Why is this information important? What are the implications?
      2. How are the methods used in this project different from other studies?
      3. Why does the Dartmouth Atlas Project focus on Medicare data? Are there similar variations in utilization and spending in the under-65 population?
      4. Why don't you have data for Medicare enrollees who are members of health maintenance organizations (HMOs)?
      5. What explains the differences in efficiency among different regions? Is it supply driven?
      6. What is the relationship between health care spending and quality of care?
      7. What do you mean more health care is not necessarily better?
      8. Evidence points out that more aggressive care in managing patient populations with chronic illness does not necessarily lead to longer length of life or improved quality of life. Are you insinuating that we shouldn't do everything we can to save a life?
      9. Dartmouth Atlas research points out that frequent use of services is not associated with either better performance on technical measures of care or marginal improvements in survival and functional status. How can you convince people they don't need additional care and how can you convince doctors not to recommend it?
      10. How does poverty impact health care spending?
      11. How do you determine how much care is too much?
      12. Whose fault is it?
      13. This research suggests savings that can be realized within the Medicare system. Don't we need to look at the whole picture to truly realize savings?
  10. Key Issues
  11. Publications
    1. Atlases & Reports
      1. All Publications by Year
        1. 2013
        2. 2012
        3. 2011
        4. 2010
        5. 2009
        6. 2008
        7. 2007
        8. 2006
        9. 2005
        10. 2000
        11. 1999
        12. 1998
        13. 1996
      2. Issue Briefs
      3. ​Topic Briefs
      4. Surgical Variation Studies
      5. National Atlas Editions
      6. Specialty-Specific Editions
      7. State Editions
      8. Regional Editions
    2. Research Articles
      1. 2013
      2. 2012
      3. 2011
      4. 2010
      5. 2009
      6. 2008
      7. 2007
      8. 2006
      9. 2005
      10. 2004
      11. 2003
      12. 2002
      13. 2001
      14. 2000
      15. 1999
      16. 1998
      17. 1984
      18. 1977
      19. 1975
      20. 1973
  12. Press Room
    1. Recent News & Press Releases
    2. Press Contact Information
    3. In the Media
      1. 1
      2. 2
      3. 3
      4. 4
      5. 5
      6. 6
      7. 7
      8. 8
      9. 9
      10. 10
      11. 11
      12. 12
      13. 13
      14. 14
      15. 15
  13. NEXT

The Dartmouth Atlas of Health Care

Last modified
Table of contents
  1. Story
  2. Screen Capture
  3. Spotfire Dashboard
  4. Research Notes
  5. The Dartmouth Atlas of Health Care
    1. Understanding of the Efficiency and Effectiveness of the Health Care System
      1. Tools
      2. Percent of Deaths Occuring in Hospitals, 2010
      3. View Other Data By
      4. View Other Data By Zip Code
    2. Spotlight
      1. Tracking Improvement In The Care Of Chronically Ill Patients: A Dartmouth Atlas Brief On Medicare Beneficaries Near The End Of Life
        1. Introduction
          1. Table. National trends in selected measures of the care of chronically ill patients near the end of life
        2. Overall change in care near the end of life
        3. Change in care near the end of life across academic medical centers
        4. What can we learn from end-of-life care?
        5. References
          1. 1
          2. 2
          3. 3
          4. 4
          5. 5
          6. 6
          7. 7
          8. 8
        6. The Dartmouth Atlas Project
      2. Press Release
        1. New findings show longitudinal change for care provided to chronically ill Medicare patients
        2. Medicare spending per patient during the last two years of life
        3. Deaths occurring in hospitals
        4. Patients seeing 10 or more doctors during the last six months of life
        5. About the Dartmouth Atlas Project
      3. Download the Data
      4. Comments on James D. Reschovsky et al.
        1. Geographic Variation in Fee-for-Service Medicare Beneficiaries’ Medical Costs Is Largely Explained by Disease Burden, Medical Care Research & Review, 2013.
    3. Stay Informed
    4. Other
  6. Data By Region
    1. About Our Regions
      1. Hospital Referral Regions
      2. Hospital Service Areas
      3. Primary Care Service Areas
  7. Data By Hospital
    1. Browse Hospitals
    2. About Our Hospital Data
  8. Data By Topic
    1. Care of Chronic Illness in Last Two Years of Life
    2. Medicare Reimbursements
    3. Hospital Use
    4. Medical Discharges
    5. Surgical Procedures
    6. Post-Acute Care
    7. Quality/Effective Care
    8. Hospital & Physician Capacity
    9. End of Life Care
    10. Primary Care Service Area (PCSA)
  9. Tools
    1. Downloads
      1. Atlas Downloads
        1. Crosswalk files
          1. ZIP code crosswalks
          2. Other crosswalks
        2. Geographic boundary files
        3. Post-discharge events
          1. 2010
          2. 2004 and 2009
          3. 2008
        4. Care of chronically ill patients during the last two years of life
          1. Deaths occurring in 2010
          2. Deaths occurring 2003-07
          3. Deaths occurring 2001-05
        5. Cancer deaths occurring 2003-07
      2. Atlas rate tables
        1. Medicare mortality rates
        2. Selected surgical discharge rates
        3. Selected medical discharge rates
        4. Selected measures of inpatient utilization during the last six months of life
        5. Selected Medicare reimbursement measures
        6. Selected hospital and physician capacity measures
        7. Selected measures of primary care access and quality
        8. Pacemaker insertion
    2. PCSA Downloads
      1. PCSA v 2.1 Data
      2. Populations
        1. ZCTA Level 2008 Population Estimates
        2. PCSA Level 2008 Population Estimates
        3. PCSA Level 2006 Insurance Population Estimates
        4. County Level 2006 Insurance Population Estimates
        5. ZCTA Level 2006 HPSA/MUA Population Estimates
        6. PCSA Level 2006 HPSA/MUA Population Estimates
      3. Clinicians
        1. ZCTA Level 2007 AMA/AOA Physicians
        2. PCSA Level 2007 AMA/AOA Physicians
      4. Utilization
        1. ZCTA Level 2005 Medicare Utilization
        2. PCSA Level 2005 Medicare Utilization
        3. ZCTA Level 2007 CHC-FQHC-RHC Location Data
        4. PCSA Level 2007 CHC-FQHC-RHC Location Data
      5. Crosswalks
        1. ZIP Code to ZCTA 2009
        2. ZIP Code to ZCTA 2008
        3. ZIP Code to ZCTA 2007
        4. ZIP Code to ZCTA 2006
        5. ZCTA to PCSA v2.1
        6. PCSA to County 2000
        7. RUCA to PCSA 2004
      6. GIS Shape Files
        1. ZCTA 2000 Shape File
        2. PCSA 2000 Shape File
      7. Archives
        1. Populations
        2. Clinicians
        3. Crosswalks
    3. Glossary
      1. [AAA] -
      2. [ACS conditions] -
      3. [AF4Q] -
      4. [AMI] -
      5. [Arthroplasty] -
      6. [BETOS codes] -
      7. [CABG] -
      8. [Capitated] -
      9. [CHF] -
      10. [CMG] -
      11. [CMHS file] -
      12. [CMS] -
      13. [Confidence interval] -
      14. [COPD] -
      15. [COTH] -
      16. [CPT codes] -
      17. [DME] -
      18. [DRG] -
      19. [E&M] -
      20. [EOL] -
      21. [ESRD] -
      22. [FQHC] -
      23. [FTE] -
      24. [HCAHPS] -
      25. [HCI index] -
      26. [HEDIS] -
      27. [HMO] -
      28. [HPSA] -
      29. [HRR] -
      30. [HRSA] -
      31. [HSA] -
      32. [IMG] -
      33. [L2Y] -
      34. [L6M] -
      35. [MedPAR file] -
      36. [MUA/MUP] -
      37. [NCQA] -
      38. [Part A] -
      39. [Part B] -
      40. [Part D] -
      41. [PCI] -
      42. [PCSA] -
      43. [Revascularization] -
      44. [RHC] -
      45. [RUCA] -
      46. [RVU] -
      47. [SNF] -
      48. [TURP for BPH] -
      49. [UPIN] -
      50. [ZCTA] -
    4. FAQ
      1. Why is this information important? What are the implications?
      2. How are the methods used in this project different from other studies?
      3. Why does the Dartmouth Atlas Project focus on Medicare data? Are there similar variations in utilization and spending in the under-65 population?
      4. Why don't you have data for Medicare enrollees who are members of health maintenance organizations (HMOs)?
      5. What explains the differences in efficiency among different regions? Is it supply driven?
      6. What is the relationship between health care spending and quality of care?
      7. What do you mean more health care is not necessarily better?
      8. Evidence points out that more aggressive care in managing patient populations with chronic illness does not necessarily lead to longer length of life or improved quality of life. Are you insinuating that we shouldn't do everything we can to save a life?
      9. Dartmouth Atlas research points out that frequent use of services is not associated with either better performance on technical measures of care or marginal improvements in survival and functional status. How can you convince people they don't need additional care and how can you convince doctors not to recommend it?
      10. How does poverty impact health care spending?
      11. How do you determine how much care is too much?
      12. Whose fault is it?
      13. This research suggests savings that can be realized within the Medicare system. Don't we need to look at the whole picture to truly realize savings?
  10. Key Issues
  11. Publications
    1. Atlases & Reports
      1. All Publications by Year
        1. 2013
        2. 2012
        3. 2011
        4. 2010
        5. 2009
        6. 2008
        7. 2007
        8. 2006
        9. 2005
        10. 2000
        11. 1999
        12. 1998
        13. 1996
      2. Issue Briefs
      3. ​Topic Briefs
      4. Surgical Variation Studies
      5. National Atlas Editions
      6. Specialty-Specific Editions
      7. State Editions
      8. Regional Editions
    2. Research Articles
      1. 2013
      2. 2012
      3. 2011
      4. 2010
      5. 2009
      6. 2008
      7. 2007
      8. 2006
      9. 2005
      10. 2004
      11. 2003
      12. 2002
      13. 2001
      14. 2000
      15. 1999
      16. 1998
      17. 1984
      18. 1977
      19. 1975
      20. 1973
  12. Press Room
    1. Recent News & Press Releases
    2. Press Contact Information
    3. In the Media
      1. 1
      2. 2
      3. 3
      4. 4
      5. 5
      6. 6
      7. 7
      8. 8
      9. 9
      10. 10
      11. 11
      12. 12
      13. 13
      14. 14
      15. 15
  13. NEXT

  1. Story
  2. Screen Capture
  3. Spotfire Dashboard
  4. Research Notes
  5. The Dartmouth Atlas of Health Care
    1. Understanding of the Efficiency and Effectiveness of the Health Care System
      1. Tools
      2. Percent of Deaths Occuring in Hospitals, 2010
      3. View Other Data By
      4. View Other Data By Zip Code
    2. Spotlight
      1. Tracking Improvement In The Care Of Chronically Ill Patients: A Dartmouth Atlas Brief On Medicare Beneficaries Near The End Of Life
        1. Introduction
          1. Table. National trends in selected measures of the care of chronically ill patients near the end of life
        2. Overall change in care near the end of life
        3. Change in care near the end of life across academic medical centers
        4. What can we learn from end-of-life care?
        5. References
          1. 1
          2. 2
          3. 3
          4. 4
          5. 5
          6. 6
          7. 7
          8. 8
        6. The Dartmouth Atlas Project
      2. Press Release
        1. New findings show longitudinal change for care provided to chronically ill Medicare patients
        2. Medicare spending per patient during the last two years of life
        3. Deaths occurring in hospitals
        4. Patients seeing 10 or more doctors during the last six months of life
        5. About the Dartmouth Atlas Project
      3. Download the Data
      4. Comments on James D. Reschovsky et al.
        1. Geographic Variation in Fee-for-Service Medicare Beneficiaries’ Medical Costs Is Largely Explained by Disease Burden, Medical Care Research & Review, 2013.
    3. Stay Informed
    4. Other
  6. Data By Region
    1. About Our Regions
      1. Hospital Referral Regions
      2. Hospital Service Areas
      3. Primary Care Service Areas
  7. Data By Hospital
    1. Browse Hospitals
    2. About Our Hospital Data
  8. Data By Topic
    1. Care of Chronic Illness in Last Two Years of Life
    2. Medicare Reimbursements
    3. Hospital Use
    4. Medical Discharges
    5. Surgical Procedures
    6. Post-Acute Care
    7. Quality/Effective Care
    8. Hospital & Physician Capacity
    9. End of Life Care
    10. Primary Care Service Area (PCSA)
  9. Tools
    1. Downloads
      1. Atlas Downloads
        1. Crosswalk files
          1. ZIP code crosswalks
          2. Other crosswalks
        2. Geographic boundary files
        3. Post-discharge events
          1. 2010
          2. 2004 and 2009
          3. 2008
        4. Care of chronically ill patients during the last two years of life
          1. Deaths occurring in 2010
          2. Deaths occurring 2003-07
          3. Deaths occurring 2001-05
        5. Cancer deaths occurring 2003-07
      2. Atlas rate tables
        1. Medicare mortality rates
        2. Selected surgical discharge rates
        3. Selected medical discharge rates
        4. Selected measures of inpatient utilization during the last six months of life
        5. Selected Medicare reimbursement measures
        6. Selected hospital and physician capacity measures
        7. Selected measures of primary care access and quality
        8. Pacemaker insertion
    2. PCSA Downloads
      1. PCSA v 2.1 Data
      2. Populations
        1. ZCTA Level 2008 Population Estimates
        2. PCSA Level 2008 Population Estimates
        3. PCSA Level 2006 Insurance Population Estimates
        4. County Level 2006 Insurance Population Estimates
        5. ZCTA Level 2006 HPSA/MUA Population Estimates
        6. PCSA Level 2006 HPSA/MUA Population Estimates
      3. Clinicians
        1. ZCTA Level 2007 AMA/AOA Physicians
        2. PCSA Level 2007 AMA/AOA Physicians
      4. Utilization
        1. ZCTA Level 2005 Medicare Utilization
        2. PCSA Level 2005 Medicare Utilization
        3. ZCTA Level 2007 CHC-FQHC-RHC Location Data
        4. PCSA Level 2007 CHC-FQHC-RHC Location Data
      5. Crosswalks
        1. ZIP Code to ZCTA 2009
        2. ZIP Code to ZCTA 2008
        3. ZIP Code to ZCTA 2007
        4. ZIP Code to ZCTA 2006
        5. ZCTA to PCSA v2.1
        6. PCSA to County 2000
        7. RUCA to PCSA 2004
      6. GIS Shape Files
        1. ZCTA 2000 Shape File
        2. PCSA 2000 Shape File
      7. Archives
        1. Populations
        2. Clinicians
        3. Crosswalks
    3. Glossary
      1. [AAA] -
      2. [ACS conditions] -
      3. [AF4Q] -
      4. [AMI] -
      5. [Arthroplasty] -
      6. [BETOS codes] -
      7. [CABG] -
      8. [Capitated] -
      9. [CHF] -
      10. [CMG] -
      11. [CMHS file] -
      12. [CMS] -
      13. [Confidence interval] -
      14. [COPD] -
      15. [COTH] -
      16. [CPT codes] -
      17. [DME] -
      18. [DRG] -
      19. [E&M] -
      20. [EOL] -
      21. [ESRD] -
      22. [FQHC] -
      23. [FTE] -
      24. [HCAHPS] -
      25. [HCI index] -
      26. [HEDIS] -
      27. [HMO] -
      28. [HPSA] -
      29. [HRR] -
      30. [HRSA] -
      31. [HSA] -
      32. [IMG] -
      33. [L2Y] -
      34. [L6M] -
      35. [MedPAR file] -
      36. [MUA/MUP] -
      37. [NCQA] -
      38. [Part A] -
      39. [Part B] -
      40. [Part D] -
      41. [PCI] -
      42. [PCSA] -
      43. [Revascularization] -
      44. [RHC] -
      45. [RUCA] -
      46. [RVU] -
      47. [SNF] -
      48. [TURP for BPH] -
      49. [UPIN] -
      50. [ZCTA] -
    4. FAQ
      1. Why is this information important? What are the implications?
      2. How are the methods used in this project different from other studies?
      3. Why does the Dartmouth Atlas Project focus on Medicare data? Are there similar variations in utilization and spending in the under-65 population?
      4. Why don't you have data for Medicare enrollees who are members of health maintenance organizations (HMOs)?
      5. What explains the differences in efficiency among different regions? Is it supply driven?
      6. What is the relationship between health care spending and quality of care?
      7. What do you mean more health care is not necessarily better?
      8. Evidence points out that more aggressive care in managing patient populations with chronic illness does not necessarily lead to longer length of life or improved quality of life. Are you insinuating that we shouldn't do everything we can to save a life?
      9. Dartmouth Atlas research points out that frequent use of services is not associated with either better performance on technical measures of care or marginal improvements in survival and functional status. How can you convince people they don't need additional care and how can you convince doctors not to recommend it?
      10. How does poverty impact health care spending?
      11. How do you determine how much care is too much?
      12. Whose fault is it?
      13. This research suggests savings that can be realized within the Medicare system. Don't we need to look at the whole picture to truly realize savings?
  10. Key Issues
  11. Publications
    1. Atlases & Reports
      1. All Publications by Year
        1. 2013
        2. 2012
        3. 2011
        4. 2010
        5. 2009
        6. 2008
        7. 2007
        8. 2006
        9. 2005
        10. 2000
        11. 1999
        12. 1998
        13. 1996
      2. Issue Briefs
      3. ​Topic Briefs
      4. Surgical Variation Studies
      5. National Atlas Editions
      6. Specialty-Specific Editions
      7. State Editions
      8. Regional Editions
    2. Research Articles
      1. 2013
      2. 2012
      3. 2011
      4. 2010
      5. 2009
      6. 2008
      7. 2007
      8. 2006
      9. 2005
      10. 2004
      11. 2003
      12. 2002
      13. 2001
      14. 2000
      15. 1999
      16. 1998
      17. 1984
      18. 1977
      19. 1975
      20. 1973
  12. Press Room
    1. Recent News & Press Releases
    2. Press Contact Information
    3. In the Media
      1. 1
      2. 2
      3. 3
      4. 4
      5. 5
      6. 6
      7. 7
      8. 8
      9. 9
      10. 10
      11. 11
      12. 12
      13. 13
      14. 14
      15. 15
  13. NEXT

Story

This looks like it is better than the Health.Data.gov and Heritage Network Foundation Contest data sets!

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America.

Further studies and data created with the support of the National Institute on Aging can be found here. The goal of one study was to develop an instrument and conduct a survey of Medicare beneficiaries, and to better understand the causes and consequences of geographic variation in per capita expenditures for Medicare beneficiaries. My Note: Check on this.

The percentage of chronically ill patients who died in the hospital declined by more than 10% from 2007 to 2010. Read more in "Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life" For Medicare beneficiaries with chronic illness near the end of life, quality, outcomes, and cost vary markedly across regions and hospitals. The problem shown in these analyses is now well recognized: the quality and efficiency of the care patients receive is often determined by the accident of where they live and seek care.

 
This Dartmouth Atlas brief and accompanying data release (http://www.dartmouthatlas.orgdemonstrate that improvements in care have occurred rapidly for Medicare patients in their last six months of life. Overall, patients spent fewer days in the hospital and more received hospice services in 2010 compared to 2007. These changes reflect the preferences of most patients to spend their last weeks and months in a homelike
environment whenever possible, avoiding procedures that have little chance of improving the quality or length of their lives. But the pace of change varied across hospitals, with some experiencing rapid change while other health systems showed little improvement.

Despite the trend toward less hospital care, Medicare spending per patient in the last two years of life rose from $60,694 to $69,947, a 15.2% increase during a period when the consumer price index rose only 5.3%. End-of-life care analyses also reveal important information about the relative efficiency of care. The care that patients with chronic illness receive in a particular region or hospital correlates with the care provided generally for Medicare beneficiaries. Studies show that more spending, more days in the hospital, and more physician visits are not always associated with better outcomes or with the care that patients want. Less intensive and expensive care can both save money and improve quality, satisfaction, and outcomes for many Medicare beneficiaries.

These analyses needed six kinds of boundary files:

  • State (Spotfire)
  • County (Spotfire)
  • Hospital Referral Regions (HRRs)
  • Hospital Service Areas (HSAs)
  • Primary Care Service Areas (PCSAs)
  • Zip Code Tabulation Areas (ZCTAs)

My analyses show that the Percant of Deaths Occuring in Hospitals increases with Hospital Cara Intensity and Total Medicare Spending.

Screen Capture

DartmouthAtlas-SpotfireFigure1.png

Spotfire Dashboard

For Internet Explorer Users and Those Wanting Full Screen Display Use: Web Player Get Spotfire for iPad App

Error: Embedded data could not be displayed. Use Google Chrome

Research Notes

Need these kinds of boundary files

State (Spotfire)
County (Spotfire)
Hospital Referral Regions (HRRs)
Hospital Service Areas (HSAs)
Primary Care Service Areas (PCSAs)

Zip Code Tabulation Areas (ZCTAs)

The Dartmouth Atlas of Health Care

Source: http://www.dartmouthatlas.org/

 

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America. LEARN MORE My Note: See Below

Tools

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians.

These reports and the research upon which they are based have helped policymakers, the media, health care analysts and others improve their understanding of the efficiency and effectiveness of our health care system. This valuable data forms the foundation for many of the ongoing efforts to improve health and health systems across America.

This web site provides access to all Atlas reports and publications, as well as interactive tools to allow visitors to view specific regions and perform their own comparisons and analyses. These tools have helped other groups create reports like those listed on our Case Studies page. A selection of videos and presentations can be found on our Multimedia page.

Further studies and data created with the support of the National Institute on Aging can be found here. The goal of one study was to develop an instrument and conduct a survey of Medicare beneficiaries, and to better understand the causes and consequences of geographic variation in per capita expenditures for Medicare beneficiaries.

Percent of Deaths Occuring in Hospitals, 2010

 

The percentage of chronically ill patients who died in the hospital declined by more than 10% from 2007 to 2010. Read more in "Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life".

 

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View Other Data by:

View Other Data By Zip Code

View Data by Zip Code

  • Region
  • Hospital
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© 2013 The Trustees of Dartmouth College | 35 Centerra Parkway, Lebanon, NH 03766 | (603) 653-0800

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.

 

The use of health care resources in the United States is highly localized. Most Americans use the services of physicians whose practices are nearby. Physicians, in turn, are usually affiliated with hospitals that are near their practices. As a result, when patients are admitted to hospitals, the admission generally takes place within a relatively short distance of where the patient lives. This is true across the United States. Although the distances from homes to hospitals vary with geography – people who live in rural areas travel farther than those who live in cities – in general most patients are admitted to a hospital close to where they live that provides an appropriate level of care. Data for all Dartmouth Atlas regional data reflect the experience of Medicare patients living in the region, regardless of where the care was actually delivered.

 

About Our Regions

Hospital Referral Regions

Hospital referral regions (HRRs) represent regional health care markets for tertiary medical care that generally requires the services of a major referral center. The regions were defined by determining where patients were referred for major cardiovascular surgical procedures and for neurosurgery. Each hospital service area (HSA) was examined to determine where most of its residents went for these services. The result was the aggregation of the 3,436 hospital service areas into 306 HRRs. Each HRR has at least one city where both major cardiovascular surgical procedures and neurosurgery are performed.

Hospital Service Areas

Hospital service areas (HSAs) are local health care markets for hospital care. An HSA is a collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area. HSAs were defined by assigning ZIP codes to the hospital area where the greatest proportion of their Medicare residents were hospitalized. Minor adjustments were made to ensure geographic contiguity. This process resulted in 3,436 HSAs. When these regions were created in the early 1990s, most hospital service areas contained only one hospital. In the intervening years, hospital closures have left some HSAs with no hospital; these HSAs have been maintained as distinct areas in order to preserve the continuity of the database.

Primary Care Service Areas

Primary care service areas (PCSAs) reflect Medicare patient travel to primary care providers. Each of the 6,542 PCSAs includes a ZIP code area with one or more primary care providers and any contiguous ZIP code areas whose Medicare populations seek the plurality of their primary care from those providers.


Browse Hospitals

My Note: This produces a tree that is in the spreadsheet.

Etc.

About Our Hospital Data

Hospital-specific data from the Dartmouth Atlas project reflect the treatment of Medicare patients with serious chronic illnesses who were in their last two years of life. The data are not restricted to services delivered in acute care hospitals; they include care delivered in outpatient facilities, skilled nursing and long-term care hospitals, and services delivered by home health agencies and hospice. Once a patient is assigned to a hospital -- based on the plurality of his or her medical admissions during the last two years of life -- all treatment received by that patient is attributed to that hospital, regardless of where it was actually delivered. Because seriously ill patients are highly loyal to the hospital where they receive their care, hospital-specific utilization rates reflect the approach to chronic disease management of both the hospital and the physicians who practice in association with that hospital.

Patients with surgical admissions only, as well as patients who were never hospitalized during the last two years of life, were excluded from these hospital-specific analyses. The surgery may not have been offered by the hospital and medical staff that usually provided their care; in other words, a patient whose only hospital admission was for bypass surgery could only be assigned to the hospital where the surgery was performed, even if most of his or her care was provided by physicians associated with another hospital. Excluding these patients also reduces the likelihood that a surgical complication was the cause of death.

We report data for acute care general hospitals; those that provide a range of acute care services to Medicare fee-for-service patients. The study was limited to hospitals with large enough populations to result in statistical stability and retain the confidentiality of patient information. Inpatient data for hospitals with at least 80 deaths during the study period are provided on the web site; for Part B data, which is based on a 20% sample of deaths, a hospital had to have at least 400 total deaths (80 deaths in a 20% sample) during the study period to be included.

Data By Topic

Source: http://www.dartmouthatlas.org/data/topic/

My Note: View All Topics And Indicators produces a tree.

Care of Chronic Illness in Last Two Years of Life

Caring for people with chronic disease accounts for more than 75% of health care spending. As chronic disease progresses, the amount of care delivered and the costs associated with this care increase dramatically. Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, with much of it going toward physician and hospital fees associated with repeated hospitalizations.

Medicare Reimbursements

Medicare spending varies more than threefold among hospital referral regions. Spending also varies from state to state, and from one hospital to another, even among hospitals within the same region. Most of this variation is not due to differences in the price of care in different parts of the country, but rather to differences in the volume, or the amount of inpatient care delivered per patient.

Hospital Use

Most hospitalizations are for conditions that have high or very high patterns of variation in their discharge rates. Medical discharges are more variable than surgical discharges. For medical conditions, the majority of variation is associated with hospital capacity (as measured by the per capita supply of hospital beds).

Medical Discharges

For patients with medical conditions, geography matters; patients with medical conditions receive very different care depending upon where they live. Why does care vary so much? The most obvious explanation might seem to be regional differences in how sick patients are. But the prevalence and severity of illness accounts for remarkably little of the variation in care.

Surgical Procedures

Most patients defer to their physicians when it comes to deciding what care they receive. When it comes to elective surgery, physician opinion can vary widely as to when the treatment is necessary, and which patients are appropriate. Consequently, the frequency of discretionary surgery such as knee or hip replacement or back surgery, also varies remarkably from one region to another.

Post-Acute Care

Improving care coordination after discharge from the hospital is important to patients, to hospitals and to Medicare. Without high-quality care coordination, patients can bounce from home to the emergency room and back into the hospital, sometimes repeatedly. Better care coordination promises to reduce readmission rates and improve patients' lives while reducing costs.

Quality/Effective Care

Effective care consists of evidence-based interventions for which the benefits so far exceed the harms that all patients in need should receive the service. Life-saving drugs following heart attack are examples. Variations in the use of such treatments among eligible patients reflect a failure to deliver needed care, or underuse.

Hospital & Physician Capacity

Regional variation in hospital and physician capacity reveals the irrational distribution of valuable and expensive health care resources. Capacity strongly influences both the quantity and per capita cost of care provided to patients. Better planning of future growth in capacity can help build a more effective and affordable health care system.

End of Life Care

Modern technology has vastly extended the ability to intervene in the lives of patients, most dramatically so when life itself is at stake. But the capability to intervene is not uniformly deployed, and health care providers do not share a uniform propensity to hospitalize dying patients or to use technology at the end of life. The American experience of death varies remarkably from one community to another.

Primary Care Service Area (PCSA)

The Primary Care Service Area (PCSA) Project offers data and analytic tools to identify primary care clinician supply and needs in communities across the United States, with areas that reflect patients’ travel to primary care. PCSA data can help identify areas with low supply of primary care and safety net providers, and populations with relatively high health risk. The PCSA project also provides information about primary care utilization by the elderly.

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians.

These reports and the research upon which they are based have helped policymakers, the media, health care analysts and others improve their understanding of the efficiency and effectiveness of our health care system. This valuable data forms the foundation for many of the ongoing efforts to improve health and health systems across America.

This web site provides access to all Atlas reports and publications, as well as interactive tools to allow visitors to view specific regions and perform their own comparisons and analyses. These tools have helped other groups create reports like those listed on our Case Studies page. A selection of videos and presentations can be found on our Multimedia page.

Further studies and data created with the support of the National Institute on Aging can be found here. The goal of one study was to develop an instrument and conduct a survey of Medicare beneficiaries, and to better understand the causes and consequences of geographic variation in per capita expenditures for Medicare beneficiaries.

Downloads

Atlas Downloads

Source: http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35

My Note: XLS and SHP


Crosswalk files

Our ZIP code to HSA to HRR crosswalk files allow you to aggregate data you may have at the ZIP code level to the hospital service area (HSA) or hospital referral region (HRR) level.

ZIP code crosswalks
  2011 
  2010 
  2009 
  2008
  2007 
  2006 
  2005 
  2004
  2003 
  2002 
  2001 
  2000
  1999 
  1998 
  1997 
  1996
  1995 
   
   
  

Geographic boundary files

Our boundary files allow you to create your own maps using ESRI® ArcGIS® software. PCSA boundaries are available on the PCSA Downloads page. The shape files are not projected. The geographic coordinate system is North American Datum 1983.

Post-discharge events

Data include 30-day readmission rates, emergency room visits within 30 days of discharge, and follow-up visits within 14 days of discharge. More information can be found in After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries.

2010
2004 and 2009
2008
Care of chronically ill patients during the last two years of life
Deaths occurring in 2010
Deaths occurring 2003-07

More information about the data can be found in Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness.

Deaths occurring 2001-05

More information about the data can be found in Tracking the Care of Patients With Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008.

Click here to read about changes in methods between the 2001-05 and 2003-07 analyses.

NOTE: the rates and populations in the HRR and state tables are lower than those in the hospital tables. The regional study includes chronically ill patients who were not hospitalized during the last two years of life, which has the effect of reducing the per capita rates (since these patients were never hospitalized, they had no hospital utilization and lower physician utilization than hospitalized patients). The populations are lower because the regional study used a 20% sample of patients; the 20% Part B database was required to identify chronically ill patients who were not hospitalized.

Cancer deaths occurring 2003-07

More information about the data can be found in Quality of End-of-Life Cancer Care for Medicare Beneficiaries.

Atlas rate tables

Medicare mortality rates
State level HRR level HSA level
2007 2007 2007
2006 2006 2006
2005 2005 2005
2004 2004 2004
2003 2003 2003
2002 2002 2002
2001 2001 2001
2000 2000 2000
1999 1999 1999

Selected surgical discharge rates

Discharge rates for 2008-10 are provided to improve the statistical precision of the rates for relatively infrequent procedures and increases the number of regions for which we can report reliable data.

State level HRR level HSA level
2008-10 2008-10 2008-10
2010 2010 2010
2009 2009 2009
2008 2008 2008
2007 2007 2007
2006 2006 2006
2005 2005 2005
2004 2004 2004
2003 2003 2003
2002 2002 2002
2001 2001 2001
2000 2000 2000
1999 1999 1999
1998 1998 1998
1997 1997 1997
1996 1996 1996
1995 1995 1995
1994 1994 1994
1993 1993 1993
1992 1992 1992

Selected medical discharge rates

Discharge rates for 2008-10 are provided to improve the statistical precision of the rates for relatively infrequent procedures and increases the number of regions for which we can report reliable data.

State level HRR level HSA level
2008-10 2008-10 2008-10
2010 2010 2010
2009 2009 2009
2008 2008 2008
2007 2007 2007
2006 2006 2006
2005 2005 2005
2004 2004 2004
2003 2003 2003
2002 2002 2002
2001 2001 2001
2000 2000 2000
1999 1999 1999
1998 1998 1998
1997 1997 1997
1996 1996 1996
1995 1995 1995
1994 1994 1994
1993 1993 1993
1992 1992 1992

Selected measures of inpatient utilization during the last six months of life
State level HRR level HSA level
2007 2007 2007
2006 2006 2006
2005 2005 2005
2004 2004 2004
2003 2003 2003
2002 2002 2002
2001 2001 2001
2000 2000 2000
1999 1999 1999
1998 1998 1998
1997 1997 1997
1996 1996 1996
1995 1995 1995
1994 1994 1994

Selected Medicare reimbursement measures

Read more about the transition from CMHS-based to claims-based reimbursement measures.

Claims-based: Price, age, sex and race-adjusted
(20% sample for 2003-09: 100% sample for 2010)
CMHS-based: Age, sex and race-adjusted
(5% sample)
State level HRR level HSA level County level State level HRR level HSA level
2010 2010 2010 2010      
2009 2009 2009 2009      
2008 2008 2008 2008      
2007 2007 2007 2007 2007 2007 2007
2006 2006 2006 2006 2006 2006 2006
2005 2005 2005 2005 2005 2005 2005
2004 2004 2004 2004 2004 2004 2004
2003 2003 2003 2003 2003 2003 2003
        2002 2002 2002
        2001 2001 2001
        2000 2000 2000
        1999 1999 1999
        1998 1998 1998
        1997 1997 1997
        1996 1996 1996
        1995 1995 1995
        1994 1994 1994
        1993 1993 1993
        1992 1992 1992

Selected hospital and physician capacity measures
HRR level HSA level  
2006 2006  
1996 1996  

Selected measures of primary care access and quality

Data include measures of primary care utilization, quality of care for diabetes, mammography, leg amputation and preventable hospitalizations. More information can be found in Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries.

State level HRR level HSA level County level
2010 2010 2010 2010
2009 2009 2009 2009
2008 2008 2008 2008
2003-07 2003-07 2003-07 2003-07

Pacemaker insertion

PCSA Downloads

 

Source: http://www.dartmouthatlas.org/tools/downloads.aspx?tab=37

My Note: DBF and PDF



PCSA v 2.1 Data

All data are listed below by classification: Population, Clinicians, Utilization, Crosswalks and GIS Shape Files. The available geographic levels and years of data are also indicated.

Information for each data file includes the file name and associated data dictionary and/or README file. All data files are in .dbf format.

The most current data are available for download. Information about earlier releases is under "Archives." Earlier data releases are available by sending a request to PCSA@dartmouth.edu.

We expect to have updated PCSA data ready by early 2013. My Note: It is mid-2013!

Populations

ZCTA Level 2008 Population Estimates

  Data Part 1
  Data Part 2
  ReadMe
  Methodology Documentation
  Data Dictionary

PCSA Level 2008 Population Estimates

  Data Part 1
  Data Part 2
  ReadMe
  Methodology Documentation
  Data Dictionary

PCSA Level 2006 Insurance Population Estimates

  Data File
  ReadMe
  Methodology Documentation
  Data Dictionary
  State Level Age 65 and Up Comparison

County Level 2006 Insurance Population Estimates

  Data File
  ReadMe
  Methodology Documentation
  Data Dictionary
  State Level Age 65 and Up Comparison

ZCTA Level 2006 HPSA/MUA Population Estimates

  Data File
  ReadMe
  Data Dictionary

PCSA Level 2006 HPSA/MUA Population Estimates

  Data File
  ReadMe
  Data Dictionary

Clinicians

ZCTA Level 2007 AMA/AOA Physicians

  Data File
  ReadMe
  Data Dictionary

PCSA Level 2007 AMA/AOA Physicians

  Data File
  ReadMe
  Data Dictionary

Utilization

ZCTA Level 2005 Medicare Utilization

  Data File
  Data Dictionary

PCSA Level 2005 Medicare Utilization

  Data File
  Data Dictionary

ZCTA Level 2007 CHC-FQHC-RHC Location Data

  Data File
  ReadMe
  Data Dictionary

PCSA Level 2007 CHC-FQHC-RHC Location Data

  Data File
  ReadMe
  Data Dictionary

Crosswalks

ZIP Code to ZCTA 2009

  Data File

ZIP Code to ZCTA 2008

  Data File

ZIP Code to ZCTA 2007

  Data File
  ReadMe
  Methodology Documentation
  Data Dictionary

ZIP Code to ZCTA 2006

  Data File
  ReadMe

ZCTA to PCSA v2.1

  Data File

RUCA to PCSA 2004

  Data File
  ReadMe
  Data Dictionary

GIS Shape Files

ZCTA 2000 Shape File

  Data File My Note: I downloaded this.
  ReadMe

PCSA 2000 Shape File

  Data File My Note: I downloaded this.
  Readme

Archives

Populations

Population Estimates: ZCTA (2000, 2003, 2006), PCSA (2000, 2003, 2006), County (2000), State (2000), MSA (2000), Minor Civil Division (2000), Congressional District (2000), Census Tract (2000), PCSA Poverty (2005)

Clinicians

AMA/AOA Physicians: ZCTA and PCSA (1999, 2001, 2005, 2006), Physician Assistants: PCSA (2005), Nurse Practitioners: PCSA (2001), Certified Nurse Midwives: PCSA (1999)

Crosswalks

PCSA to pHSA (2000), pHSA to pHRR (2000), MUA to PCSA (2005), HPSA to PCSA (2005)

Glossary

Source: http://www.dartmouthatlas.org/tools/glossary.aspx

[AAA] -

Abdominal aortic aneurysm.

[ACS conditions] -

Ambulatory care-sensitive (ACS) conditions - such as asthma, pneumonia, chronic pulmonary obstructive disease and congestive heart failure - refer to those for which hospitalization is often preventable when access to primary care is adequate.

[AF4Q] -

Aligning Forces for Quality (AF4Q) is an initiative of the Robert Wood Johnson Foundation. Its purpose is to improve the quality of care and reduce disparities in targeted communities across America and to provide models for national reform.

[AMI] -

Acute myocardial infarction, commonly referred to as heart attack.

[Arthroplasty] -

Surgical replacement of a joint, such as a hip, knee or shoulder.

[BETOS codes] -

Berenson-Eggers Type of Service codes. Used to classify Medicare claims according to type of service (such as evaluation & management, procedure, imaging, test, etc.).

[CABG] -

Coronary artery bypass grafting, often referred to as coronary artery bypass surgery, heart bypass, or open heart surgery.

[Capitated] -

Under capitation, the federal government pays health maintenance organizations (HMO) a fixed annual amount per Medicare enrollee, in exchange for which the HMO must provide all required services. If the total costs of care exceed the amount the government pays, then the HMO must absorb the loss; if they are less, then the HMO may retain the difference.

[CHF] -

Congestive heart failure.

[CMG] -

Canadian medical school graduate.

[CMHS file] -

Continuous Medicare History Sample file. This file includes a record for each beneficiary in a 5% sample for each year, going back thirty years. It includes summary expenditure data and is used to estimate Medicare spending by program component.

[CMS] -

The Centers for Medicare and Medicaid Services (CMS) is the U.S. federal agency that administers Medicare and Medicaid.

[Confidence interval] -

A range of values within which a measurement falls corresponding to a given probability. A 95% confidence interval indicates that, if the same population was sampled on numerous occasions and interval estimates were made on each occasion, the resulting intervals would bracket the true population measure in approximately 95% of the cases.

[COPD] -

Chronic obstructive pulmonary disease, including emphysema and chronic bronchitis.

[COTH] -

The Council of Teaching Hospitals of the Association of American Medical Colleges (AAMC).

[CPT codes] -

Current Procedural Terminology codes are used in medical claims to describe the services and procedures for which the bill was submitted.

[DME] -

Durable medical equipment, such as wheelchairs, prosthetics and oxygen for home use

[DRG] -

Diagnosis-related groups (DRGs) are used as part of Medicare's prospective payment system to classify hospital claims with similar characteristics into groups that can be expected to have similar hospital resource use. DRGs are assigned based on diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities.

[E&M] -

Evaluation & management (E&M) services include physician visits and consultations in all settings. Claims are classified as E&M by BETOS codes.

[EOL] -

End of life.

[ESRD] -

End stage renal disease. Medicare provides a national health insurance program for people with ESRD.

[FQHC] -

Federally Qualified Health Center. FQHC services are similar to those provided in rural health clinics (RHCs). FQHC services also include preventive primary health services.

[FTE] -

Full-time equivalent (FTE) is a standardized measure of work effort. An FTE of 1.0 means the equivalent of one full-time worker. Physician labor input measures use work relative value units (RVUs) to measure FTEs.

[HCAHPS] -

Hospital Consumer Assessment of Healthcare Providers & Systems. A national survey to measure patients' perspectives on hospital care.

[HCI index] -

Hospital Care Intensity index. The HCI index is based on two variables: the number of days patients spent in the hospital and the number of physician encounters (visits) they experienced as inpatients. It is computed as the age-sex-race-illness standardized ratio of patient days and visits. For each variable, the ratio of a given hospital’s utilization rate to the national average was calculated, and these two ratios were averaged to create the index.

[HEDIS] -

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by health plans to measure performance on important dimensions of care and service.

[HMO] -

Health Maintenance Organization. Risk-bearing HMOs received capitated payments for each member, in exchange for which they must provide all required services.

[HPSA] -

Health Professional Shortage Areas (HPSAs) are designated by HRSA as having shortages of primary medical care, dental or mental health providers.

[HRR] -

Hospital referral regions (HRRs) are regional market areas for tertiary medical care. Each HRR contains at least one hospital that performs major cardiovascular procedures and neurosurgery.

[HRSA] -

The Health Resources and Services Administration is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable.

[HSA] -

Hospital service areas (HSAs) are local health care markets for hospital care. An HSA is a collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area.

[IMG] -

International medical school graduate (non-U.S. and Canada).

[L2Y] -

Last two years of life.

[L6M] -

Last six months of life.

[MedPAR file] -

The Medicare Provider Analysis and Review (MedPAR) file includes one record for each hospital stay by Medicare beneficiaries. The record includes data on dates of admission/discharge, diagnoses, procedures and Medicare reimbursements to the hospital.

[MUA/MUP] -

Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty, and/or high elderly population.

[NCQA] -

The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization dedicated to improving health care quality.

[Part A] -

Part A is Medicare's hospital insurance program. It covers inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals.

[Part B] -

The coverage provided by Medicare Part B includes medically necessary doctor's services, outpatient care, and most other services that Part A does not cover (such as some physical or occupational therapies and some home health care services). Part B covers preventive services as well.

[Part D] -

Part D is prescription drug coverage insurance that is provided by private companies approved by Medicare.

[PCI] -

Percutaneous coronary intervention, commonly known as coronary angioplasty.

[PCSA] -

Primary Care Service Areas (PCSAs) reflect Medicare patient travel to primary care providers.

[Revascularization] -

Surgical procedure to establish or improve blood supply to a body part or organ.

[RHC] -

Rural Health Clinics (RHCs) are clinics that are located in areas designated by the Bureau of the Census as rural and by the Secretary of Department of Health and Human Services or the state as medically underserved.

[RUCA] -

Rural-Urban Commuting Areas (RUCAs) are U.S. Census tract-based classifications that use the standard Bureau of Census urban area and place definitions in combination with commuting information to characterize all of the nation's census tracts regarding their rural and urban status and relationships.

[RVU] -

Relative value units (RVUs) quantify the values of health care services. An RVU is a dollar amount assigned to each encounter, procedure, or surgery. They are calculated on the basis of the amount of work required, the expense to the practice, and the cost of malpractice insurance.

[SNF] -

Skilled nursing facility.

[TURP for BPH] -

Transurethral prostatectomy for benign prostatic hyperplasia.

[UPIN] -

Unique Provider Identification Number.

[ZCTA] -

Zip Code Tabulation Areas (ZCTAs) are generalized area representations of U.S. Postal Service (USPS) ZIP Code service areas, built by aggregating the Census 2000 blocks.

Why is this information important? What are the implications?

Health care spending is consuming an increasingly larger proportion of GDP every year, but there is little evidence that the amount we are spending is producing better health outcomes for populations or individual patients. Other countries spend far less per person and have better results. One way to address the question is to study which parts of the system appear to be producing "excess" levels of intervention, which are extremely costly but provide no additional benefit over other parts of the system that operate far more efficiently. Researchers estimate that up to 30% of current spending on health care is wasted. Finding that waste and eliminating it would not only help provide financial security for the Medicare program without loss of value to the people it covers, it would also help finance the expansion of coverage.

How are the methods used in this project different from other studies?

The Dartmouth Atlas Project uses a methodology, commonly known as small area analysis, which is population-based. The focus of small area analysis is on the experience of the population living in a defined geographic area or the population that uses a specific hospital. In contrast, many others studies use a "turnstile" approach, focusing on the number of procedures or hospitalizations in the hospital, without reference to the size of the population served.

Why does the Dartmouth Atlas Project focus on Medicare data? Are there similar variations in utilization and spending in the under-65 population?

The Centers for Medicare and Medicaid Services (CMS), the federal agency that collects data for every person and provider using Medicare health insurance, makes available a uniform national claims database for research purposes. There is no counterpart to this database for the commercially insured population. However, similar studies we have done using state all-payer data in Pennsylvania and Virginia, and with Blue Cross Blue Shield data in Michigan, have shown similar variations among the under-65 population.

Why don't you have data for Medicare enrollees who are members of health maintenance organizations (HMOs)?

Health maintenance organizations receive capitated payments from Medicare - a fixed annual amount per enrollee - in exchange for the HMO providing all required services. Since HMOs do not submit individual claims to Medicare, we must exclude members of HMOs from our claims analyses.

What explains the differences in efficiency among different regions? Is it supply driven?

The supply of resources such as hospital beds and specialist physicians does drive utilization - where there are more hospital beds per capita, more people will be admitted (and readmitted more frequently) than in areas where there are fewer beds per capita. Economically, it is important for hospitals to make sure that all available beds generate as much revenue as they can, since an unoccupied bed costs nearly as much to maintain as an occupied bed. Similarly, where there are more specialist physicians per capita, there are more visits and revisits. Other reasons for the variations in efficiency are related to practice style - the way physicians in the region practice medicine (using more or fewer prescriptions or tests, for example).

What is the relationship between health care spending and quality of care?

Studies that have looked at the additional services provided in high-spending regions have shown that the higher volume of care does not produce better outcomes for patients. Patients in high-spending regions do not receive more "effective care" (services shown by randomized trials to result in better health outcomes, such as making sure that heart attack patients get proper medication). Nor do they receive more "preference-sensitive care" (elective surgical procedures which have both benefits and risks, where patients' preferences should determine the final choice of treatment). Rather, the additional services provided to Medicare beneficiaries in higher-spending regions all fall into the category of "supply-sensitive care": discretionary care that is provided more frequently when a population has a greater per capita supply of medical resources. In regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital - and Medicare will spend more on hospital care. Where there are more intensive care unit beds, more patients will be cared for in the ICU - and Medicare will spend more on ICU care. The more CT scanners are available, the more CT scans patients will receive - and so on.

What do you mean more health care is not necessarily better?

The Dartmouth Atlas Project has observed, over the course of its research, that death rates in areas where there is less capacity and less utilization are not higher than death rates in areas where there is much higher capacity and utilization - that is, the additional investment in hospital and physician resources does not "pay off" in increased longevity. Studies by Dr. Elliott Fisher et al have indicated that there is higher mortality in high-resourced, high-utilization areas than in low-resourced, low-utilization areas. One explanation for this phenomenon is that the risks associated with hospitalizations and interventions - hospital-acquired infections, medication errors and the like - outweigh the benefits.

Evidence points out that more aggressive care in managing patient populations with chronic illness does not necessarily lead to longer length of life or improved quality of life. Are you insinuating that we shouldn't do everything we can to save a life?

Ironically, research has found that in patients with chronic illnesses, more aggressive interventions result in shorter life expectancy, probably because of the risks associated with hospitalization. This indicates that the best strategy for extending the life of people with chronic illness is to focus on those activities that provide a survival benefit - better control of blood pressure for people with diabetes, for example - rather than on "heroic" end-of-life care.

Dartmouth Atlas research points out that frequent use of services is not associated with either better performance on technical measures of care or marginal improvements in survival and functional status. How can you convince people they don't need additional care and how can you convince doctors not to recommend it?

A recent study reported that almost three-quarters of Americans say they have declined interventions that were recommended by their physicians, because they thought that it was unnecessary or the benefits did not outweigh the risks or side effects. Other studies have confirmed that informed patients want much less surgery, on average, than surgeons are inclined to perform. Making patients aware of the risks and trade-offs associated with treatment choices is one good way of reducing demand for such things as hospital admissions, redundant or unnecessary testing, and surgery when there are other options. Because physicians are reimbursed for activities, the system encourages them to do more. Paying physicians to spend more time advising patients about treatment alternatives (for example, lifestyle changes and medications, rather than bypass surgery), without penalizing them economically for doing less, is another important strategy for reducing utilization.

How does poverty impact health care spending?

Sick people require far more care than healthy people. For people who reported that they were in poor health, average annual Medicare spending was more than six times higher than for those who said they were in excellent health in 2005. Poverty also matters for health care spending: low-income people are sicker and tend to account for greater health care expenditures than those who are comparatively wealthier. However, our research has shown that regional differences in poverty and income explain almost none of the variation among regions; and, while health status does matter, it only accounts for about 18% of the variation in Medicare spending. More than 70% of the differences in spending cannot be explained away by the claim that patients in high-spending regions are poorer or sicker.

How do you determine how much care is too much?

By accurately measuring at what point more inputs do not result in better outcomes.

Whose fault is it?

Probably the most important driver of how health care resources are established and used is the current reimbursement system. Hospitals and doctors are paid for activities - hospitalizations, procedures, tests - and are economically punished for using less-invasive, less-costly strategies of care.

This research suggests savings that can be realized within the Medicare system. Don't we need to look at the whole picture to truly realize savings?

Obviously more information about the non-Medicare population would add to our knowledge about what is going on in the system and how it could be improved. Lacking that information, however, we can say two things. The first is that, even if we redirected only Medicare into high-quality, high-efficiency patterns of resource allocation and utilization, we would realize tremendous gains in quality and reductions in spending. The second is that, in several state-based studies of all health insurance claims (both Medicare and commercial) we have determined that the variations in resources and quality in the non-Medicare populations closely resemble those in the Medicare population. So the experience of Medicare enrollees is a reliable predictor of the experience of the non-Medicare population.

However, a hospital's ranking in terms of per capita spending may vary substantially for commercial payers based on market-negotiated (rather than CMS-set) unit prices and the greater spending on non-chronic conditions such as pregnancy. The best strategy for addressing these limitations would be for all payers and self-insured employers to work together to produce resource input and utilization data for cohorts across Medicare, Medicaid and commercially-insured patients.

Key Issues

Source: http://www.dartmouthatlas.org/keyissues/

Summaries of our findings related to many of these issues and links to further information can be found using the list at right (below).

Over the past two decades, the Dartmouth Atlas Project has developed a national strategy of providing population-based information describing resource inputs, utilization and outcomes of care across the United States. Much of the variation among regions in per capita resource inputs, utilization and spending has proven to be unwarranted; it cannot be adequately explained on the basis of differences among regions in prices, illness rates, patient characteristics, patient preferences, or the dictates of evidence-based medicine. Much of the variation relates to differences among providers.

The problem of unwarranted variation has attracted widespread attention from the press, policy makers and clinicians interested in quality improvement and health care reform. It has led to legislation promoting demonstration projects to deal with unwarranted variations among the Medicare population. Of particular importance is the evidence that populations living in regions with greater levels of spending and greater use of physician visits and hospitalizations do not experience better health care outcomes or better quality of care. This finding has several implications for patients and for the cost of Medicare. First and foremost, overtreatment harms patients, and it contributes to the chaotic quality of American health care. Second, overtreatment wastes taxpayer dollars. And because of the way Medicare is financed, overtreatment also entails a systematic transfer of tax dollars from residents of low-cost regions to high-cost regions, where those dollars fund the useless, and potentially harmful, care that is being delivered.

Reporting of research data from the Dartmouth Atlas Project takes several forms. We have produced twenty book-length editions of The Dartmouth Atlas of Health Care; several brief reports covering specific topics and/or clinical subject areas; and a number of issue briefs on relevant health policy topics. Atlas investigators also have an extensive bibliography of scientific articles published in peer-reviewed journals. Please use the links on the right to locate our publications.

Recently released: Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life. This brief, posted June 12, 2013, 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.

The Revolving Door: A Report on U.S. Hospital Readmissions. This report, posted February 11, 2013, shows 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. Both rates were virtually unchanged from 2008. The findings are based on new data that includes readmission rates for states, hospital referral regions, and more than 3,000 hospitals from the Dartmouth Atlas Project.

Improving Patient Decision-Making in Health Care. This series of nine reports, posted in November and December 2012, looks at the variation in surgical rates in the 306 hospital referral regions across the United States. Each report also highlights one of nine regions and shows the variation in "preference-sensitive" procedures that exists even across these smaller geographic regions. The reports reveal that, for conditions that can be treated with elective surgery, the treatment a patient receives depends more on the physician's recommendations than the patient's preferences.

All Publications by Year

Click here for publications by type, with description and links to data

1996

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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF]

​Topic Briefs

 

  • 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. Read the briefpress release, ordownload data.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF]

  • 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 herefor data tables.

    [Download the PDF] [Download Data]

  • 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.

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  • 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.

    [Download the PDF]

  • 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.

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  • 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.

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  • 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.

    [Download the PDF] [Download Data]

  • 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.

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  • 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.

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  • 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.

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  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

  • 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 anexecutive summarymethods and definitions, and frequently asked questions.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF]

  • 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.

    [Download the PDF]

  • 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.

    [Download the PDF]

Surgical Variation Studies

 

  • 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.

    [Download the PDF] [Download Data] [Purchase Link]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF]

  • 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.

    [Download the PDF]

  • 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.

    [Download the PDF]

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.

    [Download the PDF] [Download Data] [Purchase Link]

  • 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.

    [Download the PDF] [Purchase Link]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF]

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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

  • 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.

    [Download the PDF] [Download Data]

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.

    [Download the PDF]

  • 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.

    [Download the PDF]

  • 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.

    [Download the PDF]

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.
  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the East South Central Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the Great Plains Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the West South Central Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the Mountain States

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the Pacific States

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the New England Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the Middle Atlantic Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the South Atlantic Region

    [Download the PDF] [Download Data] [Purchase Link]

  • IMPROVING PATIENT DECISION-MAKING IN HEALTH CARE:, A 2012 Dartmouth Atlas Report Highlighting the Great Lakes Region

    [Download the PDF] [Download Data] [Purchase Link]

  • THE NEW ENGLAND STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE MIDDLE ATLANTIC STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE SOUTH ATLANTIC STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE GREAT LAKES STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE EAST SOUTH CENTRAL STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE GREAT PLAINS STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE WEST SOUTH CENTRAL STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE MOUNTAIN STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

  • THE PACIFIC STATES, The Dartmouth Atlas of Health Care, 1996

    [Download the PDF]

     

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The Dartmouth Atlas Project examines patterns of health care delivery and practice across the United States and evaluates the quality of health care Americans receive. The Atlas was launched in 1996, building on research methodology pioneered by Dr. John Wennberg. The research has revealed striking variations in the amount of health care delivered among hospital referral regions (HRRs), showing that in health care, geography can be destiny. The amount of care consumed by Americans is highly dependent on where they live, based on the capacity of their local health care system and on the practice styles of local physicians. This is true not only across states and regions, but among hospitals within individual states and cities.

In studying Medicare data , Atlas researchers have documented that more care does not necessarily mean better care. In fact, more hospitalizations and more procedures among similar populations can result in higher mortality than for populations that received more conservative care.

The disparities in care - seen across demographic groups as well as across regions - raise obvious concerns about the quality of care delivered and the evidence on which health care decisions are based. But they also represent billions of dollars in wasteful and unnecessary spending. Past editions of the Atlas have shown that the U.S. could lower health care costs substantially if the highest intensity hospitals adopted the practices of the nation's best performing hospitals.

This web site has been designed to provide an easy way for you to find data and reference materials to support your reporting on the crisis in U.S. health care in general and the Dartmouth Atlas in particular. The data reports provided by region, hospital and topic will help you construct your own data sets and compare hospitals, cities, and regions relevant to you. You can also view articles previously written about the Atlas project. Answers to many of your questions may also be available on one of our Key Issues or Frequently Asked Questions pages. Responses to some criticisms of Dartmouth Atlas data can be found on our Reflections on Variation page. A Q&A with Dr. Wennberg is also available for background information. For additional information, you can contact Eva Fowler at MSL Washington DC: (202) 261-2868.

Recent News & Press Releases

Source: http://www.dartmouthatlas.org/pressroom/newsandpress.aspx

  • June 12, 2013: MEDICARE SPENDING AND CARE INTENSITY AT THE END OF LIFE INCREASES, WHILE TIME IN THE HOSPITAL DECLINES.

    Medicare spending for chronically ill patients at the end of life increased more than 15 percent from 2007 to 2010, according to a new brief from the Dartmouth Atlas Project. The updated data also shows that Medicare patients spent fewer days in the hospital and received more hospice care in 2010 than they did in 2007.

  • February 21, 2013: HOSPITALS REIMBURSEMENTS BASED ON ILLNESS OF PATIENTS ARE SUSCEPTIBLE TO BIAS DUE TO INTENSITY OF CARE.

    Common methods designed to enable apples-to-apples comparisons of the performance of doctors and hospitals and fairly credit providers for treating patients who are sicker than average may themselves be biased, because they make some patient populations appear to be sicker than others when they are not, according to a study by Dartmouth researchers. In a series of papers, the latest of which was published February 21, 2013 in the British Medical Journal, a research team led by the Dartmouth Atlas Project and The Dartmouth Institute for Health Policy & Clinical Practice raises significant questions about the “risk adjustment” that Medicare and others apply to insurance claims data in an effort to make fair comparisons about performance, spending, resource use, and mortality rates among regions and hospitals.

  • February 11, 2013: THE REVOLVING DOOR SYNDROME: PATIENTS RETURNING TO HOSPITAL WITHIN DAYS OF BEING RELEASED.

    The Robert Wood Johnson Foundation (RWJF) released a report on February 11, 2013 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. Both rates were virtually unchanged from 2008. The findings are based on new data that includes readmission rates for states, hospital referral regions, and more than 3,000 hospitals from the Dartmouth Atlas Project, largely funded by RWJF. The report, “The Revolving Door: A Report on U.S. Hospital Readmissions,” also includes the results of a novel series of in-depth interviews with patients and providers that shed light on why so many patients end up back in the hospital and what hospitals, doctors, nurses, and others are doing to limit avoidable readmissions.

  • November 29, 2012: ELECTIVE SURGERY IN THE UNITED STATES: LOCATION MATTERS.

    Medicine involves decisions. But 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 research from the Dartmouth Atlas Project. The research suggests that for many conditions -- especially those that can be treated with elective surgery -- the treatment a patient receives depends more on the physician's recommendations than the patient's preferences. When studying elective procedures across the nation, researchers found remarkable variation in these surgeries for Medicare patients, even though they had similar conditions. Nine editions highlight different regions around the country and shows the variation that exists even within these smaller areas. Click here for the series.

  • October 30, 2012: FOR PHYSICIAN RESIDENTS, WHERE YOU'RE TAUGHT MEDICINE INFLUENCES HOW YOU PRACTICE.

    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? Variation in Health Care and Its Importance for Residency Training," a report from the Dartmouth Atlas Project led by physicians in training, found that 23 top academic medical centers vary markedly in the intensity of care they provide patients at the end of life, in their quality, safety and patient experience ratings, and in their use of surgical procedures when other treatment alternatives exist.

  • September 11, 2012: SIGNIFICANT POTENTIAL FOR ACCOUNTABLE CARE ORGANIZATIONS TO IMPROVE CARE, LOWER COSTS-ESPECIALLY FOR SICKEST PATIENTS.

    New health care delivery models that reward providers for coordinating and improving care hold promise for slowing the cost of treating the sickest, costliest patients in the health care system, according to "Spending Differences Associated With the Medicare Physician Group Practice Demonstration," a study by Dartmouth researchers published in the Sept. 12 issue of the Journal of the American Medical Association.

  • April 9, 2012: CARE FOR DYING MEDICARE PATIENTS AT ELITE CANCER CENTERS DIFFERS LITTLE FROM COMMUNITY HOSPITALS.

    The nation's most elite cancer care centers performed only modestly better than community hospitals at meeting recognized quality standards for treating dying cancer patients, according to a study by Dartmouth researcherspublished in the April 2012 issue of Health Affairs. The Dartmouth researchers also found that even among hospitals with a specific clinical focus on cancer care, there were significant variations in how they treated patients at the end of life.

  • January 27, 2012: MOVING BEYOND MEDICARE: DARTMOUTH ATLAS RESEARCHERS TO ANALYZE VARIATIONS IN PEDIATRIC CARE, UNDER-65 POPULATION.

    The Dartmouth Atlas Project is once again branching out beyond Medicare. Dartmouth researchers have announced plans to develop their first regional study on variations in pediatric health care, funded by a two-year grant from the New England-based Charles H. Hood Foundation, and collaboration with Blue Health Intelligence® to study geographic variation in a commercially insured adult population.

  • September 28, 2011: U.S. HOSPITALS, FACING NEW MEDICARE PENALTIES, SHOW WIDE ROOM FOR IMPROVEMENT AT REDUCING READMISSION RATES.

    As new Medicare penalties kick in for hospitals with excessive numbers of patients returning to the hospital shortly after they are discharged, a new report, "After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries," published September 28, 2011, shows little progress over a five-year period in reducing readmissions and improving care coordination for Medicare patients. On the contrary, readmission rates for some conditions have increased for many regions and at many hospitals, including some of America's most elite academic medical centers. The study also found that facilities and regions with general patterns of high use of hospitals for medical conditions were frequently the same places with high readmission rates, an indication that some communities are more likely than others to rely on the hospital as a site of care across the board.

  • May 25, 2011: MORE PRIMARY CARE ASSOCIATED WITH POSITIVE HEALTH OUTCOMES FOR MEDICARE PATIENTS.

    Medicare patients living in areas with higher levels of practicing primary care physicians have lower death rates and make fewer trips to the hospital for preventable conditions, according to "Primary Care Physician Workforce and Medicare Beneficiaries' Health Outcomes," a study by Dartmouth investigators published May 25, 2011 in theJournal of the American Medical Association. The study’s findings suggest that a larger local workforce of primary care physicians has a positive benefit for Medicare patients, but this association may not simply be the result of having more physicians in an area who are trained in primary care; instead, the benefits may be more from the amount of ambulatory clinical care provided, rather than the number of primary care physicians locally available.

  • April 12, 2011: U.S. END-OF-LIFE CARE CHANGING: WHILE MEDICARE PATIENTS ARE SPENDING LESS TIME IN THE HOSPITAL, THOSE ADMITTED RECEIVE MORE INTENSIVE CARE.

    Chronically ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but at the same time there was an increase in the intensity of care for patients who were hospitalized, according to the Dartmouth Atlas Project report “Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness.” While Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care, at the same time, they had many more visits from physicians and spent more days in intensive care units. Growth in intensive care and medical specialist capacity, the researchers say, can lead to increased aggressiveness of care.

  • March 17, 2011: GEOGRAPHY'S INFLUENCE ON CHRONIC DISEASE DIAGNOSIS.

    The likelihood of Medicare patients being diagnosed with one or more of nine chronic diseases may depend on where they live and the doctors they see, in addition to how healthy or sick they actually are, according to "Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries," a new study by Dartmouth investigators published in the Journal of the American Medical Association. This geographic variation raises important questions about the methods used to adjust risk for the severity of illness in comparative effectiveness research, the evaluation of hospital readmissions, and paying insurance plans under the Medicare Advantage program and elsewhere, including academic research into the extent of variations in medical care across America.

  • February 24, 2011: WHEN IT COMES TO ELECTIVE SURGERY, LOCATION MATTERS.

    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 theFoundation for Informed Medical Decision Making released February 24, 2011. The study, "Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota,"shows remarkably wide regional variations in elective surgery for Medicare patients with similar conditions. In addition to analyzing data on practice patterns, the report also advocates for shared decision-making, a process that helps patients understand their choices fully and allows them to share treatment decisions with their clinicians.

  • February 3, 2011: MORE PHYSICIAN SUPPLY DOESN’T LEAD TO HIGHER PATIENT SATISFACTION.

    Medicare patients living in areas with a higher supply of physicians were no more satisfied with their care than patients living in regions with a lower physician supply, according to a study released February 3, 2011 by Dartmouth investigators and the Centers for Medicare and Medicaid Services. The study, "Seniors’ Perceptions Of Health Care Not Closely Associated With Physician Supply," also found that seniors living in areas with a high supply of physicians were no more likely to report having a primary care physician as their personal doctor. In addition, there were no significant differences in the amount of time spent with a physician, or access to tests or specialists.

  • November 16, 2010: NEARLY ONE THIRD OF MEDICARE PATIENTS WITH ADVANCED CANCER DIE IN HOSPITALS AND ICUS: ABOUT HALF GET HOSPICE CARE.

    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, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries." The researchers found no consistent pattern of care or evidence that treatment patterns follow patient preferences, even among the nation’s leading academic medical centers. Rather, with one in three Medicare cancer patients spending their last days in hospitals and intensive care units, the report’s findings demonstrate that many clinical teams aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their life in their last weeks and months.

  • September 9, 2010: DARTMOUTH ATLAS PROJECT FINDS ACCESS AND USE OF PRIMARY CARE DOES NOT GUARANTEE BETTER HEALTH OUTCOMES.

    Meeting the nation's primary care needs is more than a numbers game. "Regional and Racial Variation in Primary Care and the Quality of Care Among Medicare Beneficiaries," a report from the Dartmouth Atlas Project, 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 a patient will get recommended care or experience better outcomes. Researchers also found that patients' access to and use of primary care, the quality of overall care, and their likelihood of hospitalization varied markedly in different locations. The report shows that improving access to primary care alone does not always keep people with chronic conditions out of the hospital, improve their chances of getting the optimal care recommended for their condition, or improve health outcomes.

  • June 23, 2010: RESPONSES TO THE NEW YORK TIMES.

    The Dartmouth Atlas responded twice to "Critics Question Study Cited in Health Debate" and subsequent follow-ups by Reed Abelson and Gardiner Harris of The New York Times. The first response was June 3 and the second wasJune 23.

  • May 12, 2010: CONSIDERING MOVING? WHERE YOU GO DETERMINES WHETHER YOU WILL BE TOLD YOU'RE SICK.

    Medicare beneficiaries who move to some regions of the United States receive many more diagnostic tests and new diagnoses than those who move to other regions, according to a study by Dartmouth investigators in the New England Journal of Medicine. The paper raises important questions about whether being given more diagnoses is beneficial to patients and may help to explain recent controversies about regional differences in spending.

  • April 15, 2010: DARTMOUTH ATLAS PROJECT FINDS SUBSTANTIAL VARIATION IN JOINT REPLACEMENT SURGERY.

    The rates of hip, knee, and shoulder replacement for Medicare patients are growing rapidly, and there is widespread variation in how likely patients are to undergo surgery depending on where they live and their race, according to a report released by the Dartmouth Atlas Project. "Trends and Regional Variation in Hip, Knee, and Shoulder Replacement" finds substantial increases in overall rates of joint replacement from 2000-2001 to 2005-2006. Meanwhile, the rate of shoulder replacement was 10 times higher in some regions than others during 2005-2006, and the rates of hip and knee replacements were four times higher.

  • April 2, 2009: U.S. HOSPITAL BED SUPPLY SHRINKS WHILE HOSPITAL WORKFORCE GROWS.

    The supply of hospital beds and doctors varies widely from region to region across the United States, and the variations have nothing to do with the level of care patients want or need, according to a new report from the Dartmouth Atlas Project. "Hospital and Physician Capacity Update," released April 2, 2009, analyzes current hospital and physician capacity as well as trends over a 10-year period, and reveals 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.

  • March 12, 2009: LINKING WORKFORCE POLICY TO HEALTH CARE REFORM.

    Dr. David Goodman gave invited testimony at the United States Senate Committee on Finance Hearing on "Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future." Dr. Goodman advanced the idea of a permanent health workforce commission to craft evidence-based policy that improves access to care, health outcomes and the quality and affordability of care.

  • February 26, 2009: TAMING WIDE VARIATIONS IN SPENDING KEY TO HEALTH REFORM.

    Huge inefficiencies in the U.S. health care system are hamstringing the nation's ability to expand access to care, according to a new analysis of Medicare spending by researchers of the Dartmouth Atlas Project, published February 25, 2009 in the New England Journal of Medicine. Many experts have blamed the growth in spending on advances in medical technology. But the differences in growth rates across regions show that advancing technology is only part of the explanation. Patients in high-cost regions have access to the same technology as those in low-cost regions, and those in low-cost regions are not deprived of needed care. On the contrary, the researchers note that care is often better in low-cost areas. The authors argue that the differences in growth are largely due to discretionary decisions by physicians that are influenced by the local availability of hospital beds, imaging centers and other resources-and a payment system that rewards growth and higher utilization.

  • January 27, 2009: SHARED SAVINGS: PAYMENT REFORM THAT PROMOTES HIGH-QUALITY CARE AND REDUCES MEDICARE SPENDING GROWTH.

    Medicare could save money and improve health care quality by providing financial incentives to providers for coordinating patient care through a shared savings program, according to a new paper from the Dartmouth Institute for Health Policy and Clinical Practice and the Engelberg Center for Health Care Reform at the Brookings Institution. Research by Elliott Fisher, Mark McClellan, and colleagues demonstrates that such a program, implemented with the establishment of Accountable Care Organizations (ACOs), would benefit patients, payers, and providers. The ACO shared savings concept would eliminate waste, reduce overuse and misuse of care, and support the development of health systems that can deliver high quality, affordable care.

  • December 17, 2008: EXPANDING COVERAGE WITHOUT INCREASING HEALTH CARE SPENDING: DARTMOUTH INSTITUTE WHITE PAPER RECOMMENDS COURSE FOR THE OBAMA ADMINISTRATION.

    A new 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 incoming 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. Download "An Agenda for Change: Improving Quality and Curbing Health Care Spending: Opportunities for the Congress and the Obama Administration."

  • October 13, 2008: DARTMOUTH’S JOHN E. WENNBERG WINS PRESTIGIOUS LIENHARD AWARD.

    Dr. John E. Wennberg today received the 2008 Gustav O. Lienhard Award from the Institute of Medicine for "reshaping the U.S. health care system" to focus on objective evidence and outcomes rather than physician preference as the basis for treatment decisions, and for his efforts to empower patients with greater input on decisions about their own care.

  • September 17, 2008: IT TAKES A NEIGHBORHOOD: CREATING THE STRUCTURE FOR THE MEDICAL HOME.

    The medical home has great potential to improve the delivery of coordinated health care to patients. But significant obstacles still exist in making the transition from model to reality, writes Dr. Elliott S. Fisher in the September 18th issue of the New England Journal of Medicine. A lack of incentives for providers to share information, unclear evidence that patients and physicians will embrace the medical home concept, and questions about whether the medical home will actually result in reduced health care spending, are barriers that must be addressed.

  • April 16, 2008: CLAIMS OF PHYSICIAN WORKFORCE CRISIS IGNORE REAL PROBLEMS IN HEALTH CARE.

    Increasing the size of the physician workforce has not led overall to better care, greater availability of care, or patient satisfaction with medical care. By simply adding physicians, we would be treating the symptoms of an ailing health care system, while ignoring the underlying disease: "a largely disorganized and fragmented delivery system, characterized by lack of coordination, incomplete patient information, poor communication, uneven quality, and rising costs." Moreover, increasing the size of the workforce is likely to worsen existing problems and potentially create more.

  • April 7, 2008: CHRONICALLY ILL PATIENTS GET MORE CARE, LESS QUALITY, SAYS LATEST DARTMOUTH ATLAS.

    Medicare pays many hospitals and their doctors more than the most efficient and effective health care institutions to treat chronically ill people, yet gets worse results, according to a new report from the Dartmouth Institute for Health Policy and Clinical Practice. Tracking the Care of Patients with Severe Chronic Illness shows that institutions that give better care can do it at a lower cost because they don't over-treat patients. However, the Atlas documents that Medicare and most other payers encourage the over-use of acute care hospital services and the proliferation of medical specialists thanks to misplaced financial incentives, especially for treating chronically ill people. Caring for people with chronic disease now accounts for more than 75% of all health care spending. And over-use and overspending is not just a Medicare problem - the health care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses.

  • February 20, 2008: SURGERY IS BEST FOR PATIENTS WITH SPINAL STENOSIS, THIRD SPORT STUDY SHOWS.

    Individuals suffering from a common back condition known as spinal stenosis improve more with surgery than with non-surgical treatment, according to a multi-center, multistate trial led by Dartmouth clinician-researchers. However, the study also reveals that patients who choose not to have surgery are likely to improve over time.

  • July 24, 2007: DARTMOUTH COLLEGE, BROOKINGS INSTITUTION ANNOUNCE PARTNERSHIP.

    A program to improve the value of health care by addressing uneven quality and excess costs was unveiled recently by the Brookings Institution and Dartmouth College. The initiative will link population-based research programs at the newly-created Dartmouth Institute for Health Policy and Clinical Practice with the health policy research and development expertise of scholars at the Brookings Institution. The Brookings-Dartmouth initiative will focus on bringing researchers, lawmakers, and regulators together to develop and implement policies to address major failings in the U.S. health care system.

  • April 1, 2007: THE STATE OF THE NATION'S HEALTH.

    The U.S. spends more on health care than any other nation. Does that money buy what it should? Not according to decades of Dartmouth research on regional variations in spending and outcomes. But policy-makers are now paying attention to the DMS work - and therein may lie a solution to the money-medicine puzzle." This passage introduced the cover article by Maggie Mahar in Dartmouth Medicine's Spring 2007 issue, entitled "The State of the Nation's Health." The article featured the work of the Dartmouth Atlas project and the Center for the Evaluative Clinical Sciences (now The Dartmouth Institute for Health Policy and Clinical Practice).

  • December 5, 2006: AMERICA'S HEALTH RANKINGS: A CALL TO ACTION FOR PEOPLE AND THEIR COMMUNITIES.

    The United Health Foundation released the 2006 edition of America's Health Rankings: A Call to Action for People and Their Communities. This year's ranking included state-level findings from the Dartmouth Atlas Project. The report showed not only tremendous variation in the quality and cost of medical care among the states, but that providing more services did not lead to better-quality care. In fact, in some states, the greater use of services was associated with poorer quality and lower satisfaction with care.

  • December 5, 2006: ESTABLISHING ACCOUNTABILITY FOR QUALITY AND COSTS.

    Organized care beats disorganized care. The question is how to organize it. Most physicians do not practice medicine in the multi-specialty group practices, or in similar practices integrated with hospitals, that have been shown to be the most effective and efficient delivery systems for care. In a recent Health Affairs article, Dr. Elliott Fisher and coauthors advocate focusing accountability for quality and cost on the "extended hospital medical staff." The paper demonstrates that all physicians are already members of a virtual multi-specialty medical group -- the physicians who work in or whose patients are admitted to a local hospital -- and patients, especially those who have chronic diseases, receive the vast majority of their care from these local delivery systems. It is therefore feasible to develop performance measures for these organizations. Dr. Fisher also presented his findings to the Medicare Payment Advisory Commission (MedPAC) November 9, 2006.

  • October 17, 2006: DARTMOUTH ATLAS RESEARCH IN THE NEWS.

    Dartmouth Atlas research was featured prominently in a five-day USA Today/ABC News collaboration on the U.S. health care system. USA Today reported on findings published in the November 2006 issue of Spine revealing the steady increase in rates and Medicare spending for spine surgery, particularly lumbar fusion. Another article in USA Today used Dartmouth Atlas data to explore variation in end-of-life costs. ABC News featured the Intermountain Health Care system in Salt Lake City, which the Atlas used as a benchmark for efficiency in the treatment of the chronically ill. Finally, the ABC/USA Today collaborative named the Dartmouth Atlas of Health Care web site as one of the five most important web sites in health policy.

  • March 1, 2006: THERE IS NO NEED TO EXPAND PHYSICIAN WORKFORCE TRAINING TO MEET THE FUTURE NEEDS OF AN AGING POPULATION.

    There is no need to expand physician workforce training to meet the future needs of an aging population; the current supply, if employed efficiently, is adequate through 2020. "Spending millions of dollars annually to expand our capacity to train physicians will create an oversupply at the same time that it diverts health care dollars from care that has been shown to improve the health and well being of patients," according to David C. Goodman, M.D., and colleagues at Dartmouth's Center for the Evaluative Clinical Sciences (now TDI). The research was published by the journal Health Affairs in its March/April 2006 issue.

  • November 16, 2005: FROM SACRAMENTO TO LOS ANGELES, MORE HEALTH CARE IS NOT NECESSARILY BETTER HEALTH CARE.

    Despite the wide differences in spending among hospitals in California, there is no gain in quality or patient satisfaction, according to a study by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School (now TDI). The ground-breaking study, released by the California HealthCare Foundation, looked at the performance of individual California hospitals in managing seriously ill patients over a five-year period. The study found that eliminating "Medicare overcare" by improving hospital efficiency could have saved Medicare $1.7 billion over five years in Los Angeles alone.

  • November 15, 2005: DARTMOUTH ATLAS RELEASES NEW TOPIC BRIEFS.

    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. These new briefing papers are beginner's guides to these categories. 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. 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. 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.

  • October 7, 2004: DARTMOUTH STUDIES SHOW WIDE VARIATIONS IN HOSPITAL CARE AND OUTCOMES FOR CHRONICALLY ILL MEDICARE PATIENTS.

    Medicare patients with similar chronic conditions receive strikingly different care, even among hospitals identified as "best" for geriatric care by U.S. News & World Report, according to one of several Dartmouth Medical School studies featured in a special issue of Health Affairs.

Press Contact Information

Source: http://www.dartmouthatlas.org/pressroom/presscontact.aspx

Dartmouth Atlas communications are managed jointly by The Dartmouth Institute for Health Policy and Clinical Practice and MSL Washington DC.

MSL Washington DC 
Alyssa Callahan 
(202) 261-2880 
alyssa.callahan@mslgroup.com


The Dartmouth Institute for Health Policy and Clinical Practice 
Annmarie Christensen 
(o) (603) 653-0897: (c) (802) 249-8795 
Annmarie.Christensen@dartmouth.edu

In the Media

My Note: Continues to 130 (1996)

Source: http://www.dartmouthatlas.org/pressroom/inthemedia.aspx

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