head ct scans per 1,000 children (2007-10, age-sex-payer adj.) 14.7 to19.7 (13) 12.3 to

Head CT Scans per 1,000 Children(2007-10, age-sex-payer adj.)

14.7 to 19.7 (13)12.3 to < 14.7 (14)10.5 to < 12.3 (14)

8.9 to < 10.5 (14)4.2 to < 8.9 (13)

Insufficient data (1)Not populated

3

5

7

9

11

13

15

17

19

21

Hea

d CT

sca

ns p

er 1

,000

chi

ldre

n

Bangor, ME 11.1Portland, ME 9.7Lebanon, NH 8.9Burlington, VT 8.4

Is Capacity Destiny?

No, but levels of capacity are strong, and often invisible currents, that health systems row with, or against.

3

• Greater capacity leads to higher utilization of certain types of

care.

• Capacity is generally not located where needs are greater.

• Supply-sensitive tends to have:

– Weak evidence-base about which rate is right.

– Care that occurs after first contact with health care system.

• Often weakly associated with outcomes.

• Is responsible for substantial portion of variation in spending in

the Medicare population.

Supply-Sensitive Care

4

Supply-Sensitive Care

So What? Maybe more is better!

Use of potentially harmful medications Medicare beneficiaries hospital referral regions (2010)

33.2 to 43 .0% (60)28.2 to < 33 .2% (63)23.8 to < 28 .2% (61)21.0 to < 23 .8% (61)14.0 to < 21 .0% (61)Not populated

Just simply worrisome care.

The Dartmouth Atlas of Health Care

Research, surveillance, and public reporting of

unwarranted variation in health care.

Unwarranted variation is variation that cannot be explained by:

• Patient illness• Patient preference

Unwarranted variation is the variation that is explained by differences in health system performance.

7

National Hospital Service Areas

&Hospital Referral

Regions

Dartmouth Atlas of Health Care

Tonsillectomies per 1,000 children among hospital service areas (2007-10)

7.9 to 11.0 (6)5.9 to < 7.9 (6)5.4 to < 5.9 (6)4.3 to < 5.4 (6)2.6 to < 4.3 (6)Not populated

Pediatric Surgical Areas fromjoining Hospital Service Areas

Funded by the Health Services and Resource Administration

Causes, consequences, remedies of variationCategory Cause Consequence Remedy

Unwarranted variation

Evidence-based care Clinician decisions ≠ science

Lower probability of good outcomes

Clinical microsystem improvements

Preference sensitive care

Provider-driven decisions; patients uninformed and not involved in decisions

Pt. doesn’t receive preferred care: the care with highest individual pt. utility

Shared decision making, decisions aids. Better outcomes research. Research in decision quality

Supply sensitive care Capacity that is idiosyncratically located and poorly related to outcomes

Higher resource use with marginal or no patient benefit

Wiser capital and labor investments in health care.

Desired State: Warranted variationCare in response to differences in patient needs and preferences

Application of evidence-based medicine and Shared Decision Making

Better outcomes, including higher decision quality, and often lower costs

The Six Stages of Lossof Professional Certainty

• Denial: “The data is bad.” or “My patients are sicker.”

• Anger: “Who are you to show this information that will be misinterpreted.”

• Acceptance: “OK, something is going on.”

• Curiosity: “What could cause this?”

• Discovery: “I understand the cause!”

• Remedy: “Here’s how we can fix this and let’s do it.”

Challenges assumptions; stimulates new policy

Dissemination

Talks at National and Regional Meetings

Peer-reviewed

Papers

Reports,Atlases,

Web Site,General and

Health Media

Policy Community

Health systems(e.g. hospitals)

Professional Organizations

Media

States

Academic Community

Payers/ Insurance Plans

How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

Atlas Research Greets Health Reform

“Required Reading in the White House”

The Atlas in Congress Recently

Elliott Fisher, MD MPH – Professor of Medicine • House Committee on Ways and Means (2009)

• House Subcommittee on Health of the Committee of Energy and Commerce (2007)

David Goodman, MD MS –Professor of Pediatrics

• Senate Finance Committee (2009)

• Senate Special Committee on Aging (2012)

Jonathan Skinner, PhD – Professor of Economics

• House Energy and Commerce (2009)


Informs and motivates clinical improvement

Challenges current practice; fosters engagement

Dissemination


Peer-reviewed

Papers

Reports,Atlases,


Health Media

Policy Community



Media

States

Academic Community






Engages audiences, creating public tension for change

Dissemination


Peer-reviewed

Papers

Reports,Atlases,


Health Media

Policy Community



Media

States

Academic Community



The Dartmouth Atlas of Health Carereports on unwarranted variation

First 6 months 2009:

118 million media impressionsAbout 2,000 unique media markets





Helps redefine value; stimulates new models

Provides model for state-level monitoring, feedback

Dissemination


Peer-reviewed

Papers

Reports,Atlases,


Health Media

Policy Community



Media

States

Academic Community







Helps redefine value; stimulates new models

Provides model for state-level monitoring, feedback

Stimulates & supports clinical and policy research

Dissemination


Peer-reviewed

Papers

Reports,Atlases,


Health Media

Policy Community



Media

States

Academic Community



The Scientific Foundation of the Atlas

A couple hundred research papers.

Lot’s of collaboration with other research groups, including critics.

Open access to as much Atlas data as CMS will permit, and we can afford to provide.

head ct scans per 1,000 children (2007-10, age-sex-payer adj.) 14.7 to19.7 (13) 12.3 to

Documents

head ct scans