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The Dartmouth Atlas Under Fire

07 Jun

If you’re a health policy person–even slightly–you’re bound to be familiar with the Dartmouth Atlas. In fact, after the protracted health reform debate and the highly publicized New Yorker article written by surgeon and author Atul Gawande that highlighted unexplained variation in health care spending levels in two Texas towns, it’s a safe bet that a lot of people have at least heard of the Dartmouth Atlas. But, for those of you still in the dark, I’ll explain briefly: The Dartmouth Atlas is a project that has been going on for more than two decades at Dartmouth University. It got started by John Wennberg, who pioneered the study of small area variation in health care utilization, spending, and so forth. And that’s what they do. They collect and analyze data–piles and piles of it–to try and understand why this geographic variation exists as well as how utilization, costs, and quality of care are related. That definition’s not perfect, but it will suffice.

The work of the Dartmouth Atlas isn’t perfect either–no research is–but it is highly respected by most health services researchers. That’s one reason why the Dartmouth findings were relied on so heavily during the health reform debate. Now, however, the work is coming under fire from a couple of reporters at the New York Times. You can read their story here. Essentially, they’re faulting the folks at Dartmouth for looking only at health care costs while ignoring health care quality. With all the public fear about rationing–as if it doesn’t already happen every single day–the story raises a good point. There’s just one problem: It’s not true.

The Dartmouth Atlas has indeed done studies looking at variation in health care quality–using the best, though admittedly limited, measures available. They have indeed found in many cases that health care quality declines at higher levels of health care utilization. You can find articles authored on this topic by Dartmouth faculty in Health Affairs and other top-tier peer-reviewed journals. (I doubt you’ll read them, so I’m not linking.) But, what I can point you to quickly is quality data right on the Dartmouth Atlas’ website. Again, these aren’t comprehensive–or even ideal–quality measures, but that’s very different from alleging that they ignore quality altogether.

Bloggers are all over this story, each with their own take. There’s Merrill Goozner who appears to fall in the middle between Dartmouth and the NYT, Andrew Gelman who gives a lesson in taking the Times’ piece with a grain of salt, and the Dartmouth Atlas’ own Jonathan Skinner who presents a nice reply to the Times’ article–which appeared itself in the Times almost one year ago. I suggest you read them for more.

Update: The New York Times’ David Leonhardt has more to say on this topic, Maggie Mahar goes to bat for Dartmouth, and the Dartmouth Atlas has now issued its own response that strikes back at the original NYT piece. Who knew health services research could present such high drama?

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Posted by on June 7, 2010 in Uncategorized

 

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