1. Head CT Scans per 1,000 Children (2007-10, age-sex-payer adj.) 14.7 to19.7 (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 Head CT scans per 1,000 children Bangor, ME11.1 Portland, ME 9.7 Lebanon, NH 8.9 Burlington, VT 8.4

2. 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 3

4. 4 So What? Maybe more is better!

5. Use of potentially harmful medications Medicare beneficiaries hospital referral regions (2010) 33.2 to43.0% (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.

6. 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 7

8. Tonsillectomies per 1,000 children among hospital service areas (2007-10) 7.9 to11.0 (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 from joining Hospital Service Areas

9. Funded by the Health Services and Resource Administration

10. Causes, consequences, remedies of variation CategoryCauseConsequenceRemedy Unwarranted variation Evidence-based careClinician 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 careCapacity 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 variation Care 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

11. The Six Stages of Loss of 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.”

12. 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) Health systems (e.g. hospitals) Professional Organizations Professional Organizations Media States Academic Community Payers/ Insurance Plans Payers/ Insurance Plans How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

13. Atlas Research Greets Health Reform

14. “Required Reading in the White House”

15. 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)

16. Challenges assumptions; stimulates new policy Informs and motivates clinical improvement Challenges current practice; fosters engagement 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) Health systems (e.g. hospitals) Professional Organizations Professional Organizations Media States Academic Community Payers/ Insurance Plans Payers/ Insurance Plans How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

18. Challenges assumptions; stimulates new policy Informs and motivates clinical improvement Challenges current practice; fosters engagement Engages audiences, creating public tension for change 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) Health systems (e.g. hospitals) Professional Organizations Professional Organizations Media States Academic Community Payers/ Insurance Plans Payers/ Insurance Plans How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

19. The Dartmouth Atlas of Health Care reports on unwarranted variation First 6 months 2009: 118 million media impressions About 2,000 unique media markets

20. Challenges assumptions; stimulates new policy Informs and motivates clinical improvement Challenges current practice; fosters engagement Engages audiences, creating public tension for change Helps redefine value; stimulates new models Provides model for state-level monitoring, feedback 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) Health systems (e.g. hospitals) Professional Organizations Professional Organizations Media States Academic Community Payers/ Insurance Plans Payers/ Insurance Plans How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

22. Challenges assumptions; stimulates new policy Informs and motivates clinical improvement Challenges current practice; fosters engagement Engages audiences, creating public tension for change Helps redefine value; stimulates new models Provides model for state-level monitoring, feedback Stimulates & supports clinical and policy research 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) Health systems (e.g. hospitals) Professional Organizations Professional Organizations Media States Academic Community Payers/ Insurance Plans Payers/ Insurance Plans How Does Dartmouth Atlas Reports, Papers, and Data Change Health Care?

23. 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.

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