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Wednesday, December 30, 2009

More counterpoints to the Dartmouth Atlas data

This article from the journal Circulation provides data and analysis that at least suggests that the sweeping conclusions of the Dartmouth group may not tell all of the story. h/t to this entry by the Buckeye Surgeon.

The widely quoted publications of the Dartmouth group that studied the regional variations in Medicare patient death rates have been condensed to a simple recipe to solve at least some of the country's medical problems-let's all be more like the Mayo Clinic and the implication that spending more money necessarily translates into poorer health care.

The Circulation studied looked at the outcomes of Medicare patients in 6 California teaching hospitals.Here is the conclusion of the study's authors:

Conclusions— California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.

It is only in the context of the hype generated with the Dartmouth studies that one would be surprised that spending more resources on sick patients might actually improve their outcome.It is obviously true at the extreme-if we spend no money at all good outcomes would be unlikely. Within some of the health care "reform" rhetoric we hear the theme that spending more money is necessarily bad and wasteful. Spending more can be wasteful but often it is not. It is an empirical question and very context dependent- not one determined by reference to first principles.

I have written before abut Dr. Richard Cooper's critique and criticism of the Atlas studies.See here for some details of Dr. Cooper's arguments and comments by the economist, Arnold Kling.


Michael Kirsch, M.D. said...

James, here is a link to a recent New York Times article that I thought might interest you and your readers. It focuses on what the Dartmouth data might be missing. http://bit.ly/6bPvuK
Enjoy and Happy New Year. www.MDWhistleblower.blogspot.com

james gaulte said...

Thanks for the link.This may speak to my poor powers of observation or memory, but I remember very few patients who came to see me with a note pinned to their shirt that said " I will live only a few more months so don't waste a lot of "resources"on me".

Every time I read the words " dartmouth study" I cannot help but think "ecologic fallacy"

Michael Kirsch, M.D. said...

Yeah, my individual patients aren't that interested in Dartmouth. They don't come to me interested in how cutting back on their care serves public health interests. Yet, there is a tsunami of medical excess that must be tamed. It's crushing our comptetiveness abroad. Imagine what our economy would be like if healthcare reaches 20% of GDP? How could we sell a car with an enormous, built-in health care tax? Best wishes.