Saturday, February 06, 1999
The Atlas is a collaborative effort of the Academy, American Hospital Association, Robert Wood Johnson Foundation and the Center for Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, N.H.
Dr. Weinstein is analyzing two years of Medicare data in a first-time effort to identify, measure and assess regional variations in specific musculoskeletal; surgical and nonsurgical care.
The Atlas was developed from a realization that a tremendous variation in health care delivery exists in the U.S., said Dr. Weinstein, also the director of the Patient Preference Center, Dartmouth Hitchcock Medical Center and director of the Surgical Outcomes and Assessment Program at Dartmouth Medical School. Where one lives, the capacity of the health care system in one's community, and practice styles of local physicians and health plans all affect the type of musculoskeletal care Americans receive, he said.
"The variation is not necessarily good or bad," he said. "Understanding what the issues are is what the Atlas is about." The purpose of maps showing regional differences is informational, Dr. Weinstein said. The maps do not determine what should be the "right rate," he emphasized. "We are not saying that a high or a low number is good or bad."
Dr. Weinstein described the Atlas as presenting the "surgical signature of the community." Some diagnoses, such as hip fracture, show very little geographic variation because most orthopedic surgeons agree on operative treatment, Dr. Weinstein said. With total hip or knee replacement or spine surgery, however, variations not accounted for by age or sex are seen, implying that practice style differences must exist. For example, an eight-fold variation was found in spine surgery across the country, according to Dr. Weinstein.
The Atlas will be used to further shared decision-making - using evidence-based medicine to give patients enough information to make good decisions, Dr. Weinstein said.
"We are very proud to be working with Dr. Weinstein on this project," said Academy executive vice president William W. Tipton Jr., MD.
Traditionally, physicians made decisions for the patient based on what the physician knew. "That has worked, but it has its downside," Dr. Tipton said. "We want to get to more of an evidence-based process in providing good health care to our patients."
The public today wants good information to make good decisions themselves, Dr. Weinstein added. "When patients are given good information, they make appropriate decisions."
"Patient empowerment is crucial," Dr. Tipton said. "I don't think it works anymore to have physicians tell patients what to do." The issue now is how to get orthopedists to realize they need the Atlas, he added.
The Atlas also explores the issue of supply-induced demand. The orthopedic surgeon workforce exceeds HMO benchmarks of 4.5 orthopedic surgeons per 100,000 popu-lation in over 98 percent of U.S. regions. For example, Sun City, Ariz. and Napa, Calif. have more than 12 orthopedic surgeons per 100,000.
Said Dr. Tipton, "There is no doubt, as we move toward the next millenium, that the Academy is dedicated to practicing medicine with good data."