Update Appended
Research findings about health care spending at hospitals nationwide produced by the Dartmouth Atlas of Health Care has recently come under fire in the academic community, with critics claiming that its figures inaccurately represent health care spending and quality. Researchers behind the Atlas have been challenged over their claims about the quality of health care institutions in instances when their findings only discuss spending practices, and also over failures to adjust data for geographic variations that would affect researchers' results, according to an article published Wednesday evening by The New York Times.
The institution's research played an important role in the recent efforts by President Barack Obama's administration to pass federal health care reform legislation, and was cited on numerous occasions by policymakers as a sign that federal health spending could be made more efficient while improving the quality of care.
The Times' investigation of the findings do not accurately represent the "30 years of work" investigators at the Dartmouth Institute for Health Policy and Clinical Practice have produced, Dartmouth Medical School professor and Atlas co-principal investigator Elliott Fisher said in an interview with The Dartmouth.
The group's data is largely undisputed in the scientific community, according to Fisher.
"All of this research and all the findings they cite [in The Times' article] are consistent with ours," Fisher said. "The Times is not helping advance the public's understand of what's going on -- the opportunity to understand what's going on."
The Times' article - which serves as a summarization of "more than a hundred scientific articles" on the causes and consequences of variations in health care practice and spending across the nation -- fails to adequately address the core findings of the Atlas study, according to Fisher.
"Our research has pointed to opportunities to improve the quality of care -- by insuring a more consistent and reliable delivery of effective care, by engaging patients in making informed choices about treatments they are considering and by identifying the remarkable degree of inefficiency and waste exemplified by the health care system that treats patients in the hospitals than by better primary care and outpatients," Fisher said.
The general conclusion that higher regional spending in health care is not associated with better outcomes for patients is "unrebutted so far" by health care analysts, Fisher said.
The research produced by the Atlas has determined that in regions where patients spend more time in hospitals and with a greater number of specialists, the care that they receive is not better despite being more expensive, according to Fisher. Primary care and outpatient practices can serve as an alternative to the currently wasteful system, Fisher said.
In order to save "about 20 to 30 percent of health care spending," hospitals should engage in "better performance measures, greater accountability and payment systems that reward improved performance," Fisher said.
The Times refuted this claim from Dartmouth researchers, stating that there is "little evidence" to support the assertion that better health care is often less expensive.
Although The Times criticized the magnitude of the savings, similar findings have been "supported by other investigations," Fisher said.
"Our work is not undermined by any of the criticisms raised in The New York Times," he said. "The findings have been supported by numerous articles and the superficial treatment in The Times does not accurately characterize our work."
Yet The Times also raised issues with Atlas researchers' methodology. The Atlas' ranking of hospitals based on "costs and number of treatments and procedures" may have penalized larger hospitals in big cities, where costs may be higher because factors like employees' cost of living cause greater expenses, The Times reported.
The Atlas' report also failed to take into consideration that longer in-hospital care can prolong and improve patients' lives, according to The Times article.
In an explanation of the research methodology sent to The Times, Fisher and economics professor Jonathan Skinner said that they addressed this critique in studying if highly intensive treatment of certain serious medical problems yielded better patient outcomes.
"The Dartmouth research that has looked at this question focused on patients with specific conditions, such as hip fractures and heart attacks, and followed them for several years to see how they fared. On average, higher spending was not associated with better outcomes," the letter stated.
The Times also charged that Dartmouth researchers, in their statements during the congressional health care debate, helped to shape the popular perception that the lowest-cost hospitals provide the best quality of care, though, according to The Times' findings, this is not supported by other measures of quality.
Fisher denounced these claims, citing that "some legislators from low-cost regions" had advocated for increasing the fees in low cost, high-quality regions and decreasing the fees in high cost regions in order to punish the inefficient hospitals and reward efficient health care providers.
"We oppose that," Fisher said. "That is misrepresenting. We never advocated that."
The Times implied that due to its "more-is-worse" stance on health care, the Atlas has garnered financial support from insurance companies. The Atlas lists regional Blue Cross/Blue Shield affiliates as publishing partners on its website. In 2007, the Atlas also sold its health care consulting company, Health Dialogue, to a British insurance company for approximately $800 million, according to The Times.
Update, June 14, 2:47 pm:
On June 10, The Times published two letters to the editor in regards to its article on the Atlas' findings -- one submitted by Fisher and Skinner and the other by Atul Gawande, an associate professor at the Harvard School of Public Health and Harvard Medical School -- criticizing the article's assertions.
Fisher and Skinner said the Atlas has not backed away from its past findings, despite the article's implication.
"The key point: It's not how much you spend. It's what you spend it on," the researchers wrote. "And all thoughtful scholars agree that the United States has tremendous room to improve the quality and costs of care."
Gawande criticized the article for setting up "a straw man" of the Atlas' research.
"The lesson of the Dartmouth Institute's landmark work has never been a simplistic view that a town with more health spending than another always has worse quality," he wrote. "Dartmouth's key finding has remained clear: more care does not equal better care."
