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The Dartmouth Atlas of Health Care 1998

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For Americans, the amount of health care consumed depends on where one lives, the capacity of the health care system in one's area, and the practice styles of local physicians. Variations in the intensity of use of hospitals, the striking difference in the way terminal care is delivered, and the idiosyncratic patterns of elective surgery raise significant questions about the outcomes and value of health care. This Atlas, the second in a series by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, asks these fundamental questions: "Which rate of care is right?", "How much care is enough?", and "What is fair?" One section of the Atlas documents wide variation in Medicare spending and in the supply of acute care hospital resources and physicians among the nation's hospital referral regions. Another section examines the patterns of hospitalization for several medical conditions in order to demonstrate the relationship between rates of admission to hospitals, physicians' practice styles, and hospital capacity. The Atlas also examines correlations between the incidence of hospitalization for these "high variation" conditions and the numbers of hospital beds per thousand residents. It provides a clinical explanation for the surgical signature phenomenon and examines the role of illness in determining the allocation of resources and the use of medical care. It concludes with an essay that focuses on the debate over what should be done to address unwanted variations in health care delivery and offers a two-part solution.