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New Dartmouth Atlas: improving US cardiac care?
FEATURE
New Dartmouth Atlas: improving US cardiac care? tices. First, ACC will put up a dataAnother provocative finding is that hat a difference a decade makes. base on heart failure. Additionally, the cardiac revascularisation rates had When John Wennberg pubACC hopes to develop handheld tools “essentially no relationship with the lished hallmark research highlighting that will aid physicians in calculating admission rates for acute myocardial broad geographic variation in prostate the best treatment for specific case infarction”, he points out, suggesting surgery and hysterectomy across the types. that disease was not driving aggressive USA in 1982—tying it largely to Paul Heidenreich (Stanford care. And even though cardiac revasphysician and health-care facilities University, Stanford, CA, USA) supply per caput and unrelated admits that Wennberg’s major to patient severity of thesis, that supply drives diagillness—physicians’ groups went Rights were not granted to nostic testing makes sense: “If a ballistic and flatly rejected include this image in doctor has an ECHO lab in his Wennberg’s case. electronic media. Please refer own office or can easily refer But big changes in US health patients to one nearby, patients care have made physician groups to the printed journal. will be much more likely to and insurers sit up and listen. undergo an echocardiogram. Today, managed care in the However, if ECHO labs are in USA threatens to weed out short supply and you have to go unproven services, while bolsterthat extra step of ordering an ing appropriate underused lifeelectrocardiogram, use will drop saving interventions. The Health down.” Care Financing Administration Still, Heidenreich questions (HCFA), which manages the the view that a greater use of Medicare programme, touts its echocardiograms is necessarily realigned position as a “responsiindicative of overuse. “There ble purchaser”. Physician groups are so many reasons why an recognise that unless they take a Ratio of rates of echocardiography to US average (1996) echocardiogram is ordered.” hard look at the care its members Moreover, he observes, “for patients cularisaton rates paralleled coronary provide somebody else will perhaps with a recent episode of heart failure, angiography rates, “regardless of the crack down on services deemed inapit is considered quality care to get underlying angiography rate, almost propriate or unproven. some measure of left ventricular funchalf of those catheterised go on to carSo perhaps it is no surprise that the tion after the episode and then put diac revascularisation”. first-ever Dartmouth Atlas of that patient on appropriate ACE ACC president, George Beller, says Cardiovascular Health Care, led by inhibitors”. that the College is intent on getting to David Wennberg (Maine Medical Even so, some observers might the bottom of the variation and eduCenter, Maine, USA), documenting wonder whether the Atlas will be able cating members about best practices. broad variation in cardiovascular to spur attention to unnecessary He states his case in the Aug 1 issue of practices among Medicare beneficiaoveruse, as did John Wennberg’s piothe Journal of the American College of ries across the USA in 1996, has been neering work. Despite a burgeoning Cardiology. Beller offers one possible co-sponsored by the American quality movement, most of it concenexplanation for the variation, namely College of Cardiology (ACC) and the trates on bolstering greater use of that differential dissemination of Society of Thoracic Surgeons. underused effective practices. The ACC/American Heart Association What is unusual about the Atlas is National Committee for Quality guidelines to physicians around the its focus on the up-front use of diagAssurance, for example, uses quality country accounts, in part, for inappronostic testing, which is a much less indicators that stress assuring that priate low utilisation. Beller credits studied area. Treatment data are also proven procedures (-blockers after guideline dissemination with helping included, but David Wennberg is heart attacks, routine Pap tests, ratchet up use of -blockers and especially concerned with underimmunisations, &c) are ratcheted up, aspirin among patients who have just standing the reasons why disease is in line with the best evidence and the had heart attacks. looked for, believing that although in quality movement continues to flourBeller says that opinion leaders will the short-term the risks and costs of ish through partnerships between prove important. A more aggressive diagnostic tests are usually small, they quality organisations and physicians. approach may not be warranted in drive towards more invasive proceWennberg is proud to get this inforlow-risk individuals, for example, or dures, surgery and downstream costs. mation out there and delighted that in patients with no risk factors who One of the Atlas’ most striking findthe Atlas could have the potential to have chest pain that is stable. Opinion ings is that one in ten Medicare improve cardiovascular care. “Clearly, leaders could play a major role in eduenrollees in the USA had an echocarlooking at this variation, we need betcating community physicians about diogram in 1996. Yet that rate varied ter information on outcomes and using the most cost-effective procewidely, Wennberg reports. “In patient preferences”, he says. dure first, he says. Miami, the echocardiogram rate was Nevertheless, he stresses: “We also Toward that end, the ACC board 339 per 1000 beneficiaries, but it was need to acknowledge that as long as has just approved a US$2 million only 56 per 1000 Medicare beneficiathere is uncertainty about when to test “Just In Time CME [Continuing ries in Portland, Oregon”, he says. or treat, supply will drive demand.” Medical Education]” initiative, which “Looking at this data, one has to aims to use the internet to bring question the assumption that science physicians up to date with best pracalone guides the delivery of care”. Laura Newman Dartmouth Atlas of Cardiovascular Health Care
W
660
THE LANCET • Vol 356 • August 19, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
New Dartmouth Atlas: improving US cardiac care? tices. First, ACC will put up a dataAnother provocative finding is that hat a difference a decade makes. base on heart failure. Additionally, the cardiac revascularisation rates had When John Wennberg pubACC hopes to develop handheld tools “essentially no relationship with the lished hallmark research highlighting that will aid physicians in calculating admission rates for acute myocardial broad geographic variation in prostate the best treatment for specific case infarction”, he points out, suggesting surgery and hysterectomy across the types. that disease was not driving aggressive USA in 1982—tying it largely to Paul Heidenreich (Stanford care. And even though cardiac revasphysician and health-care facilities University, Stanford, CA, USA) supply per caput and unrelated admits that Wennberg’s major to patient severity of thesis, that supply drives diagillness—physicians’ groups went Rights were not granted to nostic testing makes sense: “If a ballistic and flatly rejected include this image in doctor has an ECHO lab in his Wennberg’s case. electronic media. Please refer own office or can easily refer But big changes in US health patients to one nearby, patients care have made physician groups to the printed journal. will be much more likely to and insurers sit up and listen. undergo an echocardiogram. Today, managed care in the However, if ECHO labs are in USA threatens to weed out short supply and you have to go unproven services, while bolsterthat extra step of ordering an ing appropriate underused lifeelectrocardiogram, use will drop saving interventions. The Health down.” Care Financing Administration Still, Heidenreich questions (HCFA), which manages the the view that a greater use of Medicare programme, touts its echocardiograms is necessarily realigned position as a “responsiindicative of overuse. “There ble purchaser”. Physician groups are so many reasons why an recognise that unless they take a Ratio of rates of echocardiography to US average (1996) echocardiogram is ordered.” hard look at the care its members Moreover, he observes, “for patients cularisaton rates paralleled coronary provide somebody else will perhaps with a recent episode of heart failure, angiography rates, “regardless of the crack down on services deemed inapit is considered quality care to get underlying angiography rate, almost propriate or unproven. some measure of left ventricular funchalf of those catheterised go on to carSo perhaps it is no surprise that the tion after the episode and then put diac revascularisation”. first-ever Dartmouth Atlas of that patient on appropriate ACE ACC president, George Beller, says Cardiovascular Health Care, led by inhibitors”. that the College is intent on getting to David Wennberg (Maine Medical Even so, some observers might the bottom of the variation and eduCenter, Maine, USA), documenting wonder whether the Atlas will be able cating members about best practices. broad variation in cardiovascular to spur attention to unnecessary He states his case in the Aug 1 issue of practices among Medicare beneficiaoveruse, as did John Wennberg’s piothe Journal of the American College of ries across the USA in 1996, has been neering work. Despite a burgeoning Cardiology. Beller offers one possible co-sponsored by the American quality movement, most of it concenexplanation for the variation, namely College of Cardiology (ACC) and the trates on bolstering greater use of that differential dissemination of Society of Thoracic Surgeons. underused effective practices. The ACC/American Heart Association What is unusual about the Atlas is National Committee for Quality guidelines to physicians around the its focus on the up-front use of diagAssurance, for example, uses quality country accounts, in part, for inappronostic testing, which is a much less indicators that stress assuring that priate low utilisation. Beller credits studied area. Treatment data are also proven procedures (-blockers after guideline dissemination with helping included, but David Wennberg is heart attacks, routine Pap tests, ratchet up use of -blockers and especially concerned with underimmunisations, &c) are ratcheted up, aspirin among patients who have just standing the reasons why disease is in line with the best evidence and the had heart attacks. looked for, believing that although in quality movement continues to flourBeller says that opinion leaders will the short-term the risks and costs of ish through partnerships between prove important. A more aggressive diagnostic tests are usually small, they quality organisations and physicians. approach may not be warranted in drive towards more invasive proceWennberg is proud to get this inforlow-risk individuals, for example, or dures, surgery and downstream costs. mation out there and delighted that in patients with no risk factors who One of the Atlas’ most striking findthe Atlas could have the potential to have chest pain that is stable. Opinion ings is that one in ten Medicare improve cardiovascular care. “Clearly, leaders could play a major role in eduenrollees in the USA had an echocarlooking at this variation, we need betcating community physicians about diogram in 1996. Yet that rate varied ter information on outcomes and using the most cost-effective procewidely, Wennberg reports. “In patient preferences”, he says. dure first, he says. Miami, the echocardiogram rate was Nevertheless, he stresses: “We also Toward that end, the ACC board 339 per 1000 beneficiaries, but it was need to acknowledge that as long as has just approved a US$2 million only 56 per 1000 Medicare beneficiathere is uncertainty about when to test “Just In Time CME [Continuing ries in Portland, Oregon”, he says. or treat, supply will drive demand.” Medical Education]” initiative, which “Looking at this data, one has to aims to use the internet to bring question the assumption that science physicians up to date with best pracalone guides the delivery of care”. Laura Newman Dartmouth Atlas of Cardiovascular Health Care
W
660
THE LANCET • Vol 356 • August 19, 2000
For personal use only. Not to be reproduced without permission of The Lancet.