dartmouth atlas project

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Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

Dartmouth Atlas: Fewer Medicare Patients Dying In Hospital, More Getting Hospice Care

The new Dartmouth Atlas Project — the influential and sometimes controversial snapshot of national and regional health care trends — is out, focusing once again, on end-of-life care. The report’s top findings — that more severely ill Medicare patients are dying at home, and more likely to get hospice care — suggests the system is beginning to shift:

Medicare beneficiaries with severe chronic illness spent fewer days in the hospital at the end of life in 2007 than they did in 2003. They were also less likely to die in a hospital and more likely to receive hospice care in 2007 than in 2003.

So, have we gotten the message that less aggressive treatment, and less time spent at the hospital near the end of life might be better both for patients and for reducing costs? Not so fast. The report also found these patients had “many more visits from physicians, particularly medical specialists, and spent more days in the intensive care unit.”

And, the Dartmouth researchers found that death mirrors life in this sense: it’s all location, location, location:

Throughout this period, the constant was the importance of geography; the care patients received in the months before they died depended largely on where they lived and received their care…For example, the change in the percentage of hospital deaths ranged from a sharp decrease at some hospitals to a substantial increase at others.

Is Your Local Medical Culture Quicker To Reach For The Scalpel?


Wouldn’t you like to know whether the local medical culture that influences your doctor is likelier than most to suggest reaching for the knife and aiming it at your prostate? Or your breast? Or your back?

Call me provincial, but as soon as I saw this report full of cool maps of variations on elective surgery put out by the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making, I wondered whether they might do a version for Massachusetts any time soon. Word from the project is that they’re considering a version on Massachusetts or New England some time in the next year.

In the meanwhile, I scanned through this report on Medicare patients — which features national data and Minnesota — and Massachusetts was looking fairly restrained with its elective surgeries, with the one exception of the prostate operation mapped above.

Overall, the national variations are astonishing. The report’s press release notes:

Researchers found that men over 65 with early-stage prostate cancer who live in San Luis Obispo, Calif., are 12 times more likely to have surgery to remove their prostate than those in Albany, Ga. Medicare patients with heart disease in Elyria, Ohio, were 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu. And women over 65 living in Victoria, Texas were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Ind.

“These striking variations are the by-product of a doctor-centric medical delivery system. Continue reading