Similarly Dead, Not Similarly Ill – Quintessential Dartmouth Doubletalk

The Dartmouth Atlas Frequently Asked Questions section asks: “How do you ensure some patients were not more severely ill than others?” Here’s the Dartmouth answer:  “The study only focused on patients who died so we could be sure that patients were similarly ill across hospitals. By definition, the prognosis of all the patients in the cohort was identical – all were dead after the interval of observation. Therefore, variations cannot be explained by differences in the severity of individuals’ illnesses.”

So, let’s see. A hospital where a senior gets minimal care after an acute MI and dies in 36 hours is efficient, but a hospital where his identical twin got a full range of care and survived, only to die of a second MI on the golf course six months later is inefficient. OK, I get it. Similarly dead. Even similarly ill, at the start.  But where would you go for care? And who would ever judge “efficiency” this way?


  1. hipparchia

    Yep, that one’s a real jaw-dropper.

    These studies are coming out of a med school, and these people have MD degrees.

    I don’t expect my doctors to be ace statisticians, but there’s not much point in spending $150,000 and a decade or so training physicians if they can’t even judge the severity of their patients’ illnesses until after they’re all dead.

  2. Frank

    Let’s toss out the Dartmouth beliefs. But can that solve the problem – can health care’s cure be just that easy? The status quo just needs a few more doctors.

    Isn’t there more that needs to be done? I cannot dispute your logic about the Atlas, it just still seems like I am living in a crisis and at least the Atlas got people moving and not just talking. Does America just spend more because we have more relative poverty in our nation compared to other countries – that is to say, we have the ability to spend in the poverty stricken areas whereas other nations do not?

    It seems clear we have variation in care and that, perhaps as you suggest, it may be well warranted. It also seems that one of the drivers of variation is poverty. – or at least something unique about American poverty.

    What aspect(s) of poverty have created the variation? Is it overall genetics? Is it intellectual capacity to understand health status and health care? Is it literacy? Blind trust of providers? Is it the funding has little consequence to either the provider or the patient, so why not use more resources? And so on.

    Lastly, if the variation is warranted variation, then do we even need to go so far as health care reform, or health care redesign? Or are your beliefs that the state of health care ‘is what it is’ and we need to solve poverty and illiteracy, and let health care continue on its normal, market driven quality enhancement without a major overhaul? Said another way, what is the real crisis and where do we put our efforts to good use?

    What advice do you recommend for QI, care appropriateness, efficiency, and so on?

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