The Dartmouth Institute

(formerly The Center For Evaluative Clinical Sciences - CECS)

Director: Elliott Fisher, MD, MPH

The Dartmouth Institute for Health Policy and Clinical practice, formerly known as the Center for the Evaluative Clinical Sciences, housed within the Department of Community and Family Medicine, is a locus for scientists and clinician-scholars involved in evaluating some of the most fundamental, but often overlooked, questions in medicine. The faculty of the CECS is engaged in measuring how well medical procedures actually work, how to improve the quality of medical and surgical care, how health care resources are distributed, and how patients value medical interventions and their consequences.

Founded in 1988 by John E. Wennberg, M.D., M.P.H., he and other members of the faculty have pioneered the field of outcomes research. By challenging widely-held but often inadequately tested theories of medical practice, Wennberg and his colleagues have opened a new national debate on how physicians and patients value medical interventions.

CECS research has shown that a significant proportion of medical interventions do not have beneficial effects of the magnitude ascribed to them; more importantly, CECS investigators have shown that, given sufficient information with which to make an informed choice, patients often choose different, and more conservative, courses of treatment than their doctors would prescribe for them. The implications of these findings range from a reduction in demand for common and expensive medical procedures such as back surgery and prostatectomy, to the promise of vastly increased satisfaction with medical care for patients who have been actively involved in the decision making process.

Interdisciplinary and Collegial Collaborations:
A strength of the CECS is the broad range of interests of its investigators. Current work ranges from studies of care at the end of life to the distribution of health care resources across hospital market areas, and from geriatric health to the sociology of medical organizations. Members of the CECS faculty share an exceptionally collegial, collaborative approach to identifying and investigating problems in the evaluative clinical sciences, bringing to bear a wide variety of approaches and methodologies to identify needs and propose solutions to flaws in the health care delivery system. Principal Investigators include representatives from Medicine, Pediatrics, Radiology, Economics, Orthopedics and beyond. Broadly grouped areas of interest include Measurement/Utilization of Health Care Resources, Outcomes and Quality Improvement. Representative research projects are described below.

Measurement /Utilization of Health Care Resources:
The Dartmouth Atlas of Health Care in the United States was developed at CECS with support from the Robert Wood Johnson Foundation. The Atlas reveals startling differences in how health care is delivered in different regions in the US and allows its readers to compare physician work force distribution, Medicare reimbursements for inpatient, outpatient and home care, hospital reimbursements and capacity, rates of common diagnostic and surgical procedures, end of life care, surgical variation, physician benchmarking and more. Complementary projects look at Health Care Reform and Small Area Analysis, to promote a population-based perspective. The Illness Burden Study is designed to develop a measurement system to capture the illness burden of defined populations and apply these measurement so that leadership can help better direct resources to meet needs. The Research Data Assistance Center project, looks at ways to make HCFA data more accessible in the research community. On a smaller scale, CECS is also comparing Outpatient Practice Styles between Generalist and Specialists, with a special focus on the effect of compensation systems.

Although related to Measurement and Utilization of Resources, CECS' research on Outcomes focuses on the end result of health care delivery, looking at patient clinical outcomes, preferences and utilities. Are patients better off after receiving treatment, and how best do we measure this? These questions are being addressed in several current studies to evaluate specific drug and surgical interventions for such diseases as Osteoporosis, Pediatric Asthma and Coronary Artery and Prostate Disease. Another study entitled "Is More Actually Better," looks at the correlation between capacity of services, utilization of services and outcomes. In addition, there is on-going interest in learning more about the processes of end-of-life care, including evaluation of guidelines as well as assessment outcomes in terms of patient and family needs.

Quality Improvement:
With the recruitment of Drs. Paul Batalden and Gene Nelson, CECS has been able to expand its research and teaching contributions on the continual improvement and innovation in health care. With support of the Generalist Physician Initiative sponsored by RWJ Foundation, Dr. Batalden and colleagues are incorporating in the undergraduate and graduate curricula a variety of methods and skills that can help students to participate in the continual improvement of health care. This blending of continuous quality improvement with core medical school and residency training is experimental and will be closely evaluated and refined. Another study looks to integrate Picker Institute's patient survey results and knowledge of the processes of care to identify ways by which hospitals might improve their care with acute myocardial infarction, hip replacement and childbirth patients. These research projects, combined with on-going Accelerated Clinical Improvement (ACI) projects at Dartmouth-Hitchcock Medical Center, provide unique opportunities to expand the body of knowledge regarding the improvement of health care delivery.

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