Building on the Legacy of the Dartmouth Atlas of Healthcare to Advance Health Equity: Q & A with Dr. Amber Barnato

Amber Barnato
Amber Barnato, MD, MPH, MS. Photo by Rob Strong

At the end of April, Amber Barnato, MD, MPH, MS, director of The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine, completed a prestigious one-year training fellowship in the Hedwig van Ameringen Executive Leadership in Academic Medicine® (ELAM®) program for women. See details about Geisel’s participation in ELAM’s national Leaders Forum here.

ELAM’s fellowship program is focused on developing the skills required to lead and manage in today’s complex healthcare environment, with special attention paid to the unique challenges facing women in leadership positions. To this end, fellows engage in a variety of assignments and community building activities, including an action project they select with senior leaders at their home institutions.

In the following Q & A, Barnato talks about her project to build on the legacy of the Dartmouth Atlas to advance health equity—developed in collaboration with her ELAM sponsors Duane Compton, PhD, dean of Geisel, and Joanne Conroy, MD, president and CEO of Dartmouth Health—and the impact she hopes it can have supporting The Dartmouth Institute’s mission of improving public health, reducing disparities, and creating high-performing health systems.

Q: Why did you choose the Dartmouth Atlas of Health Care for your ELAM project?

Barnato: The Atlas is The Dartmouth Institute’s signature research, community engagement, and policy advocacy tool, and as such is a high-priority area for the institution. Over the past 25-plus years, it has helped policymakers, the media, healthcare analysts, and others better understand the workings of the healthcare system by documenting variability in the cost and quality of healthcare nationwide. It has also served as the basis for many efforts to improve health and healthcare in the U.S.

On a personal note, my whole career has been profoundly influenced by the Dartmouth Atlas—from helping me understand the troubling variation in practice I saw as a medical student and intern, to inspiring me to pursue a career in health services research (focused on variation in end-of-life treatments), to serving as an important tool in my research and teaching.

In recent years, however, the health policy landscape has shifted dramatically with funding organizations like the NIH and the Robert Wood Johnson Foundation moving away from focusing on healthcare efficiency and variation in spending and moving towards addressing factors such as social determinants of health to ensure that more people get access to the care they need.

When I met with Duane and Joanne to choose my ELAM project, we saw that creating a new Health Equity Atlas—work that we’d actually started when I became director of The Dartmouth Institute in 2021—would give us an opportunity to accelerate our efforts to respond to the pressing policy questions of the day.

Q: Could you talk a little bit about how you’ve developed the project over this last year?

Barnato: My focus this year has been two-fold. One is that we’ve convened a series of workshops for the entire community, which has included The Dartmouth Institute and other Dartmouth faculty, students, and staff. These have been one-hour workshops, led for us by an organization called We All Count, to train people about the concept of data equity and to get everyone on the same page. In this work, we’ve used a set of tools to reflect on how our values and lived experiences shape the assumptions we make in our research.

Secondly, we established a small workgroup of people interested in the future of the Dartmouth Atlas, specifically within a health equity framework. We’ve met every three weeks, working through a standard process of looking at what our assumptions are for the Atlas, what our goals are, and how those goals privilege or marginalize certain groups. We’ve worked to identify which assumptions move our research closer to aligning with our diversity, equity, inclusion, and belonging commitments, or farther away. This group is unique in that it includes people from nine different disciplines.

Q: While your ELAM project will be winding down soon, the work of building on the legacy of the Dartmouth Atlas to advance health equity will continue—what’s next?

Barnato: To date, all of our work has been internally focused to ensure that we’re all talking the same language and thinking about this in the same way. We still need to go out to the community stakeholders and policy makers to talk to them about the metrics they would like to see, the research questions that need to be asked and answered, and how we can inform them with our data.

All of the workshops and workgroup meetings will be completed by June. I’m hoping that a research proposal to the Robert Wood Johnson Foundation, asking for funding to continue this work, will be able to go out in the fall, and that perhaps as soon as January we can begin stakeholder meetings and building our test metrics.

Q: What do you envision the Dartmouth Atlas looking like in the future?

Barnato: We’ll probably continue to produce the old metrics for some time. I can’t say exactly what the new metrics are going to look like yet. But we’re going to be focusing more upstream, if you will, about variation in things that are potentially life giving such as mammograms and diabetes prevention initiatives. In other words, what are the variations we can demonstrate that if they’re acted upon would decrease the gap in health outcomes between, let’s say, black and white patients or rural and urban patients.

We’ll be using emerging methodologies to add disaggregation of the current Atlas metrics by a set of social determinants of health, exploring the impact of reconceiving how race is used in the models, and adding new equity-focused metrics—including estimates of who is missing in the data, and the potential impact of equity-focused policies to the current set of Atlas metrics.

This is at once a technical effort and a change management effort that requires bridging our historical focus on healthcare efficiency to our new focus on health equity. I feel very energized by what we’ve been able to accomplish so far and I’m excited to see where this work takes us in the future.