John E. (Jack) Wennberg, MD, MPH, founder and director emeritus of The Dartmouth Institute for Health Policy and Clinical Practice, the Peggy Y. Thomson Professor in the Evaluative Clinical Sciences Emeritus at the Geisel School of Medicine, and founding editor of the Dartmouth Atlas of Health Care, died March 10, 2024. He was 89 years old.
Since 1980, Wennberg had been a professor in the Department of Community and Family Medicine and since 1989 in the Department of Medicine becoming emeritus in June 2007, when he stepped down as director of The Dartmouth Institute for Health Policy and Clinical Practice.
Colleagues describe him as both rigorous and deeply curious. By bringing the scientific method to the evaluation of medical practice he raised important and uncomfortable questions about the adequacy of biomedical evidence, the integrity of medical decision making, and the quality of medical care. Work that changed clinical practice and policy across the world.
“His work pioneered a field that has grown into an entirely new academic discipline in medicine,” Duane Compton, PhD, Geisel School of Medicine dean, says.
In the late 1960s when Wennberg was an assistant professor of medicine at the University of Vermont, using small-area analysis, a strategy he and his colleague Alan Gittelsohn developed, he showed that rates of procedures in areas with similar populations varied greatly and determined that the variations stemmed primarily from differences in physicians' treatment beliefs.
The early research in Vermont identified three categories of small-area variation—effective care (for which nearly all patients benefit), preference-sensitive care (where decisions should be left to patient choice), and supply-sensitive care (treatments with no clinical benefit). The wide variation in all three categories indicated to Wennberg that doctors could not be using sound science in their decision making.
Based on these findings, he published his first paper in 1973 in Science on the unexplained variations in healthcare and correlations between physician supply and the delivery of care that ushered in a new type of healthcare research examining the patterns of medical resource and utilization in the U.S. Later work in Maine confirmed these findings and identified “surgical signatures” for local communities. Follow-up studies in England and Norway replicated these findings despite very different systems of health financing.
“I read the paper as a first-year medical student and decided then and there that I would try to work with him,” says Elliot Fisher, MD, MPH, professor of medicine and health policy at Geisel and a longtime colleague. “What inspired me about Jack was not just his commitment to asking important questions, he insisted on trying to translate his insights into practice or policy to improve care.”
Wennberg’s research resulted in his being named the founding director of The Dartmouth Institute for Health Policy and Clinical Practice (then the Center for Evaluative and Clinical Sciences) in 1988, enabling him to recruit international scholars and healthcare researchers to further study improving health systems.
“Few academics create a new field of research,” says Jonathan Skinner, research professor in economics and Wennberg’s longtime friend and colleague. “Jack was one of them. And while he is best known for his studies of unwarranted variation in clinical medicine and health policy research, he also provided a congenial and productive intellectual home for junior social science faculty at Dartmouth, many of whom have since become leaders in their own fields.”
Julie Bynum, MD, MPH, the Margaret Terpenning Collegiate Professor, and vice chair for faculty affairs at Michigan Medicine, University of Michigan, was a young faculty member at Dartmouth when she first met Wennberg. “I discovered a man who engaged in meaningful scientific conversations with me despite my junior rank, who had a tenacious commitment to solving healthcare, and who was deeply kind to me. I’ll always remember him for his authenticity and his vibrant mind.”
In 1996, Wennberg compiled his breakthrough insights in the Dartmouth Atlas of Health Care, a series of reports that uses Medicare data on how healthcare is used and distributed in the U.S. Since then, the Atlas project has continually reported on patterns of end-of-life care, inequities in the Medicare reimbursement system, and the underuse of preventive medicine. The Atlas was first comprehensive database that allowed him to document the dramatic differences in how medicine was practiced in different communities.
“Jack used to say he liked to ‘interrupt polite conversations with data,’” recalls Amber Barnato, MD, MPH, MS, John E. Wennberg Distinguished Professor and director of The Dartmouth Institute for Health Policy and Clinical Practice. “He fundamentally changed our understanding of physician decision making and shed light on the capriciousness of the healthcare delivery system in which those decisions are made.”
Though his initial research findings faced resistance and were not always welcomed, his discoveries challenged the medical profession to acknowledge that most care was based on tradition or opinion rather than on objective evidence of what is most effective, affecting an array of healthcare policy issues—from financing to the doctor-patient relationship. While common wisdom had been that doctors made treatment decisions based on a common set of science-based principles, Wennberg’s work indicated that physicians instead created their own approaches to treatment in the face of professional uncertainty around optimal medical care.
He also found positive correlations between supplies of medical resources, such as hospital beds, and rates of their use. This supplier-induced demand launched efforts to reduce unwarranted variation. While others responded with guidelines and other policies to standardize care, Wennberg focused on improving decision quality by combining better clinical evidence with informed patient preferences. The introduction of shared decision-making between clinicians and patients to preserve warranted variation due to patient preferences is now embedded in health policies across the globe.
This notion, especially for preference-sensitive interventions, has its origins in a series of studies Wennberg led—catalyzed by the involvement of most of the urologists in Maine in an outcomes study of prostatectomy and an accompanying decision model that highlighted the critical role of patient preferences in the decision to undergo a prostatectomy.
“Perhaps the most critical finding from these studies was that patients differed dramatically in the extent to which a given symptom level bothered them (and hence required surgery) and how they felt about the impact of possible side effects of surgery on their quality of life. Hence, the ‘best’ treatment for a given level of symptoms varied from patient to patient,” says former colleague Michael J. Barry, MD, MACP, director, Informed Medical Decisions Program Massachusetts General Hospital Division of General Internal Medicine, professor of medicine, Harvard Medical School.
Wennberg and his colleagues noted the assessment focused attention on the need for new methods to inform patients of their options and to assess treatments according to the patients' initial preference for possible outcomes of the alternative choices, giving birth to shared decision-making movement.
He cofounded, with colleague Albert Mulley, the Foundation for Informed Medical Decision Making—a nonprofit entity providing objective scientific information to patients about their treatment choices. The foundation’s work in shared decision making helped to make it a common term in both clinical practice guidelines and health policy circles. For its efforts, the foundation received The John M. Eisenberg Award for Practical Application of Medical Decision-Making Research from the Society for Medical Decision Making.
After years of gathering research data, Wennberg became a tireless advocate for healthcare reform on a national level—his goal was to convince key legislators that the federal government needed to invest in outcomes research that could help doctors, patients, and payers understand what really works in medicine. He testified at relevant hearing, suggesting that a research model he and colleagues had developed, called Patient Outcomes Research Teams (PORT), be adopted by a new federal agency—the Agency for Health Care Policy and Research (AHCPR). After a preliminary report comparing treatments for low back pain, assaults on PORT’s methodology from surgeons, along with perceived threats to their livelihood, the agency abandoned the research.
Then in 2009, the American Recovery and Reinvestment Act, the Patient Centered Outcomes Research Institute (PCORI), was charged with doing precisely the kind of research—comparing one treatment to another considering how patients experience them—that the AHCPR had to abandon. PCORI owes its existence and its focus on patient-oriented outcomes to policies whose origins can be traced directly to Wennberg.
Rooted in these findings, the 2010 Patient Protection and Accountable Care Act, and a Vermont law that set the state on a path toward a single-payer system incorporating ideas for improving care, were reflective of the changing understanding of healthcare that led to healthcare reform legislation at both the federal and state level.
Wennberg's research on measuring the outcomes of care helped shape the legislation that created the Agency for Health Care Quality and Research within the U.S. Department of Health and Human Services. Pay for performance—basing physician reimbursement on meeting performance standards—grew out of a model he devised.
He also co-founded, with James Weinstein—then chief executive officer and president of Dartmouth-Hitchcock Medical Center and Dartmouth Hitchcock Health System (now Dartmouth Health)—the Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center, the first entity in the U.S. to promote patients as partners in treatment decisions.
Over the past five decades, Wennberg’s work has inspired an international movement promoting informed patient choice. His colleagues at Dartmouth and other institutions have continued pioneering work that has reshaped the way policymakers and legislators view the healthcare landscape—one that is still plagued by wide variability in both cost and quality.
He authored numerous research articles, many of which are in his anthology, as well as the book “Tracking Medicine: A Researcher’s Quest to Understand Health Care” that provides a framework for understanding and remedying the U.S. healthcare crisis.
Widely recognized for his work, he was especially proud and honored to be named “the most influential health policy researcher of the past 25 years” by Health Affairs magazine in 2007. That year, he also received the Ernest Amory Codman Award from the Joint Commission, the nation's predominant standards-setting and accrediting body in healthcare, for his leadership in using outcomes measures to improve healthcare quality and safety.
Other awards include the National Academy of Medicine’s Gustav O. Lienhard Award for “reshaping the U.S. healthcare system” to focus on objective evidence and outcomes rather than physician preference as the basis for treatment decisions, and for his efforts to empower patients with greater input on decisions about their own care; the Association for Health Services Research's Distinguished Investigator Award; the Richard and Hinda Rosenthal Foundation Award in Clinical Medicine; and the Baxter Foundation's Health Services Research Prize.
Wennberg earned a BA from Stanford University, an MD from McGill Medical School, and an MPH from the Johns Hopkins School of Hygiene and Public Health. He was a member of the Institute of Medicine of the National Academy of Science and the Johns Hopkins University Society of Scholars.
