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Dartmouth Atlas: Putting End-of-Life Care on the Map but Missing Psychosocial Detail

• Holly G. Prigerson, PhD^, ,
• Paul K. Maciejewski, PhD

• Received 10 April 2011. Accepted 2 June 2011. Available online 23 September 2011.

• dx.doi.org/10.1016/j.suponc.2011.06.001

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In many ways, the Dartmouth Atlas has put end-of-life (EOL) care on the map of health-care policy debates. It has proven an invaluable resource to those interested in examining patterns of health-care utilization among elderly patients in the last 2 years of life. Most notably, the Dartmouth Atlas group has spearheaded research demonstrating dramatic regional variability ^{[1], [2], [3] and [4]} in the healthcare provided to patients who have died. We applaud the creation of such a valuable data repository and consider the Dartmouth Atlas to be a remarkable tool for the promotion of an evidence-based evaluation of EOL care. We are also sympathetic with its mission—the reduction of unwarranted non-uniformities and inefficiencies in health-care delivery to terminally ill patients. Like the Dartmouth Atlas authors, we share a concern about the growing number of patients who receive aggressive and extremely costly care near death. ^{[5], [6], [7], [8] and [9]}

Nevertheless, the Dartmouth Atlas alone does not provide a detailed, comprehensive view of the terrain that would be required for a thorough examination of EOL care and the influencing factors. It describes how medical resources are distributed and consumed across the United States at national, regional, and local levels. It also characterizes the aggressiveness of care provided within hospitals to Medicare patients in their final two years of life.⁴ Although it is true large variations exist in the intensity of EOL care that patients receive, we need to look beyond the regional supply of medical resources (eg, number of intensive care unit beds) for more complete explanations of why this is the case. Regional variation is part of the explanation, but we find that at least some, and perhaps considerably more, variance in the aggressiveness of EOL care is better attributed to micro- and psychosocial-level factors than to macro-, regional- or health system–level factors.