Variations that arise because of net differences in the incidence of illness among populations or because the patients living in different areas have different preferences for health care are “wanted” variations. However, as previous editions of the Atlas have demonstrated, most of the variation among regions can be explained by factors other than patient preference. Both the amounts and types of care provided are highly dependent on two factors: the capacity of the local health care system (which influences how much care is given) and the practice styles of local physicians (which determine what kind of care is given). Other factors might include patients’ access to care, advertising, and cultural issues.

The present edition of the Dartmouth Atlas shows that Michigan is like the rest of the nation. The Atlas documents:

• Systematic underuse of services known to be effective and wanted by most patients;
  
  
• Wide variations in the use of discretionary treatments, such as elective surgery;
  
  
• Wide variations in the intensity of care, such as hospitalizations for medical conditions, end of life care, and the use of prescription drugs.

The issue of unwanted variations is receiving increased public attention. The National Academy of Sciences recently convened the National Roundtable on Health Care Quality to assess the problem of quality of care in the United States. The Roundtable concluded:

“Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse and misuse of care, occur in small and large communities alike, in all parts of the country and with approximately equal frequency in managed care and fee-for-service systems of care.”

In this chapter, “best practice” benchmarks are used to evaluate the extent of underuse of effective, wanted services, including mammography, screening for colorectal cancer, diabetic eye examinations and use of life saving drugs for patients with heart attacks. The overuse of discretionary surgery is evaluated by using benchmarks from health plans and hospital referral regions where patients have been fully informed about their treatment options and encouraged to choose surgery according to their own preferences. The issue of unwanted variations in the intensity of hospitalizations, end of life care, and the use of prescription drugs is framed within the context of our failure to find evidence that more of these kinds of care is better than less.

The problem of unexplained variations seems worthy of wide social debate. Our hope is that the Atlas will stimulate such a debate in Michigan.

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NOTICE TO ATLAS READERS
While not giving answers, the atlas raises questions about health care service use that merit careful consideration. "High" rates of use are not necessarily bad and "low" volumes good (or vice versa). Our goal is to move toward rates that are consistent with high quality health care, which need to be determined with local clinical, community and patient discussion and dialogue.

The atlas is not a physician or hospital report card. When reviewing data, note that the Hospital Service Areas in the atlas were defined by the atlas author. They may differ significantly from what a hospital considers its market area.