Skip to Main Content


James is an 11-year-old boy who has had a persistent dry cough and sore throat for the past 3 weeks. Overall he feels fine but just cannot seem to shake this nagging cough. He has had three separate sore throats this winter. His mother is a bit concerned because her older son did not seem to get as many colds while he was in elementary school. She takes him to the pediatrician to get “checked out.” The pediatrician examines the young boy and reassures her that overall he is healthy and doing okay, but that due to three episodes of a sore throat, he recommends that James get a tonsillectomy.

Tonsillectomies are the most common procedures performed in children under general anesthesia, and have been so for nearly a century.1 A 1938 report by a British surgeon named J Alison Glover to the Royal Academy of Medicine in the United Kingdom showed a threefold difference in tonsillectomy procedure rates across communities cared for by clinicians in Oxford and Cambridge.2 Around the same time, a study of typical 11-year-old children in New York City found 93.5% of them either had already had a tonsillectomy or were recommended to have the procedure when sequentially evaluated by study physicians.1 In contrast, if you were an 11-year-old in some other parts of the country in the 1930s, it was unlikely that anyone ever recommended your tonsils be removed. Who actually benefits from tonsillectomies has been a point of contention for decades, with very little consensus.1

The rates of many medical and surgical procedures vary impressively between areas in the United States—no matter how big or small you define the area. Much of this variation has not been linked to better outcomes. In fact, there is no consistent correlation between more healthcare utilization and measures of quality for various diseases.3


In 1973, Dr John Wennberg published a landmark article in Science that revealed the degree of small area variations in healthcare delivery.4 This formed the basis of a lifetime of work dedicated to identifying and defining healthcare variations. The epicenter of this work has become the Dartmouth Institute for Health Policy and Clinical Practice, which was founded by Dr Wennberg in 1988 (at that time it was called The Center for the Evaluative Clinical Sciences located within Dartmouth Medical School). Since the 1980s, experts at the Dartmouth Institute for Health Policy have used administrative data, primarily Medicare claims, to show significant variation in both spending and quality of medical care across geographic regions in the United States, notably finding no consistent correlation between the two.5

The most iconic contribution of this work was the development of the Dartmouth Atlas of Health Care (available at, which was first published in 1996 and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.