Our health care in this country continues to fail us," announced Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF). The occasion was the June 2008 launch of a $300-million initiative to improve the quality of health care across the country. "There are too many patients who don't feel engaged in their health care," Lavizzo-Mourey went on. "There are too many mistakes being made, too much miscommunication, and too much inequity."

Models: With the help of Dartmouth researchers and 14 diverse U.S. communities, the RWJF hopes to develop models for national health-care reform. To guide the initiative, the foundation commissioned a report from the Dartmouth Atlas Project. The report, drawing on Medicare enrollment and claims data, confirmed what Lavizzo-Mourey called "staggering inefficiencies." It also reinforced what many previous Dartmouth Atlas studies have shown—that income and race are important determinants of the care patients receive and that there are significant geographic variations in the delivery of medical care.

"The work underscores the critical importance of focusing reform efforts on the local delivery system," says Dr. Elliott Fisher, the principal investigator for the Dartmouth Atlas of Health Care, which is published by the Dartmouth Institute for Health Policy and Clinical Practice.

Leg: The Dartmouth study was conducted in 14 communities that have been part of RWJF's Aligning Forces for Quality programsince 2006. The researchers examined five differentmeasures of care: leg amputation rates; breast cancer screening rates; diabetes blood-test rates; preventable hospital stays; and the percentage of patients with a primary-care provider.

The most striking finding was that the rate of leg amputations—a complication of diabetes and vascular disease—not only varies among regions but is four times greater in blacks than in whites. There were significant differences in the other four measures, too, including a threefold variation in hospitalizations that could have been avoided with better outpatient management of such conditions as diabetes or heart failure.

Chronic: The 14 communities were chosen in 2006 for the first phase of the RWJF initiative, which focused on improving the quality of care in outpatient settings for patients with chronic conditions. With the new $300-million investment in June, the effort was expanded to include inpatient care, to reduce racial and ethnic disparities in care, and to enhance the role of nurses. Both phases have involved patients, providers, and payers. The premise of the program is that no single person, profession, or group can improve care without the support of others.

Cities: The 14 communities represent 11% of the U.S. population and were chosen to reflect the breadth of the nation. Included are several cities, such as Seattle, Wash., and Memphis, Tenn.; a few regions, like western Michigan; and a few whole states, including Maine. The communities have already begun to show improvements.

The initiative represents a new type of partnership, noted Lavizzo-Mourey. "Improving the quality of care can only take place where patients and best practices converge," she said.