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Vital Signs

DMS exports its measurement methodologies

By Amos Esty

Everything in Kosovo's health-care system, from the ambulances that ply the streets of Pristina to the infrastructure in the country's hospitals, needs to be rebuilt.

DMS researchers have become well known throughout the United States for their measurement of usage patterns within the health-care system. Now they're helping to develop similar efforts in other countries, including the small, newly independent nation of Kosovo.

Ties: In 1999, DMS's Dr. James Strickler began working, under the auspices of the International Rescue Committee, with refugees from the Serbian conflict in Kosovo. Since then, he has led a number of initiatives that have forged strong ties between DMS and Kosovo, including student exchanges.

In 2003, a medical student named Ilir Hoxha was one of the Kosovars who visited DMS. The contacts he made at Dartmouth sparked his interest in health-care economics and policy, so Strickler encouraged him to apply for a grant to study at the Dartmouth Institute for Health Policy and Clinical Practice (TDI). In 2009, Hoxha returned to DMS as a Fulbright Scholar and spent four months working with TDI faculty. His aim was to assess whether the methods developed there to study the U.S. health-care system could be applied to Kosovo.

Skeptical: Dr. David Goodman, the director of TDI's Center for Health Policy Research, worked closely with Hoxha. At first, Goodman says, he was a little skeptical of the idea of using TDI's methodologies in Kosovo because of the country's extremely limited resources.

But Hoxha was confident that studying variations in health care was essential in Kosovo, which is still early in the process of rebuilding its health-care system following its decimation during the war. "For a country with few resources, the study of efficient use of resources becomes even more important," he says.

Goodman soon agreed. "In under-resourced countries, small measurements may have very big effects, because the needs are great," he says. "If you start building it in now, you gain benefit as you start reconstructing the health-care system."

Andrew Goodman, a 2010 graduate of the M.P.H. program at TDI (and David Goodman's son), was likewise interested in studying health-care variations in Kosovo, but he had two questions: First, were Kosovar physicians interested in studying variations in the practice of medicine? And second, how much did they already know about the concept? With the help of Hoxha and TDI faculty members, he drafted a survey to answer those questions.

Nuances: After developing the draft, Andrew Goodman spent three weeks in Kosovo this past spring, meeting with physicians and policymakers to get their feedback on the survey. He used their comments and suggestions to hone it, ensuring that it was sensitive to cultural nuances and that the concept of variation was explained clearly.

He and Hoxha had anticipated that knowledge of health-care variations would be quite low, but what they found surprised them. "People are more aware of it than you'd think," Andrew Goodman says. "There was a tremendous amount of interest in learning more."

Critical: Their next step is to disseminate the survey on a large scale. "This is a very critical time for the health-care system," says Andrew Goodman. "The physicians there are amazing people. . . . But there is a lack of feedback."

In 2009, Hoxha returned to DMS from Kosovo as a Fulbright Scholar.

Hoxha, who is now back in Kosovo, plans to develop reports on the health-care system there similar to those issued by TDI, starting by focusing on the care of mothers and infants.

Strickler is glad to see Hoxha working with TDI. "Kosovo desperately needs the kinds of studies of the health-care system that TDI does," he says. "Those studies should lead to the development of cost-efficient health-care programs."

Dartmouth continues to develop connections to Kosovo in other areas as well. Dr. Bujar Bukoshi, Kosovo's minister of health, spent a week in early September at DMS.

And Dr. Michael Zubkoff, chair of DMS's Department of Community and Family Medicine, was recently named to the board of trustees of American University in Kosovo.

Rebuild: "What you want to do," Zubkoff says, referring to Dartmouth's role in Kosovo, "is help them rebuild their own infrastructure. You want to help them retool and take control of their own destiny."

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