The new Dartmouth Atlas series on variation in the care of surgical conditions, starting with this report on the surgical treatment of obesity, raises new questions regarding surgical management of both common and less frequently occurring medical conditions. This report carefully details the scope of the ever-increasing problem of obesity and, as in previous Atlas analyses, emphasizes geographic practice variation in surgical treatment rates. However, the report also takes a more longitudinal view. The changes over time in which bariatric procedure is favored are particularly fascinating, driven as they appear to be by a mix of clinical evidence—including emerging long-term results—and reimbursement policy. Obese patients will often ask me, as a primary care physician, whether they should have one of these procedures, and, if so, where. These questions have always been hard to answer. Population-based registries, as described in the report, should go a long way toward producing the kind of widely applicable data upon which patient decision support tools should be based. Patients want to know procedure and facility-based risks and benefits. Just as the future of medicine is personalization of diagnosis and treatment, so too the future of decision support is to increasingly provide information tailored to the person and his or her health care environment. Ultimately, it is the active participation of fully informed patients that can address the question of “which rate is right,” so provocatively posed by the Dartmouth Atlas analyses. I enjoyed reading this report and will look forward to future analyses targeting other common, preference-sensitive interventions.

Michael J. Barry, M.D.

President, Informed Medical Decisions Foundation

Clinical Professor of Medicine, Harvard Medical School