Medical science provides clear guidelines about the need to hospitalize patients with some conditions. For patients with these conditions, the need for specific kinds of care determines what will be done, and the use of medical resources is not influenced by either the physician’s practice style or the per capita supply of hospital beds in the region. For example, patients with hip fractures are almost always hospitalized, because of the severity of their pain and the need for inpatient operative repair. Similarly, patients with newly diagnosed colorectal cancers are almost always hospitalized, because major bowel surgery is the universally accepted method of treating the disease.

But for many other conditions, medical science and theory are weak, and the rules of clinical practice are not nearly so clear cut. In the majority of cases of pneumonia, relapses of chronic pulmonary obstructive disease, or episodes of congestive heart failure, patients could be treated either in the hospital or in another setting (at home or in a nursing home, for example). When medical science is unclear, physicians must be guided by their subjective opinions about the effectiveness of admitting such patients to hospitals, rather than providing treatment in another setting. The variations among regions in admission rates of patients with these conditions can be ascribed to differences in clinical decision making, rather than to differences in underlying illness rates.

When science-based guidelines are weak, decisions to hospitalize are also influenced by a largely invisible factor: the capacity of the acute care hospital environment in which decisions are made. There is strong evidence that for the majority of conditions, decisions about hospitalization are dependent on physicians’ practices, which are influenced by local hospital capacity (although physicians are not aware of the per capita bed supply). When decision making takes place under the assumption that more medical care is better, it is understandable that physicians will use available resources up to the point of their exhaustion. In other words, for sick patients whose care could be managed in either the hospital or the ambulatory setting, the availability of hospital beds leads to increased use of those beds. In conditions where hospitalization is a judgment call, one of the considerations is the availability of hospital beds. The result is that variations in the rates of hospitalization are often driven by supply, rather than need.

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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.