Wednesday, November 16, 2011

Uninsured patients released from hospital sooner than insured: Significant? You tell me.

There’s a bit of excitement on Twitter today with a number of tweets and retweets about a paper just published in the Annals of Family Medicine which shows that uninsured patients are being released from  hospitals significantly sooner than insured patients. The numbers don’t lie.

From the abstract: “Across all hospital types, the mean length of stay … was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01).” These are statistically significant differences.

The authors conclude, “Future research should examine whether patients without insurance are being discharged prematurely.”

Let’s look a little closer at these numbers. The difference between the uninsured length of stay (2.77 days) and those with private insurance (2.89 days) is 0.12 days or to put it another way, 2.9 hours.

Do you really think that a difference in hospital length of stay of less than 3 hours is really clinically significant? I don’t.

Here’s another problem with the paper. Length of stay is what is called a “soft” endpoint. Having practiced surgery for 40 years, I can assure you that length of stay is very often not determined by the type of illness, treatment rendered, skill of the physician or any other parameter you can think of.

Here is what I mean. Just yesterday, a patient told me he could not go home on the day he had his laparoscopic cholecystectomy because his sister, whom he lives with, gets upset whenever he comes home from the hospital. He felt she needed another day to adjust. Patients have told me, “No one can come and pick me up today.” The care manager says, “The bed at the nursing home isn’t available today.” Three weeks ago we couldn’t send some patients home because there was a massive power outage in our area. This list of excuses goes on and on.

I have written before about the problem of things being statistically significant but not clinically significant.

The paper is another example of statistical significance not corresponding to clinical significance.


Unknown said...

Interesting to see that although health systems radically different, you guys across the pond get the same irritating reasons for delayed discharge. I'm a cardiac surgeon in UK

Skeptical Scalpel said...


Thanks for the comment. I could have listed many more.

Lastone2join said...

Completely agree. My usual dilema: Delay discharge by 2 days so patient makes it home? Or discharge to nursing home so statistically length of stay is shorter to appease these idiots? More associated costs with the later. I'm seeing many hospitalists choosing the later.

Philip said...

Often, the excuses like "I don't have a ride" or "my sister can't help me this week" translate to "if you send me home today, I'm coming right back the the ER at 4am as a bounce back." Sometimes its better to let people stay and save the expense and hassle. Seems like the uninsured have more of these issues than people who manage their lives well, plan, and design support structures in the event of illness or other calamity. Also, keep those posts coming. Blog seems to get better every time it pops up in my feed reader.

Skeptical Scalpel said...


Thanks for the comments. I agree. It's easier to let them go to a nursing home or rehab than fight the battle to discharge them home.


When a patient balks at going home, I just give in. No amount of talking will convince them that they can leave, even if you tell them insurance won't pay. They don't care and they just get angry with you.

Anonymous said...

As ever, "the median is not the message."

Would be more interesting to see whether this clinically irrelevant difference is due to a clinically relevant difference in smaller sub-groups ... of course, would need to be a planned analysis. if unplanned (data-mining) would only be hypothesis-generating ...

Skeptical Scalpel said...


I agree with you. What I don't understand is how such a paper could be (a) published and (b) reported as fact by so many so-called news outlets? It was also tweeted by a lot of people without any critical comments.

Maybe I do understand. The paper supported the "politically correct" point of view that the uninsured are mistreated. They are in a lot of instances, but this paper doesn't prove anything.

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