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This is a study that should stick a major fork in the the argument that many opposed to Health Care reform like to make, because that argument is done. The discredited argument? "People can always get emergency care they need at the ER, and it's the same quality".

Well, by one metric...a rather important one...it's not.

That metric? Dying.

ETA: Link to actual study, courtesy of commenter :).

From the article:

The findings by Harvard University researchers surprised doctors and health experts who have believed emergency room care was equitable.

"This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States," said senior author Dr. Atul Gawande, a Harvard surgeon and medical journalist

.

I'm semi-live blogging the article, since I'm reading and posting at the same time. This leaves me wondering "what's the proposed mechanism of poorer care?"

The researchers couldn't pin down the reasons behind the differences they found. The uninsured might experience more delays being transferred from hospital to hospital. Or they might get different care. Or they could have more trouble communicating with doctors.

The hospitals that treat them also could have fewer resources.

Alright, so they can't quite pin down the reason. But I rather think the latter is a strong reason. Not far from where I sit right now is an extremely busy ER where most of the uninsured in my city get their emergency care. And, the waits there are far longer than other ER's, to the point where if you have insurance you just plain don't go to that ER.

OK, so they've found that uninsured are more likely to die. What factors did they control for?

The researchers took into account the severity of the injuries and the patients' race, gender and age. After those adjustments, they still found the uninsured were 80 percent more likely to die than those with insurance — even low-income patients insured by the government's Medicaid program.

Seems like they did a pretty good statistical analysis to me.

Another possible mechanism, courtesy of a researcher who was "surprised" and wasn't involved with the study:

Some private hospitals are more likely to transfer an uninsured patient than an insured patient, said Lavonas, who wasn't involved in the new research.

"Sometimes we get patients transferred and we suspect they're being transferred because of payment issues," he said. "The transferring physician says, 'We're not able to handle this."

Ah, patient dumping. Some claim it doesn't happen...but it does. Adhering to the letter of the law while violating the spirit of the law, I see.

And, finally, some study statistics:

In the study, the overall death rate was 4.7 percent, so most emergency room patients survived their injuries. The commercially insured patients had a death rate of 3.3 percent. The uninsured patients' death rate was 5.7 percent. Those rates were before the adjustments for other risk factors.

The findings are based on an analysis of data from the National Trauma Data Bank, which includes more than 900 U.S. hospitals.

This study should be good ammunition to push Health care reform. It shows that the common "meme" that if you need life-saving care, you can get it, regardless of your insurance status still ends up being wrong, in that you're more likely to die without insurance.

I'm not familiar with the journal it's being published in but it seems reputable. I'm presuming this is a peer-reviewed study and Harvard has few, if any, crap researchers.

Brief aside at the end: I got to be one of the few non-Palin, non-bowing journals today. And this wasn't even the one I was planning on, this came up as soon as I saw the article. I'll have to keep an eye out on the usual suspects to see what other web sites post it.

Originally posted to chparadise on Mon Nov 16, 2009 at 02:31 PM PST.

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Comment Preferences

  •  I've been in emergency rooms about 20 times over (13+ / 0-)

    my lifetime, about 1/3 were at times when I was uninsured.

    What I notice is that if you are uninsured and there is a doubt about your condidition they often park you in a hallway on a gurney to see if you improve or they have to admit you.  But, they wait until they absolutely have no further excuse.

    This happened when I had food posioning when I was about 20.  I spend the whole night in the hallway while trying to decide if I needed to be admited for hepatitus or if it was a simple food poisening.  By morning they decided whatever it was wasn't lifethreatening so they let me go.

    I also have chronic diverticulosis which when infected becomes diverticulitis.   Over the last 20 years whenever I've gone to the emergency room with abdominal pains, with private insurance, they do Catscans or MRI then admit me.

    Whenever, I've gone without insurance they sometimes will do a Catscan but never have admitted me.

    Whenever I've3 gone as a Medicare patient, they always do Catscans and then wait about eight hours and then don't admit me.

    The means is the ends in the process of becoming. - Mahatma Gandhi

    by HoundDog on Mon Nov 16, 2009 at 02:54:50 PM PST

  •  They die because there's no follow-up care. (10+ / 0-)

    And we need to start pointing out to people that emergency rooms did, in fact, once turn people away if they couldn't demonstrate a means to pay.
    That was waaaaaaaaayyyyyy back....well, actually it was stopped only about thirty freakin' years ago!
    And it took federal regulation to make it end.
    Now, an ER must stabilize or determine that the patient is stable.
    Then, they're done with them.
    They discover you have breast cancer?
    They're not going to give you chemo, or radiation, or surgery.
    They're going to tell you to take something to make yourself comfortable.
    Oh, and follow up with an oncologist who you cannot pay.

    Doesn't "Stupak" sound like a political action committee for stupid people?

    by jazzmaniac on Mon Nov 16, 2009 at 03:02:56 PM PST

    •  Okay, turns out the story specifically (7+ / 0-)

      mentions uninsured ER patients being more likely to die in the hospital.  So my point about follow-up care, while valid, doesn't apply to this study.
      I'd say it's probably from a combination of poorer general health due to the lack of insurance, and quite possibly from receiving poorer care in the ER once their lack of insurance is discovered.

      Doesn't "Stupak" sound like a political action committee for stupid people?

      by jazzmaniac on Mon Nov 16, 2009 at 03:06:47 PM PST

      [ Parent ]

      •  It may even be a combo of (1+ / 0-)
        Recommended by:
        Alexandra Lynch

        subconscious and conscious neglect on the part of the ER docs and nurses.

        The ER near me people literally check themselves in with a touch screen. Triage I think is done slower so that might end up contributing a bit. I don't know their stats compared to others in my area, which would be the best "comparison set".

        We're all human, aren't we? Every human life is worth the same, and worth saving. - Kingsley Shacklebolt

        by chparadise on Mon Nov 16, 2009 at 03:14:48 PM PST

        [ Parent ]

  •  They literally wait till they're on death's door (8+ / 0-)

    before they go to the emergency room.

    "A man of true science uses but few hard words, and those only when none other will answer his purpose..." - Melville

    by ZedMont on Mon Nov 16, 2009 at 03:08:48 PM PST

  •  This refutes the "do nothing" crowd on the Left.. (6+ / 0-)

    ..as well. Failure to pass even a "watered down" bill will result in more deaths. The only difference will be that we will no longer be able to just point the finger of responsibility at the Right or insurance companies, if we allow this to fail, we will have blood on our hands as well.

    We simply must get everyone covered or as damn close as we can get.

    "Most people would sooner die than think; in fact, they do so." ...Bertrand Russell

    by sebastianguy99 on Mon Nov 16, 2009 at 03:12:39 PM PST

    •  Not really. (3+ / 0-)
      Recommended by:
      SarahLee, Kitsap River, CMYK

      I am both one of those who believes Stupak needs to be stripped and a strong public option put in, or I don't care if it passes AND one of those without health insurance who hasn't been to a doctor in years.

      I was so excited about the possiblity of finally going to a doctor it made me weep. Now, I'd rather go die on the steps of the Capitol than accept this giveaway to the insurance companies that does nothing to control costs and still takes away LEGAL rights by religious interference while forcing citizens to purchase the product of a private corporation.

      I'm sorry so many of us don't have the access we need to care. But this bill is horrible in many, many ways. I'd rather get nothing and wait for another Congress that has some compassion and sense and will stop giving the whole country away to corporations.

      "The difference between the right word and the almost-right word is like the difference between lightning and the lightning bug." -- Mark Twain

      by Brooke In Seattle on Mon Nov 16, 2009 at 04:51:58 PM PST

      [ Parent ]

      •  Hey - I'me thinking of doing my death on the (2+ / 0-)
        Recommended by:
        Alexandra Lynch, CMYK

        steps of the capital, too.  Maybe I'll see you there and we can have a last meal together.

        I do have packets made up already - full of my medical bills, tax returns, rejections from insurance companies as well as copies of letters I've sent to reps and committee chairs.  I have a packet for each of my Congress critters, plus committee chairs like Baucus.  I've got a good cover sheet story and instructions with my living will about including final bills before mailing the packets to the assholes that took single payer off the table and left millions of us to die.

        •  Hey, if you guys are up for it... (1+ / 0-)
          Recommended by:
          Charles CurtisStanley

          I seriously think we are not going to get real health care reform (with, at minimum, a strong public option, major cost controls on insurance premiums, and major controls on denials by insurers) unless somebody or a lot of somebodies do something really dramatic to demonstrate the need for it. Something that will catch the eye of the media and the public and turn opinion to an extent that Congress cannot ignore it, no matter what their corporate masters tell them to do.

          I have thought for a while that a bunch of people should stage a real die-in at the Capitol. As in, the people would be terminally ill and they would all go there to die simultaneously. While we have a death-with-dignity law in this state, I don't think it states that you have to die here. Even if it did, I wonder if we couldn't get enough people together who were terminally ill and committed to doing this...

          I will commit to this if we can get enough people. Charles doesn't want me to do it but understands why I feel I need to.

          I could live a lot more years on dialysis and even more if I got a kidney but you know, I can only ever live by medical technology. Not on my own. So maybe it's time.

          Living kidney donor needed; type B, O, or incompatible (with paired donation). Drop me a note (see profile).

          by Kitsap River on Tue Nov 17, 2009 at 12:13:42 AM PST

          [ Parent ]

          •  I'm not going to die for the Public Option (0+ / 0-)

            Sorry.

            You folks do what you must. I'm gong to take all the coverage I can get, as right now I can;t get any.

            There are programs that will help you pay all or most of high cost insurance plans, if you can get coverage. Trouble is, in some states, they don't require insurance companoes to cover those with preexisting conditions.

            So for some of us, it's about getting coverage and I really could care less if the insurance company makes more profit if it means I get to live.

            If we live, we get to continue to fight and improve things. So no, I'm not going to join any death pack, thanks and good luck with that.

            "Most people would sooner die than think; in fact, they do so." ...Bertrand Russell

            by sebastianguy99 on Tue Nov 17, 2009 at 02:40:24 AM PST

            [ Parent ]

  •  Delayed & Different Care for Uninsured (8+ / 0-)

    from the comments in the published study (my bold)

    Lack of insurance may affect mortality by several mechanisms because payer status can affect many processes of care. First, uninsured patients may experience treatment delay, thus contributing to the observed increased odds of mortality due to trauma. The purpose of the Emergency Medical Treatment and Active Labor Act (passed in 1986) is to ensure that payer status would not sway a hospital's decision to provide emergent care; it states that a patient may not be transferred from one hospital to another or refused necessary treatment when medically unstable.20 A study of pediatric orthopedic injuries21 found that children insured by Medicaid, those receiving charity care, and those who were uninsured experienced a delay in care for injuries when compared with privately insured children. In addition, a higher percentage of publicly insured and uninsured children had visited multiple emergency departments and hospitals before being treated definitively. A 2006 study of the NTDB22 revealed that minorly injured (ISS, 0-3) uninsured patients and those insured by Medicaid (compared with commercially insured patients) were more likely to be transferred to a level I trauma center after controlling for confounders such as comorbidities, age, sex, and others. The same finding was also elucidated in another study of patients who had sustained femur fractures.23 A significant delay in definitive care of transferred patients could increase the number of missed injuries or complications and prolong the hospital stay.

    Second, uninsured patients may receive different care than insured patients. Despite the Emergency Medical Treatment and Active Labor Act, hospitalized trauma patients were found to have differences in care based on payer (insurance) status; uninsured trauma patients were less likely to be admitted to the hospital and received fewer services during their admission compared with insured trauma patients.11 A study24 of 16 562 emergency department visits (in patients with similar ISS) at a single tertiary care teaching hospital showed that, although uninsured and insured patients were treated similarly in terms of the number of laboratory tests ordered, whether they received consultations, and the length of stay in the emergency department, uninsured patients received significantly fewer radiographic studies and were less likely to be admitted compared with insured patients with similar diagnoses.

    The study was conducted at Harvard and the sample size is large.

    Private health insurers always manage to stay one step ahead of the sheriff - Sen. Sherrod Brown

    by Betty Pinson on Mon Nov 16, 2009 at 03:17:55 PM PST

  •  Much less to this than meets the eye. (2+ / 0-)
    Recommended by:
    ladybug53, Alexandra Lynch

    This study explicitly addressed only ER care for trauma. Therefore you're examining a narrow subset of emergency room visits— car crashes, burns, gunshot wounds, falls. The statistics are already skewed in the direction of violent events, drunk driving, altercations, drugs & alcohol, with a smattering of unsteady older patients (falls). This subgroup is not at all representative of the larger ER patient population.

    If you then limit that subset further by addressing only the uninsured, you're automatically looking at an extremely high-risk group of patients. You've excluded everyone with Medicare, i.e. the older patients. You're excluding young people with the gumption to sign up for Medicaid. You're excluding everyone with employment-based insurance.

    The remaining extremely narrow demographic of uninsured trauma patients includes the vast majority of urban gunshot victims, who are disproportionately single, African American, poor, and more likely to be using alcohol or illegal substances. It includes a hugely disproportionate fraction of substance abusers. It includes young auto accident victims, who are disproportionately likely to be drunk or otherwise impaired. This demographic is a priori guaranteed to experience more bad outcomes than insured patients by its very composition.

    This is almost a perfect example of how to design a misleading study.

    •  Oh rly? (3+ / 0-)
      Recommended by:
      rgjdmls, huntergeo, CMYK

      Controlled factors:

      Race
      Gender
      Age
      Severity of injuries.

      Try again.

      We're all human, aren't we? Every human life is worth the same, and worth saving. - Kingsley Shacklebolt

      by chparadise on Mon Nov 16, 2009 at 03:21:08 PM PST

      [ Parent ]

      •  Those controls are not remotely sufficient. (0+ / 0-)

        As you probably know, controlling for only these demographic markers will not catch anything like all relevant distinctions between subgroups.

        Without controlling for income, socioeconomic status, place/type of residence, ad nauseum it's way too easy to get skewed or misleading results. This is the achilles heel of such retrospective studies, and has led to numerous erroneous conclusions in the past, some with seriously bad consequences. (Remember the ringing endorsement of estrogen replacement that resulted from retrospective studies? And the 180° change once good prospective studies were done?)

        Don't get me wrong, the uninsured crisis is an ongoing moral atrocity. I personally favor single payer, Medicare for all as the answer. I have no doubt that the uninsured get shabbier and less effective care in many/most locations.

        But I am unconvinced that this study truly proves the point. Too many methodologic issues.

        •  If you're right (1+ / 0-)
          Recommended by:
          Ralphdog

          It'll spur a lot of "f you, that study is wrong" research. And that can only be good, in the end, since we'll get more info.

          We're all human, aren't we? Every human life is worth the same, and worth saving. - Kingsley Shacklebolt

          by chparadise on Mon Nov 16, 2009 at 06:00:46 PM PST

          [ Parent ]

    •  The sample included all trauma patients (5+ / 0-)

      they analyzed data based on age, insurance status, etc. The used data from the National Trauma Data Bank.

      Across varying age groups, patients w/ insurance fared better than those without.

      Private health insurers always manage to stay one step ahead of the sheriff - Sen. Sherrod Brown

      by Betty Pinson on Mon Nov 16, 2009 at 03:40:29 PM PST

      [ Parent ]

      •  I just noticed the "n" and the other (7+ / 0-)

        average stats...this was a whopping data analysis

        n=687 091

        Patients were likely to be male (65.9%) and white (66.9%), with a mean age of 45.4 years

        Reading through, there's a treasure trove of secondary data that the headlines didn't even bother mentioning.

        My only concern, but with this many "n" it probably evens out, is the subjectivity of the "injury severity score", but I would think that the way of judging that is well-established and it's probably been used in other studies too

        We're all human, aren't we? Every human life is worth the same, and worth saving. - Kingsley Shacklebolt

        by chparadise on Mon Nov 16, 2009 at 03:44:56 PM PST

        [ Parent ]

    •  Bet if we pass a public option (4+ / 0-)
      Recommended by:
      SarahLee, ladybug53, Ralphdog, chparadise

      these disparities in outcome go away for this subset. The idea that treatment is equal for those with an inability to pay defies all logic of human nature. Hell, it even defies logic of the market, if wingnuts need convincing.

      It's not a campaign anymore, Mr. Obama.

      by huntergeo on Mon Nov 16, 2009 at 03:45:00 PM PST

      [ Parent ]

  •  There are probably a lot of factors that (5+ / 0-)

    bear on this data.  Of course, preexisting undiagnosed chronic disease may be one of the biggies.
    One of the more subtle ones may be the relationship between the patient and the caregivers.  Without insurance the patient is a priori a bit suspicious that they will not be treated well.  The doctors and nurses are a bit suspicious that the patient is "against" them.  I have heard a myriad of times from doctor colleagues that they think it's the uninsured that are out to sue them.  
    It's a pathetic situation for delivering good care when the relationship is founded on animosity.  There is no cure for this suspicion without going to single payer.  Medicaid patients are treated similarly to "self-pay" patients, ie poorly.  The poor treatment may not be conscious on the part of anybody but it still happens.  The descriptors that I have heard doctors use for the poorer folk in our community are beyond the pale.  Somehow I doubt those words would be heard in Canada or France.  
    For my own part, when called to the ER to see a patient, I do not look at their payer status before I see the patient and decide on a treatment course.  Occasionally I am forced to ask because I have to know what kind of medication they can actually get before I bother to prescribe or the Rx may remain unfilled and the disease will march on.

    I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

    by fayea on Mon Nov 16, 2009 at 04:04:25 PM PST

  •  I think it's more geographic differences (2+ / 0-)
    Recommended by:
    CMYK, chparadise

    as the authors commented on.  Uninsured patients tend to be grouped in areas where there aren't the best hospitals.  I'd like to see this sorted out comapring uninsured care vs insured care in certain communities.  

    Interesting though.

    •  That's a quite plausible mechanism (3+ / 0-)
      Recommended by:
      SarahLee, Hope08, CMYK

      To me, a good follow-up study would be to compare outcomes within the same geographical area - that could be more difficult or have a greater uncertainty due to lower "n" numbers but it's something that I think the data exists to go see if it's a factor.

      We're all human, aren't we? Every human life is worth the same, and worth saving. - Kingsley Shacklebolt

      by chparadise on Mon Nov 16, 2009 at 04:34:51 PM PST

      [ Parent ]

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