Uninsured patients twice as likely to die in the ER (study)

[iBlue]

CHICAGO — Uninsured patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance, according to a troubling new study.

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.

The study, appearing in the November issue of Archives of Surgery, comes as Congress is debating the expansion of health insurance coverage to millions more Americans. It could add fodder to that debate.

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.

"Those hospitals tend to be financially strapped, not have the same level of staffing, not have the same level of surgeons and testing and equipment," Gawande said. "That also is likely a major contributor."

Gawande favors health care reform and has frequently written about the inequities of the current system.
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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.

"I'm really surprised," said Dr. Eric Lavonas of the American College of Emergency Physicians and a doctor at Denver Health Medical Center. "It's well known that people without health insurance don't get the same quality of health care in this country, but I would have thought that this group of patients would be the least vulnerable."

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.'"

Federal law requires hospital ERs to treat all patients who are medically unstable. But hospitals can transfer patients, or send them away, once they're stabilized. A transfer could worsen a patient's condition by delaying treatment.

The researchers analyzed data on nearly 690,000 U.S. patients from 2002 through 2006. Burn patients were not included, nor were people who were treated and released, or dead on arrival.

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.

"We have to take the findings very seriously," said lead author Dr. Heather Rosen, a surgery resident at Los Angeles County Hospital, who found similar results when she analyzed children's trauma data for an earlier study. "This affects every person, of every age, of every race."

http://www.huffingtonpost.com/2009/1..._n_359718.html


Shameful but I'm hardly surprised. American healthcare, f*** yeah!

[mactastic]

Funny thing is, we have conservatives running around saying that "every American already has access to health care". Of course, this is what they're talking about...

[jav6454]

It is obvious and is a sad thing. No medical insurance means no way of paying for secondary treatment so people don't get it. End result medical condition worsens and voilà, another statistic. Sad.

[Zombie Acorn]

Why do the people not have insurance, did they study that? If its monetarily related it may be valid, but as most people know insurance companies deny coverage to those who are undue risk, usually those more susceptible to death from other illness.

[yg17]

Originally Posted by Zombie Acorn

Why do the people not have insurance, did they study that? If its monetarily related it may be valid, but as most people know insurance companies deny coverage to those who are undue risk, usually those more susceptible to death from other illness.

This article references traumatic injuries. Being diabetic or having high blood pressure has no effect on your chances of being in a car accident or falling off a ladder.

[Zombie Acorn]

Originally Posted by yg17

This article references traumatic injuries. Being diabetic or having high blood pressure has no effect on your chances of being in a car accident or falling off a ladder.

If you are uninsured due to prior health concerns, you are more likely to die than someone who is deemed healthy enough to be insured. Also if you are a diabetic it doesn't effect your chances of falling off of a ladder, but it will heighten your chances of dieing due to the injury. I know diabetic people who get a bruise that won't go away for weeks at a time.

[yg17]

Originally Posted by Zombie Acorn

If you are uninsured due to prior health concerns, you are more likely to die than someone who is deemed healthy enough to be insured. Also if you are a diabetic it doesn't effect your chances of falling off of a ladder, but it will heighten your chances of dieing due to the injury. I know diabetic people who get a bruise that won't go away for weeks at a time.

So you're saying it's OK to let someone die of their injuries because of a pre existing condition? Because that's the impression I get from your posts.

[harperjones99]

Originally Posted by Zombie Acorn

If you are uninsured due to prior health concerns, you are more likely to die than someone who is deemed healthy enough to be insured. Also if you are a diabetic it doesn't effect your chances of falling off of a ladder, but it will heighten your chances of dieing due to the injury. I know diabetic people who get a bruise that won't go away for weeks at a time.

Follow up care is the kicker for uninsured people...no doctor or nurse will let you die in an emergent situation based on your coverage...but they will send you a giant bill after and it's not their problem if you don't get follow up care.
This can ruin people's lives in the US...one major medical bill and it's all over.

I don't think Zombie is saying it's ok to let someone die...I think he was pointing out why many people are uninsured...they are denied because of existing medical problems. It is a crime really.

[Zombie Acorn]

Originally Posted by yg17

So you're saying it's OK to let someone die of their injuries because of a pre existing condition? Because that's the impression I get from your posts.

No, just questioning the validity of the study, it doesn't make the outcome any better.

[mactastic]

Originally Posted by Zombie Acorn

...someone who is deemed healthy enough to be insured.

The entire problem with the free-market approach to health care summed up in half a sentence, folks.

Thanks for doing the heavy lifting ZA...

[Zombie Acorn]

Originally Posted by mactastic

The entire problem with the free-market approach to health care summed up in half a sentence, folks.

Thanks for doing the heavy lifting ZA...

You may not have posted since I switched my opinion on gov. health insurance. I have been an advocate for a while, in fact I criticize the current bill because it doesn't go far enough to create an efficiency through scale, and instead feeds private industry through government intervention (something I have always despised)

[abijnk]

Originally Posted by Zombie Acorn

No, just questioning the validity of the study, it doesn't make the outcome any better.

This isn't a question of validity. It doesn't matter if the person has "pre-existing conditions" or was deemed un-insurable (whatever that means). I see what you are getting at, but that, as I see it, is actually the point. The people who need to be insured the most, who need the help the most, are the people who aren't getting it and are dying because of it.

[harperjones99]

Originally Posted by mactastic

The entire problem with the free-market approach to health care summed up in half a sentence, folks.

Thanks for doing the heavy lifting ZA...

I am generally fairly conservative but this is one thing I do agree with...making health care a business is so full of conflicts and failures it is obscene. I don't have a good answer how to pay for it but I do know that it would be a lot cheaper to pay for if the ridiculous costs were controlled. If someone goes and pays cash because they are not insured they still have to pay insane prices. The costs are just entirely unreasonable and not justifiable.

[mactastic]

Originally Posted by Zombie Acorn

You may not have posted since I switched my opinion on gov. health insurance. I have been an advocate for a while, in fact I criticize the current bill because it doesn't go far enough to create an efficiency through scale, and instead feeds private industry through government intervention (something I have always despised)

Interesting. What prompted your conversion away from the Gospel according to Ayn?

[Sun Baked]

I'm glad I'm not in THAT ER study.

But I got my appointment for a new lab rat position ...

[Gelfin]

I will cut right to the chase and hypothesize that what this reveals is that classism is much harder to eliminate from the human psyche than we would, in our more idealistic moments, like to hope. Beneath the polished veneer of rational egalitarianism found in post-enlightenment societies is a gnarled substrate of subconscious heuristics for setting our expectations of one another, crawling with subtle prejudices.

There are few things that could influence the course of one's treatment in quite the way of a subtle and inchoate assumption on the part of one's doctor. It is precisely this sort of assumption that can creep into a prognosis on the basis of a spontaneous estimate of what sort of person the patient is, and although it may say more about my faith in human beings than the subject at hand, I am skeptical whether even extensive medical experience can fully burn that tendency out of a person's brain.

It is a testable hypothesis. If I am even partly correct, and I would very much like not to be, then it should be the case that even in the UK, people with titles will tend to have better outcomes than commoners, ceteris paribus, and possibly that people with private coverage will tend to have better outcomes than people covered by the NHS alone.

[.Andy]

Interesting and atrocious outcome but alas I don't think healthcare opposition has ever been based on facts. It's ideological with "my tax money" being the crux.

[Zombie Acorn]

Originally Posted by mactastic

Interesting. What prompted your conversion away from the Gospel according to Ayn?

Some convincing statistics from other health care systems, and a realization that there was no reason this shouldn't be considered infrastructure of a nation.

About a month after my realization the dems/baucus dropped the ball by forcing everyone to jump into the private insurance industry pool. Disappointment at every turn, that is why I should be the world leader. Fair and balanced.

[mactastic]

Originally Posted by Gelfin

I will cut right to the chase and hypothesize that what this reveals is that classism is much harder to eliminate from the human psyche than we would, in our more idealistic moments, like to hope. Beneath the polished veneer of rational egalitarianism found in post-enlightenment societies is a gnarled substrate of subconscious heuristics for setting our expectations of one another, crawling with subtle prejudices.

This is certainly part of the issue, but I suspect that economic issues play a larger role. As a "for instance", I have a friend who's husband badly injured his thumb one day while working around heavy equipment. He was rushed to the hospital, but didn't have his proof of insurance on him. The doctors were preparing to stitch him up and send him home, despite his claim that he was unable to feel the tip of his thumb.

His wife, a teacher, has excellent insurance for their family. Luckily, she showed up in time, insurance card in hand. He was almost immediately wheeled into surgery, where they were able to repair the nerve damage and provide feeling in his thumb again.

I can only imagine that the economics of treatment factor heavily into the decisions about treating the uninsured. Basically, the hospital will do the minimum required by law for anyone without insurance. That necessarily means that with inferior treatment, you are more likely to die.

Using today's accepted logic, one could claim that such a system is a "death panel"...

[mactastic]

Originally Posted by Zombie Acorn

Disappointment at every turn...

That's Democrats for ya!

[mkrishnan]

Originally Posted by jav6454

It is obvious and is a sad thing. No medical insurance means no way of paying for secondary treatment so people don't get it. End result medical condition worsens and voilà, another statistic. Sad.

Actually, it's not completely obvious... from a purely surface standpoint, I can say that, having worked in level one trauma, there are not gross differences in the way uninsured individuals are treated (at least at the hospital where I did this) emergently. I think the general consensus is that the mortality statistic was higher in this group, but most of us who have worked in this kind of field would not have predicted this magnitude of difference....

Originally Posted by Zombie Acorn

Why do the people not have insurance, did they study that? If its monetarily related it may be valid, but as most people know insurance companies deny coverage to those who are undue risk, usually those more susceptible to death from other illness.

Originally Posted by yg17

This article references traumatic injuries. Being diabetic or having high blood pressure has no effect on your chances of being in a car accident or falling off a ladder.

FWIW those pre-existing conditions do have an effect on your outcome.

Statistically the uninsured actually end up being in more severe traumas for a variety of reasons that are due to mutual cause rather than a result of them being underinsured. But the study indicated that a number of controls were employed to account for these issues, and there was still excess mortality.

Overall, it adds to evidence that in general mortality is higher in uninsured individuals. But it's all preaching to the choir. Unfortunately I doubt there are many people who oppose universal coverage who will start supporting it because of this data. Probably it needs more systemic review by trauma centers to understand the causes -- it's not that obvious what it is that's causing this.

[Tomorrow]

Originally Posted by abiyng87

This isn't a question of validity. It doesn't matter if the person has "pre-existing conditions" or was deemed un-insurable (whatever that means). I see what you are getting at, but that, as I see it, is actually the point. The people who need to be insured the most, who need the help the most, are the people who aren't getting it and are dying because of it.

At the risk of sounding like I'm calling you out (and I'm not, I promise), there's something in your post that I'm curious about.

Who "needs to be insured the most"? Or perhaps better stated, how do we define whether one person needs to be insured more than another person does?

IMO, health insurance serves two purposes; it makes ongoing or chronic conditions more financially manageable, and it lessens the risk of a financial catastrophe in the event of an emergency (whether it's a sudden illness or an accident).

I can guess (and it's just a guess) that your intent is to say that those with chronic health conditions are the ones who "need" insurance the most, since a sudden illness or accident can affect anyone at any time, and doesn't discriminate based on a person's economic or insured status; and, because not all people fall into that group, but everyone does fall into the "at risk of accident or sudden illness" group. Or you might mean something else altogether.

I'm curious to see which of these scenarios can cause more financial detriment to a person; a chronic condition (supposing you have to buy maintenance prescriptions, therapy, annual tests, etc. which can add up over time) or an accident (which can cost hundreds of thousands or more, all at once). To be honest, neither sounds like a whole lot of fun, and either one can hit you in the pocketbook pretty hard.

[mkrishnan]

Originally Posted by Tomorrow

I'm curious to see which of these scenarios can cause more financial detriment to a person; a chronic condition (supposing you have to buy maintenance prescriptions, therapy, annual tests, etc. which can add up over time) or an accident (which can cost hundreds of thousands or more, all at once). To be honest, neither sounds like a whole lot of fun, and either one can hit you in the pocketbook pretty hard.

It's an interesting question... I don't know the formal numbers, but when I hear about people running into issues like hitting a private insurance lifetime maximum payout threshold, it's almost invariably related to cancer (not all cancer, but particularly pesky cancers), so I would tend to go chronic health. Of course, the percentage of Americans who could not have insurance, get into a serious MVA, and then pay out of pocket for the associated costs, is teeny, tiny, teeny, and of course all those people also have insurance already.

I'm an advocate of universal health insurance, and honestly, I like single payor / nationalized systems the best. But outside that option, I tend to feel that the safety net should extend first to all of these high dollar, high quality of life impact issues. I strongly believe in prevention -- don't get me wrong. But there's not that much variance in what you can do to prevent yourself from being in a future car accident, or from contracting testicular cancer, or from having a baby with a cleft lip. The idea of a social safety net in essence is that these vagaries of life should not bowl people over.

So I would be tempted to put those high on the list as a matter of principle, although ultimately, even though people do have accidents unpredictably, the highest dollar value efficacy (meaning how much quality of life or mortality avoidance or whatever are you going to get for each dollar you put in) is going to be in making preventative medicine accessible.

So that's kind of a quandry... if we want to save lives, I'm fairly convinced that the efficacy is in providing primary prevention.

[Tomorrow]

Either way, until we get rid of (or greatly ease) the preexisting condition clauses, we're talking about having insurance before you know whether you belong to either group, no?

[mkrishnan]

Originally Posted by Tomorrow

Either way, until we get rid of (or greatly ease) the preexisting condition clauses, we're talking about having insurance before you know whether you belong to either group, no?

In general, yes, sure. Unless you're my mother, who believes that all disease is a manifestation of avoidable development of character flaws.