Does biased care lead to an increase in patient morbidity and overall use of healthcare system resources?

From the 2019 HVPAA National Conference

Dr. Jagan Kansal (University of Cincinnati), Dr. Eric Fichtenbaum (University of Cincinnati), Dr. Eamonn Bahnson (University of Cincinnati)

Introduction and Objectives

Providing unbiased care to patients with and without insurance coverage can be challenging in the current healthcare environment. We aimed to evaluate whether this was a problem at our academic institution and assess the outcomes related to patient care and use of healthcare system resources.


A retrospective review was performed of all patients reporting to our academic emergency department (ED) from January 2014 to December 2014 with an uncomplicated obstructing ureteral stone requiring surgical management. Patients were exclude from analysis for sepsis, stone size >1 cm or bilateral stones. Demographic information was abstracted. All patients were managed with initial stent placement followed by staged ureteroscopy with lithotripsy. For analysis patients were divided into two groups: Group 1- uninsured/under-insured and Group 2- insured. Statistical analysis [IBM SPSS v2.0] was used to compare outcomes between both groups. Primary outcomes were time from stent to ureteroscopy (URS), URS to stent removal, and total treatment time defined as time from initial stent placement to final stent removal. Secondary outcomes were interim ED visits, computed tomography (CT) scans, patient phone calls and pain medication prescriptions.


A total of 88 patients were identified, of which 80 (Group 1, n=34 and Group 2, n=46) met inclusion criteria for analysis. Demographics of each group were similar with no statistically significant difference between mean age, sex, stone size or location. Group 1 had a significant delay in total treatment time compared to Group 2 (40 vs. 24 days, p<0.001), with the main contributing interval occurring between stent placement and time to URS (32 vs. 17 days day, p<0.001). Moreover, statistically significant differences were observed between Group 1 and Group 2 patients in regards to interim ED visits/patient (1.35 vs 0.11, p<0.0001), number of CT scans/patient (0.41 vs 0.02, p<0.0001), phone calls/patient (2.6 vs 1.1, p<0.001) and pain prescriptions/patient (1.47 vs 0.72, p<0.011).


There was a significant bias in treatment time among patients without insurance coverage compared to patients with insurance coverage. Delays in treatment of the uninsured patient population led to higher morbidity and distress; and as a result these patients tended to use more healthcare system resources than their insured counterparts.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog