The influence of social deprivation on length of hospitalisation

Author(s): Engin Yilmaz and Denis Raynaud

Source: The European Journal of Health Economics, Vol. 14, No. 2 (April 2013), pp. 243-252
Published by: Springer
Stable URL: https://www.jstor.org/stable/23357794
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Eur J Health Econ (2013) 14:243-252
DOI 10.1007/s 10198-011 -0365-4

ORIGINAL PAPER

The influence of social deprivation on length of

Engin Yilmaz • Denis Raynaud

Received: 26 May 2011 / Accepted: 17 October 2011 /Published online: 18 November 2011
© Springer-Verlag 2011

Abstract The implementation of activity-based

housing (+17%). The
payment
impact of low income on the length
system named T2A—tarification à l'activité— in However,
of stay is less important. 2004 low income associated
profoundly modified the financing of with French hospitals.
inadequate housing significantly increases lengths of
stay (+24%).medicine, sur
Presently applied to activities concerning
gery and obstetrics, the pricing for these activities was
Keywords Social
developed using the National Costs Study. The deprivation
consider • Length of stay
Case mixin
able differences observed between costs • DRG
the private
sector and those in the public sector are in part justified, by
the latter, by caring for patients with JEL Classification
social 118 132 C35
deprivation.
The goal of this study is to measure the influence of social
deprivation on the length of hospitalisation. A survey on
Introduction
inpatient social deprivation was carried out from Novem
ber to December 2008 by the French Ministry of Health
(Department of Research, Study, Evaluation and Statis
The French hospital landscape is composed of three types
tics—DREES, and technical agency of of Hospital informa
healthcare facilities: public hospitals, private not-for
tion—ATIH). Four dimensions of social deprivation
profit werefor-profit hospitals.
hospitals and private
taken into consideration after a previous In qualitative
2004, the financing
study:of hospitals was profoundly
social isolation, quality of housing, level
modifiedof income
with and
the implementation of the activity-based
access to rights. The sample is based on 27
payment hospitals,
reform named T2A—tarification à l'activité [2],
including public and private (for-profitbased
and on the principles of yardstick competition [19].
not-for-profit),
Previously,
representing 57,175 stays, 6,800 of which were two patients
different funding systems were used.
with social deprivation. After multivariate
Public and
analyses
private not-for-profit
adjus hospitals had global bud
ted for age, severity of illness and DRG, we private
gets, while found that hospitals were funded using
for-profit
per day rates with
there was a longer length of stay for inpatients with several
socialcomponents: daily tariffs cov
deprivation (+16%), and in particular for
ering
patients
the cost ofliving
accommodation
in and paramedical care and
social isolation (+17%) and for patients
separate
with payments
inadequate
for each diagnostic and therapeutic
procedures [14]. This new system currently concerns only
medical, surgical and obstetric activities, it is activity
based and it also benefits from additional funding for
E. Yilmaz (Kl) • D. Raynaud general interest missions and other actions on a contractual
Department of Research, Study, Evaluation and Statistics
basis (MIGAC). T2A was fully implemented in 2005 in
(DREES) of the French Ministry of Health,
private for-profit hospitals, whereas there was a progressive
14 Avenue Duquesne, 75350 Paris 07 SP, France
e-mail: Engin.yilmaz@sante.gouv.fr implementation in public hospitals (and in private not
D. Raynaud for-profit hospitals): the funding linked to activity-based
e-mail: Denis.raynaud@sante.gouv.fr payment (T2A) went from 25 to 50% from 2005 to 2007.

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 244 E. Yilmaz, D. Raynaud

The tariffs on are

the length of stay: this impact ranges from 5% for the
developed
0étude CMU indicator to 20% fordes
nationale the homeless variable. It would
coûts—
rates coexist: one
be difficult to generalise public and
the results of this study obtained in
hospitals, the Île-de-France
for the region alone. Moreover, the current
same h
(GHM, Groupe Homgène
informational systems do not enable carrying out such a
Diagnosis Related
study on the entire territory. Group
patient A recent study carried out by a Paris hospital
hospitalisation isattempted
su
inpatients to understand the impact of
groups caring for inpatients in situa
(GHM) in
(principal diagnoses, med
tions of social deprivation within the context of the T2A
associated diagnoses).
reform by using an ad hoc survey [4], The
Each
authors of this
that is study refer
called a more to a concept of social handicap, a term
Homogenou
T2A introduced by the law of 19 Novemberthe
implementation, 1974. Social c
was initiallydeprivation
planned was approached through a for
questionnaire that
20
2018. all of the inpatients completed. The authors noted that
Several studies show a considerable difference between through this term, "social deprivation is not only limited to
income
costs in the public sector and those in the private sector, the and its potential unpredictability, but concerns
other factors." They add that "the concept of a social
former justify these differences by their public service
handicap
missions and the latter by a quest for efficiency [1]. In fact, relays the disadvantage, which could only be a
temporary
an empirical study showed the impact of research on the situation and not lifelong stigmata like a phys
costs [3]. These differences can also be explainedical
byor mental handicap can be." Despite the interest of this
the inpatients' characteristics [13, 16]. Inpatients' approach,
social it seems again difficult to reproduce this meth
deprivation in public hospitals is often one of theodology
expla survey at a national level essentially for reasons of
nations used to justify the extra cost. Our study resources.
occurs
On the national level, work done by the PMS
within this context: it aims to shed quantitative light upon
on data from 1998 has also shown that social d
the additional costs for inpatient with social deprivation.
This problem, which is recurrent in activity-basedwas pay a factor in lengthening hospitalisations
ment systems, has already been seen in countries thatgenerally
have was a factor generating extra costs [
work, the social deprivation has been identif
adopted this payment system. Thus, several international
studies in Belgium and the United States have shownsurveysig conducted by the hospital staff. They u
codes
nificant lengthening of hospital stays for inpatients in situ to approach the social deprivation situati
ations of social deprivation [6, 7], integrated into the hospital information system
deprivation has been defined according to thre
In effect, this payment method does not give financial
value to the extra time required to care for inpatientsfinancial, social and environmental. In fact, afte
for case mix, the results show the lengths
in situations of social deprivation. Additional financing
completes often the device. inpatients suffering from social deprivation w
In France, some studies have also provided the 36% same higher than those of inpatients not suffe
results. Thus, a study carried out on inpatients in the social
Public deprivation. For these inpatients, the aver
Assistance-Hospitals of Paris (AP-HP) showed the average
of stay is approximately 2.52 days longer than
suffering from social deprivation. These result
length of hospitalisation for those in situations of social
deprivation was superior to those not in situations of that
social the effects of social deprivation are more
socially
deprivation with an identical case mix [9]. Nonetheless, the isolated patients. However, one of th
characteristic "social deprivation" in this study chosen
was to define social deprivation notably tha
social isolation ("subject waiting to be admitted
assessed with administrative criterion proper to the AP-HP
in an adequate facility") poses an endogeno
informational system. This database provided the following
deprivation measures: recipients of Couverture Maladie
likely to increase the estimation of social depr
Universelle (CMU, basic and complementary universal the length of stay. In fact, this variable define a h
of or
insurance adapted for underprivileged French citizens), stay not necessary linked to the social d
situations.
aide médicale d'Etat (AME, health and medical emergency
These studies showed the variability of soc
insurance adapted for underprivileged non-French citizens
living in France) and homeless patients. However,tion
this definitions that can be used. It is therefore
system does not enable identifying social isolation.
clarify this concept and these different dim
Adjusted by pathologies, age and gender, results show a
measure its effect on the length of stay throu
of count model, which are discussed in the "Data and
differentiated impact for each social deprivation indicator

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 The influence of social deprivation 245

methods" section. had

Twoa significantquestions were
impact on the four cost items: nursing a
study. The first relates, in length
care, social accompaniment, inpatient
of stay and the degree h
comparison of the length
of severity of
or seriousness of stay
the pathology. In fact, adju
the
"social work" time
between hospitalisations of materialised
patients by an increase in
in timesit
deprivation and those who
spent listening to andare
talking tonot.
inpatients inThe
situations ofsec
the differential effects according
social deprivation to length
leads to an increased average the of di
deprivation. stay, in particular for inpatients suffering most from social
deprivation, those who are isolated, homeless or living in
inadequate housing conditions. This phenomenon is
Data and methods accentuated with the problem of support structures. Social
deprivation linked to housing is also a factor in increased
Concepts of social deprivation lengths of stay, insofar as it keeps the patient from being
discharged before securing care homes or a medico-social
Social deprivation is a complex, multidimensional concept
healthcare centre. Moreover, people in situations of social
that cannot be reduced to a single economic dimension [10,
deprivation are less to care as an outpatient hospitalisation.
21]. The definitions of social deprivation insist upon its their social isolation deprives them of support
In fact,
multidimensionality (economic, social, family...).hospital
From discharge, or their housing conditions are not
there, it is difficult to get practical and operationalincompatible
indi with these care.
cators that enable a better understanding of the different
Therefore, these qualitative studies have identified four
criterion of social deprivation. dimensions of social deprivation that may increase the
Thus, to define simple and operational indicators toof stay in hospitals. Then, indicators were developed
length
to collect
measure the social deprivation, a preliminary study on this information on these four dimensions in the
question was conducted by a team of researchers that was information systems.
hospital
commissioned by the DREES—ministry of health [11].
The concept of social deprivation retained in thisData sources
study
comes from the conclusions of this last study. The study's
Thethe
objectives were twofold: first, the study was to review data used come from the French DRG1-based infor
concept of social deprivation so as to better define mation
it and system in hospitals (Programme de Médicalisation
secondly, to identify the different kinds of extra costs
du Système d'Information—PMSI). This database depicts
associated with caring for this type of inpatient. activities pertaining to short-term hospital stays and, for
In order to reach these objectives, this study dreweach
bothhospitalisation, gives information about the inpa
on a review of literature and a qualitative survey carried
tients' characteristics (age, gender, place of residence...)
and information
out on personnel from three healthcare facilities located in on their hospitalisation. The latter is
the Ile-de-France. Two of the three hospitals are divided
in the into two categories: medical (diagnostics, treat
public sector, and the third is in the private for-profit ment
sector.given during the hospitalisation...) and administra
tive (date and method of arrival and discharge, origin,
Within each hospital, resource persons were met individ
ually on the basis of interview guide approach: department
destination, etc.). A stay report written up upon the inpa
heads, doctors, healthcare executives, caregivers, tients'
admindischarge classifies the hospitalisation into a Grou
istrative personnel and social workers. The interestpes Homogènes des Malades (GHM—the equivalent of
of the
different interviews was to clarify to the personnel ques
Diagnosis-Related Group in the US). Using Chap. XXI2 of
tioned the profiles of inpatients generating additionalthe International Classification of Disease (ICD), which
costs,
the definitions of social deprivation and the criterion for medically describing all hospitalisations in medi
enables
cine,the
identifying inpatients in situations of social deprivation, surgery and obstetrics (MCO), the PMSI also enables
factors and the identification of extra costs related to social characterising social deprivation according to the definition
deprivation, the organisations (official and ad hoc) and theretained [15]. In order to best collect data on hospitalisa
means implemented to give better care to such inpatients.
tions of people in situations of social deprivation using the
Through the interviews of personnel from healthcareICD codes, a specific survey was carried out on healthcare
facilities, the authors concluded that it was possible tofacilities. Setting up this collection was justified insofar as
characterise social deprivation in four dimensions: social the codes retained corresponding to markers of social
relations, quality of housing, income level and access to
rights (inpatient with public healthcare insurance for illegal
1 Diagnosis-Related Groups.
immigrants or without any healthcare insurance). The
2 This chapter corresponds to factors influencing the state of health
analysis of these interviews revealed that these four factors
and reasons for having recourse to healthcare services.

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 246 E. Yilmaz, D. Raynaud

Table 1 eliminated.
Markers of social Ou
depr

Dimensions of social ICD codes than 48 h. M

deprivation hospitalisation
sample), the a
Social relation Z55.0 illiteracy and low-level literacy
629. To perm
Z60.3 acculturation difficulty
eliminated the
Z60.1 atypical parenting situation
patients in situ
Z74.1 need for assistance and hygiene care
in situations o
Z74.2 need for assistance at home and no
180 GHMs ret
other household member able to render
care
the hospitalisa
The sample re
Housing Z59.0 homelessness
hospitalisatio
Z59.1 inadequate housing
people in situa
Financial Z59.5 extreme poverty
Z59.6 low income
the hospitalisat
The available database contains both the socio-eco
Z56.0 unemployment, unspecified
nomic characteristics of the hospitalisations (age, patie
Access to rights Z59.7 insufficient social insurance and
welfare support gender and situation of social deprivation) and the med
characteristics measured by the GHM.
Source: Chapter XXI of the International Classification of Diseases
Each hospitalisation could be marked by one or sever
(ICD)
deprivation markers. So, two types of deprivation indi
tors were built. On one hand, a hospitalisation will
deprivation are not often used because theses codes have
qualified as pertaining to someone suffering from soci
no impact on classifying GHM hospitalisations. Coding deprivation if it presents at least one of the social depr
guidelines were thus given to the facilities. So, the latter
vation codes retained. On the other hand, as a complim
were requested to systematically look for the 11 to social
this overall indicator, finer social deprivation indicat
deprivation codes in Chap. XXI for patients hospitalised
werein built that take the dimension(s) of social deprivat
MCO and to code them as other diagnoses with the cor
presented and the links between them into account.
responding codes from the ICD (Table 1). These 11 codes
were chosen so as to provide information on the Specification
four model
dimensions of social deprivation. These guidelines were
defined by the DREES in collaboration with the Our ATIHstudy focused on comparing the lengths of inpatie
(technical agency for hospital information), whichhospitalisation between the population in situations
informed the hospitals. The decision was made to use social
those deprivation and the population not in situations
participating in the National Costs Study, which would
social deprivation. This necessitated taking some fact
enable a subsequent study on the link between social
that could influence the length of stay into account, nota
deprivation and the costs as measured by the ENCC. the
The hospital's case mix, which measures the range of ca
survey took place in November and December 2008. treated. In fact, the length of stay belonging to "heavy
Our study was thus based on the data from the anony
cases will be greater than those of other stays. To do thi
mised discharge reports (résumés de sorties anonymisées—
multivariate analysis adjusted for others by GHM enab
RSA) of healthcare facilities having participated in the
measuring the effect of social deprivation on the length
stay,
2008 National Costs Study. Some of these hospitals did not everything else being equal. As the sample w
composed of 180 GHMs, we thus introduced 180 bin
participate in the collection nor did so incompletely making
it impossible to use their data in the study. In the end, we
variables corresponding to each GHM. The analyses wer
retained 27 out of 99 hospitals. While this sample is also
not adjusted by age (classified) and gender.
representative, it does cover the three categories of hospi
Data collected in the hospital information system have
tals (16 public, 2 private and 9 private non-profit) as well as
hierarchical structure [18]. In fact, for each hospital, w
small and large hospitals. Moreover, the sample constituted
have information on the stays. And to take into accoun
respects a certain geographic diversity. unobservable characteristics on hospitals that could hav
an impact on the length of stay, we use regression metho
Data sets called fixed effect models [20].

3 The version of the GHM classification is the VIOc.

As our analysis was centred on lengths of stay, outpatient
hospitalisations and non-group hospitalisations were
4 Source: comprehensive 2008 PMSI (ATIH).

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 The influence of social deprivation 247

100
The variable length of hospitalisation may
90
to be a count variable insofar as it takes discrete and non 80

negative values and its distribution cannot be considered to70

60
be Gaussian [17]. 50

In general, two types of models are used: the Poisson 40

30
model and the negative binomial model. 20
Using the Poisson model, we estimate the probability 10
0
that a random variable Y takes the value y for the /th
individual in the y'th hospital:

e 1-"
Fig. 1 Variability in the length of inpatient hospitalisation between
P(Yij = y) = —-f-, where ytj = 0,1,2...
the hospitalisations of people in situations of social deprivation and
those not in situations of social deprivation. Reading: 10% of stays of
The X parameter verifies the following relationship: people in situations of the social deprivation have a length of stay
exceeds 18 days against 14 days for 10% of stays of people not
hj = exp (ctj + Xtjß), (1) in situations of social deprivation. Source: Authors' calculations
based on our sample
with X representing the regressor vectors and ß that of the
coefficients to estimate, and where a,- is the «fixed-effect»
Choosing between two modelling strategies entails
or hospital-effect.
carrying out a statistical test on the equidispersion property.
However, the use of this type of model is based on a
Thus, if we observe that the coefficient 1/(5 tends towards 0,
hypothesis of equality between the average and the vari
then the negative binomial model can be assimilated with
ance, a hypothesis that is not, in practice, always respected.
the Poisson model. The specification of the Poisson law is
We then speak of an overdispersion of observations when
tested by the null hypothesis H0: Ô = 0 by using either the
the variance of the parameter is superior to its average. In
Wald test or the likelihood ratio test, or even the Lagrange
that case, the use of a Poisson model reveals an underes
multiplier test [8].
timation of the parameters' variances that which implies
In this study, because of overdispersion problem, we
degrees of underestimated significativity.
used the negative binomial model.
In this case, is it possible to deal with this problem by
using the negative binomial model? In this estimation, the
endogenous variable always follows a Poisson Law, but its
Descriptive statistics
mathematical expectation is marred by an error term. The
variable thus follows a Poisson distribution with parameter:
Rough links between social deprivation and length
M,y = exp (ai + Xjjß + £y) (2) of hospitalisation

Substituting Eq. 1 into Eq. 2, we obtainGlobally,

thethe following
average length of inpatient stay for people
equation: in situations of social deprivation is 1.6 days longer than
uij — XijLljj hospitalisations of those qualified as not being in situations
of social deprivation (8.1 days as compared to 6.5 days).
This specification necessitates an additional hypothesis Figure 1 shows great variability of lengths of hospital
for the dispersion parameter //y that therefore follows a isation between the two subpopulations. For example, 10%
gamma law y(S, S). The two parameters of the gamma of stays of people in situations of the social deprivation
law are equally chosen and so that = 1. In this have a length of stay exceeds 18 days against 14 days
case, the variance of this parameter is equal to V(ft,j) = for
116.10% of stays of people not in situations of social
Finally, the length of stay yj thus follows a negative deprivation.
binomial parameter law (Ay, <5). The moments of this law
However, this difference in the average lengths of hos
are thus:
pitalisations between the two subpopulations could be
explained by differences in morbidity. These results do
E(yij/Xu) = No
not take into account confusion factors such as case mix,5
the age or the gender of the inpatients. Thus, the average

where Xij represents the observable characteristics (age,

gender, GHM...). 5 The case mix corresponds to the range of the facilities' activities
This model can be estimated by maximum likelihood. described through GHMs (Diagnosis-Related Groups).

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 248 E. Yilmaz, D. Raynaud

lengths of Thus, we observe that the accumulation of dimensions

hospitalisation
cases treated of social proper
deprivation significantly influences the to
length of eac
Under these conditions, all structural differences in stay. In fact, the average length of hospitalisation pre
terms of GHMs between the subpopulation of people senting one single dimension of social deprivation is 7.9,
in situations of social deprivation on one side and those not whereas it is 8.6 for hospitalisations presenting two or more
in situations of social deprivation on the other side would dimensions of social deprivation. However, the length of
automatically lead to a difference in length of hospitalistay with only the social relations dimension is longer
sation, without having this difference really being attrib (9.5 days).
uted to the proper effect of social deprivation. Moreover, counter-intuitive elements appear. For
example, hospitalisations presenting one single dimension
Are there differential effects of social deprivation of social relations have an average length of hospitalisation
on the length of hospitalisation depending greater than those presenting both the social relations and
upon the dimension of social deprivation? financial dimensions (9.5 days as compared to 8.7 days).
This observation confirms the interest of taking the afore
Table 2 shows us the multidimensional nature of social mentioned confusion factors into account.

deprivation. It also highlights that the financial dimension

cannot take into account all of the situations of social
Estimation
deprivation. In fact, for three-fourths of hospitalisations of results
people in situations of social deprivation, only one
The estimation of the model was made using the SAS
dimension of social deprivation is present. The dimension
"social relations" is the most often seen: it concerns almost software's GENMOD procedure.
40% of the hospitalisations. Then come the hospitalisations The aforementioned results were confirmed by one of
of with financial instability, which represent almost 30% the
of results from the econometric model enabling us to
hospitalisations. isolate the proper effects of the different dimensions of
The previous analysis highlighted the increase in lengthsocial deprivation by adjusting the case mix, age and
gender.
of inpatient hospitalisation for those in situations of social
deprivation taken in their totality. When we examine this in Table 3 presents results from the negative binomial
models examining the influence of social deprivation on
greater detail, it appears that this effect is differentiated
according to the dimensions of social deprivation. Table the
2 length of stay, everything else being equal. It seems that
presents the average length of hospitalisation according
part of the difference in length of inpatient hospitalisation
to interactions between different dimensions of socialpreviously observed between the two subpopulations could
deprivation. be explained by differences in case mix or age between the

Table 2 Comparison of N Standard

Average
average length of hospitalisation
length of stay deviation
stays according to the
combination of social
50,375
Hospitalisations of patients not suffering from social deprivation 6.5 6.1
deprivation markers
Hospitalisations of patients suffering from social deprivation 6,800 8.1 7.4

One dimension of social deprivation 5.083 7.9 7.3

Social relations 2,679 9.5 8.0

Housing 171 8.5 7.7

Financial instability 2,002 5.9 5.6

Access to rights 231 7.1 6.9

Two dimensions of social deprivation 1,278 8.5 7.5

Social-housing 148 9.4 8.3

Social-financial 711 8.7 7.6

Social-rights 99 7.1 6.5

Housing-financial 163 9.4 8.3

Housing-rights 49 7.1 6.3

Financial-rights 108 5.9 5.3

Source: Authors' calculations
Three or more dimensions 439 8.4 7.7
based on our sample

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 The influence of social deprivation 249

Table 3 Influence of social

Model la Model 2a
deprivation on the length of
inpatient hospitalisation Constant 1.11*** (0.09) 1.11*** (0.09)
Gender

Female Ref.

Male 0.01 (0.01) 0.01 (0.01)

Age
0-9 -0.13*** (0.03) -0.13*** (0.03)
10-19 -0.13*** (0.03) -0.13*** (0.03)
20-29 0.00 (0.02) 0.00 (0.02)
30-39 0.00 (0.02) 0.00 (0.02)
40^19 Ref.

50-59 0.09*** (0.02) 0.09*** (0.02)

60-69 0.14*** (0.02) 0.14*** (0.02)
70-79 0.14*** (0.02) 0.14*** (0.02)
80 et+ 0.17*** (0.02) 0.16*** (0.02)
Social characteristics of hospitalisation
Ref.
Hospitalisations of patients not suffering from social deprivation
Hospitalisations of patients suffering from social deprivation 0.16*** (0.01) -

One single
Social relations -

0.16**
Housing -

0.18*** (0.07)
Financial instability -

0.05
Access to
-

0.13**
right
Two dimensions of so
Social-housing -

0.27
Social-financial -

0.25*
The two models are controlled Social-rights -

0.18*
by the fixed-effect on hospital 0.38
Housing-financial
-

and the medical characteristics

0.49*
Housing-rights -

of the hospitalisations as
measured with 180 GHMs Financial-rights -

0.07
common to both Three or more dimensions -

0.32*
subpopulations. These Method of discharge
parameters are available upon Transfer 0.45*** (
0.45**
request to the corresponding
author
Normal transfer 0.40*** (0.01) 0.39*** (0.01)
Home Ref.
Source: Authors' calculations
based on our sample Death 0.12*** (0.02) 0.12*** (0.02)
Fit statistics
***, **,* Denote significance at
1, 5 and 10%, respectively Deviance 63,664 63,657
a Parameter estimates and 218 229
Number of parameters
standard errors in parentheses

populations in situations of social deprivation and those not influence the length of stay (+16 and +18%, + 27% when
in situations of social deprivation. they are combined). When the two other dimensions linked
These results are coherent with the other studies carried to financial instability and access to rights are taken indi
out on this subject. The length of stay is on average 16%vidually, their impact on the length of stay is smaller (+5
and +13%).
greater for hospitalisations of those in situations of social
deprivation as compared to hospitalisations of those not Within social relations deprivation, the need for assis
in situations of social deprivation. We find the hierarchy of
tance appears as the criterion most influencing the length of
effects of different dimensions of social deprivation high stay. Thus, the impact of the "need for home assistance"
lighted in the exploratory analysis. Above all, social rela code on the length of stay increases the length of inpatient
tions and those linked to housing most significantlyhospitalisation by an average of +25% and of the code

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 250 E. Yilmaz, D. Raynaud

"needs assistance
Table 4and hy
Break d
the accumulation of these two needs for assistance effect on the len

increases the length of stay by +27% as compared to Model 3a

hospitalisations of those not in situations of social depri
Social characteristics of stay
vation with everything else being equal. Furthermore, the
Hospitalisations of patients not Ref.
other social relation codes (single-parent situations, illit
suffering from social deprivation
eracy...) do not significantly increase the length of stay
One single dimension of social deprivation
(Table 4).
Needs assistance and hygiene care 0.07* (0.04)
As for social deprivation linked to housing, the homeless
Needs assistance at home 0.25*** (0.03)
factor has the greatest influence on the length of stay
Needs assistance (both together) 0.20*** (0.05)
(+44%) as opposed to the impact of inadequate housing,
Needs assistance and other 0.27*** (0.07)
which is not significant.
Other social relations 0.04 (0.04)
Everything else being equal, low income alone increases
Homeless 0.44*** (0.11)
the length of inpatient hospitalisation (+5%). However,
Inadequate housing —0.03 (0.10)
when it is combined with degraded housing conditions, it
Low income 0.05** (0.03)
adds to the poor housing conditions effect and further
Unemployment 0.08 (0.09)
increases much the length of hospitalisation (+38%).6
Low income and unemployment 0.02 (0.11)
Access to rights 0.13** (0.07)
Discussion Two dimensions of social deprivation
Social-housing 0.27*** (0.08)
Social-financial 0.25*** (0.04)
The goal of this study was thus to examine the link between
social deprivation and length of inpatient hospitalisation.Social-rights 0.17 (0.10)
The definition of social deprivation retained in this study Housing-financial
is 0.38*** (0.07)
based on a qualitative work carried out by a team of Housing-rights 0.49*** (0.14)
Financial-rights 0.07 (0.10)
researchers: after having completed a literary review on the
concept of social deprivation, different dimensionsThreeof or more dimensions 0.32*** (0.05)
social deprivation that generate extra cost for hospitals
Fit statistics

were identified through interviews with staff from three

Deviance 63,658
healthcare facilities. The International Classification of Number of parameters 236
Diseases (ICD-10) codes were used to provide the hospitals
The models are controlled by the fixed-effec
surveyed with a series of social deprivation markers
agethat
and medical characteristics of the hosp
were recorded as significant associated diagnoses using the
with 180 GHMs common to both subpopula
PMSI. are available upon request to the correspond

By using count models, we were able to estimateSource:

the Authors' calculations based on our
***,
impact of social deprivation and its different dimensions on **,* Denote significance at 1, 5 and 10
a Parameter estimates and standard errors in
length of inpatient hospitalisation by adjusting our results
by case mix measured using the GHM.
Two important findings resulted from this study. On one
hand, using more recent data, our results confirmed low
the income associated with poor livin
icantly
positive impact of social deprivation on the length of increases the length of hospita
The study's limits must be pointed
inpatient stay. On the other hand, this effect is differenti
resentativeness of our sample could
ated according to the different dimensions of social
were only able to gather data from 2
deprivation. Thus, the increase in length of stay is much
more marked for inpatients who are socially isolated the
and survey was addressed to the 99
from the National Cost Study. Despite
dependant as well as for the homeless. Financial poverty
of the hospitalisations represented as
alone does not influence the length of stay. Nonetheless,
of the types of hospitals enabled a re
ysis. Moreover, the results of this study
previous studies: as shown by a previ
6 This result is obtained when "financially poor" is mixed with
isolation is the most influential fac
"homeless," which seems obvious, but also when "financially poor"
hospitalisation while the effect of fin
is mixed with "inadequate housing," whereas when not combined,
these two variables do not appear to be significant. less significant or even insignificant

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 The influence of social deprivation 251

comparison with this

extra costsprevious study,
that are not studied here, for example, the need th
social deprivationto have
is more lower
social workers than in (16%
rich areas. as co
Second, does the
Our results not study
question theinclude
regulator on how to take outpa
into
account are
tions, whose tariffs the criterionlower
of social isolation in(or
the information
somet
tariffs corresponding
system. We to think an inpatient
that it could hos
be too difficult to collect this
did not measure the effect
type of information in order of social
to give extra d
money to hos
length of stay, pitals. Indeed,
which if the collecting method
transits throughis generalised, then
les
care. Insofar as the
thatpricing policy
raises the issue of over-coding gives
if a financial reward is
patient rather thengiven for patients socially deprived.
inpatient care, In fact,hospit
it would be
this mode of support [5].
difficult to control this Caring
information. this
deprivation may limit
Therefore,this
beyond the financing
development.
of the social depriva
social deprivation tion, these
and results question the regulatorcare,
outpatient on the mode ofout
should be the organisation.
subject of Afurther
policy implication could be to develop
work.
The stays were classified
support structures. These
according
medico-social structures could
to t
VIOc of GHMs classification (800
support patients who need for assistance. gro
The cost of these
version of classification
structures may be(VI1) has
lower than keeping people include
in hospital.
severity by But,leading
GHM, it requires conducting
toa global
aanalysis
numberon the
groups. It would be healthcare delivery at a regional level.
interesting to This mission
reprodu should
this new classification
be conducted that
by the Regional
reduces
Health Authorities (Agences
hete
each GHM. Insofar Régionales
as those de Sante', ARS) who
patients
are currently in charge
in of s
deprivation were healthcare
on policy at the regional
average and departmentala
sicker, level.
bet
severity in the So, ARS are responsible for thescheme
classification adequacy of the healthcare
mig
impact of social delivery and the need of theon
deprivation population, and for the articof
length
Currently, in the ulation
Frenchbetween social services
hospital
and health by improving
regul
there are two payments that
coordination of ambulatory, may
hospital and pot
long-term care.
account a part of the extra cost resul
deprivation. First, Acknowledgments
there We thank Alberto Holly
exists aandcompens
all participants of
the 2010 Irdes workshop on applied health economics and policy
with a very high length of stay based on
evaluation for their comments and suggestions. We are also grateful
per diem rate. Our results show
to Renaud Legal, different that
reviewers by DREES for theirs the
comments, ex
linked to social deprivation
and the anonymous reviewers for theiris modest
constructive comments and
suggestions.
eligibility conditions to this extra pay
consider that this supplementary paym
pensation for social deprivation extra cos
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