RESEARCH METHODS AND STATISTICS

Parametric Versus Nonparametric Statistical

Tests: The Length of Stay Example
Munirih Qualls, MD, MPH, Daniel J. Pallin, MD, MPH, and Jeremiah D. Schuur, MD, MHS

Abstract
Objectives: This study examined selected effects of the proper use of nonparametric inferential statisti-
cal methods for analysis of nonnormally distributed data, as exemplified by emergency department
length of stay (ED LOS). The hypothesis was that parametric methods have been used inappropriately
for evaluation of ED LOS in most recent studies in leading emergency medicine (EM) journals. To illus-
trate why such a methodologic flaw should be avoided, a demonstration, using data from the National
Hospital Ambulatory Medical Care Survey (NHAMCS), is presented. The demonstration shows how
inappropriate analysis of ED LOS increases the probability of type II errors.
Methods: Five major EM journals were reviewed, January 1, 2004, through December 31, 2007, and all
studies with ED LOS as one of the reported outcomes were reviewed. The authors determined whether
ED LOS was analyzed correctly by ascertaining whether nonparametric tests were used when indicated.
An illustrative analysis of ED LOS was constructed using 2006 NHAMCS data, to demonstrate how
inferential testing for statistical significance can deliver differing conclusions, depending on whether
nonparametric methods are used when indicated.
Results: Forty-nine articles were identified that studied ED LOS; 80% did not perform a test of normal-
ity on the ED LOS data. Data were not normally distributed in all 10 of the studies that did perform such
tests. Overall, 43% failed to use appropriate nonparametric methods. Analysis of NHAMCS data con-
firmed that failure to use nonparametric bivariate tests results in type II statistical error and in multivari-
ate models with less explanatory power (a smaller R2 value).
Conclusions: ED LOS, a key ED operational metric, is frequently analyzed incorrectly in the EM litera-
ture. Applying parametric statistical tests to such nonnormally distributed data reduces power and
increases the probability of a type II error, which is the failure to find true associations. Appropriate use
of nonparametric statistics should be a core component of statistical literacy because such use increases
the validity of ED research and quality improvement projects.
ACADEMIC EMERGENCY MEDICINE 2010; 17:1113–1121 ª 2010 by the Society for Academic Emer-
gency Medicine
Keywords: length of stay, parametric, nonparametric, methodology, statistics, quality

S
tatistical literacy is a critical skill for users of the
medical literature, for clinicians and researchers
alike. A key premise of evidence-based medicine
From the Department of Emergency Medicine, Brigham and
Women’s Hospital (MQ, DJP, JDS), Boston, MA; Harvard
Medical School (DJP, JDS), Boston, MA; and the Division of
Emergency Medicine, Children’s Hospital Boston (DJP),
Boston, MA.
Received December 15, 2009; revisions received March 21 and
April 7, 2010; accepted April 11, 2010.
Presented at the Society for Academic Emergency Medicine
annual meeting, New Orleans, LA, May 14–17, 2009.
Disclosures: Part of Dr. Schuur’s time is supported by a Jahni-
gen Career Development Award, funded by the Atlantic Philan-
thropies and the Hartford Foundation.
Supervising Editor: Gary Gaddis, MD, PhD.
Address for correspondence: Munirih Qualls, MD, MPH;
e-mail: mqualls@partners.org. Reprints will not be available.
(EBM) is that clinicians should depend on primary medi-
cal literature to inform patient care decisions.1 To prac-
tice EBM well requires the ability to understand and
recognize sources of bias in the medical literature.
Biased studies are more likely to derive incorrect conclu-
sions that can mislead practitioners of EBM. Bias can
occur due to faulty study design and ⁄ or methodology, as
well as inappropriate choice of inferential statistical tests.
Consequently, biostatistical training has become more
emphasized in medical schools2 and emergency medicine
(EM) residency programs.3
Despite this recent increased emphasis on statistical
literacy, many physicians cannot demonstrate compe-
tence with basic biostatistical concepts.1,4,5 This leads to
mistakes in statistical analysis6 and reluctance to con-
duct research.7,8 This limitation is particularly germane
to EM, which has been highly self-critical regarding
research methodology.9,10 Although the rigor of EM
research has increased with the maturation of the

ª 2010 by the Society for Academic Emergency Medicine ISSN 1069-6563

doi: 10.1111/j.1553-2712.2010.00874.x PII ISSN 1069-6563583 1113
1114
specialty, and the creation of dedicated research train-
ing activities such as research fellowships,11 there is
still room for improvement. Appropriate use of non-
parametric statistical analyses for nonnormally distrib-
uted data represents just such an opportunity for
improvement.6,12 EM researchers must understand how
to choose appropriate statistical methods, and clinicians
and peer reviewers who read their studies should be
able to recognize basic errors.
Emergency department length of stay (ED LOS) is a
continuously distributed interval variable with a non-
normal distribution due to its frequent high degree of
skew, as illustrated in Figure 1. ED LOS is an impor-
tant, frequently studied outcome variable in EM opera-
tions research because it is a key indicator of
operational efficiency. Parametric statistical tests are
usually inappropriate13–17 for analysis of ED LOS. Since
the Institute of Medicine identified ED crowding as an
obstacle to high-quality emergency care, and a series of
studies have linked crowding to adverse safety and
quality outcomes, ED LOS has become a proxy for
quality-of-care processes.18–23 The National Quality
Forum (NQF) has endorsed median ED LOS as an indi-
cator of safety and efficiency,24 and the Joint Commis-
sion announced that it will include the NQF’s ED LOS
measures in its 2010 hospital specifications manuals.25
These are the first steps toward inclusion of ED LOS in
mandatory hospital quality measures, making it likely
that within a few years every hospital’s ED LOS will be
available for the public to view on the Medicare web-
site, Hospital Compare.26
Our study has two goals. The first goal is to test the
hypothesis that inferential statistical analysis of ED LOS
in published studies is usually performed inappropri-
ately, because of a suspicion that ED LOS is usually
analyzed using parametric methods. The second goal is
to demonstrate, by example, that inappropriate use of
parametric methods increases the probability of com-
mitting a type II error. We present several analyses of
Figure 1. Distribution of ED LOS in the NHAMCS (n = 26,618). The graph is truncated at ED LOS £ 1,800 minutes. ED LOS was
greater than 1800 minutes at 123 visits. LOS = length of stay; NHAMCS = National Hospital Ambulatory Medical Care Survey.
Qualls et al. • PARAMETRIC VS. NONPARAMETRIC STATISTICAL TESTS
ED LOS, using data from the National Hospital Ambu-
latory Medical Care Survey (NHAMCS). We test the
theory that type II errors, and not type I errors, pre-
dominate when inappropriate parametric tests are
used.17
METHODS
Study Design
We hand-reviewed all original research articles pub-
lished between January 1, 2004, and December 31,
2007, in Academic Emergency Medicine, the American
Journal of Emergency Medicine, Annals of Emergency
Medicine, the Canadian Journal of Emergency Medicine,
and Emergency Medicine Journal. The first three jour-
nals are the three highest ranked U.S. EM journals by
impact factor.27 The others are the two leading English
language non-U.S. EM journals. Using the 2006 NHA-
MCS database, we conducted illustrative analyses of
ED LOS using both parametric and nonparametric
methods.
Data Sources
Our literature review included any original research
article using ED LOS as a primary or secondary out-
come. We used the ED Benchmarking Alliance consen-
sus definition of ED LOS: time from ED arrival to
discharge, admission, or death in the ED.28 For our
illustrative analyses, we used the ED component of the
2006 NHAMCS. This is a multistage probability survey
of U.S. ED visits in institutional, general, and short-stay
hospitals, whose methods have been detailed previ-
ously.29 NHAMCS defines ED LOS as ‘‘length of visit,
calculated from arrival time to time of discharge from
the ED.’’29
Study Protocol
We determined standards used to describe or test non-
normally distributed data and then compared the
ACAD EMERG MED • October 2010, Vol. 17, No. 10 • www.aemj.org
Table 1
Standards Used to Describe or Test Nonnormally Distributed
Data
Criterion Appropriate Standard
Test of normality LOS data must be evaluated for
nonnormal distribution.
Descriptor of central LOS data must be described
tendency using median, or median and
mean.
Aggregation of data Aggregate LOS data, such as
weekly mean ED LOS, should
not be used in statistical
analyses.
Bivariate statistical Nonparametric tests of
tests significance (Mann-Whitney,
Wilcoxon, or Kruskal-Wallis)
should be used to analyze
data with a nonnormal
distribution, rather than
parametric tests such as
Student’s t-test.
Transformation of Nonnormal LOS data must be
LOS in regression appropriately transformed
analysis prior to regression analysis
(e.g., log-transformation).
LOS = length of stay.
selected articles against these standards (Table 1).
Descriptor of central tendency was categorized as
mean, median, or both. For all other criteria, we deter-
mined a rating of ‘‘Yes’’ or ‘‘No’’ based on the statistical
techniques used. To assess whether a test of normality
was performed, we recorded whether the authors sta-
ted that they performed a test of normality on the ED
LOS data or if they explicitly mentioned the distribution
of ED LOS. For articles that did not describe the distri-
bution of ED LOS data, we considered ED LOS to have
a nonnormal distribution, unless a normal distribution
was reported or unless sufficient data were provided
for us to determine that ED LOS was normally distrib-
uted. When ED LOS was not normal, we deemed the
study to have conducted appropriate nonparametric
analysis if it met three criteria: 1) reported a median as
the description of central tendency, 2) used appropriate
nonparametric bivariate tests of significance (e.g.,
Mann-Whitney, Wilcoxon, or Kruskal-Wallis),30 and
3) conducted appropriate log-transformations of ED
LOS data prior to regression analyses.31
In contrast, we deemed a study with nonnormal ED
LOS data not to have used appropriate methods if it:
1) reported only the mean as a measure of central ten-
dency for nonnormally distributed ED LOS data,
2) used inappropriate bivariate tests of significance
(such as Student’s t-test), and 3) failed to perform a log-
transformation prior to linear regression analysis.
In our NHAMCS analyses, we included all adult (age
‡ 18 years) ED visits in the NHAMCS 2006 data set and
evaluated associations between ED LOS and three cate-
gories of variables, which were hospital type, visit
events, and patient demographic characteristics. To
evaluate bivariate predictors of ED LOS, we selected 10
dichotomous variables for which there existed a clinical
or administrative rationale to suggest an association
1115
with ED LOS. The hospital type variable was urban
hospital defined by location in a metropolitan statistical
area (Yes ⁄ No). The visit event variables were diagnostic
tests performed (Yes ⁄ No), was imaging performed
(Yes ⁄ No), was care by midlevel provider (nurse practi-
tioner or a physician assistant; Yes ⁄ No), and arrival by
ambulance (Yes ⁄ No). The patient demographic charac-
teristics were Hispanic ethnicity (Yes ⁄ No), race (white
vs. nonwhite), sex (male ⁄ female), age (18–65 years, > 65
years), and presenting level of pain (dichotomized to
severe ⁄ not severe [none ⁄ mild ⁄ moderate]).
For the multivariate analysis, we included the 10 vari-
ables listed above, plus five additional categorical vari-
ables that were not eligible for bivariate analysis
because they could not easily be dichotomized. The
additional variables were as follows:
1. Hospital ownership (proprietary; voluntary non-
profit; government, nonfederal).
2. Hospital region (Northeast, Midwest, South, West).
3. Number of medications given in the ED.
4. Day of the week.
5. Number of procedures performed (e.g., wound care
or IV fluids) during the visit.
Outcome Measures
The primary outcome measure in the literature review
portion of this manuscript was the proportion of pub-
lished articles that inappropriately employed para-
metric methods for description or analysis of ED LOS
data.
Data Analysis
We analyzed the results of the literature review using
descriptive statistics. We tested the NHMACS data for
normality using three methods. The Anderson-Darling
test is a formal test of normality; a p-value less than
0.01 signifies a nonnormal distribution.32 The second
method is ‘‘mean-median difference,’’ which represents
the degree of skewness by calculating the difference
between the median and the mean as a percentage of
the mean. A small percentage difference (i.e., 1% to
5%) suggests that the mean and the median are close to
each other, and the data are likely to be normally dis-
tributed. A larger difference suggests that the mean
and the median are far from each other and the data
are not normally distributed.33 The third method is the
‘‘standard deviation to mean ratio.’’ If the standard
deviation (SD) is more than half of the mean, the distri-
bution is likely to be nonnormal.33
We examined the bivariate relationship between
NHAMCS ED LOS and the 10 dichotomizable covari-
ates with parametric (t-test) and nonparametric (Wilco-
xon rank sum test) bivariate tests.33
We created a multivariate regression model from the
15 independent variables (10 dichotomous and five non-
dichotomous, as described above) using NHAMCS
data. We constructed one model with raw ED LOS as
the dependent variable and another with log-trans-
formed ED LOS. The R2 values, the F-values, and the
p-values of the two models were compared. The mea-
ning of these parameters is defined elsewhere.33 In
brief, the R2 is a measure of the total amount of
1116 Qualls et al.
variability described by the equation constituting a mul-
tivariate linear regression. The F-value represents the
proportion of the variance explained by each predictor
variable. The p-value is a means of interpreting the
F-value in terms of statistical significance. For purposes
of the modeling exercise, we have focused on the
change in R2 and F-values that occurs when one log-
transforms existing explanatory variables to better nor-
malize their distributions, without addressing issues of
colinearity, residual analysis, and outliers.
We considered a two-sided p < 0.01 to be significant,
as recommended by the National Center for Health
Statistics for analysis of NHAMCS data, due to the
large size of the data set and the frequency with which
it is queried.34 We performed bivariate parametric
tests and multivariate linear regression models using
both standard and weighted survey techniques that
account for the design characteristics of NHAMCS.
We performed nonparametric tests using standard
techniques, as weighting cannot be accounted for with
nonparametric techniques surveys. All statistical analy-
ses were performed with SAS 9.1 software (SAS Insti-
tute, Cary, NC).
RESULTS
Literature Review
We identified 49 articles with ED LOS as a primary or
secondary outcome. Ten of the 49 (20%) articles
included a test of normality on the ED LOS data; all
10 of these articles reported that the data were not
normally distributed. Of the 39 articles that did not
perform a test of normality, 17 reported sufficient data
to allow calculation of the distribution of the ED LOS
data set using two of the summary methods described
above. Ten of these 17 articles (59%) had a nonnormal
distribution of ED LOS. The ED LOS of the remaining
22 articles was assumed to be nonnormally distrib-
uted, consistent with the methodology described
above.
Sixteen of 49 articles (33%) appropriately accounted
for the nonparametric distribution of ED LOS by
reporting median ED LOS and analyzing ED LOS using
a nonparametric bivariate test or transforming ED LOS
prior to multivariate regression. Twenty-one of the 49
articles (43%) failed to account for the nonnormal dis-
tribution of ED LOS and used only parametric methods
of analysis. The remaining 12 articles used a combina-
tion of parametric and nonparametric methods and
descriptive statistics.
Among all 49 articles with ED LOS as an outcome,
47% exclusively reported mean LOS as the description
of central tendency. Of the 32 articles that performed
bivariate tests of significance, 14 (44%) used only the
parametric Student’s t-test. Of the 14 articles that cre-
ated multivariate regression models with ED LOS as
the dependent variable, 10 (71%) used only raw ED
LOS data.
Two articles (4%) used other appropriate techniques
to account for skewed data: one included a histogram,
a graphic representation of normality, and another
reported trimming the data of outliers that contributed
to a rightward skew of the data. Five articles (10%)
• PARAMETRIC VS. NONPARAMETRIC STATISTICAL TESTS
performed statistical analyses on aggregate mean LOS
data. Three used daily mean, one used weekly mean,
and one used monthly mean. This is an inappropriate
approach, as it does not change the underlying non-
parametric distribution of ED LOS data and does not
have the power advantages of nonparametric statistical
techniques.
NHAMCS Analysis
Mean ± SD adult ED LOS for U.S. EDs was
229 ± 257 minutes, and median ED LOS was 164 min-
utes (interquartile range [IQR] = 93–272 minutes). Adult
ED LOS was nonnormally distributed in the 2006 NHA-
MCS data set by all three tests of normality. The Ander-
son-Darling test revealed nonnormality, with p < 0.005.
Mean-median difference was 30% of the value of the
mean. The mean to SD ratio was 0.9. A histogram
graphically illustrates the rightward skew of adult ED
LOS compared to the normal distribution (Figure 1).
The distribution of ED LOS closely fits a log-normal dis-
tribution.
In our bivariate analysis, we found that three of the
10 variables evaluated as predictors of ED LOS did not
meet our a priori threshold for statistical significance
using the parametric Student’s t-test (Table 2). In con-
trast, all 10 variables were significant (p < 0.001) using
the nonparametric Wilcoxon rank sum test. The three
variables that were significant in nonparametric analy-
sis and not significant in parametric analysis were: sex
(p = 0.806), care by a midlevel provider (p = 0.021), and
pain (p = 0.091).
In our multivariate linear regression analysis, we
found that log-transforming ED LOS resulted in a bet-
ter fitting model than raw ED LOS, as determined by
larger F-value (with the exception of ‘‘Hospital Owner-
ship’’) for the predictor variables, and a larger R2 value
for the regression model (Table 3). Only one variable
was significant in the transformed ED LOS model and
not significant in the raw ED LOS model (sex,
p = 0.049). In both our bivariate and our multivariate
analyses, we found no type I errors resulting from inap-
propriate use of parametric tests.
Sensitivity Analysis: Weighted Survey Techniques
As the NHAMCS is a multistage probability sample, it
is recommended that users account for the visit weights
when drawing inferences from the data. Although we
used the data as an example of a nonparametric data
set and are not proposing conclusions based on rela-
tionships between variables, we performed bivariate
tests and multivariate linear regression using both sur-
vey and unweighted techniques, as readers familiar
with NHAMCS will expect. When the weighted tech-
niques were used for the bivariate tests (t-tests), one
more variable was nonsignificant with the t-test (His-
panic ethnicity, p = 0.02), but all other directions of
effect and conclusions were unchanged from the results
reported above. When the multivariate models were
run with survey weights applied, two more variables
were nonsignificant in the raw ED LOS model (hospital
region, p = 0.02; and ownership, p = 0.08) and one in
the log-transformed ED LOS model (hospital owner-
ship, p = 0.12). Most importantly, no examples of type I
ACAD EMERG MED • October 2010, Vol. 17, No. 10 • www.aemj.org 1117

Table 2
Results of Bivariate Parametric and Nonparametric Analysis of ED LOS From the NHAMCS*

Wilcoxon Rank
Variable Mean (95% CI) t-test Median (IQR) Sum Test
Urban hospital 239 (236–243) <0.001 174 (100–286) <0.001
Nonurban hospital 157 (149–166) 109 (62–173)
No diagnostic tests performed 133 (128–138) <0.001 88 (51–154) <0.001
Diagnostic tests performed 251 (247–255) 183 (111–294)
No imaging performed 197 (193–202) <0.001 127 (70–222) <0.001
Imaging performed 264 (259–268) 205 (129–315)
No care by midlevel provider 230 (227–233) 0.021  165 (94–273) 0.006
Care by midlevel provider 216 (205–228) 154 (89–259)
No arrival in ambulance 208 (207–213) <0.001 150 (105–355) <0.001
Arrival in ambulance 291 (283–300) 214 (137–334)
Hispanic ethnicity 257 (248–267) <0.001 184 (102–307) <0.001
Non-Hispanic ethnicity 225 (222–228) 161 (91–268)
Nonwhite race 248 (242–254) <0.001 180 (104–304) <0.001
White race 222 (218–226) 158 (90–261)
Female 229 (225–234) 0.806  167 (95–276) 0.002
Male 228 (224–234) 159 (90–266)
Age > 65 yr 256 (249–263) <0.001 200 (125–306) <0.001
Age < 65 yr 223 (219–226) 155 (88–262)
High pain 225 (220–231) 0.091  170 (100–280) <0.001
Low pain 220 (216–224) 159 (91–260)

IQR = interquartile range; LOS = length of stay; NHAMCS = National Hospital Ambulatory Medical Care Survey.
* Based on 26,618 adult ED visits in the 2006 NHAMCS. Some variables were calculated based on smaller sample sizes,
as missing values were excluded. Statistical calculations are based on unweighted techniques.
 Variables that differed significantly between parametric and nonparametric test.

Table 3
ED LOS Regression Models Using Raw and Transformed ED LOS Data From the 2006 NHAMCS*

Raw ED LOS Log-transformed ED LOS

Predictor Variable F-value p-value F-value p-value

Urban hospital 132 <0.001 543 <0.001
Hospital ownership 72.6 <0.001 44.4 <0.001
Hospital region 28.1 <0.001 39.6 <0.001
Imaging performed 87.9 <0.001 407 <0.001
Diagnostic tests performed 148 <0.001 817 <0.001
Total number of procedures 18.7 <0.001 61.2 <0.001
Day of week (weekday ⁄ weekend) 10.3 <0.001 37.8 <0.001
Care by midlevel provider (Yes ⁄ No) 0.390 0.531 2.40 0.121
Number of medications administered 712 <0.001 1163 <0.001
Arrival by ambulance (Yes ⁄ No) 126 <0.001 127 <0.001
Race White ⁄ nonwhite 89.2 <0.001 106 <0.001
Ethnicity (Hispanic ⁄ non-Hispanic) 31.9 <0.001 63.4 <0.001
Sex (male ⁄ female) 3.85 0.049  8.66 0.003
Age, yr 69.8 <0.001 187 <0.001
Pain (high ⁄ low) 0.81 0.369 3.27 0.071
R2 for regression model Raw ED LOS: Log-transformed ED LOS:
0.12 0.23

LOS = length of stay; NHAMCS = National Hospital Ambulatory Medical Care Survey.
*Models based on 23,842 of 26,618 adult ED visits in the 2006 NHAMCS with complete data for all predictor variables.
Statistical calculations are based on unweighted techniques.
 Variables which differed in significance between parametric and nonparametric test.

error were identified when data were analyzed with
weighted survey techniques.
DISCUSSION
Statistical literacy is important for emergency physi-
cians engaged in research or quality improvement or
interested in practicing EBM. To recognize sources of
bias in research, readers should be able to identify
biases associated with inappropriate experimental
design or inappropriate statistical methods. ‘‘Parame-
ter’’ and ‘‘parametric’’ are among the most frequently
misunderstood words in clinical research. A parameter
is defined as the unknown value of a variable in an
entire population, which is derived by estimating the
value of that variable from a random sample derived
1118 Qualls et al. • PARAMETRIC VS. NONPARAMETRIC STATISTICAL TESTS

from that population. The value of the variable in
the sample is called the ‘‘sample value’’ or the ‘‘point
estimate.’’
Accuracy and validity of a ‘‘nonparametric’’ statistical
inferential statistical test result does not rely on an
assumption that the outcome and predictor variables
are distributed normally in the source population. Non-
parametric tests, unlike parametric tests, do not have to
be ‘‘robust’’ against violations of the inherent mathe-
matical assumptions of the test. An assumption of para-
metric tests is normality of the distribution of the data
analyzed by the inferential test. Nonparametric statisti-
cal tests do not assume that the parameter is distributed
normally, and thus they are appropriate and accurate
(robust) even when the sample value is not distributed
normally.
The easiest example to illustrate the difference
between parametric and nonparametric is a comparison
of mean versus median. The mean is inferior to the
median as a summary of the central tendency of the
data because the mean is a misleading indicator of cen-
tral tendency when the data are skewed. In contrast,
the median is said to be more robust, because it
remains an accurate description of the central tendency
(50th percentile) of the sample, even when the values of
the individual data are skewed. In the case of income,
for example, there is rightward skew, meaning that
there are a few values that are very high. The presence
of one billionaire in a less-developed country will
change mean income significantly, without affecting
median income. The mean is accurate as a summary
statistic of central tendency only when the distribution
is normal, or bell-shaped. On the other hand, the med-
ian is determined by identifying the middle value in the
list of incomes and is an accurate description of the
central tendency regardless of whether the data are
skewed. In our NHAMCS example, sex provides a clear
illustration of this principle. The mean LOS is not statis-
tically different between men and women (228.6 vs.
229.5), while the median LOS differs significantly (159
vs. 167). This becomes apparent examining the distribu-
tion of ED LOS by percentile between men and women.
Men had shorter LOS until approximately the 85th per-
centile, above which their ED LOS exceeded that of
women. Thus the rightward skew of these outliers influ-
ences the mean enough to cause the populations to
acquire a similar measure of central tendency when
comparing means. However, by comparing ranks, it
becomes clear that for the majority of the population
(approximately 85% of patients), men have a shorter
LOS than women.
Length of stay in health care settings tends to have a
rightward skew due to the minority of patients who
have disproportionately long stays (Figure 1).13,14,35
Health care expenditures, utilization of health services,
and consumption of unhealthy commodities are other
common skewed variables.15 Distributions of data with
heavy tails, extreme skews, or unknown population
characteristics should be analyzed with nonparametric
tests.17 Table 4 displays common statistical tests and
explains why each is parametric or nonparametric.
When authors and readers of the medical literature
express concern about inappropriate use of parametric
statistical tests, they often assume that inappropriate
use of an inferential statistical test can result in an erro-
neously low p-value or an erroneously narrow 95%
confidence interval (CI). This can potentiate reaching a
conclusion that a difference between groups exists in
the source population, when in reality no difference
exists. In other words, it is widely and incorrectly
assumed that inappropriate use of inferential tests pot-
entiates making a type I error. In fact, the true problem
with parametric tests is that they lack power when their
assumptions are violated, as occurs when they are
applied to analyze nonparametric data.17 When analyz-
ing nonnormally distributed data with parametric tests,
the analyst is more likely to fail to detect a difference in
the source population when one truly exists. This is the
definition of a type II error.17 Choice of the wrong sta-
tistical test is unlikely to result in type I error.
Our demonstration elucidates this principle. The 2006
NHMACS ED LOS data had a strong rightward skew.
If we had used the Student’s t-test to analyze the cova-
riates, we would have concluded that care by a mid-
level provider, and patient sex, were not associated
with ED LOS. However, using the Wilcoxon rank sum
test, we found that these variables were significantly
associated with ED LOS. If applied to actual ED LOS

Table 4
Commonly Used Parametric and Nonparametric Statistical Tests

Statistical Test What Is Being Compared Why Parametric or Nonparametric

Parametric statistical tests
Student’s t-test
Linear regression
Nonparametric statistical tests
Wilcoxon rank sum, Mann-Whitney
U, and Kruskal-Wallis tests
(inferential tests for ordinal data)
Chi-square test (inferential test for
nominal data)
Whether the mean is larger in one
group vs. the other.
Slope, which is a mean
Whether values tend to be larger in
one group vs. the other.
Chance of falling into one group or
another.
Only accurate if the values are
distributed normally.
Only accurate if four assumptions are
met: normal distribution of dependent
variable, homoscedasticity, lack of
autocorrelation, and linearity.
Result is accurate whether data are
distributed normally or not.
Result is accurate whether data are
distributed normally or not.
ACAD EMERG MED • October 2010, Vol. 17, No. 10 • www.aemj.org
analyses, this error could affect quality improvement
projects or interhospital comparisons.
Failure to transform a skewed dependent variable
during linear regression is similar to using parametric
tests on a nonnormally distributed variable. The statisti-
cal methodology underlying linear regression depends
on four assumptions, one of which is a normal distribu-
tion of the dependent variable. The violation of this
assumption jeopardizes the fit of the model,36 resulting
in a decreased R2 value. This can affect the result of a
study because an ill-fitting model underestimates the
relationship between the dependent variable and the
independent variables. It may be that the dependent
variable is very strongly correlated with the set of inde-
pendent variables, but if the dependent variable is
highly skewed, the linear regression will not completely
capture the magnitude of the relationship. The solution
is to transform the nonnormal variable so that it
approximates the normal distribution or use a nonlinear
model equation that better fits the data. Figure 1 visu-
ally illustrates how a log-normal distribution closely fits
the NHAMCS data, while a normal distribution does
not. For highly skewed data, one can log-transform the
dependent variable or use variations of multiple regres-
sion that better fit skewed data, such as Poisson regres-
sion and negative binomial regression.31
Statistical techniques that maximize power, therefore
minimizing type II error, allow researchers to find sig-
nificant differences between groups with smaller sam-
ple sizes.15,37 This is particularly salient for ED LOS,
which is often analyzed in small single-site quality
improvement projects. In these small-scale projects, the
inherently lower power of any selected statistical test,
due to the predictable effect of the likely small sample
size, is likely to affect the results and conclusions. If a
study examines an operational intervention aimed to
reduce median ED LOS, comparison of means can
cause the investigator to miss a true reduction in ED
LOS. For example, a reduction in lab test turnaround
time that accounts for 5 minutes per patient may not
appear significant if a small number of patients are
boarding in the ED with ED LOS of greater than
24 hours, whereas it may actually affect the median ED
LOS and represent improved ED operations and care.
Our NHAMCS demonstration had an extremely large
sample (n = 26,618) and was therefore highly powered.
Nonetheless, we were able to demonstrate type II error
in both bivariate and multivariate tests conducted with
inappropriate parametric methods. This effect would be
amplified in a smaller study, which is inherently
lower powered, due to the smaller sample size, and
thus likely to yield p-values closer to the traditional
‘‘cutoff’’ of 0.05.
In our NHAMCS demonstration, we analyzed ED
LOS in the 2006 NHAMCS data set, a chart review sur-
vey designed to allow national estimates of ED visits by
multistage probability sampling. When analyzing NHA-
MCS to determine accurate estimates of national visits,
it is important to use weighted survey techniques in sta-
tistical software. We performed analyses with both
weighted survey statistics and unweighted statistics.
We did not find any material differences between these
techniques, so we report the unweighted results. To
1119
answer our study question, whether applying a para-
metric test to a nonparametric data set leads to diver-
gent results, we believe that the unweighted statistics
provide a sufficiently accurate and informative answer.
First, we used NHAMCS as an illustrative data set to
show the relationship between nonparametric and
parametric tests when applied to nonparametric data.
We are not proposing conclusions about the relation-
ships between the actual variables (for example, patient
race and ED LOS). Alternatively, we could have gener-
ated a simulated data set for the same analysis,17 but as
ED LOS in NHAMCS is nonnormally distributed, it is a
reasonable data set in which to test this hypothesis.
Second, the unweighted results are more easily compa-
rable between techniques, as there do not exist any
straightforward nonparametric tests that account for
survey weights. By design, nonparametric tests assign
value to each observation’s rank, not its value, so are
not directly applicable to weighted observations. Statis-
tical models have been developed to apply nonparamet-
ric statistics to weighted samples, but they are not in
common use.38–40 Focusing on the use of survey
weights risks ‘‘losing the forest for the trees,’’ as we
found no material difference in results between stan-
dard techniques and complex survey techniques. The
major finding of our analysis is that parametric and
nonparametric statistical tests will produce material
differences in statistical results if applied to nonpara-
metric data.
LIMITATIONS
In analyzing the results of our literature review, we
assumed that ED LOS data are nonnormally distrib-
uted and that the use of nonparametric methods
might have changed the result of the studies in some
cases. We cannot definitely prove this assumption
without access to the data sets of all articles. However,
LOS in health care settings is known to be skewed,13,14
and our NHAMCS simulation demonstrates that the
use of nonparametric methods can quantitatively affect
results at alpha levels commonly reported in medical
journals. Additionally, all articles that performed tests
of normality on their data elected to use nonpara-
metric tests, which implies a widespread belief by
these authors that including formal analysis of normal-
ity before deciding which statistical test to use does
affect the results of a study. Our review is also likely
affected by publication bias, since studies with a
negative parametric result may not have reached
publication. Our study investigates the effect of data
distributions on hypothesis testing as opposed to
parameter estimates. Hypothesis testing is frequently
used in EM literature and quality improvement pro-
jects, and an understanding of the strengths and limi-
tations inherent in different statistical methods, and
their influence on type I and type II error rates, is
important. An alternative strategy that is sometimes
useful is graphical illustration of data (e.g., histograms)
that will show distribution differences.41 However, this
approach does not provide a standard way for readers
to draw inferences from the data displayed and is still
relatively uncommon.
1120
CONCLUSIONS
Understanding the descriptive and analytic statistics
that underlie EM research is an essential part of the
practice of EM.1,4,5 Emergency department length of
stay has been identified as a key process metric of
ED function, and numerous studies have shown an
association between ED length of stay and patient
satisfaction,21,22 quality of care,19,20 and departmental
revenue.23 With the recent National Quality Forum
approval and Joint Commission implementation of ED
length of stay as a national metric of quality care, there
will be pressure to reduce ED LOS, as there has previ-
ously been upon door-to-balloon time in ST-elevation
myocardial infarction.25 However, in the current EM lit-
erature, most studies analyzing ED length of stay use
inappropriate statistical methods, designed for para-
metric data. This can bias the conclusions regarding
quality and efficiency and may affect reimbursement in
the future. We cannot afford to miscalculate our own
outcomes.
Contrary to popular belief, inappropriate use of para-
metric tests results in an increased probability of a
type II error, not a type I error. If a study reports a sta-
tistically significant finding after using inappropriate
parametric statistics, the finding would be statistically
significant if derived via nonparametric methods. It
should therefore be considered valid, because the result
would be expected to have had a lower p-value, which
is to say a lower likelihood to have occurred by chance
alone, if the data were reanalyzed with appropriate
nonparametric methods.17
References
1. West CP, Ficalora RD. Clinician attitudes toward
biostatistics. Mayo Clin Proc. 2007; 82:939–43.
2. Association of American Medical Colleges. Contem-
porary Issues in Medicine: Basic Science and Clini-
cal Research. Available at: https://services.aamc.org/
publications. Accessed Aug 20, 2010.
3. Chapman DM, Hayden S, Sanders AB, et al. Inte-
grating the Accreditation Council for Graduate
Medical Education Core Competencies into the
model of the Clinical Practice of Emergency Medi-
cine. Ann Emerg Med. 2004; 43:756–69.
4. Windish DM, Huot SJ, Green ML. Medicine
residents’ understanding of the biostatistics and
results in the medical literature. JAMA. 2007;
298:1010–22.
5. Hack JB, Bakhtiari P, O’Brien K. Emergency medi-
cine residents and statistics: what is the confidence?
J Emerg Med. 2009; 37:313–8.
6. Gaddis ML, Gaddis GM. Introduction to biostatis-
tics: part 1, basic concepts. Ann Emerg Med. 1990;
19:86–9.
7. Goodacre S. Critical appraisal for emergency medi-
cine 2: statistics. Emerg Med J. 2008; 25:362–4.
8. Carley S, Lecky F. Statistical consideration for
research. Emerg Med J. 2003; 20:258–62.
9. Biros MH. Emergency medicine research: where
are we now and where do we need to be? Acad
Emerg Med. 1997; 4:1101–3.
Qualls et al. • PARAMETRIC VS. NONPARAMETRIC STATISTICAL TESTS
10. Lewis RJ. Statistical methodology and effective
emergency medicine: what is the connection?
[Commentary] Acad Emerg Med. 1996; 3:824.
11. Biros MH. SAEM emergency medicine research
fellowship guidelines. Acad Emerg Med. 1999; 6:
1067–8.
12. Barrett TW, Schriger DL. Measures of emergency
department crowding, odds ratios, and the dangers
of making continuous data categorical: answers to
January 2008 Journal Club questions. Ann Emerg
Med. 2008; 51:782–9.
13. Weissman C. Analyzing intensive care unit length
of stay data: problems and possible solutions. Crit
Care Med. 1997; 25:1594–600.
14. Kulinskaya E, Kornbrot D, Gao H. Length of stay as
a performance indicator: robust statistical method-
ology. IMA J Manag Math. 2005; 16:369–81.
15. Manning WG, Mullahy J. Estimating log models: to
transform or not to transform? J Health Econ. 2001;
20:461–94.
16. Altman DG. Practical Statistics for Medical
Research. New York, NY: Chapman and Hall, 1991.
17. Vickers AJ. Parametric versus non-parametric sta-
tistics in the analysis of randomized trials with non-
normally distributed data. BMC Med Res Methodol.
2005; 5:35.
18. Institute of Medicine (U.S.). Committee on the
Future of Emergency Care in the United States
Health System. Emergency Medical Services at the
Crossroads. Washington, DC: National Academies
Press, 2007.
19. Schull MJ, Vermeulen M, Slaughter G, Morrison L,
Daly P. Emergency department crowding and
thrombolysis delays in acute myocardial infarction.
Ann Emerg Med. 2004; 44:577–85.
20. Diercks DB, Roe MT, Chen AY, et al. Prolonged
emergency department stays of non–ST-segment
elevation myocardial infarction patients are associ-
ated with worse adherence to the American College
of Cardiology ⁄ American Heart Association Guide-
lines for Management and increased adverse
events. Ann Emerg Med. 2007; 50:489–96.
21. Thompson DA, Yarnold PR, Williams DR, Adams
SL. Effects of actual waiting time, perceived waiting
time, information delivery, and expressive quality
on patient satisfaction in the emergency depart-
ment. Ann Emerg Med. 1996; 28:657–65.
22. Taylor C, Benger JR. Patient satisfaction in emer-
gency medicine. Emerg Med J. 2004; 21:528–32.
23. Bayley MD, Schwartz JS, Shofer FS, et al. The
financial burden of emergency department conges-
tion and hospital crowding for chest pain patients
awaiting admission. Ann Emerg Med. 2005; 45:
110–7.
24. National Quality Forum. NQF Endorses Measures
to Address Care Coordination and Efficiency in
Hospital Emergency Departments: Measures Can
Help Decrease Wait Time, Increase Physician Pro-
ductivity, and Safety. Available at: http://www.
Qualityforum.org. Accessed Aug 24, 2010.
25. Centers for Medicare and Medicaid Services. Medi-
care Program: Proposed Changes to the Hospital
Inpatient Prospective Payment Systems and Fiscal
ACAD EMERG MED • October 2010, Vol. 17, No. 10 • www.aemj.org
Year 2009 Rates; Proposed Changes to Disclosure
of Physician Ownership in Hospitals and Physician
Self-Referral Rules; Proposed Collection of Informa-
tion Regarding Financial Relationships Between
Hospitals and Physicians; Proposed Rule. Federal
Register. 2008; 73(84):42. FR Parts 411, 412, 413.
26. U.S. Department of Health and Human Services.
Medicare.gov - Hospital Compare. Available at: http://
www.medicare.gov/Hospital/Search/Welcome.asp.
Accessed Jul 14, 2010.
27. Thomson Reuters. ISI Web of Knowledge: ISI
Thomson Impact Factor. Available at: http://
thomsonreuters.com/products_services/science/free/
essays/impact_factor/. Accessed Jul 14, 2010.
28. Welch S, Augustine J, Camargo CA Jr, Reese C.
Emergency department performance measures and
benchmarking summit. Acad Emerg Med. 2006;
13:1074–80.
29. U.S. Department of Health and Human Services:
National Center for Health Statistics. National Hos-
pital Ambulatory Medical Care Survey. Available at:
http://www.cdc.gov/nchs/ahcd.htm. Accessed Jul
14, 2010.
30. Norman GR, Streiner DL. Biostatistics : The Bare
Essentials. Hamilton, Ontario: B. C. Decker Inc.,
2000.
31. Tabachnick BG, Fidell LS. Using Multivariate Statis-
tics. Boston, MA: Allyn and Bacon, 2001.
32. U.S. Commerce Department Technology Adminis-
tration. NIST ⁄ SEMATECH e-Handbook of Statisti-
cal Methods. Available at: http://www.itl.nist.gov/
div898/handbook/. Accessed Jul 14, 2010.
33. Peat J, Barton B. Medical Statistics: A Guide to
Data Analysis and Critical Appraisal. Malden, MA:
Blackwell Publishing Ltd, 2005.
1121
34. Hing E, Gousen G, Shimizu I, Burt C. Guide to
using masked design variables to estimate standard
errors in public use files of the National Ambulatory
Medical Care Survey and the National Hospital
Ambulatory Medical Care Survey. Inquiry. 2003;
40:401.
35. Fan J, Kao W, Yen DH, Wang L, Huang C, Lee C.
Risk factors and prognostic predictors of unex-
pected intensive care unit admission within 3 days
after ED discharge. Am J Emerg Med. 2007;
25:1009–14.
36. Miles J, Shevlin M. Applying Regression and Corre-
lation: A Guide for Students and Researchers.
Thousand Oaks, CA: Sage Publications, 2001.
37. Bridge PD, Sawilowsky SS. Increasing physicians’
awareness of the impact of statistics on research
outcomes: comparative power of the t-test and Wil-
coxon rank-sum test in small samples applied
research. J Clin Epidemiol. 1999; 52:229–35.
38. Kassam SA, Thomas JB. Nonparametric weighted-
signs tests for location. SIAM J Appl Math. 1977;
32:649–52.
39. Cristóbal J, Alcalá J. An overview of nonparametric
contributions to the problem of functional estima-
tion from biased data. TEST. 2001; 10:309–32.
40. Kang Q, Nelson PI. Nonparametric tests for the
median from a size-biased sample. J Nonparametric
Stat. 2008; 20:19–37.
41. Schriger DL, Cooper RJ. Achieving graphical excel-
lence: suggestions and methods for creating high-
quality visual displays of experimental data. Ann
Emerg Med. 2001; 37:75–87.