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Webb M, Brownell NK, Gabrielian S, Fonarow GC, Ziaeian B. Examining Heart Failure Outcomes Amid Housing Insecurity. J Card Fail 2024:S1071-9164(24)00227-6. [PMID: 38971296 DOI: 10.1016/j.cardfail.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND How housing insecurity might affect patients with heart failure (HF) is not well characterized. Housing insecurity increases risks related to both communicable and noncommunicable diseases. For patients with HF, housing insecurity is likely to increase the risk for worse outcomes and rehospitalizations. METHODS AND RESULTS We analyzed hospitalizations due to HF in the United States by using the 2020 National Inpatient Sample and Nationwide Readmissions Database to evaluate the impacts of housing insecurity on HF outcomes and hospital use. Individuals were identified as having housing insecurity by using diagnostic International Classification of Disease (ICD)-10 codes. Demographics and comorbidities were compared between patients with HF with and without housing insecurity. An adjusted logistic regression was performed to evaluate the relationships between housing insecurity and socioeconomic status on in-hospital mortality. Using a Cox proportional hazards model, patients with HF and without housing insecurity were evaluated for the risk of all-cause and HF-specific readmissions over time. Of the 1,003,270 hospitalizations for HF in the U.S. in 2020, 16,150 were identified as having housing insecurity (1.6%), and 987,120 were identified as having no housing insecurity (98.4%). The median age of patients with housing insecurity who were hospitalized for HF was 57, as compared to 73 in the population with no housing insecurity. A higher proportion of patients in the housing-insecurity group were Black (35% vs 20.1%) or Hispanic (11.1% vs 7.3%). Patients with housing insecurity were more likely to carry a diagnosis of alcohol-use disorder (15.2% vs 3.3%) or substance-use disorder (70.2% vs 17.8%) but were less likely to use tobacco (18.3% vs 28.7%). Patients with housing insecurity were over 4.5 times more likely to have Medicaid (52.4% vs 11.3%). Median length of stay did not differ between patients with housing insecurity vs those without it. Patients with housing insecurity were more likely to discharge against medical advice (11.4% vs 2.03%). After adjusting for patients' characteristics, housing insecurity was associated with lower in-hospital mortality rates (OR 0.60, 95% CI 0.39-0.92). Housing insecurity was associated with a higher risk of all-cause readmissions at 180 days (HR 1.13, 95% CI 1.12-1.14). However, there was no significant difference in the risk of HF-specific readmissions at 180 days (HR 1.07, 95% CI 0.998-1.14) CONCLUSIONS: Patients with HF and housing insecurity have distinct demographic characteristics. They are also more likely to be readmitted after their initial hospitalization when compared to those without housing insecurity. Identifying and addressing specific comorbid conditions for patients with housing insecurity who are hospitalized for HF may allow clinicians to provide more focused care, with the goal of preventing morbidity, mortality and unnecessary readmissions.
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Affiliation(s)
- Martine Webb
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Nicholas K Brownell
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sonya Gabrielian
- Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA; VA Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; VA Health Service Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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de Zeeuw Wright M, Morgan C. Certified Peer Support in the Field of Homelessness: Stories Behind the Work. Community Ment Health J 2024:10.1007/s10597-024-01315-1. [PMID: 38956000 DOI: 10.1007/s10597-024-01315-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
Certified peer support specialists (CPSS) are used as a paraprofessional workforce to engage hard-to-reach populations, including people experiencing homelessness. Thematic analysis was used to explore with CPSS (N = 7) what contributed to their effectiveness when working with this population. Participants were recruited at a HUD lead organization in the southeastern United States. Open-ended semi-structured questions were used in online, synchronous interviews. Themes related to three areas, experience, competence, and the organization, contributed to participants being effective. Specifically, interviewees observed that their lived experiences and abilities to speak a common language with clients contributed to their effectiveness. They identified how personal qualities and unique skillsets suited them for the work. Participants also valued the training they received; certification helped them to develop competencies and to balance vulnerability, empathy, and connection. Finally, participants attributed their effectiveness to clarity about their roles within the organization, supervision, attention to self-care, and co-worker support. Findings from this study may have implications for the value of lived and learned knowledge coexisting in organizations serving those who experience homelessness.
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Affiliation(s)
| | - Candice Morgan
- College of Social Work, University of South Carolina, Columbia, USA
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3
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Silver CM, Janczewski LM, Royan R, Chung JW, Bentrem DJ, Kanzaria HK, Stey AM, Bilimoria KY, Merkow RP. Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness. Ann Surg Oncol 2024; 31:1468-1476. [PMID: 38071712 DOI: 10.1245/s10434-023-14713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH. METHODS This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs. RESULTS Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH. CONCLUSIONS PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.
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Affiliation(s)
- Casey M Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren M Janczewski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Regina Royan
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jeannette W Chung
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago, Chicago, IL, USA.
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Biederman DJ, O'Donohue H, Gamble J. Opportunities for Nurses to Decrease the Stigma Associated with Housing Instability and Homelessness. Nurs Clin North Am 2024; 59:63-74. [PMID: 38272584 DOI: 10.1016/j.cnur.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The number of people experiencing homelessness (PEH) in the United States has increased in the past 5 years. PEH have a higher disease burden and early mortality compared to people who are housed. Stigma adds to the burden of disease and disease management for PEH. In this article the authors review stigma, define housing and homelessness, describe the health and health care disparities PEH experience, and using the socio-ecological model as a framework, offer opportunities for nurses to intervene in efforts to decrease the stigma that PEH and housing instability encounter to improve health outcomes.
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Affiliation(s)
- Donna J Biederman
- Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710, USA.
| | - Heather O'Donohue
- New Hanover Regional Medical Center, 2131 South 17th Street, Wilmington, NC 28403, USA
| | - Julia Gamble
- Duke Outpatient Clinic, 4220 North Roxboro Street, 2nd Floor, Durham, NC 27704, USA
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Mohottige D. Paving a Path to Equity in Cardiorenal Care. Semin Nephrol 2024; 44:151519. [PMID: 38960842 DOI: 10.1016/j.semnephrol.2024.151519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Cardiorenal syndrome encompasses a dynamic interplay between cardiovascular and kidney disease, and its prevention requires careful examination of multiple predisposing underlying conditions. The unequal distribution of diabetes, heart failure, hypertension, and kidney disease requires special attention because of the influence of these conditions on cardiorenal disease. Despite growing evidence regarding the benefits of disease-modifying agents (e.g., sodium-glucose cotransporter 2 inhibitors) for cardiovascular, kidney, and metabolic (CKM) disease, significant disparities remain in access to and utilization of these essential therapeutics. Multilevel barriers impeding their use require multisector interventions that address patient, provider, and health system-tailored strategies. Burgeoning literature also describes the critical role of unequal social determinants of health, or the sociopolitical contexts in which people live and work, in cardiorenal risk factors, including heart failure, diabetes, and chronic kidney disease. This review outlines (i) inequality in the burden and treatment of hypertension, type 2 diabetes, and heart failure; (ii) disparities in the use of key disease-modifying therapies for CKM diseases; and (iii) multilevel barriers and solutions to achieve greater pharmacoequity in the use of disease-modifying therapies. In addition, this review provides summative evidence regarding the role of unequal social determinants of health in cardiorenal health disparities, further outlining potential considerations for future research and intervention. As proposed in the 2023 American Heart Association presidential advisory on CKM health, a paradigm shift will be needed to achieve cardiorenal health equity. Through a deeper understanding of CKM health and a commitment to equity in the prevention, detection, and treatment of CKM disease, we can achieve this critical goal.
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Affiliation(s)
- Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, NY; Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Decker HC, Graham LA, Titan A, Hawn MT, Kanzaria HK, Wick E, Kushel MB. Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans. Health Aff (Millwood) 2024; 43:234-241. [PMID: 38315919 DOI: 10.1377/hlthaff.2023.01003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.
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Affiliation(s)
- Hannah C Decker
- Hannah C. Decker , University of California San Francisco, San Francisco, California
| | - Laura A Graham
- Laura A. Graham, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ashley Titan
- Ashley Titan, Stanford University, Stanford, California
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Ergui I, Salama J, Hooda U, Ebner B, Dangl M, Vincent L, Sancassani R, Colombo R. In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019. Clin Cardiol 2024; 47:e24235. [PMID: 38366788 PMCID: PMC10873680 DOI: 10.1002/clc.24235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS). HYPOTHESIS Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients. METHODS The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05). RESULTS We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints. CONCLUSIONS These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.
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Affiliation(s)
- Ian Ergui
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Joshua Salama
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Urvashi Hooda
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Bertrand Ebner
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Michael Dangl
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Louis Vincent
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Rhea Sancassani
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
| | - Rosario Colombo
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
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Hircock C, Huan P, Pizzola C, McDonald M. A scoping review of surgical care for people experiencing homelessness: prevalence, access, and disparities. Can J Surg 2024; 67:E27-E39. [PMID: 38278550 PMCID: PMC10824397 DOI: 10.1503/cjs.004023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Numerous studies have highlighted the inequitable access to medical and psychiatric care that people experiencing homelessness (PEH) face, yet the surgical needs of this population are not well understood. We sought to assess evidence describing surgical care for PEH and to perform a thematic analysis of the results. METHODS Ovid MEDLINE, Embase, and Web of Science were searched using the terms "surgery" AND "homelessness." Grey literature was also searched. We used a stepwise scoping review methodology, followed by thematic analysis using an inductive approach. RESULTS We included 104 articles in our review. Studies were included from 5 continents; 63% originated in the United States. All surgical specialties were represented with varying surgical conditions and procedures for each. Orthopedic surgery (21%) was the most frequently reported specialty. Themes identified included characteristics of PEH receiving surgical care, homeless-to-housed participants, interaction with the health care system, educational initiatives, barriers and challenges, and interventions and future strategies. CONCLUSION We identified significant variation and gaps, representing opportunities for further research and interventions. Further addressing the barriers and challenges that PEH face when accessing surgical care can better address the needs of this population.
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Affiliation(s)
- Caroline Hircock
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald).
| | - Peter Huan
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
| | - Christina Pizzola
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
| | - Madeline McDonald
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
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Lin C, DeRussy AJ, Richman JS, Montgomery AE. Predictors of Incident Stroke and Subsequent Mortality Among a Sample of Veterans with Experience of Housing Instability. J Health Care Poor Underserved 2024; 35:465-480. [PMID: 38828576 PMCID: PMC11197050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Homelessness is associated with poor health outcomes and early development of cardiovascular disease. This study investigated the correlates of incident stroke and its association with mortality among Veterans experiencing housing instability. Using a national sample of Veterans (n=565,608) with incident housing instability between 2014-2018, we compared characteristics of Veterans who did and did not experience incident stroke and conducted logistic regressions to assess two outcomes: incident stroke and mortality. Almost four percent experienced a first stroke and were more frequently male, older than 55 years, Black, and non-Hispanic. A higher rate of mortality was observed among those with a first stroke compared with those with no stroke (17.6% vs. 10.8%), although the difference was not statistically significant. Incident stroke was associated with triple the odds of death among unstably-housed Veterans compared with those who did not have an incident stroke. Implications include the need to screen and monitor for stroke risk among Veterans with experience of housing instability, particularly for those who are older.
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Mistry N, Knoeckel J, McBeth L, Johnson A, Bredenberg E, Raffel K, Cunningham J, Sarcone E, Misky G, Stella SA. Prevalence of homelessness among hospitalized patients: A point-in-time survey. J Hosp Med 2024; 19:45-50. [PMID: 38058085 DOI: 10.1002/jhm.13241] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/24/2023] [Accepted: 11/04/2023] [Indexed: 12/08/2023]
Abstract
Although homelessness is associated with increased acute healthcare utilization and poorer health outcomes, the prevalence of homelessness and housing insecurity in hospitalized patients is poorly characterized. We conducted an in-person survey to determine the prevalence of housing insecurity and homelessness among hospitalized patients at two hospitals in metropolitan Denver in conjunction with the Housing and Urban Development point-in-time count on January 24, 2022. Of the 271 surveyed patients, 79 (29.2%) reported experiencing either housing insecurity (17.3%) or homelessness (11.8%). Of those experiencing housing insecurity or homelessness, 69.6% reported chronic health conditions, 55.7% reported multiple hospitalizations in the preceding year, 38% reported mental health concerns and 39.2% reported substance use. The prevalence of homelessness among a hospitalized patient population was over 20-fold higher than community prevalence estimates. Housing insecurity also impacted a substantial proportion of hospitalized patients and was associated with high rates of co-morbid conditions.
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Affiliation(s)
- Neelam Mistry
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Julie Knoeckel
- Division of Hospital Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Lauren McBeth
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda Johnson
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin Bredenberg
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Katie Raffel
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John Cunningham
- Division of Hospital Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Ellen Sarcone
- Division of Hospital Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Gregory Misky
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sarah A Stella
- Division of Hospital Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
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MADDOX KARENEJOYNT. THE ROLE OF HEALTH POLICY IN IMPROVING HEALTH OUTCOMES AND HEALTH EQUITY. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2024; 134:200-213. [PMID: 39135594 PMCID: PMC11316889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Despite higher per-capita health care spending than any other country, the United States lags far behind in health outcomes. Additionally, there are significant health inequities by race, ethnicity, socioeconomic position, and rurality. One set of potential solutions to improve these outcomes and reduce inequities is through health policy. Policy focused on improving access to care through insurance coverage, such as the Affordable Care Act's Medicaid expansion, has led to better health and reduced mortality. Policy aimed at improving health care delivery, including value-based payment and alternative payment models, has improved quality of care but has had little impact on population health outcomes. Policies that influence broader issues of economic opportunity likely have a strong influence on health, but lack the evidence base of more targeted interventions. To advance health outcomes and equity, further policy change is crucial.
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Velasquez DE, Sandhu S, Koh KA, Ganguli I. Advancing social risk-informed care for people experiencing homelessness. J Hosp Med 2023; 18:1041-1044. [PMID: 37039109 PMCID: PMC10616886 DOI: 10.1002/jhm.13100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/12/2023]
Affiliation(s)
- David E. Velasquez
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
- Harvard Kennedy School of Government, Cambridge, Massachusetts, USA
| | - Sahil Sandhu
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine A. Koh
- Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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13
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Dahle G. Disparity issues in coronary artery surgery. Curr Opin Cardiol 2023; 38:478-483. [PMID: 37556404 DOI: 10.1097/hco.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease is the third leading cause of mortality worldwide. Coronary artery surgery is an important treatment option. Certain groups such as people of color, those from lower socioeconomic backgrounds and women tend to have lower rates of receiving the surgery they need ( Fig. 1 ). RECENT FINDINGS Still there are disparities in treatment options for coronary artery disease among different groups, due to geographic location, economical situation, institutional tradition and sex. SUMMARY Through continued research, awareness and utilization of innovative technologies, we can improve access and equity in healthcare for all patients, including patients in need of coronary surgery.
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Affiliation(s)
- Gry Dahle
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
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Curtis TM, Boozarpour O, Rebagliati DE, Colwell CB, Dailey MW. Prehospital Chest Pain Management: Disparity Based on Homeless Status. PREHOSP EMERG CARE 2023; 27:1101-1106. [PMID: 37459650 DOI: 10.1080/10903127.2023.2238309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND People experiencing homelessness may use emergency medical services to access health care. We sought to examine the relationship between homelessness and prehospital evaluation and treatment of chest pain. METHODS We obtained 2019 data of all emergency medical services activations from a single 9-1-1 provider in San Francisco, California with a clinician's primary impression of chest pain. Using chart review, we categorized patients as experiencing homelessness or not and determined treatment rates between the two groups based on local chest pain/acute coronary syndrome protocol. We then stratified the two groups based on primary impression subcategories: "chest pain-not cardiac" and "chest-pain-cardiac/STEMI"; ST elevation myocardial infarction (STEMI). RESULTS A total of 601 chest pain calls were analyzed after excluding non-transports and pediatric patients. 120 incidents (20%) involved patients experiencing homelessness. Across all chest pain impressions, people experiencing homelessness were less likely to receive aspirin (35% vs 53%; p < 0.001), intravenous access (38% vs 62%; p < 0.001), and nitroglycerin (21% vs 39%; p < 0.001). No patients experiencing homelessness received analgesic medication, though only 4% of other patients received this intervention (0% vs 4%; p = 0.020). People experiencing homelessness were more likely to receive a clinical impression of "chest pain-not cardiac" compared to "chest pain-cardiac/STEMI" (68% vs 32%; p < 0.001). Results were less significant in most fields when adjusted for impression sub categorizations: "chest pain-not cardiac" versus "chest pain-cardiac/STEMI." Greater than 97% of all patients received 12 lead electrocardiograms. CONCLUSIONS Significant disparities were observed between patients experiencing and not experiencing homelessness in the prehospital treatment of chest pain. Larger scale evaluations are needed to further assess potential disparities in care for people experiencing homelessness in the prehospital setting. Using prehospital clinician impression as a proxy for acuity may mask existing bias and disparity; however, 12-lead ECG acquisition, the key diagnostic tool, was appropriately performed in more than 97% of all chest pain patients.
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Affiliation(s)
| | | | | | - Christopher B Colwell
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, California, USA
| | - Michael W Dailey
- Department of Emergency Medicine, Albany Medical College, Albany, New York, USA
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Subramanian K, Alayo QA, Sedarous M, Nwaiwu O, Okafor PN. Healthcare Disparities Among Homeless Patients Hospitalized With Gastrointestinal Bleeding: A Propensity-Matched, State-Level Analysis. J Clin Gastroenterol 2023; 57:707-713. [PMID: 36730876 DOI: 10.1097/mcg.0000000000001742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
GOALS Examine outcomes among homeless patients admitted with gastrointestinal (GI) bleeding, including all-cause mortality and endoscopic intervention rates. BACKGROUND Hospitalizations among homeless individuals have increased steadily since at least 2007 but little is known about GI outcomes in these patients. STUDY The 2010-2014 Healthcare Utilization Project (HCUP) State Inpatient Databases from New York and Florida were used to identify adults admitted with a primary diagnosis of acute upper or lower GI bleed. Homeless patients were 1:3 matched with nonhomeless patients using a propensity-score greedy-matched algorithm. The primary outcome (all-cause in-hospital mortality) and secondary outcomes (30-day readmission rates, endoscopy utilization, length of stay, and total hospitalization costs) were compared. RESULTS We matched 4074 homeless patients with 12,222 nonhomeless patients. Most hospitalizations for homeless individuals were concentrated in 113 (26.4%) of 428 hospitals. Homeless adults were more likely to be younger, male, African American or Hispanic, and on Medicaid. They experienced significantly higher odds of all-cause inpatient mortality compared with nonhomeless patients admitted with GI bleeding (OR 1.37, 95% CI 1.11-1.69). Endoscopy utilization rates were also lower for both upper (OR 0.62, 95% CI 0.55-0.71) and lower (OR 0.76, 95% CI 0.68-0.85) GI bleeding, though upper endoscopy rates within the first 24 hours were comparable (OR 1.11, 95% CI 1.00-1.23). Total hospitalization costs were lower ($9,715 vs. $12,173, P <0.001) while 30-day all-cause readmission rates were significantly higher in the homeless group (14.9% vs. 18.4%, P <0.001). CONCLUSIONS Homeless patients hospitalized for GI bleeding face disparities, including higher mortality rates and lower endoscopy utilization.
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Affiliation(s)
- Kavitha Subramanian
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Quazim A Alayo
- Division of Internal Medicine, St. Luke's Hospital, Chesterfield, MO, USA
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, MO
| | - Mary Sedarous
- Department of Medicine, McMaster University, Hamilton, ON L8S4L8
| | - Obioma Nwaiwu
- Department of Medicine, University of Arkansas School of Medical Sciences, Little Rock, AR
| | - Philip N Okafor
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Cole KL, Findlay MC, Earl E, Sherrod BA, Cutler CB, Nguyen S, Grandhi R, Menacho ST. Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries. Neurosurgery 2023; 93:292-299. [PMID: 36892284 DOI: 10.1227/neu.0000000000002408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/14/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. OBJECTIVE To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries. METHODS Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. RESULTS Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). CONCLUSION Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.
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Affiliation(s)
- Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Emma Earl
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Christopher B Cutler
- College of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Sarah Nguyen
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Sarah T Menacho
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Taylor SN, Munson D. Health Care of People Experiencing Homelessness: Part I. NEJM EVIDENCE 2023; 2:EVIDra2300123. [PMID: 38320148 DOI: 10.1056/evidra2300123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.
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Affiliation(s)
| | - David Munson
- Massachusetts General Hospital, Boston
- Boston Health Care for the Homeless Program, Boston
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18
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Pourat N, Yue D, Chen X, Zhou W, O'Masta B. Easy to use and validated predictive models to identify beneficiaries experiencing homelessness in Medicaid administrative data. Health Serv Res 2023; 58:882-893. [PMID: 36755383 PMCID: PMC10315373 DOI: 10.1111/1475-6773.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE To develop easy to use and validated predictive models to identify beneficiaries experiencing homelessness from administrative data. DATA SOURCES We pooled enrollment and claims data from enrollees of the California Whole Person Care (WPC) Medicaid demonstration program that coordinated the care of a subset of Medicaid beneficiaries identified as high utilizers in 26 California counties (25 WPC Pilots). We also used public directories of social service and health care facilities. STUDY DESIGN Using WPC Pilot-reported homelessness status, we trained seven supervised learning algorithms with different specifications to identify beneficiaries experiencing homelessness. The list of predictors included address- and claims-based indicators, demographics, health status, health care utilization, and county-level homelessness rate. We then assessed model performance using measures of balanced accuracy (BA), sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (area under the curve [AUC]). DATA COLLECTION/EXTRACTION METHODS We included 93,656 WPC enrollees from 2017 to 2018, 37,441 of whom had a WPC Pilot-reported homelessness indicator. PRINCIPAL FINDINGS The random forest algorithm with all available indicators had the best performance (87% BA and 0.95 AUC), but a simpler Generalized Linear Model (GLM) also performed well (74% BA and 0.83 AUC). Reducing predictors to the top 20 and top five most important indicators in a GLM model yields only slightly lower performance (86% BA and 0.94 AUC for the top 20 and 86% BA and 0.91 AUC for the top five). CONCLUSIONS Large samples can be used to accurately predict homelessness in Medicaid administrative data if a validated homelessness indicator for a small subset can be obtained. In the absence of a validated indicator, the likelihood of homelessness can be calculated using county rate of homelessness, address- and claim-based indicators, and beneficiary age using a prediction model presented here. These approaches are needed given the rising prevalence of homelessness and the focus of Medicaid and other payers on addressing homelessness and its outcomes.
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Affiliation(s)
- Nadereh Pourat
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
- Department of Health Policy and ManagementUCLA Fielding School of Public HealthLos AngelesCaliforniaUSA
| | - Dahai Yue
- Department of Health Policy and ManagementUniversity of Maryland School of Public HealthCollege ParkMarylandUSA
| | - Xiao Chen
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
| | - Weihao Zhou
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
| | - Brenna O'Masta
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
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Warburton TM, Rush LD, Cullen EGR, Wiener JH, McManus BTK, Heath L, Evans D. The Impact of Homelessness, Substance Use, and Mental Illness on Surgical Inpatient Outcomes in Australia. Asia Pac J Public Health 2023; 35:335-341. [PMID: 37198924 DOI: 10.1177/10105395231175563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
This study investigated inpatient surgical outcomes for people experiencing homelessness (PEH) in Australia. Retrospective administrative health data of emergency surgical admissions from a single center over five years, 2015 to 2020, was included. Independent associations between factors and outcomes were analyzed with binary logistic and log-linear regression. Of 11 229 admissions, 2% were experiencing homelessness. People experiencing homelessness were on average younger (49 vs 56 years), more likely to be males than females (77% vs 61%), suffer mental illness (10% vs 2%), and substance use disorders (54% vs 10%). People experiencing homelessness were not more likely to suffer surgical complications. However, male sex, older age, mental illness, and substance use were risk factors for poor surgical outcomes. Homelessness predicted greater odds of discharge against medical advice (4.3 times) and longer length of stay (1.25 times). These results highlighted the need for health interventions simultaneously addressing physical, mental health, and substance use issues in the care of PEH.
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Affiliation(s)
- Thomas Mostyn Warburton
- Department of Surgery, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia
| | - Levon Delaney Rush
- Faculty of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Emma Grace Ruthven Cullen
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia
- Department of Anaesthetics, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Jonathan Harry Wiener
- Department of Surgery, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia
| | - Bryan Thomas Kelvin McManus
- Department of Surgery, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucienne Heath
- Department of Surgery, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia
| | - David Evans
- Department of Surgery, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
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Jiang GY, Urwin JW, Wasfy JH. Medicaid Expansion Under the Affordable Care Act and Association With Cardiac Care: A Systematic Review. Circ Cardiovasc Qual Outcomes 2023; 16:e009753. [PMID: 37339189 DOI: 10.1161/circoutcomes.122.009753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/20/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes. METHODS Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes. RESULTS A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities. CONCLUSIONS Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.
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Affiliation(s)
- Ginger Y Jiang
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - John W Urwin
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
| | - Jason H Wasfy
- Division of Cardiovascular Medicine (GYJ) and Department of Medicine (JWU), Beth Israel Deaconess Medical Center, Boston, MA. Cardiology Division, Massachusetts General Hospital, Boston, MA (JHW). Harvard Medical School, Boston, MA (GYJ, JWU, JHW)
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21
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Rodriguez LA, Thomas TW, Finertie H, Wiley D, Dyer WT, Sanchez PE, Yassin M, Banerjee S, Adams A, Schmittdiel JA. Identifying Predictors of Homelessness Among Adults in a Large Integrated Health System in Northern California. Perm J 2023; 27:56-71. [PMID: 36911893 PMCID: PMC10013725 DOI: 10.7812/tpp/22.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors' objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or "homeless/shelter" in address name). The predictors were measured in 2018-2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.
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Affiliation(s)
- Luis A Rodriguez
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Tainayah W Thomas
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Holly Finertie
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Deanne Wiley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Wendy T Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Perla E Sanchez
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Maher Yassin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Alyce Adams
- Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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22
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Fisher Z, Hughes G, Staggs J, Moore T, Kinder N, Vassar M. Health Inequities in Coronary Artery Bypass Grafting Literature: A Scoping Review. Curr Probl Cardiol 2023; 48:101640. [PMID: 36792023 DOI: 10.1016/j.cpcardiol.2023.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023]
Abstract
Although life saving, health inequities exist regarding access and patient outcomes in Coronary artery bypass grafting (CABG), especially among marginalized groups. This scoping review's goal is to outline existing literature and highlight gaps for future research. Researchers followed guidance from the Joanna Briggs Institute and PRISMA extension for scoping reviews. We conducted a search to identify articles published between 2016 and 2022 regarding CABG and inequity groups, defined by the National Institutes of Health. Fifty-seven articles were included in our final sample. Race/Ethnicity was examined in 39 incidences, Sex or Gender 29 times, Income 17 instances, Geography 10 instances, and Education Level 3 instances. Occupation Status 2 instances, and LGBTQ+ 0 times. Important disparities exist regarding CABG access and outcomes, especially involving members of the LGBTQ+, Native American, and Black communities. Further research is needed to address health disparities and their root causes for focused action and improved health of minoritized groups.
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Affiliation(s)
- Zachariah Fisher
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK.
| | - Griffin Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Jordan Staggs
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Ty Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | | | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
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23
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Huang K, Waken RJ, Luke AA, Carter EB, Lindley KJ, Joynt Maddox KE. Risk of delivery complications among pregnant people experiencing housing insecurity. Am J Obstet Gynecol MFM 2023; 5:100819. [PMID: 36436788 DOI: 10.1016/j.ajogmf.2022.100819] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/28/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Housing insecurity is increasingly being recognized as an important social determinant of health. Pregnant individuals experiencing housing insecurity may represent a particularly vulnerable subset of this population, but few studies have examined this population nationally. In particular, racial and ethnic minority individuals may be at risk for poor outcomes within this group because of structural racism and discrimination. The introduction of the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify patients with housing insecurity nationally. OBJECTIVE This study aimed to evaluate the prevalence of and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race and ethnicity. STUDY DESIGN This was a retrospective cohort study using data from the 2016 to 2018 National Inpatient Sample. Delivery hospitalizations for people experiencing housing insecurity were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code Z59. Among hospitals that coded at least 1 delivery for a patient with housing insecurity, logistic regression models were used to assess the odds of severe maternal morbidity associated with housing insecurity, adjusting for clinical risk and pregnancy characteristics. RESULTS Of 539,950 delivery hospitalizations, 1820 hospitalizations (0.3%) were for patients with housing insecurity. Compared to deliveries for patients with housing security, deliveries for patients with housing insecurity were more likely for patients who identified as Black (34.8% vs 18.1%; P<.001) and who had Medicaid insurance (83.5% vs 46.2%; P<.001). People with housing insecurity were more likely to have comorbidities and higher-risk pregnancies, including higher rates of substance use disorders (54.0% vs 6.9%), major mental health disorders (37.5% vs 8.7%), preeclampsia with severe features (7.4% vs 4.3%), and preterm birth <37 weeks gestation (23.7% vs 11.6%) (all P<.001). In regression analyses, patients with housing insecurity had more than twice the odds of severe maternal morbidity than patients with housing security during the delivery hospitalization (odds ratio, 2.17; 95% confidence interval, 1.75-2.68). After adjusting for clinical risk and pregnancy characteristics, the differences were attenuated overall (adjusted odds ratio, 1.17; 95% confidence interval, 0.94-1.47) and among racial and ethnic groups (White patients: adjusted odds ratio, 1.39; 95% confidence interval, 0.95-2.03; Black patients: adjusted odds ratio, 1.05; 95% confidence interval, 0.73-1.52; Hispanic patients: adjusted odds ratio, 1.04; 95% confidence interval, 0.59-1.84; Asian or Pacific Islander or Native American or other race patients: adjusted odds ratio, 1.08; 95% confidence interval, 0.45-2.58). CONCLUSION Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been marginalized historically, had higher rates of comorbidities, and worse delivery outcomes. After risk adjustment, differences in the odds of severe maternal mortality were attenuated. Screening for housing insecurity may identify these patients earlier and connect them to services that could improve disparities in outcomes.
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Affiliation(s)
- Kristine Huang
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (Ms Huang and Drs Waken, Lindley, and Joynt Maddox)
| | - R J Waken
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (Ms Huang and Drs Waken, Lindley, and Joynt Maddox)
| | - Alina A Luke
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA (Ms Luke)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO (Dr Carter)
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (Ms Huang and Drs Waken, Lindley, and Joynt Maddox)
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (Ms Huang and Drs Waken, Lindley, and Joynt Maddox); Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO (Dr Joynt Maddox).
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Wang C, Lindquist K, Krumholz H, Hsia RY. Trends in the likelihood of receiving percutaneous coronary intervention in a low-volume hospital and disparities by sociodemographic communities. PLoS One 2023; 18:e0279905. [PMID: 36652416 PMCID: PMC9847957 DOI: 10.1371/journal.pone.0279905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/17/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Over the past two decades, percutaneous coronary intervention (PCI) capacity has increased while coronary artery disease has decreased, potentially lowering per-hospital PCI volumes, which is associated with less favorable patient outcomes. Trends in the likelihood of receiving PCI in a low-volume center have not been well-documented, and it is unknown whether certain socioeconomic factors are associated with a greater risk of PCI in a low-volume facility. Our study aims to determine the likelihood of being treated in a low-volume PCI center over time and if this likelihood differs by sociodemographic factors. METHODS We conducted a retrospective cohort study of 374,066 hospitalized patients in California receiving PCI from January 1, 2010, to December 31, 2018. Our primary outcome was the likelihood of PCI discharges at a low-volume hospital (<150 PCI/year), and secondary outcomes included whether this likelihood varied across different sociodemographic groups and across low-volume hospitals stratified by high or low ZIP code median income. RESULTS The proportion of PCI discharges from low-volume hospitals increased from 5.4% to 11.0% over the study period. Patients of all sociodemographic groups considered were more likely to visit low-volume hospitals over time (P<0.001). Latinx patients were more likely to receive PCI at a low-volume hospital compared with non-Latinx White in 2010 with a 166% higher gap in 2018 (unadjusted proportions). The gaps in relative risk (RR) between Black, Latinx and Asian patients versus non-Latinx white increased over time, whereas the gap between private versus public/no insurance, and high versus low income decreased (interaction P<0.001). In low-income ZIP codes, patients with Medicaid were less likely to visit low-volume hospitals than patients with private insurance in 2010; however, this gap reversed and increased by 500% in 2018. Patients with low income were more likely to receive PCI at low-volume hospitals relative to patients with high income in all study years. CONCLUSIONS The likelihood of receiving PCI at low-volume hospitals has increased across all race/ethnicity, insurance, and income groups over time; however, this increase has not occurred evenly across all sociodemographic groups.
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Affiliation(s)
- Christina Wang
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Karla Lindquist
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Harlan Krumholz
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, United States of America
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Zeien J, Vieira J, Hanna J, Surendra L, Stenzel J, Ramirez A, Miller C, Rosales C. Mpox Case Reports in an Urban Homeless Population and a Proof of Concept for a Street-Based Mobile Mpox Vaccination Clinic. J Prim Care Community Health 2023; 14:21501319231169991. [PMID: 37191007 DOI: 10.1177/21501319231169991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Mpox is a new public health outbreak that particularly threatens the homeless population. Street Medicine Phoenix (SMP) is a student-led interprofessional volunteer organization that provides medical care and other essential services to individuals experiencing homelessness in Phoenix, Arizona. In addition to core services such as wound care; health screenings (blood pressure and blood glucose.); vision screenings; HIV testing; naloxone education and distribution; flu, COVID-19, and Hepatitis A vaccinations; and community resource referrals, SMP began offering mpox education and vaccination at outreach events. During an outreach event shortly after the onset of the mpox outbreak, SMP identified 2 suspected mpox cases. Accordingly, SMP has partnered with the Maricopa County Public Health Department to set up mobile mpox vaccination clinics on the streets outside of Phoenix Arizona's largest homeless shelter. We share the details of these 2 cases along with our early efforts vaccinating individuals experiencing homelessness for mpox via our mobile vaccination clinic. Our experiences demonstrate the importance of community agencies providing direct outreach to underserved populations where they are at, particularly the homeless population, to address public health concerns such as emerging disease outbreaks like mpox. In addition, these cases highlight the potential significant impact that street medicine programs can have on their respective homeless communities in the context of infectious disease mitigation and emphasize the importance of partnerships with local health departments.
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Affiliation(s)
- Justin Zeien
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jaime Vieira
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jeffery Hanna
- University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Likith Surendra
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jake Stenzel
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Alma Ramirez
- University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Catherine Miller
- University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Cecilia Rosales
- University of Arizona College of Public Health, Phoenix, AZ, USA
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Kiernan K, Dodge SE, Kwaku KF, Jackson LR, Zeitler EP. Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes. Heart Rhythm O2 2022; 3:807-816. [PMID: 36589011 PMCID: PMC9795300 DOI: 10.1016/j.hroo.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.
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Affiliation(s)
- Katherine Kiernan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shayne E. Dodge
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kevin F. Kwaku
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Larry R. Jackson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Emily P. Zeitler
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute, Lebanon, New Hampshire
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Yue D, Pourat N, Essien EA, Chen X, Zhou W, O'Masta B. Differential associations of homelessness with emergency department visits and hospitalizations by race, ethnicity, and gender. Health Serv Res 2022; 57 Suppl 2:249-262. [PMID: 35593107 PMCID: PMC9660436 DOI: 10.1111/1475-6773.14009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender. DATA SOURCES California Medicaid enrollment and claims. STUDY DESIGN We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates. DATA COLLECTION We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data. PRINCIPAL FINDINGS We found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females. CONCLUSIONS Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH.
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Affiliation(s)
- Dahai Yue
- Department of Health Policy and ManagementUniversity of Maryland School of Public HealthCollege ParkMarylandUSA
| | - Nadereh Pourat
- Department of Health Policy and ManagementUCLA Fielding School of Public HealthLos AngelesCaliforniaUSA
| | - Elsie A. Essien
- Department of Health Policy and ManagementUniversity of Maryland School of Public HealthCollege ParkMarylandUSA
| | - Xiao Chen
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
| | - Weihao Zhou
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
| | - Brenna O'Masta
- Health Economics and Evaluation Research ProgramUCLA Center for Health Policy ResearchLos AngelesCaliforniaUSA
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Rao K, Brieger D, Baer A, Nour D, Allum J, Bhindi R. Cardiovascular Disease in Australians Experiencing Homelessness. Heart Lung Circ 2022; 31:1585-1593. [PMID: 36856289 DOI: 10.1016/j.hlc.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/06/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022]
Abstract
Australia has one of the highest rates of homelessness in the world, at 498 per 100,000 people, and Australians experiencing homelessness (AEH) are a particularly vulnerable cohort, with a greater prevalence of cardiovascular disease, and poorer health outcomes, when compared to the general population. This narrative review explores how a combination of inadequately managed traditional and non-traditional cardiovascular risk factors, along with several personal, practical and relationship challenges with the health system, have created unique barriers in the diagnosis and management of cardiovascular disease in AEH. To help address these inequalities, we propose a targeted and collaborative strategy, which includes government proactivity, stable and affordable housing, and involvement of specialist health professionals, community leaders and major homelessness organisations. Furthermore, the delivery of health care needs to be a combination of outreach and opportunistic services, with a focus on flexible and individualised preventative care.
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Affiliation(s)
- Karan Rao
- Royal North Shore Hospital, Sydney, NSW, Australia; North Shore Private Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | | | | | - Daniel Nour
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jenny Allum
- SCEGGS, Sydney, NSW, Australia. https://twitter.com/Ravinay
| | - Ravinay Bhindi
- Royal North Shore Hospital, Sydney, NSW, Australia; North Shore Private Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
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29
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Gula AL, Ramos J, Simpson JM, Jiang L, Martin E, Wice M, Erqou S, Wu WC, Rudolph JL. Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness. J Pain Symptom Manage 2022; 64:471-477. [PMID: 35901868 DOI: 10.1016/j.jpainsymman.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.
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Affiliation(s)
- Annie Laurie Gula
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jacob Ramos
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Jane M Simpson
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Edward Martin
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA
| | - Mitchell Wice
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Rhode Island Hospital and Lifespan Health System of Providence (A.L.G., J.R., J.M.S., S.E., W.C.W.), RI, USA; Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA
| | - James L Rudolph
- Department of Medicine, The Warren Alpert Medical School of Brown University (E.M., M.W., S.E., W.C.W., J.L.R.), Providence, RI, USA; Center of Innovation in Long Term Services and Supports (L.J., M.W., S.E., W.C.W., J.L.R.), Providence VA Medical Center, Providence, RI, USA.
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Chandra R, Meier J, Khoury MK, Weisberg A, Nguyen YT, Peltz M, Jessen ME, Heid CA. Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00230-1. [PMID: 36223817 DOI: 10.1053/j.semtcvs.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.
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Affiliation(s)
- Raghav Chandra
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Jennie Meier
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas, Texas.
| | - Mitri K Khoury
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Asher Weisberg
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Yen T Nguyen
- Department of Surgery, North Texas Veterans Affairs Health Care System, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Christopher A Heid
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework. J Am Coll Surg 2022; 235:350-360. [PMID: 35839414 PMCID: PMC9668043 DOI: 10.1097/xcs.0000000000000214] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.
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Parekh T, Xue H, Cheskin LJ, Cuellar AE. Food insecurity and housing instability as determinants of cardiovascular health outcomes: A systematic review. Nutr Metab Cardiovasc Dis 2022; 32:1590-1608. [PMID: 35487828 DOI: 10.1016/j.numecd.2022.03.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/26/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022]
Abstract
AIMS The primary objective of this study is to conduct a systematic review of existing literature on the association between food insecurity and housing instability with CVD and its subtypes-related outcomes. Summarizing the comprehensive evidence for independent/interchangeable relationship of food and housing instability with CVD outcomes may inform specific interventions strategies to reduce CVD-risk. DATA SYNTHESIS The search focused on English-language articles in PubMed/Medline, from January 1, 2010, to June 1, 2021, with restriction to the US adult population. We included studies estimating the association between food insecurity or/and housing instability(exposure) and CVD-subtypes-related health outcomes (outcome). The study methodological quality was assessed using the Study Quality Assessment Tools (SQAT). Nineteen studies met eligibility criteria, consisted of 15 cross-sectional and 4 cohort studies. Of total studies, 7 examined housing instability, 11 studies focused on food insecurity, and one examined both. Food insecurity/housing instability was associated with increased overall CVD-mortality rate and greater healthcare cost utilization, while evidence were mixed for hospital readmission rate. By subtype, stroke mortality was greater with food insecurity but not with housing instability. The likelihood of myocardial infarction, coronary heart disease, and congestive heart failure was greater with food insecurity. Although mortality with MI was higher with housing instability, readmission and surgical procedure rates were significantly lower than housing stable adults. CONCLUSION Findings from this review suggest an urgent need to test the impact of screening for food and housing insecurities, referral services, and community engagement for CV health, within clinical and public health settings. PROTOCOL REGISTRATION Prospero CRD4202123352.
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Affiliation(s)
- Tarang Parekh
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Hong Xue
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Lawrence J Cheskin
- Department of Nutrition and Food Studies, George Mason University, Fairfax, VA, USA
| | - Alison E Cuellar
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA.
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Wilson DA, Boadu O, Jones AL, Kim N, Mor MK, Hausmann LRM, Essien UR. Analysis of Initiating Anticoagulant Therapy for Atrial Fibrillation Among Persons Experiencing Homelessness in the Veterans Affairs Health System. JAMA Netw Open 2022; 5:e2223815. [PMID: 35881400 PMCID: PMC9327581 DOI: 10.1001/jamanetworkopen.2022.23815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/09/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- David A. Wilson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Osei Boadu
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Utibe R. Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Patlolla SH, Kanwar A, Belford PM, Applegate RJ, Zhao DX, Singh M, Vallabhajosyula S. Influence of Household Income on Management and Outcomes of Acute Myocardial Infarction Complicated by Cardiogenic Shock. Am J Cardiol 2022; 177:7-13. [PMID: 35701236 DOI: 10.1016/j.amjcard.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/25/2022]
Abstract
The impact of socioeconomic status on care and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains understudied. Hence, adult admissions with AMI-CS were identified from the National Inpatient Sample database (2005 to 2017) and were divided into quartiles on the basis of median household income for zip code (0 to 25th, 26th to 50th, 51st to 75th, and 76th to 100th). In-hospital mortality, use of cardiac and noncardiac procedures, and resource utilization were compared between all 4 income quartiles. Among a total of 7,805,681 AMI admissions, cardiogenic shock was identified in 409,294 admissions (5.2%) with comparable prevalence of cardiogenic shock across all 4 income quartiles. AMI-CS admissions belonging to the lowest income quartile presented more often with non-ST-elevation myocardial infarction and had comparable use of coronary angiography and percutaneous coronary intervention but lower use of early coronary angiography, early percutaneous coronary intervention, mechanical circulatory support devices, and pulmonary artery catheterization than higher income quartiles. In the adjusted analysis, admissions belonging to the 0 to 25th income quartile (odds ratio [OR] 1.17 [95% confidence interval [CI] 1.15 to 1.20], p <0.001), 26th to 50th quartile (OR 1.11 [95% CI 1.09 to 1.14], p <0.001), and 51st to 75th income quartile (OR 1.06 [95% CI 1.04 to 1.09], p <0.001) had higher adjusted in-hospital mortality than the highest income quartile (76th to 100th). Lowest income quartile admissions had lower rates of palliative care consultations and higher rates of do-not-resuscitate status than the higher income quartiles. Hospitalization charges and length of stay were higher for admissions belonging to the highest income quartile. In conclusion, lowest income quartile AMI-CS admissions were associated with higher rates of non-ST-elevation myocardial infarction, lower use of mechanical circulatory support devices, and higher in-hospital mortality.
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Affiliation(s)
| | - Ardaas Kanwar
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - P Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Robert J Applegate
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Del Buono BC, Salhi BA, Kimmel AE, Santen SA, Jarrell KL, White MH, Brown CK, Moll JL. Prioritizing homelessness in emergency medicine education: A concept paper. AEM EDUCATION AND TRAINING 2022; 6:S85-S92. [PMID: 35774356 PMCID: PMC9222893 DOI: 10.1002/aet2.10753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/03/2022] [Accepted: 03/25/2022] [Indexed: 06/15/2023]
Abstract
Patients experiencing homelessness visit the emergency department (ED) often and have worse clinical outcomes. Caring for this patient population is complex, challenging, and resource-intensive. Emergency medicine (EM) education is lacking in formal curricula on the topic of homelessness, despite benefits for resident morale and patient care. Our goals were to identify a gap in EM education and training of the intersection of housing and health and propose educational topics and teaching methods to be included in residency curricula. Methodology was based on the development of a didactic session at the 2021 SAEM Annual Meeting. A needs assessment was performed through a review of medical education literature, a national survey of EM residency curricula, the individual curricula utilized by respective team members, and perspective from the team's own individual experiences with teaching about homelessness. Topics presented were chosen through discussion between the authors and determined to be common and relevant and cover a broad spectrum of content. The four presented topics included the intersection of COVID-19 and housing, the impact of LGBTQIA+ status on homelessness, housing status related to health system utilization and health outcomes, and housing inequity as a means of perpetuating structural racism. Suggestions for education of these topics included case-based learning, journal clubs, simulation, collaboration with social work, quality improvement projects, and engagement with community leaders. The ED is uniquely positioned to encounter the impacts of homelessness on health. Emergency physicians should be prepared to effectively care for these patients with complex social needs. Structured learning on this topic would benefit EM resident growth and lead to better patient care through improved screening, recognition of risk factors, and use of social resources.
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Affiliation(s)
- Benedict C. Del Buono
- Department of Emergency MedicineVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - Bisan A. Salhi
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Alexis E. Kimmel
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Sally A. Santen
- Virginia Commonwealth University School of MedicineProfessor, Emergency Medicine and Medical EducationUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Kelli L. Jarrell
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Melissa H. White
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Christopher K. Brown
- Department of Emergency MedicineVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - Joel L. Moll
- Department of Emergency MedicineVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
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Abstract
Stable housing is essential for health. Over 580,000 Americans experienced homelessness during one night in 2020, and over 37 million households spend over 30% of their income on housing. Unstable housing has been associated with mortality, acute care utilization, communicable and non-communicable diseases, a higher risk of kidney disease, and kidney disease progression. In this review, we define various forms of unstable housing, provide an overview of the interaction between unstable housing and health, and discuss existing evidence associating housing and kidney disease. We provide historical context for unstable housing in the United States, and detail policy, community, and individual-level factors that contribute to the risk of unstable housing. Unstable housing likely affects kidney health via a complex interplay of individual and structural factors. Various screening tools are available for use by providers. Special considerations should be made when working with individuals experiencing unstable housing to meet their unique needs, facilitate health care engagement, and optimize outcomes. Housing interventions have been shown to improve outcomes and should be examined for their role in kidney disease.
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Affiliation(s)
- Tessa K. Novick
- Division of Nephrology, University of Texas at Austin, Dell Medical School, Austin, TX
| | - Margot Kushel
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA
| | - Deidra Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Khan SU, Yedlapati SH, Khan MZ, Virani SS, Blaha MJ, Sharma G, Jordan JE, Kash BA, Vahidy FS, Arshad A, Mossialos E, Nasir K. Clinical and Economic Profile of Homeless Young Adults with Stroke in the United States, 2002 - 2017. Curr Probl Cardiol 2022:101190. [PMID: 35346726 DOI: 10.1016/j.cpcardiol.2022.101190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION . Homelessness is a major social determinant of health. We studied the clinical and economic profile of homeless young adults hospitalized with stroke. METHODS . We studied the National Inpatient Sample database (2002-2017) to evaluate trends of stroke hospitalization, clinical outcomes, and health expenditure in homeless vs. non-homeless young adults (<45 years). RESULTS . We identified 3,134 homeless individuals out of 648,944 young adults. Homeless patients were more likely to be men, Black adults and had a higher prevalence of cardiometabolic risk factors and psychiatric disorders than non-homeless adults. Both homeless and non-homeless adults had a similar prevalence of ischemic and hemorrhagic stroke. Between 2002 and 2017, hospitalization rates per million increased for both non-homeless (295.8 to 416.8) and homeless adults (0.5 to 3.6) (P≤0.01). Between 2003 and 2017, the decline in in-hospital mortality was limited to non-homeless adults (11% to 9%), while it has increased in homeless adults (3% to 11%) (P<0.01). The prevalence of acute myocardial infarction (6.8% vs. 3.3%, P<0.01), and acute kidney injury (13.1% vs. 9.4%, P<0.01) was also higher in homeless vs. non-homeless adults. The length of stay and inflation-adjusted care cost were comparable between both study groups. Finally, a higher proportion of homeless patients left the hospital against medical advice than non-homeless adults. CONCLUSIONS . Homeless young stroke patients had significant comorbidities, increased hospitalization rates, and adverse clinical outcomes. Therefore, public health interventions should focus on multidisciplinary care to reduce health care disparities among young homeless adults.
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Affiliation(s)
- Safi U Khan
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston TX, US
| | - Siva H Yedlapati
- Department of Medicine, Erie County Medical Center, Buffalo, NY, US
| | - Muhammad Zia Khan
- Department of Cardiology, West Virginia University, Morgantown, WV, US
| | - Salim S Virani
- Michael E. DeBakey Veterans Affair Medical Center & Department of Medicine, Baylor College of Medicine, Houston, TX, US
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, MD, US
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, MD, US
| | - John E Jordan
- Chair, American College of Radiology, Commission on Neuroradiology and Health Equity Workgroup, US; Providence Little Company of Mary Medical Center, Torrance, CA, US
| | - Bita A Kash
- Center for Outcomes Research, Houston Methodist, Houston, TX, US
| | - Farhaan S Vahidy
- Center for Outcomes Research, Houston Methodist, Houston, TX, US
| | - Adeel Arshad
- Department of Internal Medicine, The Ohio State Comprehensive Cancer Center, Columbus, OH, US
| | - Elias Mossialos
- London School of Economics and Political Science, London, UK
| | - Khurram Nasir
- Department of Internal Medicine, The Ohio State Comprehensive Cancer Center, Columbus, OH, US; Division of Cardiovascular Prevention and Wellness, Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA; Center for Computational Health & Precision Medicine (C3-PH), Houston Methodist, Houston, TX, USA.
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Riley ED, Delucchi K, Rubin S, Weiser SD, Vijayaraghavan M, Lynch K, Tsoh JY. Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies. Addict Behav 2022; 125:107125. [PMID: 34673360 DOI: 10.1016/j.addbeh.2021.107125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women. METHODS We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use. RESULTS Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR/5 yrs: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39). CONCLUSION Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.
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Gewahrsamsfähigkeitsuntersuchungen in der Notaufnahme. Notf Rett Med 2022. [DOI: 10.1007/s10049-021-00971-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Asaithambi G, Marino EH, Ho BM, Tipps ME. Outcomes of Homeless Ischemic Stroke Patients Receiving Intravenous Thrombolysis in the United States. J Stroke Cerebrovasc Dis 2021; 30:105862. [PMID: 34034124 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Morbidity and mortality among homeless people with cardiovascular diseases and stroke in the United States is high. Adverse outcomes within the homeless population may be the result of seeking care too late to receive time-sensitive interventions. We sought to investigate the impact of homelessness on ischemic stroke patients who received intravenous thrombolysis (IVT). METHODS We determined rates of post-thrombolytic intracranial hemorrhage (ICH), in-hospital death, and development of moderate to severe disability among homeless ischemic stroke patients treated with IVT. Patients were identified using the Nationwide (National) Inpatient Sample between 2002 and 2017. We compared rates of the various outcomes to non-homeless ischemic stroke patients treated with IVT. RESULTS There were 514 homeless (mean age 54.7 ± 10.2 years, 20.4% women) and 364,408 non-homeless (mean age 68.6 ± 14.7 years, 49.7% women) ischemic stroke patients who received IVT. There was no difference in post-thrombolytic ICH rates between the two groups (6.6% homeless versus 8.8% non-homeless, p = 0.09). Homeless patients were more frequently discharged to self-care (p = 0.003). Homeless patients were less likely than non-homeless patients to suffer in-hospital death (AOR 0.499 [95% CI 0.30-0.84], p = 0.009) and moderate to severe disability (AOR 0.423 [95% CI 0.29 - 0.62], p < 0.001). CONCLUSION Homeless ischemic stroke patients who receive IVT are not at an increased risk of developing post-thrombolytic ICH or in-hospital death. Efforts are needed to encourage this unique population to seek medical attention as soon as possible for time-sensitive interventions that may decrease the risk of permanent disability or death associated with ischemic stroke.
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Affiliation(s)
| | - Emily H Marino
- Neuroscience Research, Allina Health, Minneapolis, MN, USA.
| | - Bridget M Ho
- Neuroscience Research, Allina Health, Minneapolis, MN, USA.
| | - Megan E Tipps
- Neuroscience Research, Allina Health, Minneapolis, MN, USA.
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Lin LP, Wang LY, Wang TW, Chen YC, Lin JD. Factors Associated with Free Hospital Outpatient Service Use among Middle-Aged and Older Urban Homeless Adults in Taipei. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105330. [PMID: 34067784 PMCID: PMC8156856 DOI: 10.3390/ijerph18105330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022]
Abstract
Homeless individuals have many negative experiences with inequality regarding access to and the use of primary healthcare services, so policies to eliminate the disparities in and barriers to primary care access for these people are needed. The aim of this study was to explore the use and determinants of free hospital outpatient services for homeless people, in order to describe the provision of free healthcare policies for this vulnerable population in Taipei. One cross-sectional survey was conducted to recruit homeless people aged 45 years old and over in Taipei in 2018. A structured questionnaire was used, and face-to-face interviews were conducted by three social workers to collect the data. Finally, 129 participants were recruited in the study. The results show that 81.4% of the homeless people had made free hospital outpatient care visits (mean = 5.9 visits) in the last three months. An unadjusted logistic regression analysis showed that those homeless people who reported having usual healthcare providers, with higher depressive symptom scores, who used medication and had been hospitalized within one year, and had more chronic diseases, were significantly more likely to make free hospital outpatient visits. The adjusted logistic regression model indicates that homeless people with severe depressive symptoms (odds ratio (OR) = 9.32, 95% CI = 1.15–56.07), who had received medication (OR = 3.93; 95% CI = 1.06–14.52), and who had more than five chronic diseases (OR = 1.06, 95% CI = 1.35–13.27), were significantly more likely to make free hospital outpatient visits than their counterparts. The findings highlight that homeless people have higher healthcare requirements than the general population, and the healthcare system should pay more attention to factors associated with higher outpatient service use, such as homelessness, severe depressive symptoms, the receipt of medication and chronic diseases.
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Affiliation(s)
- Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Li-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Jin-Ding Lin
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence:
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Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting with ST-Elevation Myocardial Infarction. Can J Cardiol 2021; 37:1555-1561. [PMID: 34004281 DOI: 10.1016/j.cjca.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cardiovascular disease remains a major cause of morbidity and mortality among homeless adults. Despite major advances in the management of ST elevation myocardial infarction (STEMI), limited information is available for the clinical presentation and management and outcome of STEMI among patients experiencing homelessness (PEH). METHODS All patients presenting with STEMI between January 1, 2008 and December 31, 2017 at a PCI capable STEMI network inner city hospital comprised the study population. Baseline characteristics, homeless status and clinical outcomes were determined from hospital records. The primary outcome of in-hospital mortality was compared between PEH and non-homeless patients using a log-binomial regression model with propensity score adjusted standardized mortality ratio weighting (SMRW). RESULTS Among 2854 STEMI admissions during the study period, 75 (2.6%) patients were identified as PEH. The PEH group was younger (58 vs. 63 years, p=0.0002), predominantly male (96% vs. 76%, p<0.0001) and more likely to present with cardiogenic shock or cardiac arrest (17% vs. 6%, p=0.0004) compared to non-homeless cohort. The in-hospital mortality remained significantly higher among PEH (RR: 3.83; 95% CI: 1.27, 11.60) after propensity score adjustment. CONCLUSIONS Despite universal health care and contemporary STEMI management, PEH presenting with STEMI experienced a 4-fold higher in-hospital mortality compared to non-homeless cohort. Targeted interventions are needed to improve STEMI outcomes in this high risk group.
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Miyawaki A, Khullar D, Tsugawa Y. Processes of care and outcomes for homeless patients hospitalised for cardiovascular conditions at safety-net versus non-safety-net hospitals: cross-sectional study. BMJ Open 2021; 11:e046959. [PMID: 36107751 PMCID: PMC8039275 DOI: 10.1136/bmjopen-2020-046959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Evidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals. DESIGN Cross-sectional study. SETTING Data including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014. PARTICIPANTS We analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals. OUTCOME MEASURES Risk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects. RESULTS At safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals. CONCLUSION Disparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.
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Affiliation(s)
- Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Dhruv Khullar
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Khan MZ, Munir MB, Khan MU, Kuprica T, Balla S. Burden of Infective Endocarditis in Homeless Patients in the United States: A National Perspective. Am J Med Sci 2021; 362:39-47. [PMID: 33798460 DOI: 10.1016/j.amjms.2021.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/06/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Earlier studies have shown disparate cardiovascular care in homeless patients. Limited data exist on burden of infective endocarditis (IE) in homeless patients and in this study, we aimed to analyze it using a nationally representative United States population sample. METHODS Data were extracted from National Inpatient Sample database from January 2000 to December 2017. Patients with endocarditis were sampled using International Classification of Diseases, 9th Revision, Clinical Modification codes of 421.0, 421.1 or 421.9 and International Classification of Diseases, 10th Revision, Clinical Modification codes of I33.0 or I33.9. Homeless patients were identified using codes of V60 and Z59. Linear regression was used for trend analysis and logistic regression was utilized to identify predictors of mortality. 1:1 propensity score (PS) matching was also done to balance confounders and outcomes were assessed in both unmatched and matched cohorts. RESULTS We found an increase in proportion of homeless patients admitted with endocarditis from 0.2% in year 2000 to 2.4% in year 2017. Mortality was not statistically significant in PS matched homeless and non-homeless cohorts (4.7% vs 6.6%, p = 0.072). There was a trend towards increased mortality in homeless endocarditis patients over our study years with lower utilization of valvular surgeries. Advanced age, alcohol abuse and admission to large hospitals were independently associated with mortality in homeless endocarditis patients. CONCLUSION Homeless patients have rising trend of IE and IE related mortality and also found to have low utilization of life saving valvular surgeries when compared to general population.
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Affiliation(s)
- Muhammad Zia Khan
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA.
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA; Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Muhammad U Khan
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Troy Kuprica
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
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Minejima E, Wang J, Boettcher S, Liu L, Lou M, She RC, Wenzel SL, Spellberg B, Wong-Beringer A. Distance Between Home and the Admitting Hospital and Its Effect on Survival of Low Socioeconomic Status Population With Staphylococcus aureus Bacteremia. Public Health Rep 2021; 137:110-119. [PMID: 33715536 PMCID: PMC8721749 DOI: 10.1177/0033354921994897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Bacteremia is the presence of bacteria in the bloodstream. The objective of this study was to determine the relationship between low socioeconomic status (SES) and the epidemiology, process of care, and outcomes of patients with Staphylococcus aureus bacteremia (SAB). METHODS We conducted a multicenter, retrospective, cohort study that evaluated adult patients with SAB in 3 Los Angeles County hospitals from July 15, 2012, through May 31, 2018. We determined SES (low SES, intermediate SES, and high SES) for each patient and compared sociodemographic and epidemiologic characteristics, management of care received by patients with SAB (ie, process of care), and outcomes. We used a Cox proportional hazards model to determine predictors of 30-day mortality for each SES group. RESULTS Of 915 patients included in the sample, 369 (40%) were in the low-SES group, 294 (32%) in the intermediate-SES group, and 252 (28%) in the high-SES group. Most significant predictors of 30-day mortality in the Cox proportional hazards model were admission to an intensive care unit (hazard ratio [HR] = 9.04; 95% CI, 4.26-19.14), Pitt bacteremia score ≥4 indicating critical illness (HR = 4.30; 95% CI, 2.49-7.44), having ≥3 comorbidities (HR = 2.05; 95% CI, 1.09-3.85), and advanced age (HR = 1.03; 95% CI, 1.01-1.05). Distance between home and admitting hospital affected mortality only in the low-SES group (HR = 1.02; 95% CI, 1.00-1.02). CONCLUSIONS SES did not independently affect the outcome of SAB; however, the farther the patient's residence from the hospital, the greater the negative effect on survival in a low-SES population. Our findings underscore the need to develop multipronged, targeted public health efforts for populations that have transportation barriers to health care.
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Affiliation(s)
- Emi Minejima
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA,Los Angeles County–University of Southern California Medical Center, Los Angeles, CA, USA
| | - Joshua Wang
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Stormmy Boettcher
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Lihua Liu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mimi Lou
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - Rosemary C. She
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Suzanne L. Wenzel
- Department of Adults and Healthy Aging, University of Southern California School of Social Work, Los Angeles, CA, USA
| | - Brad Spellberg
- Los Angeles County–University of Southern California Medical Center, Los Angeles, CA, USA
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA,Department of Pharmacy, Huntington Hospital, Pasadena, CA, USA,Annie Wong-Beringer, PharmD, University of Southern California School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90033, USA.
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Maqsood MH, Kamal O, Charytan D. Cardiovascular Issues Among Homeless People: An Issue that Needs Attention. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820975038. [PMID: 33343203 PMCID: PMC7727041 DOI: 10.1177/1179546820975038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/14/2020] [Indexed: 11/24/2022]
Abstract
Cardiovascular disease is one of the most common causes of death with social factors increasingly recognized as determinants of cardiovascular prognosis. Homelessness, transient or chronic, may be one of the factors which predict treatment access and eventual outcomes as socially and economically disadvantaged group has high prevalence of cardiovascular risk factors such as smoking, and delayed diagnosis and poor control of other risk factors such as diabetes and hypertension. This perspective article aims to discuss the issues associated with cardiovascular disease treatment, outcomes and future directions for homeless patients.
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Affiliation(s)
- Muhammad Haisum Maqsood
- Research Fellow, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Omer Kamal
- Postdoctoral Research Fellow, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Charytan
- Chief, Nephrology Division, NYU Langone Medical Center, New York, NY, USA
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Miyawaki A, Hasegawa K, Tsugawa Y. Lessons from Influenza Outbreaks for Potential Impact of COVID-19 Outbreak on Hospitalizations, Ventilator Use, and Mortality Among Homeless Persons in New York State. J Gen Intern Med 2020; 35:2781-2783. [PMID: 32500333 PMCID: PMC7272140 DOI: 10.1007/s11606-020-05876-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/28/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Miyawaki A, Burke LG, Khullar D, Tsugawa Y. Comparison of 30-day readmission and emergency department revisit rates among homeless patients at teaching versus non-teaching hospitals. Soc Sci Med 2020; 263:113283. [PMID: 32836166 DOI: 10.1016/j.socscimed.2020.113283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/20/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
Providing quality healthcare for homeless patients is a major public health challenge, and some hospitals may be better at treating homeless patients than others. However, whether the quality of care that homeless patients receive differs by the teaching status of hospitals remains unclear. Using statewide databases that include all hospital admissions and emergency department (ED) visits in four states (Florida, Massachusetts, Maryland, and New York) in 2014, we compared 30-day readmission and ED revisit rates for homeless and non-homeless patients discharged from teaching hospitals versus non-teaching hospitals, after adjusting for patient and hospital characteristics. Among 3,438,538 patients (median age [IQR]: 63 [49-77] years) analyzed, 132,025 (4%) were homeless patients. Overall, homeless patients had a higher readmission rate (28.3% vs. 17.7%; average marginal effects [AME], 10.5%; 95% confidence interval [CI], 8.2%-12.9%; p < 0.001) and a higher ED revisit rate (37.6% vs. 23.9%; AME, 13.7%; 95%CI, 10.9%-16.6%; p < 0.001) than non-homeless patients. Patients from teaching hospitals had similar readmission rate (18.2% vs. 18.3%; AME, -0.1%; 95%CI, -0.8%-0.5%; p = 0.69) and slightly lower ED revisit rate than those from non-teaching hospitals (24.1% vs. 25.2%; AME, -1.1%; 95%CI, -1.9% to -0.3%; p < 0.01). When we focus on joint effects of homelessness and hospital teaching status, we found that homeless patients treated at teaching hospitals had lower rates of 30-day readmission (AME, -5.8%; 95%CI, -9.7% to -1.8%; p < 0.01) and ED revisit (AME, -9.3%; 95%CI, -13.1% to -5.5%; p < 0.001) compared to those treated at non-teaching hospitals. For non-homeless patients, in contrast, we found no evidence that rates of hospital readmission (AME, 0%, 95%CI, -0.1%-0.1%; p = 0.94) or ED revisit (AME, -0.9%; 95%CI, -1.7% to -0.1%; p = 0.02) differ between teaching and non-teaching hospitals. These findings suggest the healthcare settings in which homeless patients receive care have important implications for their patient outcomes.
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Affiliation(s)
- Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan; Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan.
| | - Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Dhruv Khullar
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA; Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA; UCLA Center for Health Policy Research, Los Angeles, CA, USA
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50
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Wang LY, Lin LP, Chen YC, Wang TW, Lin JD. Correlates of Depressive Symptoms among Middle-Aged and Older Homeless Adults Using the 9-Item Patient Health Questionnaire. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134754. [PMID: 32630635 PMCID: PMC7370065 DOI: 10.3390/ijerph17134754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 01/01/2023]
Abstract
This study investigates the screening for depressive symptoms among middle-aged and older homeless adults based on Patient Health Questionnaire-9 (PHQ-9) and examines the possible factors associated with their major depressive symptoms. A cross-sectional survey was employed, and research subjects included 129 homeless people aged 45 years old and over in Taipei Wanhua District and Taipei Main Station. We used a structured questionnaire and face-to-face interview conducted by three social workers to collect data in the analyses. The content of the questionnaire included an informed consent form, demographic characteristics, enabling and need factors of healthcare, and PHQ-9 of homeless people. Results revealed that 15.5% respondents were free of depressive symptoms, 16.3% had mild level (score 5–9), 31.8% had moderate level (score 10–14), 26.4% had moderately severe level (score 15–19), and 10.1% had severe level of depressive symptoms (score 20–27). Adopting a PHQ-9 score 10 as a cut-off point for major depressive symptoms, 68.3% of middle-aged and older homeless adults were the cases needing to be referred to healthcare settings for further recheck in the near future. A multiple regression analysis found gender, age, and usage of psychiatric outpatient care were associated with major depressive symptom occurrence. The female participants were less likely to have major depressive symptoms than the male participants (OR = 0.29, 95% CI = 0.09–0.96). The elderly participants were more likely to have major depressive symptoms than the aged 45–54 years (OR = 5.29, 95% CI = 1.44–19.41). Those participants who have ever used psychiatric outpatient care were significantly more correlated with the occurrence of major depressive symptoms than their counterparts (OR = 3.65, 95% CI = 1.46–9.09). The present study suggests that in the future health policy should eliminate the risk factors of depressive symptoms and improve mental healthcare access, to improve the health and wellbeing of the homeless population.
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Affiliation(s)
- Lin-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 144, Taiwan; (Y.-C.C.); (T.-W.W.)
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 144, Taiwan; (Y.-C.C.); (T.-W.W.)
| | - Jin-Ding Lin
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence: ; Tel.: +886-2-2636-0303-1816
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