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Leeds IL, Park LS, Akgun K, Weintrob A, Justice AC, King JT. Postoperative Outcomes Associated with the Timing of Surgery After SARS-CoV-2 Infection. Ann Surg 2024; 280:241-247. [PMID: 38323413 PMCID: PMC11236522 DOI: 10.1097/sla.0000000000006227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Examine the association between prior SARS-CoV-2 infection, interval from infection to surgery, and adverse surgical outcomes. SUMMARY BACKGROUND DATA Earlier series have reported worse outcomes for surgery after COVID-19 illness, and these findings have led to routinely deferring surgery seven weeks after infection. METHODS We created a retrospective cohort of patients from the US Veterans Health Administration facilities nationwide, April 2020 to September 2022, undergoing surgical procedures. Primary outcomes were 90-day all-cause mortality and 30-day complications. Within surgical procedure groupings, SARS-CoV-2 infected and uninfected patients were matched in a 1:4 ratio. We categorized patients by 2-week intervals from SARS-CoV-2 positive test to surgery. Hierarchical multilevel multivariable logistic regression models were used to estimate the association between infection to surgery interval versus no infection and primary end points. RESULTS We identified 82,815 veterans undergoing eligible operations (33% general, 27% orthopedic, 13% urologic, 9% vascular), of whom 16,563 (20%) had laboratory-confirmed SARS-CoV-2 infection before surgery. The multivariable models demonstrated an association between prior SARS-CoV-2 infection and increased 90-day mortality (odds ratio (OR) 1.42, 95% CI: 1.08, 1.86) and complications (OR 1.32, 95% CI: 1.11, 1.57) only for patients having surgery within 14 days of infection. ASA-stratified multivariable models showed that the associations between increased 90-day mortality (OR 1.40, 95% CI: 1.12, 1.75) and complications (OR 1.73, 95% CI: 1.34, 2.24) for patients having surgery within 14 days of infection were confined to those with ASA 4-5. CONCLUSIONS In a contemporary surgical cohort, patients with prior SARS-CoV-2 infection only had increased postoperative mortality or complications when they had surgery within 14 days after the positive test. These findings support revising timing recommendations between surgery and prior SARS-CoV-2 infection.
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, CT
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Lesley S Park
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Kathleen Akgun
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Amy Weintrob
- Veterans Affairs Washington DC Healthcare System, Washington, DC
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Medicine, Yale University School of Medicine, New Haven, CT
- Department of Public Policy, School of Public Health, Yale University School of Medicine, New Haven, CT
| | - Joseph T King
- Veterans Affairs Connecticut Healthcare System, West Haven, CT
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
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Fischer FS, Shahzad H, Khan SN, Quatman CE. Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation. OTA Int 2024; 7:e335. [PMID: 38757142 PMCID: PMC11098169 DOI: 10.1097/oi9.0000000000000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 05/18/2024]
Abstract
Objectives To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. Design Retrospective cohort study. Setting Mariner claims database. Patients/Participants Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. Intervention Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. Main Outcome Measures One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. Results Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41). Conclusions Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. Level of Evidence Prognostic Level III.
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Affiliation(s)
- Fielding S. Fischer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Hania Shahzad
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Safdar N. Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Carmen E. Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH and Department of Emergency Medicine, The Ohio State University, Columbus, OH
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Johnson CB. Nurse informaticists' role in promoting health equity. Nursing 2024; 54:38-44. [PMID: 38640033 DOI: 10.1097/01.nurse.0001007640.39208.74] [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: 04/21/2024]
Abstract
ABSTRACT Nurse informaticists (NIs) play a pivotal role in addressing health-related social needs through integrating technology into electronic health records. NIs navigate regulatory landscapes, emphasizing screening for social determinants of health during hospital encounters. This article underscores NIs' strategic contributions to optimizing data collection, supporting health equity, and utilizing innovative technologies to bridge gaps in healthcare outcomes.
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Affiliation(s)
- Charla B Johnson
- Charla B. Johnson is the Director of Clinical Information Systems and Nursing Informatics at Franciscan Missionaries of Our Lady Health System in Baton Rouge, La
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Park S, Kim S, Kim HK, Tabarsi E, Hom B, Gallagher S, Ugarte C, Clark D, Schellenberg M, Martin M, Inaba K, Matsushima K. Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma. Am Surg 2024:31348241248691. [PMID: 38655755 DOI: 10.1177/00031348241248691] [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: 04/26/2024]
Abstract
BACKGROUND The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients. METHODS We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups. RESULTS A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks. CONCLUSIONS This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.
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Affiliation(s)
- Stephen Park
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Sean Kim
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Hye Kwang Kim
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Emiliano Tabarsi
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Brian Hom
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Shea Gallagher
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Chaiss Ugarte
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Damon Clark
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Matthew Martin
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
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Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: A qualitative analysis. Surgery 2024; 175:1095-1102. [PMID: 38142144 DOI: 10.1016/j.surg.2023.11.009] [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: 06/29/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Unhoused patients have worse surgical outcomes than the general population. However, the drivers of this inequity have not been studied. METHODS We conducted 26 semi-structured interviews of clinicians who care for patients with surgical disease, using a purposive sampling strategy to intentionally recruit participants with significant experience caring for unhoused patients across different roles. We used thematic analysis to analyze the resulting data. RESULTS We conducted 26 interviews: 11 with surgeons (42%), 8 with internal medicine physicians (30%), 2 with surgical advanced practice providers (8%), 3 with social workers or case managers (11%), and 2 with registered nurses (8%). One-third of the participants worked in either medical respite or street medicine programs. We identified 5 themes, each of which was most relevant at a distinct point along the spectrum of surgical care: (1) patients and clinicians face multiple challenges meeting preoperative requirements, (2) although surgeons do not make major operative decisions based on housing status, some take it into consideration for minor care decisions, (3) clinicians perceive that unhoused patients have negative postoperative experiences in the hospital, (4) discharge options for unhoused patients are commonly imperfect, which can lead to inadequate postoperative care, (5) challenges with formal communication between surgeons and non-surgeons are amplified when caring for unhoused patients. CONCLUSION Clinicians who care for unhoused patients with surgical disease relayed multiple challenges throughout all phases of surgical care and relied on both formal and informal mechanisms to mitigate these challenges. There may be opportunities to intervene and improve access to surgical care for this vulnerable group.
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Affiliation(s)
- Hannah Decker
- Department of Surgery, University of California at San Francisco, San Francisco, CA.
| | - Mukund Raguram
- School of Medicine, University of California at San Francisco, San Francisco, CA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, Benioff Homelessness and Housing Initiative, University of California at San Francisco, San Francisco, CA. https://twitter.com/hkanzaria
| | - Michael Duke
- Benioff Homelessness and Housing Initiative, University of California at San Francisco, San Francisco, CA
| | - Elizabeth Wick
- Department of Surgery, University of California at San Francisco, San Francisco, CA
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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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Alur R, Hall E, Smith MJ, Zakrison T, Loughran C, Cosey-Gay F, Kaufman EJ. What medical-legal partnerships can do for trauma patients and trauma care. J Trauma Acute Care Surg 2024; 96:340-345. [PMID: 38147579 DOI: 10.1097/ta.0000000000004167] [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: 12/28/2023]
Abstract
ABSTRACT Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.
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Affiliation(s)
- Rucha Alur
- From the Perelman School of Medicine (R.A.); Carey School of Law (R.A.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (E.H.), Medstar Washington Hospital Center, Community Violence Intervention Program (M.J.S.), Washington, District of Columbia; Critical Trauma Research (T.Z.), University of Chicago Medicine; Legal Aid Chicago (C.L.); Violence Recovery Program (F.C.-G.), University of Chicago Medicine, Chicago, Illinois; and Traumatology, Surgical Critical Care, and Emergency Surgery (E.J.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Decker HC, Kanzaria HK, Evans J, Pierce L, Wick EC. Association of Housing Status With Types of Operations and Postoperative Health Care Utilization. Ann Surg 2023; 278:883-889. [PMID: 37232943 DOI: 10.1097/sla.0000000000005917] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To analyze the association between housing status and the nature of surgical care provided, health care utilization, and operational outcomes. BACKGROUND Unhoused patients have worse outcomes and higher health care utilization across multiple clinical domains. However, little has been published describing the burden of surgical disease in unhoused patients. METHODS We conducted a retrospective cohort study of 111,267 operations from 2013 to 2022 with housing status documented at a single, tertiary care institution. We conducted unadjusted bivariate and multivariate analyses adjusting for sociodemographic and clinical characteristics. RESULTS A total of 998 operations (0.8%) were performed for unhoused patients, with a higher proportion of emergent operations than housed patients (56% vs 22%). In unadjusted analysis, unhoused patients had longer length of stay (18.7 vs 8.7 days), higher readmissions (9.5% vs 7.5%), higher in-hospital (2.9% vs 1.8%) and 1-year mortality (10.1% vs 8.2%), more in-hospital reoperations (34.6% vs 15.9%), and higher utilization of social work, physical therapy, and occupational therapy services. After adjusting for age, sex, comorbidities, insurance status, and indication for operation, as well as stratifying by emergent versus elective operation, these differences went away for emergent operations. CONCLUSIONS In this retrospective cohort analysis, unhoused patients more commonly underwent emergent operations than their housed counterparts and had more complex hospitalizations on an unadjusted basis that largely disappeared after adjustment for patient and operative characteristics. These findings suggest issues with upstream access to surgical care that, when unaddressed, may predispose this vulnerable population to more complex hospitalizations and worse longer term outcomes.
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Affiliation(s)
| | | | | | - Logan Pierce
- Department of Medicine, University of California, San Francisco, CA
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Decker HC, Graham LA, Titan A, Kanzaria HK, Hawn MT, Kushel M, Wick E. Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA Netw Open 2023; 6:e2349143. [PMID: 38127343 PMCID: PMC10739065 DOI: 10.1001/jamanetworkopen.2023.49143] [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: 06/25/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. Objective To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Design, Setting, and Participants This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Exposures Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. Main Outcomes and Measures The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. Results This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. Conclusions and Relevance In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.
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Affiliation(s)
| | - Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- S-SPIRE, Stanford University, Stanford, California
| | - Ashley Titan
- Department of Surgery, Stanford University, Stanford, California
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Mary T. Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Division of General Internal Medicine, Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
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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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Russolillo A, Moniruzzaman A, Carter M, Raudzus J, Somers JM. Association of homelessness and psychiatric hospital readmission-a retrospective cohort study 2016-2020. BMC Psychiatry 2023; 23:459. [PMID: 37353747 PMCID: PMC10288711 DOI: 10.1186/s12888-023-04945-z] [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: 12/14/2022] [Accepted: 06/09/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital. METHODS A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression. RESULTS The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period. CONCLUSIONS Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed. QUESTION Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission? FINDINGS In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission. MEANING Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission.
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Affiliation(s)
- Angela Russolillo
- Department of Psychiatry, St. Paul's Hospital, Providence Health Care, 1081 Burrard Street, BC, V6Z 1Y6, Vancouver, Canada.
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, BC, V6B 5K3, Vancouver, Canada.
| | - Akm Moniruzzaman
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, BC, V6B 5K3, Vancouver, Canada
| | - Michelle Carter
- Department of Psychiatry, St. Paul's Hospital, Providence Health Care, 1081 Burrard Street, BC, V6Z 1Y6, Vancouver, Canada
| | - Julia Raudzus
- Department of Psychiatry, St. Paul's Hospital, Providence Health Care, 1081 Burrard Street, BC, V6Z 1Y6, Vancouver, Canada
| | - Julian M Somers
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, BC, V6B 5K3, Vancouver, Canada
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Devin CL, Shaffer VO. Social Determinants of Health and Impact in Perioperative Space. Clin Colon Rectal Surg 2023; 36:206-209. [PMID: 37113281 PMCID: PMC10125291 DOI: 10.1055/s-0043-1761155] [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: 01/30/2023]
Abstract
The Centers for Disease Control and Prevention (CDC) defines the social determinants of health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a range of health, functioning, and quality-of-life outcomes and risks," which includes economic stability, access to quality health care, and physical environment. There is increasing evidence that SDOH have an impact in shaping a patient's access and recovery from surgery. This review evaluates the role surgeons play in reducing these disparities.
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Affiliation(s)
- Courtney L. Devin
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Virginia O. Shaffer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Impact of Housing Insecurity on Outcomes in Abdominal Aortic Aneurysm Repair Among Veterans. Ann Vasc Surg 2023; 89:36-42. [PMID: 36749106 DOI: 10.1016/j.avsg.2022.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/15/2022] [Accepted: 09/18/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Veterans are disproportionately affected by housing insecurity (HI), which can lead to adverse health outcomes and reduced life expectancy. We sought to examine the impact of HI on the outcomes of veterans who underwent abdominal aortic aneurysm (AAA) repair at our regional Veterans Affairs medical center. METHODS Retrospective chart review was performed on patients who underwent AAA repair at our institution between January 1, 2000, and December 31, 2020. We examined medical history, procedure details, hospitalization course, and postoperative outcomes. Primary endpoints were a 30-day mortality and median survival. Secondary endpoints were hospital length of stay, readmission rate, and perioperative complications. Hypothesis testing was performed with t-test and chi-squared analysis. Survival analysis was conducted using Kaplan-Meier estimation. RESULTS Of the 314 veterans that underwent AAA repair (mean age of 71.4 ± 7.8 years, 99.7% male) over the 21-year period, we identified 39 (12.4%) patients with a history of HI. The HI was associated with a positive smoking history (100% vs. 88.0%, P = 0.022), lower rate of hypertension diagnosis (69.2% vs. 84.0%, P = 0.024), and increased rate of surgical site infections (SSI) (10.3% vs. 1.8%, P = 0.016). The median postoperative survival was lower in the HI group (7.6 years [CI 6.0-11.2] vs. 8.9 [CI 6.9-10.3]). CONCLUSIONS HI was associated with reduced median postoperative survival, greater readmission rate, and increased risk of SSI following AAA repair.
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Rollings KA, Kunnath N, Ryus CR, Janke AT, Ibrahim AM. Association of Coded Housing Instability and Hospitalization in the US. JAMA Netw Open 2022; 5:e2241951. [PMID: 36374498 PMCID: PMC9664259 DOI: 10.1001/jamanetworkopen.2022.41951] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Housing instability and other social determinants of health are increasingly being documented by clinicians. The most common reasons for hospitalization among patients with coded housing instability, however, are not well understood. OBJECTIVE To compare the most common reasons for hospitalization among patients with and without coded housing instability. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, retrospective study identified hospitalizations of patients between age 18 and 99 years using the 2017 to 2019 National Inpatient Sample. Data were analyzed from May to September 2022. EXPOSURES Housing instability was operationalized using 5 International Classification of Diseases, 10th Revision, Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; and other related problems. MAIN OUTCOMES AND MEASURES The primary outcome of interest was reason for inpatient admission. Bivariate comparisons of patient characteristics, primary diagnoses, length of stay, and hospitalization costs among patients with and without coded housing instability were performed. RESULTS Among the 87 348 604 hospitalizations analyzed, the mean (SD) age was 58 (20) years and patients were more likely to be women (50 174 117 [57.4%]) and White (58 763 014 [67.3%]). Housing instability was coded for 945 090 hospitalizations. Hospitalized patients with housing instability, compared with those without instability, were more likely to be men (668 255 patients with coded instability [70.7%] vs 36 506 229 patients without [42.3%]; P < .001), younger (mean [SD] age 45.5 [14.0] vs 58.4 [20.2] years), Black (235 355 patients [24.9%] vs 12 929 158 patients [15.0%]), Medicaid beneficiaries (521 555 patients [55.2%] vs 15 541 175 patients [18.0%]), uninsured (117 375 patients [12.4%] vs 3 476 841 patients [4.0%]), and discharged against medical advice (28 890 patients [8.4%] vs 451 855 patients [1.6%]). The most common reason for hospitalization among patients with coded housing instability was mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%]), which cost a total of $3.5 billion. Other common reasons included injury (69 270 patients [7.3%]) and circulatory system diseases (64 700 patients [6.8%]). Coded housing instability was also significantly associated with longer mean (SD) hospital stays (6.7 [.06] vs 4.8 [.01] days) and a cost of $9.3 billion. Hospitalized patients with housing instability had 18.6 times greater odds of having a primary diagnosis of mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%] vs 4 470 675 patients [5.2%]; odds ratio, 18.56; 95% CI, 17.86 to 19.29). CONCLUSIONS AND RELEVANCE In this cross-sectional study, hospitalizations among patients with coded housing instability had higher admission rates for mental, behavioral, and neurodevelopmental disorders, longer stays, and increased costs. Findings suggest that efforts to improve housing instability, mental and behavioral health, and inpatient hospital utilization across multiple sectors may find areas for synergistic collaboration.
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Affiliation(s)
- Kimberly A. Rollings
- Health and Design Research Fellowship Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Caitlin R. Ryus
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander T. Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy/Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
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Subedi K, Acharya B, Ghimire S. Factors Associated With Hospital Readmission Among Patients Experiencing Homelessness. Am J Prev Med 2022; 63:362-370. [PMID: 35367105 PMCID: PMC9398926 DOI: 10.1016/j.amepre.2022.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Homelessness is associated with increased acute care utilization and poor healthcare outcomes. This study aims to compare hospital readmission rates among patients experiencing homelessness and patients who are not homeless and assess the impact of different clinical and demographic characteristics on acute care utilization among patients experiencing homelessness. METHODS This was a retrospective study of patients encountered in 2018 and 2019 at ChristianaCare Health Systems. The analysis was done in August 2021. The prevalence of major chronic conditions among patients experiencing homelessness (n=1,329) and those not experiencing it (n=143,360) was evaluated. Patients experiencing homelessness were matched with nonhomeless patients using 1:1 propensity score matching. Time-to-event analysis approaches were used to analyze time-to-readmission and 30-day readmission rates. RESULTS The 30-day readmission rates were 42.8% among patients experiencing homelessness and 19.9% among matched patients not experiencing homelessness. The hazard of 30-day readmission among patients experiencing homelessness was 2.6 (95% CI=1.93, 3.53) times higher than that among the matched nonhomeless cohort. In patients experiencing homelessness, drug use disorder, major depressive disorder, chronic kidney disease, obesity, arthritis, HIV/AIDS, and epilepsy were associated with shortened time to readmission. Moreover, Black racial identity was associated with shortened time to readmission. CONCLUSIONS Patients experiencing homelessness had higher acute care utilization than those not experiencing homelessness. Black racial identity and several comorbidities were associated with increased acute care utilization among patients experiencing homelessness. Efforts to address upstream social determinants of health, destigmatization, and healthcare management accounting for the whole spectrum of clinical comorbidities might be important in promoting the health of people experiencing homelessness.
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Affiliation(s)
- Keshab Subedi
- Institute for Research on Equity and Community Health, ChristianaCare Health Systems, Wilmington, Delaware.
| | - Binod Acharya
- Urban Health Collaborative, Drexel University, Philadelphia, Pennsylvania
| | - Shweta Ghimire
- Center for Bioinformatics & Computational Biology, University of Delaware, Newark, Delaware
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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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Abel MK, Lin JA, Wick EC. How Can We Improve Surgical Care of Patients Who Are Homeless? JAMA Surg 2022; 157:846-847. [DOI: 10.1001/jamasurg.2022.2586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mary Kathryn Abel
- University of California, San Francisco School of Medicine, San Francisco
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco
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Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital. J Am Acad Orthop Surg 2022; 30:523-527. [PMID: 35294408 DOI: 10.5435/jaaos-d-21-00651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Homelessness is a key social determinant of health, and the patient population has grown to over 580,000. Total joint arthroplasty (TJA) is an effective treatment of symptomatic end-stage osteoarthritis of the hip and knee and has been shown to improve health-related quality of life in the general population. However, the literature on the outcomes of TJA among homeless patients is limited. METHODS We retrospectively reviewed 442 patients who underwent primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. Based on self-reported living status, we classified 28 homeless patients and 414 control nonhomeless patients. Fisher exact tests, Student t-tests, and multivariate logistic regression were used to compare the demographics, preoperative conditions, and surgical outcomes between the two groups. RESULTS The homeless group were younger, more often male, and smokers; had alcohol use disorder; and used illicit drugs. After controlling for age, sex, and preoperative medical and social conditions, homeless patients were 15.83 times more likely to have an emergency department visit (adjusted odds ratio, 15.83; 95% confidence interval, 5.05 to 49.59; P < 0.0001) within 90 days but had similar rates of readmission (P = 0.25), revision surgery (P = 0.38), and prosthetic joint infection (P = 0.25) when compared with nonhomeless patients. DISCUSSION Although homeless patients did not have higher rates of readmission or revision surgery, homelessness still presents unique challenges for the TJA patients and providers. With careful preoperative optimization and collaborative support, however, the benefits of TJA may outweigh the risk of poor outcomes for these patients.
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Johnson CB, Luther B, Wallace AS, Kulesa MG. Social Determinants of Health: What Are They and How Do We Screen. Orthop Nurs 2022; 41:88-100. [PMID: 35358126 DOI: 10.1097/nor.0000000000000829] [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: 11/25/2022] Open
Abstract
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report recognizes nurses' impact on the medical and social factors that drive health outcomes (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). The report calls for nursing to take bold steps to address individual and structural level social determinants of health (SDoH)-or social and environmental factors contributing to poor health, poor health outcomes, and health disparities (NASEM, 2021, p. 5). Nurses must recognize the significance of SDoH on patient health outcomes in order to advance health equity and employ nursing interventions to affect positive change for our patients. SDoH are part of our patients' stories, and holistic nursing means we know the whole patient story. Although it is now widely recognized that SDoH affect health outcomes, a key challenge for nurses is that they represent an enormous range of factors-from food and housing insecurity to personal safety and environmental exposures-that may be more or less able to change with interventions in clinical settings. Furthermore, concerns have been raised that screening for SDoH-especially when not done with sensitivity, cultural competence, or ready intervention-may compromise therapeutic relationships and marginalize patients (Wallace et al., 2020). However, despite these concerns, healthcare systems are widely adopting SDoH assessments, generally through electronic health record screening questions, and attempting to implement associated workflows and interventions. Given this landscape, the purpose of this article, within this special issue of Orthopaedic Nursing, is to provide an overview of SDoH factors, identify best practices related to screening and referral, and highlight nurse-directed interventions in clinical settings.
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Affiliation(s)
- Charla B Johnson
- Charla B. Johnson, DNP, RN-BC, ONC, System Director, Nursing Informatics, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Brenda Luther, PhD, RN, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Andrea S. Wallace, PhD, RN, Assistant Dean of Research, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Marjorie Gibson Kulesa, RN, BS, ONC, CNOR-E, Retired Nurse Coordinator, Department of Orthopaedic Surgery, NYU Langone Long Island, NY
| | - Brenda Luther
- Charla B. Johnson, DNP, RN-BC, ONC, System Director, Nursing Informatics, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Brenda Luther, PhD, RN, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Andrea S. Wallace, PhD, RN, Assistant Dean of Research, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Marjorie Gibson Kulesa, RN, BS, ONC, CNOR-E, Retired Nurse Coordinator, Department of Orthopaedic Surgery, NYU Langone Long Island, NY
| | - Andrea S Wallace
- Charla B. Johnson, DNP, RN-BC, ONC, System Director, Nursing Informatics, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Brenda Luther, PhD, RN, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Andrea S. Wallace, PhD, RN, Assistant Dean of Research, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Marjorie Gibson Kulesa, RN, BS, ONC, CNOR-E, Retired Nurse Coordinator, Department of Orthopaedic Surgery, NYU Langone Long Island, NY
| | - Marjorie Gibson Kulesa
- Charla B. Johnson, DNP, RN-BC, ONC, System Director, Nursing Informatics, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA
- Brenda Luther, PhD, RN, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Andrea S. Wallace, PhD, RN, Assistant Dean of Research, Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT
- Marjorie Gibson Kulesa, RN, BS, ONC, CNOR-E, Retired Nurse Coordinator, Department of Orthopaedic Surgery, NYU Langone Long Island, NY
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20
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The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital. J Am Acad Orthop Surg 2022; 30:e59-e66. [PMID: 34288892 DOI: 10.5435/jaaos-d-21-00293] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/20/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The functional disability after amputation is tremendous and imposes a high economic burden on patients and health systems. The current literature on the costs of amputation has been limited to the index hospitalization or a short time window around the amputation procedure, which covers a small percentage of the total costs. METHODS We conducted a retrospective cohort study of patients who underwent lower extremity amputations at a single urban public level 1 trauma hospital. Resource utilization and healthcare costs 1 year before and 1 year after the index amputation were examined. Hospitalization costs were estimated using cost center-based cost-to-charge ratios for the 2-year follow-up. RESULTS The sample comprised 90 patients (73 men and 17 women) with a mean age of 55.9 years (SD, 9.9). Most amputations were secondary to diabetes (74%) and vascular disease in the absence of diabetes (22%). During the 2-year window around the index amputation, patients had an average of 2.7 admissions (SD, 2.3), mean index length of stay of 14.6 days (SD, 22.3), and a mean cumulative length of stay of 31.3 days (SD, 43.4). The patients had a mean of 2.3 (SD, 3.2) additional procedures performed on their amputated limb. Twenty-one patients (23%) required additional proximal amputations, with an average change of 2.2 (SD, 1.6) levels. The mean cost, per patient, of the index hospitalization was $51,481. Over the 2-year period, the mean cost of hospitalizations was $114,292 per patient with a total cost, summed over the cohort, of $10,286,250. Approximately 64% of the total cost went uncompensated. DISCUSSION Over a 2-year window, amputees endured multiple procedures, readmissions, and reamputations, leading to high healthcare costs. Further research into resource-conscious interventions and programs is needed to control the burdens faced by amputees and the health systems that care for them.
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21
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Das RK, Drolet BC. Surgical equity: Care for persons experiencing homelessness. Am J Surg 2021; 223:1220-1221. [PMID: 34789383 DOI: 10.1016/j.amjsurg.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/02/2021] [Accepted: 11/09/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Rishub K Das
- Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Brian C Drolet
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Biomedical Informatics and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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22
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Rajasingh CM, Graham LA, Richman J, Mell MW, Morris MS, Hawn MT. Challenging weekend discharges associated with excess length of stay in surgical patients at Veterans Affairs hospitals. Surgery 2021; 171:405-410. [PMID: 34736786 DOI: 10.1016/j.surg.2021.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Challenging discharges can lead to prolonged hospital stays. We hypothesized that surgical patients discharged from Veterans Affairs hospitals on weekdays have longer hospital stays and greater excess length of stay. METHODS We identified inpatient general and vascular procedures at Veterans Affairs hospitals from 2007 to 2014. Expected length of stay was calculated using a stratified negative binomial model adjusted for patient/operative characteristics. Excess length of stay was defined as the difference between observed and expected length of stay. RESULTS We identified 135,875 patients (80.4% weekday discharges, 19.6% weekend discharges). The average length of stay was 7.5 days. Patients with weekday discharges spent on average 2.5 more days in the hospital compared with patients discharged on weekends (8.0 vs. 5.5 days, P < .001); 28.5% of patients with weekday discharges had an observed length of stay at least 1 day longer than expected, compared with 16.4% of patients with weekend discharges (P < .001). CONCLUSION Surgical patients are less frequently discharged from Veterans Affairs hospitals on the weekends than during the week, and this corresponds to an increased excess length of stay for patients ultimately discharged on weekdays. Exploring the opportunity to coordinate safe weekend discharges may improve efficiency of post-surgery hospital care and reduce healthcare costs.
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Affiliation(s)
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, CA; S-SPIRE Center, Department of Surgery, Stanford University, CA
| | - Joshua Richman
- Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL
| | - Matthew W Mell
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL
| | - Mary T Hawn
- Department of Surgery, Stanford University, CA
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Dell KC, Staph J, Hillary FG. Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course. Brain Inj 2021; 35:1192-1200. [PMID: 34460346 DOI: 10.1080/02699052.2021.1958009] [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] [Indexed: 10/20/2022]
Abstract
Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.
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Affiliation(s)
- Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States.,Department of Neurology, Hershey Medical Center, Hershey, Pennsylvania, United States
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Lewer D, Menezes D, Cornes M, Blackburn RM, Byng R, Clark M, Denaxas S, Evans H, Fuller J, Hewett N, Kilmister A, Luchenski SA, Manthorpe J, McKee M, Neale J, Story A, Tinelli M, Whiteford M, Wurie F, Yavlinsky A, Hayward A, Aldridge R. Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients. J Epidemiol Community Health 2021; 75:681-688. [PMID: 33402395 PMCID: PMC8223662 DOI: 10.1136/jech-2020-215204] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission. METHODS We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios. RESULTS After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients. CONCLUSIONS Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.
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Affiliation(s)
- Dan Lewer
- Institute of Health Informatics, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Dee Menezes
- Institute of Health Informatics, University College London, London, UK
| | - Michelle Cornes
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Ruth M Blackburn
- Institute of Health Informatics, University College London, London, UK
| | - Richard Byng
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Michael Clark
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Alan Turing Institute, British Library, London, UK
| | - Hannah Evans
- Institute of Health Informatics, University College London, London, UK
| | - James Fuller
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | | | - Alan Kilmister
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | | | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alistair Story
- Find & Treat, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michela Tinelli
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Martin Whiteford
- Department of Nursing & Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Fatima Wurie
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Alexei Yavlinsky
- Institute of Health Informatics, University College London, London, UK
| | - Andrew Hayward
- Collaborative Centre for Inclusion Health, University College London, London, UK
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Robert Aldridge
- Institute of Health Informatics, University College London, London, UK
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Karashchuk IP, Solomon EA, Greenhalgh DG, Sen S, Palmieri TL, Romanowski KS. Follow-up After Burn Injury Is Disturbingly Low and Linked With Social Factors. J Burn Care Res 2021; 42:627-632. [PMID: 33959754 DOI: 10.1093/jbcr/irab065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
For medical and social reasons, it is important that burn patients attend follow-up appointments (FUAs). Our goal was to examine the factors leading to missed FUAs in burn patients. A retrospective chart review was conducted of adult patients admitted to the burn center from 2016 to 2018. Data collected included burn characteristics, social history, and zip code. Data analysis was conducted using chi-square, Wilcoxon Rank-Sum tests, and multivariate regression models. A total of 878 patients were analyzed, with 224 (25.5%) failing to attend any FUAs and 492 (56.0%) missing at least one appointment (MA). Patients who did not attend any FUAs had smaller burns (4.5 [8]% vs 6.5 [11]% median [inter quartile range]), traveled farther (70.2 [111.8] vs 52.5 [76.7] miles), and were more likely to be homeless (22.8% vs 6.9%) and have drug dependence (47.3% vs 27.2%). Patients who had at least one MA were younger (42 [26] vs 46 [28] years) and more likely to be homeless (17.5% vs 2.6%) and have drug dependence (42.5% vs 19.4%). On multivariate analysis, factors associated with never attending an FUA were distance from hospital (odds ratio [OR] 1.004), burn size (OR 0.96), and homelessness (OR 0.33). Factors associated with missing at least one FUA: age (OR 0.99), drug dependence (OR 0.46), homelessness (OR 0.22), and Emergency Department visits (OR 0.56). A high percentage of patients fail to make any appointment following their injury and/or have at least one MA. Both FUAs and MAs are influenced by social determinants of health.
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Affiliation(s)
- Irina P Karashchuk
- UC Davis School of Medicine, University of California, Davis, Sacramento, USA
| | - Eve A Solomon
- UC Davis School of Medicine, University of California, Davis, Sacramento, USA
| | - David G Greenhalgh
- Department of Surgery, Division of Burn Surgery, University of California, Davis, Sacramento, USA
| | - Soman Sen
- Department of Surgery, Division of Burn Surgery, University of California, Davis, Sacramento, USA
| | - Tina L Palmieri
- Department of Surgery, Division of Burn Surgery, University of California, Davis, Sacramento, USA
| | - Kathleen S Romanowski
- Department of Surgery, Division of Burn Surgery, University of California, Davis, Sacramento, USA
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Fisher DG, Reynolds GL, Khoiny N, Huckabay L, Rannalli D. Application of the Frailty Framework among Vulnerable Populations to Hospitalization Outcomes of Individuals Experiencing Homelessness in Long Beach, California. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2021; 31:163-171. [PMID: 36439946 PMCID: PMC9697922 DOI: 10.1080/10530789.2021.1908487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 03/07/2021] [Accepted: 03/20/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Individuals experiencing homelessness have a high prevalence of infectious diseases that may result in hospitalization. However, low ability to navigate the healthcare system and lack of health insurance may mean that those who are experiencing homelessness may not receive the healthcare that they need. OBJECTIVES This study uses risk factors at baseline to predict hospitalization at follow-up. This paper also presents the associations between reporting homelessness and selected infectious diseases. RESEARCH DESIGN Longitudinal study of baseline and follow-up conducted August 2000 through July 2014. SUBJECTS 4916 Not experiencing homelessness mean age 37.9 years, 29% female, and 2692 experiencing homelessness age 42.1 years, 29% female received services from a research/service center in a low-income, high-crime area of Long Beach, CA. MEASURES Risk Behavior Assessment, Risk Behavior Follow-up Assessment, laboratory testing for hepatitis A, hepatitis B, hepatitis C, syphilis, chlamydia, and gonorrhea. RESULTS Predictors of hospitalization at follow-up were ever use of crack cocaine, income from Social Security or disability, reporting homelessness, female, and those who identify as Black compared to White race/ethnicity. CONCLUSIONS Income from the safety net of Social Security or disability appears to provide the participant with experience that transfers to being able to obtain healthcare. A higher proportion of those experiencing homelessness, compared to those not experiencing homelessness, appear to be hospitalized at follow-up. Women, those who identified as Black, and those who used crack at baseline are more likely to be hospitalized at follow-up whether or not they were experiencing homelessness. We recommend coordination with substance abuse treatment programs for discharge planning for homeless patients. Our findings support use of the Frailty Framework when working with individuals experiencing both homelessness and hospitalization.
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Affiliation(s)
- Dennis G Fisher
- California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840
| | - Grace L Reynolds
- California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840
| | - Noushin Khoiny
- California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840
| | - Loucine Huckabay
- California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840
| | - Debby Rannalli
- California State University, Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840
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Giannouchos TV, Gary JC, Anyatonwu S, Kum HC. Emergency Department Utilization by Adolescents Experiencing Homelessness in Massachusetts. Med Care 2021; 59:S187-S194. [PMID: 33710094 DOI: 10.1097/mlr.0000000000001436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adolescents who experience homelessness rely heavily on emergency departments (EDs) for their health care. OBJECTIVES This study estimates the relationship between homelessness and ED use and identifies the sociodemographic, clinical, visit-level, and contextual factors associated with multiple ED visits among adolescents experiencing homelessness in Massachusetts. RESEARCH DESIGN We used the Healthcare Cost and Utilization Project State Emergency Department Databases on all outpatient ED visits in Massachusetts from 2011 to 2016. We included all adolescents who were 11-21 years old. We estimated the association between homelessness and ED utilization and investigated predictors of multiple ED visits among adolescents who experience homelessness using multivariate logistic and negative binomial regressions. RESULTS Our study included 1,196,036 adolescents, of whom about 0.8% experienced homelessness and this subset of adolescents accounted for 2.2% of all ED visits. Compared with those with stable housing, adolescents who were homeless were mostly covered through Medicaid (P<0.001), diagnosed with 1 or more comorbidities (P<0.001), and visited the ED at least once for reasons related to mental health; substance and alcohol use; pregnancy; respiratory distress; urinary and sexually transmitted infections; and skin and subcutaneous tissue diseases (P<0.001). Homeless experience was associated with multiple ED visits (incidence rate ratio=1.18; 95% confidence intervals, 1.16-1.19) and frequent ED use (4 or more ED visits) (adjusted odds ratio=2.21; 95% confidence interval, 2.06-2.37). Factors related to clinical complexity and Medicaid compared with lack of coverage were also significant predictors of elevated ED utilization within the cohort experiencing homelessness. CONCLUSIONS Adolescents who experience homelessness exhibit higher ED use compared with those with stable housing, particularly those with aggravated comorbidities and chronic conditions. Health policy interventions to integrate health care, housing, and social services are essential to transition adolescents experiencing homelessness to more appropriate community-based care.
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Affiliation(s)
- Theodoros V Giannouchos
- Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah, Salt Lake City, UT
- Population Informatics Lab, Texas A&M University, College Station
| | | | - Sophia Anyatonwu
- Population Informatics Lab, Texas A&M University, College Station
- Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, TX
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station
- Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, TX
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Ethics Consultation in Surgical Specialties. HEC Forum 2021; 34:89-102. [PMID: 33674985 PMCID: PMC7934986 DOI: 10.1007/s10730-021-09447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022]
Abstract
Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.
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Dual use of Department of Veterans Affairs and community healthcare: Homeless veterans' experiences, perspectives, and perceptions. J Am Assoc Nurse Pract 2021; 33:991-998. [PMID: 34747906 DOI: 10.1097/jxx.0000000000000551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veteran homelessness is a pervasive problem and a high-priority, mission-oriented area of investigation in the United States (US). Most veterans enrolled in healthcare with the Department of Veterans Affairs (VA) carry additional health coverage, which may increase their access to care. For veterans, dual use of VA and non-VA healthcare has potentially positive and negative consequences. PURPOSE To explore homeless veterans' experiences seeking and obtaining healthcare within and outside the VA. METHODOLOGY US homeless veterans were recruited from a large, urban Northeast Healthcare for the Homeless program from two sites. This was a descriptive phenomenological study. Three semistructured focus group interviews were conducted (total n = 21 distinct participants). We used inductive content analysis procedures to identify main themes in the data. RESULTS We found four main themes: dual use decision making, access to care, preferences and perceptions of care, and suggestions for improving VA care. Although veterans in our sample had mixed positive and negative experiences with both systems, positive responses were more common regarding community care than VA. Veterans provided more verbose responses when describing negative VA experiences and more succinct responses for positive experiences. CONCLUSIONS We found mixed positive and negative experiences for both healthcare systems, although reports were more positive for non-VA care than VA. IMPLICATIONS Veterans' healthcare concerns and needs appeared difficult to meet. Future research is warranted to improve veteran-centered care access and care experiences.
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Callejo-Black P, Biederman D, Douglas C, Silberberg M. Eviction as a Disruptive Factor in Health Care Utilization: Impact on Hospital Readmissions and No-show Rates. J Health Care Poor Underserved 2021; 32:386-396. [PMID: 33678703 DOI: 10.1353/hpu.2021.0030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Residential eviction is a component of housing instability that negatively affects physical and mental health, but the effect of eviction on health care utilization, specifically hospital readmissions and outpatient no-show rates, is not known. METHODS We conducted a retrospective review of health care utilization of individuals evicted from public housing between January 2013 and December 2017, investigating hospital readmissions and no-show rates one year before and after eviction. RESULTS 131 individuals who had been evicted had one year of data pre-and post-eviction. The majority were African American (97.7%) and female (80.9%). There was no significant change in 30-, 60-, and 90-day hospital readmissions (p>.05). No-show rate decreased from 27.57 per person per year to 20.13 (p=.05). CONCLUSIONS For our study population, health care utilization was not disrupted. The decreased no-show rate represents an opportunity for health systems to engage with patients on social factors affecting their health post-eviction.
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Khatana SAM, Wadhera RK, Choi E, Groeneveld PW, Culhane DP, Kushel M, Kazi DS, Yeh RW, Shen C. Association of Homelessness with Hospital Readmissions-an Analysis of Three Large States. J Gen Intern Med 2020; 35:2576-2583. [PMID: 32556872 PMCID: PMC7458973 DOI: 10.1007/s11606-020-05946-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 05/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Individuals experiencing homelessness have higher hospitalization and mortality rates compared with the housed. Whether they also experience higher readmission rates, and if readmissions vary by region or cause of hospitalization is unknown. OBJECTIVE Evaluate the association of homelessness with readmission rates across multiple US states. DESIGN Retrospective analysis of administrative claims PATIENTS: All inpatient hospitalizations in Florida, Massachusetts, and New York from January 2010 to October 2015 MAIN MEASURES: Thirty- and 90-day readmission rates KEY RESULTS: Out of a total of 23,103,125 index hospitalizations, 515,737 were for patients who were identified as homeless at the time of discharge. After adjusting for cause of index hospitalization, state, demographics, and clinical comorbidities, 30-day and 90-day readmission rates were higher for index hospitalizations in the homeless compared with those in the housed group. The difference in 30-day readmission rates between homeless and housed groups was the largest in Florida (30.4% vs. 19.3%; p < 0.001), followed by Massachusetts (23.5% vs. 15.2%; p < 0.001) and New York (15.7% vs. 13.4%; p < 0.001) (combined 17.3% vs. 14.0%; p < 0.001). Among the most common causes of hospitalization, 30-day readmission rates were 4.1 percentage points higher for the homeless group for mental illness, 4.9 percentage points higher for diseases of the circulatory system, and 2.4 percentage points higher for diseases of the digestive system. CONCLUSIONS After adjusting for demographic and clinical characteristics, homelessness is associated with significantly higher 30- and 90-day readmission rates, with a significant variation across the three states. Interventions to reduce the burden of readmissions among individuals experiencing homelessness are urgently needed. Differences across states point to the potential of certain public policies to impact health outcomes for individuals experiencing homelessness.
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Affiliation(s)
- Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, 19104-5162, USA. .,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Eunhee Choi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Dennis P Culhane
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Margot Kushel
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Koeman J, Mehdipanah R. Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health. Popul Health Manag 2020; 24:316-321. [PMID: 32808870 DOI: 10.1089/pop.2020.0154] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
US health systems have begun to address housing instability within a larger effort to address social determinants of health. To explore existing themes within efforts by health systems to reduce housing instability and improve health, the authors conducted a scoping review supplemented with key informant interviews. Twenty-two articles were analyzed and 7 participants from 6 health systems were interviewed. Themes identified from the literature and interviews included intervention strategies and funding, access, coordination, and administrative processes and evaluation. As more health systems integrate housing-related interventions, findings from this study highlight the need for more upstream focus, consistent funding, and reliable evaluation strategies.
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Affiliation(s)
- Jamison Koeman
- Health Policy and Management and University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Roshanak Mehdipanah
- Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Swisher J, Blitz J, Sweitzer B. Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 2: Sex Considerations and Homeless Patients. Anesthesiol Clin 2020; 38:263-278. [PMID: 32336383 DOI: 10.1016/j.anclin.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patients anticipating surgery and anesthesia often need preoperative care to lower risk and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges are vital to reducing disparities in health and health care.
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Affiliation(s)
- Jenna Swisher
- Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 5-704, Chicago, IL 60611, USA
| | - Jeanna Blitz
- Duke University School of Medicine, DUMC 3094, Durham, NC 27710, USA. https://twitter.com/philchengmd
| | - BobbieJean Sweitzer
- Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 5-704, Chicago, IL 60611, USA.
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