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Ergui I, Salama J, Hooda U, Ebner B, Dangl M, Vincent L, Sancassani R, Colombo R. In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019. Clin Cardiol 2024; 47:e24235. [PMID: 38366788 PMCID: PMC10873680 DOI: 10.1002/clc.24235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS). HYPOTHESIS Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients. METHODS The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05). RESULTS We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints. CONCLUSIONS These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.
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Affiliation(s)
- Ian Ergui
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Joshua Salama
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Urvashi Hooda
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Bertrand Ebner
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Michael Dangl
- Division of Internal Medicine, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Louis Vincent
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Rhea Sancassani
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
| | - Rosario Colombo
- Division of Cardiology, Department of MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of CardiologyJackson Memorial HospitalMiamiFloridaUSA
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Willison CE, Lillvis D, Mauri A, Singer PM. Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2021; 46:1019-1052. [PMID: 34075407 PMCID: PMC9648193 DOI: 10.1215/03616878-9349142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
CONTEXT Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems. METHODS We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation. FINDINGS Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid. CONCLUSIONS Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.
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Sakai-Bizmark R, Kumamaru H, Estevez D, Marr EH, Haghnazarian E, Bedel LEM, Mena LA, Kaplan MS. Health-Care Utilization Due to Suicide Attempts Among Homeless Youth in New York State. Am J Epidemiol 2021; 190:1582-1591. [PMID: 33576370 PMCID: PMC8484771 DOI: 10.1093/aje/kwab037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 02/10/2021] [Indexed: 11/14/2022] Open
Abstract
Suicide remains the leading cause of death among homeless youth. We assessed differences in health-care utilization between homeless and nonhomeless youth presenting to the emergency department or hospital after a suicide attempt. New York Statewide Inpatient and Emergency Department Databases (2009-2014) were used to identify homeless and nonhomeless youth aged 10-17 who utilized health-care services following a suicide attempt. To evaluate associations with homelessness, we used logistic regression models for use of violent means, intensive care unit utilization, log-transformed linear regression models for hospitalization cost, and negative binomial regression models for length of stay. All models adjusted for individual characteristics with a hospital random effect and year fixed effect. We identified 18,026 suicide attempts with health-care utilization rates of 347.2 (95% confidence interval (CI): 317.5, 377.0) and 67.3 (95% CI: 66.3, 68.3) per 100,000 person-years for homeless and nonhomeless youth, respectively. Length of stay for homeless youth was statistically longer than that for nonhomeless youth (incidence rate ratio = 1.53, 95% CI: 1.32, 1.77). All homeless youth who visited the emergency department after a suicide attempt were subsequently hospitalized. This could suggest a higher acuity upon presentation among homeless youth compared with nonhomeless youth. Interventions tailored to homeless youth should be developed.
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Affiliation(s)
- Rie Sakai-Bizmark
- Correspondence to Dr. Rie Sakai-Bizmark, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, 1124 W. Torrance Street, Torrance, CA 90502 (e-mail: )
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Sakai-Bizmark R, Webber EJ, Estevez D, Murillo M, Marr EH, Bedel LEM, Mena LA, Felix JCD, Smith LM. Health Care Utilization Due to Substance Abuse Among Homeless and Nonhomeless Children and Young Adults in New York. Psychiatr Serv 2021; 72:421-428. [PMID: 33789461 PMCID: PMC8106548 DOI: 10.1176/appi.ps.202000010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Substance abuse, particularly among homeless youths, is a significant public health challenge in the United States. Detailed data about health care utilization resulting from this preventable behavior remain sparse. This study aimed to compare health care utilization rates related to substance abuse among homeless and nonhomeless youths. METHODS A secondary data analysis evaluated records of homeless and nonhomeless patients under age 25 with a primary diagnosis of substance abuse, identified in 2013 and 2014 New York Statewide Inpatient and Emergency Department (ED) Databases. Outcomes included ED visit rate, hospitalization rate, in-hospital mortality, cost, length of stay (LOS), intensive care unit (ICU) utilization, and revisit or readmission rate. Multivariable regression models with a year fixed effect and facility random effect were used to evaluate the association between homelessness and each outcome. RESULTS A total of 68,867 cases included hospitalization or an ED visit related to substance abuse (68,118 nonhomeless and 749 homeless cases). Rates of ED visits related to substance abuse were 9.38 and 4.96, while rates of hospitalizations related to substance abuse were 10.53 and 1.01 per 1,000 homeless and nonhomeless youths, respectively. Homeless patients were more likely to utilize and revisit the ICU, be hospitalized or readmitted, incur higher costs, and have longer LOS than nonhomeless youths (all p<0.01). CONCLUSIONS The hospitalization and ED visit rates related to substance abuse were 10 and two times higher among homeless youths compared with nonhomeless youths, respectively. Detailed observation is needed to clarify whether homeless youths receive high-quality care for substance abuse when necessary.
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Affiliation(s)
- Rie Sakai-Bizmark
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Eliza J Webber
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Dennys Estevez
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Mary Murillo
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Emily H Marr
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Lauren E M Bedel
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Laurie A Mena
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Jayde Clarice D Felix
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
| | - Lynne M Smith
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California (all authors); Department of Pediatrics, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, California (Sakai-Bizmark, Smith)
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Sakai-Bizmark R, Mena LA, Estevez D, Webber EJ, Marr EH, Bedel LEM, Yee JK. Health Care Utilization of Homeless Minors With Diabetes in New York State From 2009 to 2014. Diabetes Care 2020; 43:2082-2089. [PMID: 32616618 PMCID: PMC7646203 DOI: 10.2337/dc19-2219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aims to describe differences in health care utilization between homeless and nonhomeless minors with diabetes. RESEARCH DESIGN AND METHODS Data from the Healthcare Cost and Utilization Project's Statewide Inpatient Database from New York for years 2009-2014 were examined to identify pediatric patients <18 years old with diabetes. Outcomes of interest included hospitalization rate, in-hospital mortality, admission through the emergency department (ED), diabetic ketoacidosis (DKA), hospitalization cost, and length of stay (LOS). Other variables of interest included age-group, race/ethnicity, insurance type, and year. Multivariate logistic regression models were used for in-hospital mortality, admission through ED, and DKA. Log-transformed linear regression models were used for hospitalization cost, and negative binomial regression models were used for LOS. RESULTS A total of 643 homeless and 10,559 nonhomeless patients were identified. The hospitalization rate was higher among homeless minors, with 3.64 per 1,000 homeless population compared with 0.38 per 1,000 in the nonhomeless population. A statistically significant higher readmission rate was detected among homeless minors (20.4% among homeless and 14.1% among nonhomeless, P < 0.01). Lower rates of DKA (odds ratio 0.75, P = 0.02), lower hospitalization costs (point estimate 0.88, P < 0.01), and longer LOS (incidence rate ratio 1.20, P < 0.01) were detected among homeless minors compared with nonhomeless minors. CONCLUSIONS This study found that among minors with diabetes, those who are homeless experience a higher hospitalization rate than the nonhomeless. Housing instability, among other environmental factors, may be targeted for intervention to improve health outcomes.
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Affiliation(s)
- Rie Sakai-Bizmark
- The Lundquist Institute for Biomedical Innovation, Torrance, CA .,Department of Pediatrics, Harbor-UCLA Medical Center and David Geffen School of Medicine, University of California, Los Angeles, Torrance, CA
| | - Laurie A Mena
- The Lundquist Institute for Biomedical Innovation, Torrance, CA
| | - Dennys Estevez
- The Lundquist Institute for Biomedical Innovation, Torrance, CA
| | - Eliza J Webber
- The Lundquist Institute for Biomedical Innovation, Torrance, CA
| | - Emily H Marr
- The Lundquist Institute for Biomedical Innovation, Torrance, CA
| | | | - Jennifer K Yee
- The Lundquist Institute for Biomedical Innovation, Torrance, CA.,Department of Pediatrics, Harbor-UCLA Medical Center and David Geffen School of Medicine, University of California, Los Angeles, Torrance, CA
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