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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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Walton MT, Mackie J, Todd D, Duncan B. Delivering the Right Care, at the Right Time, in the Right Place, From the Right Pocket: How the Wrong Pocket Problem Stymies Medical Respite Care for the Homeless and What Can Be Done About It. Med Care 2024; 62:376-379. [PMID: 38728677 DOI: 10.1097/mlr.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Affiliation(s)
- Matthew T Walton
- University of Kentucky, Institute for Biomedical Informatics, Lexington, KY
- Kentucky Cabinet for Health and Family Services, Office of Data Analytics, Frankfort, KY
| | - Jacob Mackie
- University of Kentucky, Institute for Biomedical Informatics, Lexington, KY
- Kentucky Cabinet for Health and Family Services, Office of Data Analytics, Frankfort, KY
| | - Darby Todd
- University of Kentucky, Institute for Biomedical Informatics, Lexington, KY
- Kentucky Cabinet for Health and Family Services, Office of Data Analytics, Frankfort, KY
| | - Benjamin Duncan
- University of Kentucky, Institute for Biomedical Informatics, Lexington, KY
- Kentucky Cabinet for Health and Family Services, Office of Data Analytics, Frankfort, KY
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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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Silver CM, Janczewski LM, Royan R, Chung JW, Bentrem DJ, Kanzaria HK, Stey AM, Bilimoria KY, Merkow RP. Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness. Ann Surg Oncol 2024; 31:1468-1476. [PMID: 38071712 DOI: 10.1245/s10434-023-14713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH. METHODS This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs. RESULTS Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH. CONCLUSIONS PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.
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Affiliation(s)
- Casey M Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren M Janczewski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Regina Royan
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jeannette W Chung
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago, Chicago, IL, USA.
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Hircock C, Huan P, Pizzola C, McDonald M. A scoping review of surgical care for people experiencing homelessness: prevalence, access, and disparities. Can J Surg 2024; 67:E27-E39. [PMID: 38278550 PMCID: PMC10824397 DOI: 10.1503/cjs.004023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Numerous studies have highlighted the inequitable access to medical and psychiatric care that people experiencing homelessness (PEH) face, yet the surgical needs of this population are not well understood. We sought to assess evidence describing surgical care for PEH and to perform a thematic analysis of the results. METHODS Ovid MEDLINE, Embase, and Web of Science were searched using the terms "surgery" AND "homelessness." Grey literature was also searched. We used a stepwise scoping review methodology, followed by thematic analysis using an inductive approach. RESULTS We included 104 articles in our review. Studies were included from 5 continents; 63% originated in the United States. All surgical specialties were represented with varying surgical conditions and procedures for each. Orthopedic surgery (21%) was the most frequently reported specialty. Themes identified included characteristics of PEH receiving surgical care, homeless-to-housed participants, interaction with the health care system, educational initiatives, barriers and challenges, and interventions and future strategies. CONCLUSION We identified significant variation and gaps, representing opportunities for further research and interventions. Further addressing the barriers and challenges that PEH face when accessing surgical care can better address the needs of this population.
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Affiliation(s)
- Caroline Hircock
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald).
| | - Peter Huan
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
| | - Christina Pizzola
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
| | - Madeline McDonald
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont. (Hircock, Huan); the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (McDonald); and the Department of Surgery, McMaster University, Hamilton, Ont. (McDonald)
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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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