Comparative treatment of homeless persons with an infectious disease in the US emergency department setting: a retrospective approach

BACKGROUND

Research has long documented the increased emergency department usage by persons who are homeless compared with their housed counterparts, as well as an increased prevalence of infectious diseases. However, there is a gap in knowledge regarding the comparative treatment that persons who are homeless receive. This study seeks to describe this potential difference in treatment, including diagnostic services tested, procedures performed and medications prescribed.

METHODS

This study used a retrospective, cohort study design to analyse data from the 2007-2010 United States National Hospital Ambulatory Medical Care Survey database, specifically looking at the emergency department subset. Complex sample logistic regression analysis was used to compare variables, including diagnostic services, procedures and medication classes prescribed between homeless and private residence individuals seeking emergency department treatment for infectious diseases. Findings were then adjusted for potential confounding variables.

RESULTS

Compared with private residence individuals, persons who are homeless and presenting with an infectious disease were more likely (adjusted OR: 10.99, CI 1.08 to 111.40, p<0.05) to receive sutures or staples and less likely (adjusted OR: 0.29, CI 0.10 to 0.87, p<0.05) to be provided medications when presenting with an infectious disease in US emergency departments. Significant differences were also detected in prescribing habits of multiple anti-infective medication classes.

CONCLUSION

This study detected a significant difference in suturing/stapling and medication prescribing patterns for persons who are homeless with an infectious disease in US emergency departments. While some findings can likely be explained by the prevalence of specific infectious organisms in homeless populations, other findings would benefit from further research.

Changes in Medication Utilization and Adherence Associated with Homeless Adults' Entry into Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) programs, which have grown over the last decade, have been associated with changes in health care utilization and spending. However, little is known about the impact of such programs on use of prescription drugs critical for managing chronic diseases prevalent among those with unstable housing.

OBJECTIVE

To evaluate the effects of PSH on medication utilization and adherence among Medicaid enrollees in Pennsylvania.

DESIGN

Difference-in-differences study comparing medication utilization and adherence between PSH participants and a matched comparison cohort from 7 to 18 months before PSH entry to 12 months post PSH entry.

SUBJECTS

Pennsylvania Medicaid enrollees (n = 1375) who entered PSH during 2011-2016, and a propensity-matched comparison cohort of 5405 enrollees experiencing housing instability who did not receive PSH but received other housing services indicative of episodic or chronic homelessness (e.g., emergency shelter stays).

MAIN MEASURES

Proportion with prescription fill, mean proportion of days covered (PDC), and percent adherent (PDC ≥ 80%) for antidepressants, antipsychotics, anti-asthmatics, and diabetes medications.

KEY RESULTS

The PSH cohort saw a 4.77% (95% CI 2.87% to 6.67%) relative increase in the proportion filling any prescription, compared to the comparison cohort. Percent adherent among antidepressant users in the PSH cohort rose 7.41% (95% CI 0.26% to 14.57%) compared to the comparison cohort. While utilization increased in the other medication classes among the PSH cohort, differences from the comparison cohort were not statistically significant.

CONCLUSIONS

PSH participation is associated with increases in filling prescription medications overall and improved adherence to antidepressant medications. These results can inform state and federal policy to increase PSH placement among Medicaid enrollees experiencing homelessness.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County

Objective

To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population.

Methods

Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2.

Results

Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure.

Conclusion

Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.

Barriers to adherence to antiretroviral therapy: identifying priority areas for people with HIV and healthcare professionals

BACKGROUND

Challenges to antiretroviral therapy adherence are well-known and continue to be a major hurdle in HIV care. The objective of this paper is to identify barriers to antiretroviral therapy (ART) adherence that are relevant to HIV care from the perspective of people living with HIV and healthcare and social service professionals.

METHODS

This study used an online survey design to collect information from the two groups. A total of 100 areas that covered six domains and 20 subdomains were administered to people living with HIV and care professionals in Canada and France. The survey asked participants to rate the importance of each area for HIV care on a four-point Likert scale. Any areas rated 3 or 4 were considered important and ranked. A Chi-square test was conducted for the difference between the groups, people living with HIV and professionals, and between women and men.

RESULTS

A response rate of 87% (58/66) in Canada and 65% (38/58) was achieved. 15 of 43 (35%) areas were endorsed as important barriers by both groups, across countries and sex-covering subdomains - drug cost coverage, challenging material circumstances, HIV stigma, and privacy concerns, affect, motivation, beliefs, acceptance of HIV, comorbidity, side effects, and demands and organisation of daily life. People living with HIV identified two, and care professionals identified nine, additional areas as important barriers to HIV care across different domains and subdomains.

CONCLUSION

The study identified some common and distinct barriers to ART from the perspective of the people living with HIV and care professionals.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness

BACKGROUND

Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied.

OBJECTIVE

To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care.

DESIGN

Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019).

PARTICIPANTS

PEH diagnosed or treated for a depressive disorder.

MAIN MEASURES

The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings.

KEY RESULTS

Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004).

CONCLUSIONS

Homeless-tailored primary care approaches may improve depression care for PEH.

Attending to the Mental Health of People Who Are Homeless by Mobile Telephone Follow-Up: A Systematic Review

BACKGROUND

More than 20% of the world's population has no decent or suitable home. People who are homeless have more health problems than the rest of the population, especially mental health-type problems. The main objective of this study was to identify follow-up interventions by using mobile telephones to improve the mental health of people who are homeless and to analyze their efficiency.

METHODS

To do so, a systematic review was carried out in the Web of Science, PubMed, Scopus, Ebscohost, and PsyInfo databases.

RESULTS

Studies conclude that mobile phone use is a suitable means to improve adherence to medication and the mental health of the homeless. However, significant attempts to demonstrate health benefits by means of reliable and valid instruments that supplement qualitative satisfaction and feedback instruments appear to be lacking.

CONCLUSIONS

The literature about mental health benefits through technology for people who are homeless is scarce and shows methodological limitations that can lead to failure when setting up methodologies in clinical practice.

Cardiovascular Disease in Australians Experiencing Homelessness

Australia has one of the highest rates of homelessness in the world, at 498 per 100,000 people, and Australians experiencing homelessness (AEH) are a particularly vulnerable cohort, with a greater prevalence of cardiovascular disease, and poorer health outcomes, when compared to the general population. This narrative review explores how a combination of inadequately managed traditional and non-traditional cardiovascular risk factors, along with several personal, practical and relationship challenges with the health system, have created unique barriers in the diagnosis and management of cardiovascular disease in AEH. To help address these inequalities, we propose a targeted and collaborative strategy, which includes government proactivity, stable and affordable housing, and involvement of specialist health professionals, community leaders and major homelessness organisations. Furthermore, the delivery of health care needs to be a combination of outreach and opportunistic services, with a focus on flexible and individualised preventative care.

Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience

Objective

While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions.

Methods

We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques.

Results

All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as “lifelines” to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones.

Conclusion

The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.

Non-adherence to psychiatric medication in adults experiencing homelessness is associated with incurred concussions

This study investigated the relationship between concussions and medication adherence among 247 adults experiencing homelessness in Oklahoma City, Oklahoma, who were prescribed medication for a psychiatric disorder. Participants were asked whether they had “ever experienced a blow to the head that caused a concussion,” and medication adherence was measured by asking participants whether they had taken their psychiatric medication yesterday. The data were analyzed using univariate and multivariable logistic regressions. Results showed that more than half of the sample had a concussion history (61.9%), and homeless adults with a concussion history had higher odds of non-adherence to psychiatric medications compared with those who reported no concussion history [OR = 2.13 (95% CI = 1.08, 4.18)]. Findings suggest that medication non-adherence is associated with incurred concussions. Raising awareness among service providers of the relationship between traumatic brain injury and medication adherence may increase efforts to improve adherence in this underserved population.

Psychopharmacoepidemiology of antidepressant medications among homeless and unstably housed service users in the Veterans Affairs healthcare system

OBJECTIVE

This study conducted a pharmacoepidemiologic examination of antidepressant prescription patterns in homeless and unstably housed (HUH) populations.

METHODS

Data were analyzed on over 2.6 million veterans from the U.S. Department of Veterans Affairs (VA), the largest provider of healthcare for HUH veterans and a system that does not require healthcare insurance.

RESULTS

Multivariable analyses revealed that HUH veterans with depression and PTSD were less likely to receive an antidepressant Rx compared to their stably housed (SH) counterparts with these conditions (OR = 0.77, 99% CI = 0.74-0.79; and OR = 0.87, 99% CI = 0.84-0.90, respectively). Antidepressants were mostly prescribed in specialty mental health care settings, but HUH veterans were less likely to be prescribed antidepressants in primary care settings than SH veterans. In the total sample, the 40-49 age group, female sex, VA service-connected disability, outpatient mental health visits, and emergency department visits were positively associated with any antidepressant Rx. Nearly all psychiatric diagnoses were more associated with prescription of selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (SSRIs/SNRIs) than tricyclic antidepressants.

CONCLUSION

These findings highlight socioeconomic disparities in antidepressant Rx in a healthcare system that does not rely on insurance and suggest clinical challenges with antidepressant prescriptions in HUH populations.

Homelessness and Vulnerably-Housed Defined: A Synthesis of the Literature

There is no single accepted definition used in policy or research for the concepts of homelessness and vulnerably housed. Neuman's systems model (NSM) was the framework for this mixed-studies review, with the client system defined as these social issues and categorized as environmental stressors. Eighteen unique definitions of the concepts were identified in 30 studies. Extrapersonal stressors included housing history, interpersonal stressors included dependence on others for housing, and intrapersonal stressors included self-identification. Each level of stressor should be considered when defining these populations for inclusion in future research. Proposed definitions were formulated from the analysis of the results.

Assessing the determinants of completing OAT induction and long-term retention: A population-based study in British Columbia, Canada

BACKGROUND

Pharmacological treatments for opioid use disorder are essential, life-saving medications, yet successful induction of them and long-term retention on them is limited in many settings. Induction into opioid agonist treatment (OAT) features the highest risk of mortality throughout the treatment course, and greatest risk of discontinuation. We aimed to identify determinants of completing OAT induction and, among those completing induction, time to OAT discontinuation in British Columbia (BC), Canada.

METHODS

We conducted a retrospective study using linked population-level health administrative databases to capture all individuals in BC receiving at least one OAT dispensation from January 1, 2008, to September 30, 2018. We constructed covariates capturing client demographics, clinical history, and characteristics of the treatment episode and the primary prescribing physician. We estimated a two-part model to identify determinants of the probability of completing induction using a generalized linear mixed model with logit link and the time to OAT discontinuation among those completing induction using a Cox proportional hazards frailty model.

RESULTS

We observed 220,474 OAT episodes (73.9% initiated with methadone, 24.7% with buprenorphine, and 1.4% with slow-release oral morphine) among 45,608 individuals over the study period. Less than 60% of all OAT episodes completed induction (59.0% for methadone episodes, 56.7% for buprenorphine/naloxone, 41.0% for slow-release oral morphine) and half of all episodes that completed induction reached the minimum effective dosage (51.0% for methadone episodes [60 mg/day], 48.2% for buprenorphine/naloxone [12 mg/day], 59.4% for slow-release oral morphine [240 mg/day]). In multiple regression analysis, the adjusted odds of completing induction with buprenorphine improved over time, exceeding that of methadone in 2018: 1.46 (1.40, 1.51). For those who completed induction, buprenorphine use was associated with shorter times to discontinuation throughout the study period, but the estimated rate of discontinuation decreased over time (adjusted hazard ratio, vs. methadone in 2008: 2.50 (2.35, 2.66); in 2018: 1.79 (1.74, 1.85)).

CONCLUSION

We found low rates of completing OAT induction and, for those who did complete it, low rates of reaching the minimum effective dose.

Twenty-year trends in use of electroconvulsive therapy among homeless and domiciled veterans with mental illness

BACKGROUND

To examine socioeconomic disparities in use of electroconvulsive therapy (ECT) among homeless or unstably housed (HUH) veterans with mental illness.

METHODS

National data from medical records in years 2000 to 2019 on 4 to 6 million veterans with mental illness, including 140 000 to 370 000 homeless veterans served annually from the U.S. Department of Veterans Affairs (VA) healthcare system, were analyzed to examine ECT utilization and changes in utilization over time.

RESULTS

ECT utilization was higher among HUH veterans (58-104 per 1000) than domiciled veterans with mental illness (9-15 per 1000) across years with a trend toward increasing use of ECT use among HUH veterans over time. Among HUH and domiciled veterans who received ECT, veterans received an average of 5 to 9 sessions of ECT. There were great regional differences in rates of ECT utilization among HUH and domiciled veterans with the highest overall rates of ECT use at VA facilities in the Northeast and Northwest regions of the country.

DISCUSSION

ECT is commonly and safely used in HUH veterans in a comprehensive healthcare system, but geographic and local factors may impede access to ECT for veterans who may benefit from this treatment. Efforts should be made to reduce barriers to ECT in the HUH population.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

"Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness

BACKGROUND

People experiencing homelessness (PEH) live with a high burden of chronic illness, functional and cognitive impairments, and serious mental illness. Many PEH are prescribed complex medication regimens to manage symptoms and improve health and functioning. However, medication use within the context of homelessness is complicated, and adherence is often suboptimal.

OBJECTIVE

To document medication use within the context of homelessness and explore experiences of medication use among people experiencing homelessness (PEH).

METHODS

This study used mixed methods including photo-elicitation interviews. Participants were given a digital camera and asked to take pictures of people, places, things, and situations that represented every day medication use. Participants were also asked to write down reasons for taking the pictures. After two weeks, participants returned the camera and notes. At a subsequent interview, the photographs and notes were reviewed and discussed. Demographic and health-related information was also collected for each participant. An interpretive description approach was used for qualitative data analysis. Quantitative data were analyzed using descriptive statistics in order to describe the sample.

RESULTS

Seven PEH completed this study. Mean age was 45 years (SD = 11.3) and length of homelessness was 6.1 years (SD = 11.3). All reported multiple chronic conditions (≥2) and reported taking 6.6 (SD = 2.6) medications. Participants reported medication adherence barriers with mean score of 37 (SD = 5.5) on the ASK-12, a 12-item scale with a range of 12-60 (higher scores indicate more barriers). Qualitative analysis identified four categories: medication-related burdens, medication-related beliefs, connectedness, and stigmatizing encounters.

CONCLUSIONS

Medication use among PEH is complex and cannot be considered separately from daily life or from struggles to meet basic needs. Multi-level interventions are needed to optimize medication use among PEH, and healthcare professionals including community pharmacists should reinforce beliefs that medication-related benefits outweigh the burdens and then tailor services to the context of homelessness.

Sociodemographic Determinants of Nonadherence to Depression and Anxiety Medication among Individuals Experiencing Homelessness

Psychiatric medication nonadherence continues to be a leading cause of poor health outcomes for individuals experiencing homelessness. Identifying the sociodemographic factors that contribute to medication nonadherence may help guide strategies to care for and support this group. This study examined 200 adults with depression diagnoses and active anti-depressant prescriptions (Mage = 43.98 ± 12.08, 59.4% Caucasian, 58.5% male, 70% uninsured, 89.5% unemployed) and 181 adults with anxiety diagnoses and active anti-anxiety prescriptions (Mage = 43.45 ± 11.02, 54.4% Caucasian, 57.5% male, 66.3% uninsured, 88.9% unemployed) recruited from six homeless-serving agencies in Oklahoma City. Self-reported sociodemographic variables included: age, sex, race/ethnicity, education, monthly income, employment status, and health insurance status. Adjusted logistic regression analyses revealed that employed (OR = 4.022, CI_0.95: 1.244–13.004) and insured (OR = 2.923, CI_0.95: 1.225–6.973) participants had greater odds of depression medication nonadherence. For anxiety, being employed (OR = 3.573, CI_0.95: 1.160–11.010) was associated with greater odds of anxiety medication nonadherence, whereas having depression and anxiety diagnostic comorbidity (OR = 0.333, CI_0.95: 0.137–0.810) was associated with lower odds of anxiety medication nonadherence. Interventions aimed at facilitating accessible prescription acquisition or otherwise reducing barriers to prescription medications for employed adults, including those with health insurance, may benefit adherence, but more research is needed. Future studies would benefit from using a qualitative approach to better delineate nuanced barriers to psychiatric medication adherence.

Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness

BACKGROUND

People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients.

OBJECTIVE

To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness.

DESIGN

This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals.

PARTICIPANTS

Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission.

MAIN MEASURES

Unplanned all-cause readmission to the study hospital within 90 days of discharge.

KEY RESULTS

Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23).

CONCLUSION

Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.

Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain

Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.

Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting with ST-Elevation Myocardial Infarction

BACKGROUND

Cardiovascular disease remains a major cause of morbidity and mortality among homeless adults. Despite major advances in the management of ST elevation myocardial infarction (STEMI), limited information is available for the clinical presentation and management and outcome of STEMI among patients experiencing homelessness (PEH).

METHODS

All patients presenting with STEMI between January 1, 2008 and December 31, 2017 at a PCI capable STEMI network inner city hospital comprised the study population. Baseline characteristics, homeless status and clinical outcomes were determined from hospital records. The primary outcome of in-hospital mortality was compared between PEH and non-homeless patients using a log-binomial regression model with propensity score adjusted standardized mortality ratio weighting (SMRW).

RESULTS

Among 2854 STEMI admissions during the study period, 75 (2.6%) patients were identified as PEH. The PEH group was younger (58 vs. 63 years, p=0.0002), predominantly male (96% vs. 76%, p<0.0001) and more likely to present with cardiogenic shock or cardiac arrest (17% vs. 6%, p=0.0004) compared to non-homeless cohort. The in-hospital mortality remained significantly higher among PEH (RR: 3.83; 95% CI: 1.27, 11.60) after propensity score adjustment.

CONCLUSIONS

Despite universal health care and contemporary STEMI management, PEH presenting with STEMI experienced a 4-fold higher in-hospital mortality compared to non-homeless cohort. Targeted interventions are needed to improve STEMI outcomes in this high risk group.

Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact

BACKGROUND

Cost-related nonadherence to medications (CRNA) is common in many countries and thought to be associated with adverse outcomes. The characteristics of CRNA in Canada, with its patchwork coverage of increasingly expensive medications, are unclear.

OBJECTIVES

Our objective in this systematic review was to summarize the literature evaluating CRNA in Canada in three domains: prevalence, predictors, and effect on clinical outcomes.

METHODS

We searched MEDLINE, Embase, Google Scholar, and the Cochrane Library from 1992 to December 2019 using search terms covering medication adherence, costs, and Canada. Eligible studies, without restriction on design, had to have original data on at least one of the three domains specifically for Canadian participants. Articles were identified and reviewed in duplicate. Risk of bias was assessed using design-specific tools.

RESULTS

Twenty-six studies of varying quality (n = 483,065 Canadians) were eligible for inclusion. Sixteen studies reported on the overall prevalence of CRNA, with population-based estimates ranging from 5.1 to 10.2%. Factors predicting CRNA included high out-of-pocket spending, low income or financial flexibility, lack of drug insurance, younger age, and poorer health. A single randomized trial of free essential medications with free delivery in Ontario improved adherence but did not find any change in clinical outcomes at 1 year.

CONCLUSION

CRNA affects many Canadians. The estimated percentage depends on the sampling frame, the main predictors tend to be financial, and its association with clinical outcomes in Canada remains unproven.

Supporting Primary Care Access and Use among Homeless Persons

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

Outcomes Among Homeless Patients With Non-Small-Cell Lung Cancer: A County Hospital Experience

PURPOSE

Lung cancer remains the leading cause of cancer death in the United States, with outcomes likely worsened by the presence of poorer outcomes among vulnerable populations such as the homeless. We hypothesized that homeless patients experience delays in biopsy, decreased appointment adherence, and increased overall mortality rates.

METHODS

We conducted a retrospective electronic medical record-based review of all patients with non-small-cell lung cancer (NSCLC; N = 133) between September 2012 and September 2018 at an academic county hospital in Seattle, Washington.

RESULTS

Of the 133 patients treated for NSCLC, 22 (17%) were homeless at the time of their treatment. Among homeless patients with localized lung cancer, the mean time from radiographic finding to biopsy was 248 days, compared with 116 days among housed patients (P = .37). Homeless patients with advanced disease missed a mean of 26% of appointments in the year after diagnosis, compared with 16% among housed patients (P = .03). Homeless patients with advanced NSCLC had a median survival of 0.58 years, versus 1.30 years in housed patients (P = .48).

CONCLUSION

To our knowledge, this is the first US study comparing outcomes among homeless and housed patients with NSCLC within the same institution; we found homeless patients had longer delays to biopsy, increased rates of missed appointments, and a trend toward decreased survival. This study shows potential areas where interventions could be implemented to improve lung cancer outcomes in this patient population.

Examining Recovery Program Participants by Gender: Program Completion, Relapse, and Multidimensional Status 12 Months After Program Entry

This study examined individual-level characteristics and factors associated with program completion, relapse, and multidimensional status at follow-up for 213 men and 248 women who entered one of 17 peer-led recovery programs and who completed a follow-up interview 12 months later. Study results found that although there were some significant gender differences at program entry among participants entering Recovery Kentucky, there were few gender differences at follow-up. In addition, although participants had significant psychosocial problems, polysubstance use patterns, and severe substance use disorder (SUD), the majority of both men and women reported completing the program (80.3%), a small minority reported relapse (9.5%), and about one third had worse multidimensional status about 12 months after program entry. Lower quality of life rating at program entry was associated with program completion and with better multidimensional status at follow-up. Study results suggest the recovery program provides an important option for some of the most vulnerable individuals with SUD.

Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions

IMPORTANCE

Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes.

OBJECTIVE

To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n = 24 890) and nonhomeless adults (n = 1 827 900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019.

MAIN OUTCOMES AND MEASURES

Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates.

RESULTS

Of the 1 852 790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24 890 occurred among patients who were homeless (11 452 women and 13 438 men; mean [SD] age, 65.1 [14.8] years) and 1 827 900 occurred among patients who were not homeless (850 660 women and 977 240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P < .001), percutaneous coronary intervention (24.8% vs 47.4%; P < .001), and coronary artery bypass graft (2.5% vs 7.0%; P < .001). Among adults hospitalized with stroke, those who were homeless were less likely than nonhomeless individuals to undergo cerebral angiography (2.9% vs 9.5%; P < .001) but were as likely to receive thrombolytic therapy (4.8% vs 5.2%; P = .28). In the cardiac arrest cohort, homeless adults were less likely than nonhomeless adults to undergo coronary angiography (10.1% vs 17.6%; P < .001) and percutaneous coronary intervention (0.0% vs 4.7%; P < .001). Risk-standardized mortality was higher for homeless persons with ST-elevation myocardial infarction compared with nonhomeless persons (8.3% vs 6.2%; P = .04). Mortality rates were also higher for homeless persons than for nonhomeless persons hospitalized with stroke (8.9% vs 6.3%; P < .001) or cardiac arrest (76.1% vs 57.4%; P < .001) but did not differ for heart failure (1.6% vs 1.6%; P = .83).

CONCLUSIONS AND RELEVANCE

There are significant disparities in in-hospital care and mortality between homeless and nonhomeless adults with cardiovascular conditions. There is a need for public health and policy efforts to support hospitals that care for homeless persons to reduce disparities in hospital-based care and improve health outcomes for this population.

Medication adherence in patients with mental illness and recent homelessness: contributing factors and perceptions on mobile technology use

OBJECTIVES

The primary objective was to determine medication-taking behaviours and factors influencing adherence in patients with mental illness and recent homelessness. Secondary objectives were to explore patients' perceptions on mobile technology use to support adherence.

METHODS

A constructivist approach and qualitative description method was used. The sample population consisted of patients with recent homelessness and mental illness affiliated with a community-based outreach programme in Canada. Participants were purposefully selected; semi-structured interviews were conducted to elicit information on medication-taking strategies and mobile technology to support adherence. A standardized questionnaire collected demographic and medical information; the Medication Adherence Rating Scale (MARS) was used to evaluate self-reported adherence. Questionnaire data were analysed using summary descriptive statistics. Interview data were subject to qualitative content analysis.

KEY FINDINGS

Fifteen participants with a mean age of 44 years were included. The mean MARS score ± standard deviation was 7.3 ± 1.5. Themes arising from the data included patient factors (i.e. insight, attitudes towards medications, coping strategies) and external factors (i.e. therapeutic alliance, family support that impacted adherence) and technology use and health. Eight participants (53%) had access to a mobile phone. There was a moderate interest in the use of mobile technology to support adherence, with cost and technology literacy identified as barriers.

CONCLUSION

External supports and individual medication management strategies were important in supporting medication adherence in this patient group. Perceived need for mobile technology, in addition to existing supports for adherence, was not high. Challenges accessing and maintaining consistent mobile technology and individual preferences should be considered when developing mobile technology-based interventions.

Health Care While Homeless: Barriers, Facilitators, and the Lived Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional Municipality

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

Descriptive study of homeless patients' perceptions that affect medication adherence

PURPOSE

Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported.

METHODS

A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes.

RESULTS

Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects.

CONCLUSION

In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.

An Adapted Model of Cost-Related Nonadherence to Medications Among People With Disabilities

Despite emerging evidence on cost-related nonadherence (CRNA) to prescription medications, there is little conceptualization and exploration of this phenomenon with respect to disability. Specifically, there is a gap in the literature that explores factors influencing medication cost–adherence relationship among individuals living with a disability. To advance research on and policy for CRNA to medications among people with disabilities, we need a framework that can contribute towards guiding solutions to this problem. We examined the applicability of Piette and colleagues’ existing model for CRNA to the context of people with disabilities and suggested an adapted model (CRNA to medications for persons with disability [CRNA-d]) that can provide a more specific conceptualization of CRNA with respect to disability. The adapted CRNA-d model depicts that CRNA to prescription medications with respect to disability is a dynamic and multifaceted phenomenon, determined by various socioeconomic, disability-related, medication-related, prescriber-related, and system-related factors. We discuss how higher susceptibility to health complications, barriers to income and employment, additional health care costs, the complexity of medical regimens, limited access to physician services, and other policy-related factors increase the risk of persons with disabilities to face cost-related barriers to fulfill their necessary medications.

Cardiovascular Disease and Homelessness

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

Interventions for improved diabetes control and self-management among those experiencing homelessness: protocol for a mixed methods scoping review

BACKGROUND

Diabetes is a chronic medical condition that requires patients to be actively engaged in intensive self-management to achieve optimal clinical outcomes. Unfortunately, individuals who are experiencing homelessness often struggle to manage diabetes and consequently suffer numerous and severe complications-both acute and chronic. There are many barriers to optimal diabetes self-management among this population, and this may be exacerbated by the lack of tailoring and customization of care to this unique population. Given this disconnect, it is likely that many organizations have attempted to provide specialized innovations for this population-which may or may not be reported in the formal literature. Our objective is to perform a scoping review to summarize and synthesize the experiences of those who have attempted to provide tailored interventions.

METHODS

We propose a mixed methods scoping review that will include both a formal search of the published literature (MEDLINE, CINAHL, EMBASE, Web of Science, Scopus) and a thorough search of the grey literature. Eligible articles and documents are those that report on an intervention or guideline for the management of diabetes among those experiencing homelessness. All titles and abstracts will undergo duplicate review, as will the full article/document. We will include any report that either includes a description of an intervention or provides recommendations for the treatment of individuals who are homeless with diabetes. We will extract both qualitative and quantitative data for analysis and interpretation. Meta-analysis will not be performed.

DISCUSSION

Those experiencing homelessness who also have diabetes often struggle to manage their chronic condition. When care is tailored to suit their needs, it is feasible that outcomes may be improved. By collating and synthesizing information from diverse organizations and jurisdictions, we hope to facilitate the sharing of knowledge with others who wish to provide this type of care.

Linking women experiencing incarceration to community-based HIV pre-exposure prophylaxis care: protocol of a pilot trial

BACKGROUND

Women experiencing incarceration (WEI) engage in high rates of sex- and drug-related behavior that places them at risk for HIV. Pre-exposure prophylaxis (PrEP) is an efficacious means of reducing HIV acquisition. There is a general lack of knowledge regarding PrEP among women at elevated risk, and only a small percentage of at-risk women are currently engaged in PrEP care. The period of incarceration represents an opportunity to identify at-risk women, initiate PrEP during incarceration, and establish linkage to community-based PrEP care upon release from incarceration. Further, post-release is a time period that is particularly risky, and there are numerous barriers, including substance use, that may impede linkage to community-based care in the absence of intervention. The current protocol describes plans for the development and pilot randomized controlled trial (RCT) of an intervention to promote PrEP uptake during incarceration and facilitate linkage to community-based PrEP care post-release.

METHODS/DESIGN

The motivational interviewing-navigation (MI-NAV) study intervention is being developed, refined, and tested over three phases within the framework of the social ecological model. All phases of the study are being conducted at a women's correctional facility and community-based PrEP provider located in the Northeastern region of the United States. Phase 1 consists of individual qualitative interviews to be conducted with key stakeholders (n = 6-10) from the community-based PrEP care site and (n = 6-10) from the women's correctional facility, as well as with (n = 18-30) WEI. Recruitment for Phase 1 was initiated in November 2017. In Phase 2, MI-NAV will be piloted with a small cohort (n = 8-12) of WEI and will be refined based upon participant feedback. During Phase 3, a pilot RCT of MI-NAV and a standard of care condition will be conducted with 80 WEI. RCT participants will complete baseline and follow-up assessments 1, 3, and 6 months post-release. The primary study outcome is linkage to community-based PrEP care, verified via medical records.

DISCUSSION

This study will develop and evaluate a psychosocial intervention (MI-NAV) to promote PrEP uptake and facilitate linkage to community-based PrEP care among women at-risk for HIV. It is expected that, as a result of this project, the feasibility, acceptability, and preliminary efficacy of MI-NAV will be determined. If found to be efficacious, this intervention has the potential to reduce HIV acquisition in a high-need, underserved community. Clinical trial registration NCT03281343.

Cost-related nonadherence to prescription medications in Canada: a scoping review

PURPOSE

The evidence is emerging that prescription medications are the topmost drivers of increasing health care costs in Canada. The financial burden of medications may lead individuals to adopt various rationing or restrictive behaviors, such as cost-related nonadherence (CRNA) to medications. Therefore, the purpose of this study is to provide an overview of the type, extent, and quantity of research available on CRNA to prescription drugs in Canada, and evaluate existing gaps in the literature.

METHODS

The study was conducted using a scoping review methodology. Six databases were searched from inception till June 2017. Articles were considered for inclusion if they focused on extent, determinants, and consequences of CRNA to prescription medication use in the Canadian context. Variables extracted for data charting included author(s), year of publication, study design, the focus of the article, sample size, population characteristics, and key outcomes or results.

RESULTS

This review found 37 studies that offered evidence on the extent, determinants, and consequences of CRNA to prescription medications in Canada. Depending on the population characteristics and province, the prevalence of CRNA varies between 4% and 36% in Canada. Canadians who are young (between 18 and 64 years), without drug insurance, have lower income or precarious or irregular employment, and high out-of-pocket expenditure on drugs are most likely to face CRNA to their prescriptions. The evidence that CRNA has negative health and social outcomes for patients is insufficient. Literature regarding the influence of prescribing health care professionals on patients' decisions to stop taking medications is limited. There is also a dearth of literature that explores patients' decisions and strategies to manage their prescription cost burden.

CONCLUSION

More evidence is required to make a strong case for national Pharmacare which can ensure universal, timely, and burden-free access to prescription medications for all Canadians.

The Psychology of Health and Illness: The Mental Health and Physiological Effects of Intimate Partner Violence on Women

Violence against women is a global public health problem with about one in three women experiencing either physical and or sexual intimate partner violence during their lifetime. Globally as many as 38% of homicides committed against women are by a male intimate partner. Violence against women may have negative effects on their mental, physical, and reproductive health (WHO fact sheet, 2016). Untreated individuals who have experienced violence or life-threatening situations may develop posttraumatic stress disorder (PTSD). This disorder has the potential to be life-changing and cause negative psychological and medical issues (Rokach, Ahmed, & Patel, 2017). This potentially life-changing nature and consequence of violence affecting women world-wide deserves greater attention to ensure elimination of risk factors, financial support of investigational studies to promote detection of victims, and research to increase therapeutic efficacy of remediation. These efforts should be bolstered by all physicians, mental health experts, social service specialists, and public health advocates.

Perceptions of Housing and Shelter among People with Histories of Unstable Housing in three Cities in Canada: A Qualitative Study

Housing is a key social determinant of health that contributes to the well-documented relationship between socioeconomic status and health. This study explored how individuals with histories of unstable and precarious housing perceive their housing or shelter situations, and the impact of these settings on their health and well-being. Participants were recruited from the Health and Housing in Transition study (HHiT), a longitudinal, multi-city study that tracked the health and housing status of people with unstable housing histories over a 5-year period. For the current study, one-time semi-structured interviews were conducted with a subset of HHiT study participants (n = 64), living in three cities across Canada: Ottawa, Toronto, and Vancouver. The findings from an analysis of the interview transcripts suggested that for many individuals changes in housing status are not associated with significant changes in health due to the poor quality and precarious nature of the housing that was obtained. Whether housed or living in shelters, participants continued to face barriers of poverty, social marginalization, inadequate and unaffordable housing, violence, and lack of access to services to meet their personal needs.

Homelessness as a predictor of mortality: an 11-year register-based cohort study

PURPOSE

The purpose of this study was to examine the association between homelessness and psychiatric disorders, including substance use disorders, on one hand, and cause-specific and all-cause mortality on the other in a high-income country.

METHODS

A historical nationwide register-based cohort study of the Danish population from 15 years of age between 2000 and 2011 was conducted. The association between homelessness, psychiatric disorders, and mortality was analysed by Poisson Regression adjusting for important confounders. Standardised mortality ratios (SMRs) were calculated for people with a history of homelessness compared with the general population using direct age-standardisation.

RESULTS

During 51,892,324 person-years of observation, 656,448 died. People with at least one homeless shelter contact accounted for 173,592 person-years with 4345 deaths. The excess mortality in the population experiencing homelessness compared with the general population was reduced by 50% after adjusting for psychiatric diagnoses, including substance use disorders (mortality rate ratio (MRR) for men 3.30, 95% CI 3.18-3.41; women 4.41, 95% CI 4.14-4.71). Full adjustment including physical comorbidity and socioeconomic factors in a sub-cohort aged 15-29 years resulted in an MRR of 3.94 (95% CI 3.10-5.02) compared with the general population. The excess mortality associated with homelessness differed according to psychiatric diagnosis, sex, and cause of death.

CONCLUSIONS

A mental health or a substance use disorder combined with homelessness considerably increases the risk of death. However, homelessness is also independently associated with high mortality. Differences in the association between homelessness and mortality in men and women suggest the need for sex-tailored interventions.

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness

BACKGROUND

Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada.

MATERIAL AND METHODS

Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics.

RESULTS

Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051).

CONCLUSIONS

The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.

Treating Adult Asthma Exacerbations With a 2-Day Course of Dexamethasone in the Emergency Department: New Protocols to Improve Compliance

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and emergency nurse (RN) and to assist with the translation of research into practice. For each column, a topic and a research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. In the current column, we examine the findings of from their article, titled "Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial."

Adherence to antipsychotic medication among homeless adults in Vancouver, Canada: a 15-year retrospective cohort study

PURPOSE

The purpose of this study was to investigate the level of adherence to antipsychotic prescription medication in a well-defined homeless cohort over a 15-year period. We hypothesized that adherence would be well below the recommended threshold for clinical effectiveness (80 %), and that it would be strongly associated with modifiable risk factors in the social environment in which homeless people live.

METHOD

Linked baseline data (including comprehensive population-level administrative prescription records) were examined in a subpopulation of participants from two pragmatic-randomized trials that investigated Housing First for homeless and mentally ill adults. Adherence to antipsychotic medication was operationalized using the medication possession ratio. Multivariable logistic regression was used to estimate effect sizes between socio-demographic, homelessness-related and illness factors, and medication possession ratio.

RESULTS

Among the 290 participants who met inclusion criteria for the current analysis, adherence to antipsychotic prescription was significantly associated with: history of psychiatric hospitalization; receipt of primary medical services; long-acting injectable antipsychotic formulations; and duration of homelessness. Mean medication possession ratio in the pre-randomization period was 0.41. Socio-demographic characteristics previously correlated with antipsychotic non-adherence were not significantly related to medication possession ratio.

CONCLUSIONS

This is the first study to quantify the very low level of adherence to antipsychotic medication among homeless people over an extended observation period of 15 years. Each of the four factors found to be significantly associated with adherence presents opportunities for intervention. Strategies to end homelessness for this population may represent the greatest opportunity to improve adherence to antipsychotic medication.

Validation of the Medication Adherence Rating Scale in homeless patients with schizophrenia: Results from the French Housing First experience

The Medication Adherence Rating Scale (MARS) is one of the most widely used measurements of adherence in schizophrenia (SZ), but there is no available data regarding its psychometric properties in homeless SZ patients (HSZ). The aim of this study was therefore to assess the psychometric properties of the MARS in a large multicenter sample of HSZ subjects. This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. Three hundred and fifty-three patients were included. The 3-factor structure of the MARS was confirmed using confirmatory factor analysis: RMSEA = 0.045, CFI = 0.98, TLI = 0.97 and WRMR = 0.76. The unidimensionality of each factor was supported by the satisfactory INFIT statistics. Item internal consistencies were all higher than 0.20 and the Kuder–Richardson were higher than to 0.6, except for factor 2, which was closed to 0.5. Significant associations with symptoms, functioning and quality of life showed satisfactory external validity. The acceptability was satisfactory with missing data lower than 5% for each dimension. The MARS is a short self-administered instrument with acceptable psychometric properties in homeless SZ patients that yields interesting information about medication adherence.

Zoonotic and Vector-Borne Infections Among Urban Homeless and Marginalized People in the United States and Europe, 1990-2014

INTRODUCTION

In high-income countries, homeless individuals in urban areas often live in crowded conditions with limited sanitation and personal hygiene. The environment of homelessness in high-income countries may result in intensified exposure to ectoparasites and urban wildlife, which can transmit infections. To date, there have been no systematic evaluations of the published literature to assess vector-borne and zoonotic disease risk to these populations.

OBJECTIVES

The primary objectives of this study were to identify diversity, prevalence, and risk factors for vector-borne and zoonotic infections among people experiencing homelessness and extreme poverty in urban areas of high-income countries.

METHODS

We conducted a systematic review and narrative synthesis of published epidemiologic studies of zoonotic and vector-borne infections among urban homeless and very poor people in the United States and Europe from 1990 to 2014.

RESULTS

Thirty-one observational studies and 14 case studies were identified (n = 45). Seroprevalence to the human louse-borne pathogen Bartonella quintana (seroprevalence range: 0-37.5%) was identified most frequently, with clinical disease specifically observed among HIV-positive individuals. Seropositivity to Bartonella henselae (range: 0-10.3%) and Rickettsia akari (range: 0-16.2%) was noted in multiple studies. Serological evidence of exposure to Rickettsia typhi, Rickettsia prowazekii, Bartonella elizabethae, West Nile virus, Borellia recurrentis, lymphocytic choriomeningitis virus, Wohlfartiimonas chitiniclastica, Seoul hantavirus (SEOV), and Leptospira species was also identified in published studies, with SEOV associated with chronic renal disease later in life. HIV infection, injection drug use, and heavy drinking were noted across multiple studies as risk factors for infection with vector-borne and zoonotic pathogens.

CONCLUSIONS

B. quintana was the most frequently reported vector-borne infection identified in our article. Delousing efforts and active surveillance among HIV-positive individuals, who are at elevated risk of complication from B. quintana infection, are advised to reduce morbidity. Given documented exposure to rodent-borne zoonoses among urban homeless and marginalized people, reducing human contact with rodents remains an important public health priority.