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Waddell CJ, Saldana CS, Schoonveld MM, Meehan AA, Lin CK, Butler JC, Mosites E. Infectious Diseases Among People Experiencing Homelessness: A Systematic Review of the Literature in the United States and Canada, 2003-2022. Public Health Rep 2024; 139:532-548. [PMID: 38379269 PMCID: PMC11344984 DOI: 10.1177/00333549241228525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Homelessness increases the risk of acquiring an infectious disease. We conducted a systematic review of the literature to identify quantitative data related to infectious diseases and homelessness. We searched Google Scholar, PubMed, and SCOPUS for quantitative literature published from January 2003 through December 2022 in English from the United States and Canada. We excluded literature on vaccine-preventable diseases and HIV because these diseases were recently reviewed. Of the 250 articles that met inclusion criteria, more than half were on hepatitis C virus or Mycobacterium tuberculosis. Other articles were on COVID-19, respiratory syncytial virus, Staphylococcus aureus, group A Streptococcus, mpox (formerly monkeypox), 5 sexually transmitted infections, and gastrointestinal or vectorborne pathogens. Most studies showed higher prevalence, incidence, or measures of risk for infectious diseases among people experiencing homelessness as compared with people who are housed or the general population. Although having increased published data that quantify the infectious disease risks of homelessness is encouraging, many pathogens that are known to affect people globally who are not housed have not been evaluated in the United States or Canada. Future studies should focus on additional pathogens and factors leading to a disproportionately high incidence and prevalence of infectious diseases among people experiencing homelessness.
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Affiliation(s)
- Caroline J. Waddell
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Carlos S. Saldana
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, GA, USA
| | - Megan M. Schoonveld
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, US Department of Energy, Oak Ridge, TN, USA
| | - Ashley A. Meehan
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christina K. Lin
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Jay C. Butler
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, GA, USA
| | - Emily Mosites
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Zhao F, Nianogo RA. Evaluating the impact of the Medicaid expansion program on diabetes hospitalization. J Public Health Policy 2024; 45:86-99. [PMID: 38238590 DOI: 10.1057/s41271-023-00463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 03/09/2024]
Abstract
Diabetes is the most expensive chronic disease in the United States, and hospital inpatient care accounts for 30% of the total medical expenditures. Medical costs for people with limited resources are covered by Medicaid, a joint federal and state program, and its expansion that extent the coverage to those with incomes up to 138% of the federal poverty level. We investigated the impact of Medicaid expansion on diabetes hospitalizations by states and payer, among adults aged 19 to 64 years old, 5 years after the expansion. We found that Medicaid expansion decreased total diabetes hospitalization in most states and a diabetes hospitalization payer mix shifted from private insurance and uninsured to Medicaid. The percentage of diabetes hospitalizations paid by Medicaid increased by 11% (95% CI 7%, 16%), while the percentage paid by private insurance decreased by 6% (95% CI - 8%, - 3%) and the percentage of uninsured diabetes hospitalization decreased by 13% (95% CI - 18%, - 9%).
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Affiliation(s)
- Fan Zhao
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA.
| | - Roch A Nianogo
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA, 90095-1772, USA
- California Center for Population Research (CCPR), Los Angeles, CA, USA
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3
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O'Neill M, Michalski C, Hayman K, Hulme J, Dube S, Diemert LM, Kornas K, Schoffel A, Rosella LC, Boozary A. "Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department. BMC Health Serv Res 2024; 24:147. [PMID: 38287378 PMCID: PMC10826204 DOI: 10.1186/s12913-023-10532-5] [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: 02/02/2023] [Accepted: 12/27/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer. METHODS Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data. RESULTS Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department. CONCLUSIONS The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.
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Affiliation(s)
- Meghan O'Neill
- Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Camilla Michalski
- Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kate Hayman
- University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer Hulme
- University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sané Dube
- University Health Network, Toronto, ON, Canada
- Gattuso Centre for Social Medicine and Population Health, University Health Network, Toronto, ON, Canada
| | - Lori M Diemert
- Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kathy Kornas
- Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Alice Schoffel
- University Health Network, Toronto, ON, Canada
- Gattuso Centre for Social Medicine and Population Health, University Health Network, Toronto, ON, Canada
| | - Laura C Rosella
- Population Health Analytics Lab, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Andrew Boozary
- University Health Network, Toronto, ON, Canada.
- Gattuso Centre for Social Medicine and Population Health, University Health Network, Toronto, ON, Canada.
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Berkman ND, Chang E, Seibert J, Ali R. Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis. Ann Intern Med 2022; 175:1728-1741. [PMID: 36343343 DOI: 10.7326/m21-4562] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. PURPOSE To identify characteristics and criteria to distinguish HNHC patients. DATA SOURCES Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. STUDY SELECTION English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. DATA EXTRACTION Independent, dual-review extraction and quality assessment. DATA SYNTHESIS The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. LIMITATION Little evidence distinguished potentially preventable or modifiable health care use from overall use. CONCLUSION A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).
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Affiliation(s)
- Nancy D Berkman
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
| | - Eva Chang
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina, and Advocate Aurora Health, Advocate Aurora Research Institute, Downers Grove, Illinois (E.C.)
| | - Julie Seibert
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, and North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disability and Substance Abuse Services, Raleigh, North Carolina (J.S.)
| | - Rania Ali
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
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Smout E, Phyu K, Hughes GJ, Parker L, Rezai R, Evans A, McLaren J, Bush S, Davey S, Aldersley MA, Ruf M, Page EE. Real-world clinical effectiveness and sustainability of universal bloodborne virus testing in an urban emergency department in the UK. Sci Rep 2022; 12:19257. [PMID: 36357472 PMCID: PMC9648896 DOI: 10.1038/s41598-022-23602-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
Innovative testing approaches and care pathways are required to meet HIV, hepatitis B (HBV) and hepatitis C (HCV) elimination goals. Routine testing for blood-borne viruses (BBVs) within emergency departments (EDs) is suggested by the European Centre for Disease Prevention and Control but there is a paucity of supporting evidence. We evaluated the introduction of routine BBV testing in EDs at a large teaching hospital in northern England. In October 2018, we modified the electronic laboratory ordering system to reflex opt-out HIV, HBV and HCV testing for all ED attendees aged 16-65 years who had a routine blood test for urea and electrolytes (U&Es). Linkage to care (LTC) was attempted for newly diagnosed patients, those never referred and those who had previously disengaged from care. The project operated for 18 months, here we present evaluation of the initial nine months (2 October 2018-1 July 2019). We analysed testing uptake, BBV seropositivity, LTC and treatment initiation within six months post-diagnosis. Over 9 months, 17,026/28,178 (60.4%) ED attendees who had U&Es performed were tested for ≥ 1 BBV. 299 active BBV infections were identified: 70 HIV Ab/Ag-positive (0.4% seroprevalence), 73 HBsAg-positive (0.4%) and 156 HCV RNA-positive (1.0%). Only 24.3% (17/70) HIV Ab/Ag-positive individuals required LTC, compared to 94.9% (148/156) HCV RNA-positive and 53.4% (39/73) HBsAg-positive individuals. LTC was successful in 94.1% (16/17) HIV Ab/Ag-positive and 69.3% (27/39) HBsAg-positive individuals. However, at 6 months LTC was just 39.2% (58/148) for HCV RNA-positive individuals, with 64% (37/58) of these commencing treatment. Universal opt-out ED BBV testing proved feasible and effective in identifying active BBV infections, especially among marginalised populations with reduced healthcare access. Our integrated approach achieved good LTC rates although further service development is necessary, particularly for HCV RNA-positive people who inject drugs.
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Affiliation(s)
- Elizabeth Smout
- grid.515304.60000 0005 0421 4601UK Field Epidemiology Training Programme, UK Health Security Agency, Leeds, UK ,grid.515304.60000 0005 0421 4601Field Service, UK Health Security Agency, Leeds, UK
| | - Khine Phyu
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Gareth J. Hughes
- grid.515304.60000 0005 0421 4601Field Service, UK Health Security Agency, Leeds, UK
| | - Lee Parker
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Roozbeh Rezai
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Amy Evans
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Joscelyne McLaren
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Stephen Bush
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Sarah Davey
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Mark A. Aldersley
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
| | - Murad Ruf
- grid.476328.c0000 0004 0383 8490Public Health, Medical Affairs, Gilead Sciences Ltd, London, UK
| | - Emma E. Page
- grid.418161.b0000 0001 0097 2705Leeds Teaching Hospitals Trust, Leeds General Infirmary, Great George St, Leeds, LS1 3EX UK
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Miller-Archie SA, Walters SC, Bocour A, Moore MS, Wiewel E, Singh T, Lim S. The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection. J Infect Dis 2022; 226:S363-S371. [PMID: 36208165 PMCID: PMC9547527 DOI: 10.1093/infdis/jiac292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/08/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection. METHODS We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility. RESULTS We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years. CONCLUSIONS Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.
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Affiliation(s)
- Sara A Miller-Archie
- Correspondence: S. A. Miller-Archie, MPH, New York City Department of Health and Mental Hygiene, Division of Epidemiology, 4209 28th St., Long Island City, NY 11101 ()
| | - Sarah C Walters
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Angelica Bocour
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Miranda S Moore
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ellen Wiewel
- Division of Disease Control, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Tejinder Singh
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
| | - Sungwoo Lim
- Division of Epidemiology, New York City Department of Health and Mental Hygiene, Long Island City, New York, USA
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Zhao F, Nianogo RA. Medicaid Expansion's Impact on Emergency Department Use by State and Payer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:630-637. [PMID: 35365307 DOI: 10.1016/j.jval.2021.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/04/2021] [Accepted: 09/24/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The Affordable Care Act's Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method. METHODS In this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018. RESULTS Overall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT -5.80%; 95% CI -7.40 to -4.12) and uninsured share of ED visits (ATT -6.66%; 95% CI -9.78 to -3.55). CONCLUSIONS Medicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.
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Affiliation(s)
- Fan Zhao
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Roch A Nianogo
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; California Center for Population Research, Los Angeles, CA, USA.
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Courchesne-Krak NS, Kepner W, Rubano A, Marienfeld C. Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis. Am J Obstet Gynecol MFM 2022; 4:100559. [PMID: 34990875 PMCID: PMC8891059 DOI: 10.1016/j.ajogmf.2021.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND As a vulnerable population, pregnant women with a substance-related diagnosis (ie, substance use, misuse, or dependence) may use healthcare disproportionately. OBJECTIVE The primary goal of this study was to evaluate the differences in the use of outpatient clinical visits, emergency department visits, and inpatient days in the hospital among women with and without a substance-related diagnosis during the antepartum period. STUDY DESIGN This retrospective study retrieved electronic health record data on women (age, 18-44 years) who delivered a single live birth or stillbirth at ≥20 weeks of gestation from April 1, 2012, to September 30, 2019. Imbalance in measured maternal sociodemographic and obstetrical characteristics between women with and without a substance-related diagnosis was attenuated using propensity score matching on key demographic characteristics (eg, age), yielding a matched 1:1 sample. Unadjusted and adjusted logistic regressions models were used to determine the association between a substance-related diagnosis and outpatient visits, emergency visits, and inpatient days. RESULTS From the total sample (n=16,770), the matched cohort consisted of 1986 deliveries. Of these, most were White (51.0%), or mixed or of some other race (31.1%). The mean age was 29.8 (standard deviation, 5.6). A substance-related diagnosis was identified in 993 women (50%) because of matching. Women with a substance-related diagnosis were more likely to have ≤10 outpatient visits than women without a substance-related diagnosis (adjusted odds ratio, 1.81 [95% confidence interval, 1.44-2.28]; P<.0001). Alcohol-, opioid-, and stimulant-related diagnoses were independently associated with ≤10 outpatient visits (adjusted odds ratio, 3.16 [95% confidence interval, 1.67-6.04]; P=.0005; adjusted odds ratio, 3.02 [95% confidence interval, 1.79-5.09]; P<.0001; adjusted odds ratio, 2.18 [95% confidence interval, 1.39-3.41]; P=.0007, respectively). Women with a substance-related diagnosis were more likely to have ≥1 emergency visit than women without a substance-related diagnosis (adjusted odds ratio, 1.36 [95% confidence interval, 1.00-1.85]; P<.0001). Opioid-, stimulant-, and nicotine-related diagnoses were independently associated with ≥1 emergency visit (adjusted odds ratio, 2.28 [95% confidence interval, 1.09-4.77]; P=.0287; adjusted odds ratio, 2.01 [95% confidence interval, 1.07-3.78]; P=.0301; adjusted odds ratio, 3.38 [95% confidence interval, 1.90-6.02]; P<.0001, respectively). Women with a substance-related diagnosis were more likely to have ≥3 inpatient days than women without a substance-related diagnosis (adjusted odds ratio, 1.69 [95% confidence interval, 1.07-2.67]; P=.0256). Opioid-, stimulant-, and nicotine-related diagnosis were independently associated with ≥3 inpatient days (adjusted odds ratio, 3.52 [95% confidence interval, 1.42-8.75]; P=.0067; adjusted odds ratio, 3.51 [95% confidence interval, 1.31-9.34]; P=.0123; adjusted odds ratio, 2.74 [95% confidence interval, 1.11-6.73]; P=.0285, respectively). CONCLUSION Women with a substance-related diagnosis during the antepartum period who delivered a single live birth or stillbirth at ≥20 weeks of gestation were experiencing fewer outpatient visits, more emergency department visits, and more inpatient days than women without a substance-related diagnosis. The type of substance-related diagnosis (eg, alcohol, opioids, stimulants, or nicotine) was associated with different patterns of healthcare use. The results from this study have reinforced the need to identify substance-related diagnoses in pregnant women early to minimize disproportionate healthcare service utilization through intervention and treatment.
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Affiliation(s)
- Natasia S Courchesne-Krak
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld).
| | - Wayne Kepner
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld)
| | - Amanda Rubano
- University of Rochester School of Medicine and Dentistry, Rochester, NY (Ms Rubano)
| | - Carla Marienfeld
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld)
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Investigating Healthcare Provider Bias Toward Patients Who Use Drugs Using a Survey-based Implicit Association Test: Pilot Study. J Addict Med 2022; 16:557-562. [PMID: 36201677 PMCID: PMC9537726 DOI: 10.1097/adm.0000000000000970] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Negative bias against people who use illicit drugs adversely affects the care that they receive throughout the hospital. We hypothesized that emergency providers would display stronger negative bias toward these patients due to life-threatening contexts in which they treat this population. We also hypothesized that negative implicit bias would be associated with negative explicit bias. METHODS Faculty, nurses, and trainees at a midwestern tertiary care academic hospital were invited (June 26, 2019-September 5, 2019) to complete an online implicit association test and explicit bias survey. RESULTS Mean implicit association test results did not vary across demographics (n = 79). There were significant differences in explicit bias scores between departments regarding whether patients who use drugs deserve quality healthcare access (P = 0.017). We saw no significant associations between implicit and explicit bias scores. CONCLUSION Though limited by sample size, the results indicate that emergency and obstetrics/gynecology providers display more negative explicit bias toward this patient population than other providers.
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Houri I, Horowitz N, Katchman H, Weksler Y, Miller O, Deutsch L, Shibolet O. Emergency department targeted screening for hepatitis C does not improve linkage to care. World J Gastroenterol 2020; 26:4878-4888. [PMID: 32921964 PMCID: PMC7459203 DOI: 10.3748/wjg.v26.i32.4878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/13/2020] [Accepted: 08/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is a leading cause of chronic liver disease worldwide. New treatments for HCV revolutionized management and prompted the world health organization to set the goal of viral elimination by 2030. These developments strengthen the need for HCV screening in order to identify asymptomatic carriers prior to development of chronic liver disease and its complications. Different screening strategies have been attempted, most targeting high-risk populations. Previous studies focusing on patients arriving at emergency departments showed a higher prevalence of HCV compared to the general population.
AIM To identify previously undiagnosed HCV carriers among high risk emergency room attendees and link them to care for anti-viral treatment.
METHODS In this single center prospective study, persons visiting the emergency department in an urban hospital were screened by a risk factor-specific questionnaire. The risk factors screened for were exposure to blood products or organ transplantation before 1992; origins from countries with high prevalence of HCV; intravenous drug use; human immunodeficiency virus carriers; men who have sex with men; those born to HCV-infected mothers; prior prison time; and chronic kidney disease. Those with at least one risk factor were tested for HCV by serum for HCV antibodies, a novel oral test from saliva (OraQuick®) or both.
RESULTS Five hundred and forty-one participants had at least one risk factor and were tested for HCV. Eighty four percent of all study participants had only one risk factor. Eighty five percent of participants underwent OraQuick® testing, 34% were tested for serum anti-HCV antibodies, and 25% had both tests. 3.1% of patients (17/541) had a positive result, compared to local population incidence of 1.96%. Of these, 82% were people who inject drugs (current or former), and 64% served time in prison. One patient had a negative HCV-RNA, and two patients died from non-HCV related reasons. On review of past medical records, 12 patients were found to have been previously diagnosed with HCV but were unaware of their carrier state. At 1-year follow-up none of the remaining 14 patients had completed HCV-RNA testing, visited a hepatology clinic or received anti-viral treatment.
CONCLUSION Targeted high-risk screening in the emergency department identified undiagnosed and untreated HCV carriers, but did not improve treatment rates. Other strategies need to be developed to improve linkage to care in high risk populations.
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Affiliation(s)
- Inbal Houri
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Noya Horowitz
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
| | - Helena Katchman
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Yael Weksler
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Ofer Miller
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Liat Deutsch
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Oren Shibolet
- Department of Gastroenterology and Hepatology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
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11
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Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study. Public Health 2020; 185:224-231. [DOI: 10.1016/j.puhe.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
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12
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Williams J, Vickerman P, Douthwaite S, Nebbia G, Hunter L, Wong T, Ruf M, Miners A. An Economic Evaluation of the Cost-Effectiveness of Opt-Out Hepatitis B and Hepatitis C Testing in an Emergency Department Setting in the United Kingdom. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1003-1011. [PMID: 32828211 DOI: 10.1016/j.jval.2020.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/14/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The prevalence of hepatitis is high in emergency department (ED) attendees in the United Kingdom, with a prevalence of up to 2% for hepatitis B (HBV) HBsAg, and 2.9% for hepatitis C (HCV) RNA. The aim of this paper is to perform an economic evaluation of opt-out ED-based HCV and HBV testing. METHODS A Markov model was developed to analyze the cost-effectiveness of opt-out HCV and HBV testing in EDs in the UK. The model used data from UK studies of ED testing to parameterize the HCV and HBV prevalence (1.4% HCV RNA, 0.84% HBsAg), test costs, and intervention effects (contact rates and linkage to care). For HCV, we used an antibody test cost of £3.64 and RNA test cost of £68.38, and assumed direct-acting antiviral treatment costs of £10 000. For HBV, we used a combined HBsAg and confirmatory test cost of £5.79. We also modeled the minimum prevalence of HCV (RNA-positive) and HBV (HBsAg) required to make ED testing cost-effective at a £20 000 willingness to pay per quality-adjusted life-year threshold. RESULTS In the base case, ED testing was highly cost-effective, with HCV and HBV testing costing £8019 and £9858 per quality-adjusted life-year gained, respectively. HCV and HBV ED testing remained cost-effective at 0.25% HCV RNA or HBsAg prevalence or higher. CONCLUSIONS Emergency department testing for HCV and HBV is highly likely to be cost-effective in many areas across the UK depending on their prevalence. Ongoing studies will help evaluate ED testing across different regions to inform testing guidelines.
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Affiliation(s)
- Jack Williams
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, England, UK.
| | - Peter Vickerman
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, England, UK; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Sam Douthwaite
- Department of Infection, Guy's and St Thomas' NHS Trust, London, England, UK
| | - Gaia Nebbia
- Department of Infection, Guy's and St Thomas' NHS Trust, London, England, UK
| | - Laura Hunter
- Emergency Department, Guy's and St Thomas' NHS Trust, London, England, UK
| | - Terry Wong
- Department of HIV/GU Medicine, Guy's and St Thomas' NHS Trust, London, England, UK
| | - Murad Ruf
- Gilead Sciences Medical Department, London, England, UK
| | - Alec Miners
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College, London, England, UK
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13
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Iwundu CN, Agrawal P, Businelle MS, Kendzor DE, Reitzel LR. Predictors of Overnight and Emergency Treatment among Homeless Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4271. [PMID: 32549281 PMCID: PMC7345623 DOI: 10.3390/ijerph17124271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 12/02/2022]
Abstract
High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.
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Affiliation(s)
- Chisom N. Iwundu
- Department of Rehabilitation and Health Services, College of Public and Health, University of North Texas Services, Denton, TX 76203, USA
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
| | - Pooja Agrawal
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- School of Medicine, University of Texas Medical Branch, Galveston, TX 78701, USA
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Lorraine R. Reitzel
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- HEALTH Research Institute, University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA
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14
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Himsworth C, Paudyal P, Sargeant C. Risk factors for unplanned hospital admission in a specialist homeless general practice population: case-control study to investigate the relationship with tri-morbidity. Br J Gen Pract 2020; 70:e406-e411. [PMID: 32424048 PMCID: PMC7239039 DOI: 10.3399/bjgp20x710141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND 'Tri-morbidity' describes the complex comorbidity of chronic physical illness, mental illness, and alcohol and/or drug misuse within the homeless population. Poor health outcomes of homeless people are reflected by the higher rate of unplanned hospital admissions compared with the non-homeless population. AIM To identify whether tri-morbidity is a risk factor for unplanned hospital admissions in the homeless population. DESIGN AND SETTING A case-control study of patients who were registered with a specialist homeless GP surgery in Brighton (72 cases and 72 controls). METHOD Cases were defined as those who had ≥1 overnight hospital admission within a 12-month period. Controls were matched for demographics but with no hospital admission. The primary care record was analysed, and tri-morbidity entered into binomial logistic regression with admission as the dichotomous dependent variable. RESULTS The logistic regression analysis demonstrated that other enduring mental health disorders and/or personality disorder (odds ratio [OR] 3.84, 95% confidence interval [CI] = 1.56 to 9.44), alcohol use (OR 2.92, 95% CI = 1.42 to 5.98), and gastrointestinal disorder (OR 2.90, 95% CI = 1.06 to 7.98) were independent risk factors for admission. Tri-morbidity increased odds of admission by more than four-fold (OR 4.19, 95% CI = 1.90 to 9.27). CONCLUSION This study shows that tri-morbidity is an important risk factor for unplanned hospital admissions among the homeless population, and provides an interesting starting point for the development of a risk stratification tool to identify those at risk of unplanned admission in this population.
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Affiliation(s)
| | - Priyamvada Paudyal
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton
| | - Christopher Sargeant
- ARCH Healthcare, Education Fellow Pathway; Department of Medical Education, Brighton and Sussex Medical School, Brighton
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15
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Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use. Community Ment Health J 2020; 56:271-279. [PMID: 31552539 DOI: 10.1007/s10597-019-00470-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/18/2019] [Indexed: 10/26/2022]
Abstract
Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.
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16
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Kerman N, Aubry T, Adair CE, Distasio J, Latimer E, Somers J, Stergiopoulos V. Effectiveness of Housing First for Homeless Adults with Mental Illness Who Frequently Use Emergency Departments in a Multisite Randomized Controlled Trial. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 47:515-525. [DOI: 10.1007/s10488-020-01008-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Gabet M, Grenier G, Cao Z, Fleury MJ. Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4965. [PMID: 31817747 PMCID: PMC6950268 DOI: 10.3390/ijerph16244965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 11/22/2022]
Abstract
This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg-Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.
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Affiliation(s)
- Morgane Gabet
- Département de Gestion, Évaluation et Politiques de Santé, École de santé publique, Université de Montréal, 7101 av. du Parc, Montréal, QC H3X1X9, Canada;
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Guy Grenier
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Zhirong Cao
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
| | - Marie-Josée Fleury
- Research Center, Douglas MH University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada; (G.G.); (Z.C.)
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada
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18
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Thakarar K, Rokas KE, Lucas FL, Powers S, Andrews E, DeMatteo C, Mooney D, Sorg MH, Valenti A, Cohen M. Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services. PLoS One 2019; 14:e0225460. [PMID: 31770395 PMCID: PMC6879163 DOI: 10.1371/journal.pone.0225460] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background The addiction crisis is widespread, and unsafe injection practices among people who inject drugs (PWID) can lead to infective endocarditis. Methods A retrospective analysis of adult patients with definite or possible infective endocarditis admitted to a tertiary care center in Portland, Maine was performed over three-year period. Our primary objective was to examine differences in demographics, health characteristics, and health service utilization between injection drug use (IDU)-associated infective endocarditis and non-IDU infective endocarditis. The association between IDU and mortality, morbidity (defined as emergency department visits within 3 months of discharge), and cardiac surgery was examined. Bivariate and multivariate analyses were performed. A subgroup descriptive analysis of PWID was also performed to better examine substance use disorder (SUD) characteristics, treatment with medication for opioid use disorder (MOUD) and health service utilization. Results One-hundred and seven patients were included in the study, of which 39.2% (n = 42) had IDU-associated infective endocarditis. PWID were more likely to be homeless, uninsured, and lack a primary care provider. PWID were notably younger and had less documented comorbidities, however had similar in-hospital mortality rates (10% vs. 14%, p = 0.30), ED visits (50% vs. 54%, p = 0.70) and cardiac surgery (33% vs. 26%, p = 0.42) compared to those with non-IDU infective endocarditis. Ninety-day mortality was less among PWID (19.0% vs. 36.9%, p = 0.05). IDU was not associated with morbidity (adjusted odds ratio (AOR) 0.73, 95% CI 0.18–3.36), 90-day mortality (AOR 0.72, 95% CI 0.17–3.01), or cardiac surgery (AOR 0.15, 95% CI 0.03–0.69). Ninety-day mortality among PWID who received MOUD was lower (3% vs 15%, p = 0.45), as were ED visits (10% vs. 41%, p = 0.42) compared to those who did not receive MOUD. Conclusions Our results highlight existing differences in health characteristics and social determinants of health in people with IDU-associated versus non-IDU infective endocarditis. PWID had less comorbidities and were significantly younger than those with non-IDU infective endocarditis and yet still had similar rates of cardiac surgery, ED visits, and in-hospital mortality. These findings emphasize the need to deliver comprehensive health services, particularly MOUD and other harm reduction services, to this marginalized population.
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Affiliation(s)
- Kinna Thakarar
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States of America
- Tufts University School of Medicine, Boston, MA, United States of America
- Maine Medical Center, Portland, ME, United States of America
- InterMed Infectious Disease, South Portland, ME, United States of America
- * E-mail:
| | | | - F. L. Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States of America
| | - Spencer Powers
- Maine Medical Center, Portland, ME, United States of America
| | | | | | - Deirdre Mooney
- Tufts University School of Medicine, Boston, MA, United States of America
- Maine Medical Center, Portland, ME, United States of America
| | - Marcella H. Sorg
- Margaret Chase Smith Policy Center, University of Maine, Orono, ME, United States of America
| | - August Valenti
- Tufts University School of Medicine, Boston, MA, United States of America
- Maine Medical Center, Portland, ME, United States of America
- InterMed Infectious Disease, South Portland, ME, United States of America
| | - Mylan Cohen
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, United States of America
- Tufts University School of Medicine, Boston, MA, United States of America
- Maine Medical Center, Portland, ME, United States of America
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19
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Leggio WJ, Giguere A, Sininger C, Zlotnicki N, Walker S, Miller MG. Homeless Shelter Users and Their Experiences as EMS Patients: A Qualitative Study. PREHOSP EMERG CARE 2019; 24:214-219. [DOI: 10.1080/10903127.2019.1626954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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Chiu Y, Racine-Hemmings F, Dufour I, Vanasse A, Chouinard MC, Bisson M, Hudon C. Statistical tools used for analyses of frequent users of emergency department: a scoping review. BMJ Open 2019; 9:e027750. [PMID: 31129592 PMCID: PMC6537981 DOI: 10.1136/bmjopen-2018-027750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user. METHODS We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis. RESULTS We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used. CONCLUSIONS This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.
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Affiliation(s)
- Yohann Chiu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Racine-Hemmings
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Dufour
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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21
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Chan Carusone S, Guta A, Robinson S, Tan DH, Cooper C, O’Leary B, de Prinse K, Cobb G, Upshur R, Strike C. "Maybe if I stop the drugs, then maybe they'd care?"-hospital care experiences of people who use drugs. Harm Reduct J 2019; 16:16. [PMID: 30760261 PMCID: PMC6373073 DOI: 10.1186/s12954-019-0285-7] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Drug use is associated with increased morbidity and mortality but people who use drugs experience significant barriers to care. Data are needed about the care experiences of people who use drugs to inform interventions and quality improvement initiatives. The objective of this study is to describe and characterize the experience of acute care for people who use drugs. METHODS We conducted a qualitative descriptive study. We recruited people with a history of active drug use at the time of an admission to an acute care hospital, who were living with HIV or hepatitis C, in Toronto and Ottawa, Canada. Data were collected in 2014 and 2015 through semi-structured interviews, audio-recorded and transcribed, and analyzed thematically. RESULTS Twenty-four adults (18 men, 6 women) participated. Participants predominantly recounted experiences of stigma and challenges accessing care. We present the identified themes in two overarching domains of interest: perceived effect of drug use on hospital care and impact of care experiences on future healthcare interactions. Participants described significant barriers to pain management, often resulting in inconsistent and inadequate pain management. They described various strategies to navigate access and receipt of healthcare from being "an easy patient" to self-advocacy. Negative experiences influenced their willingness to seek care, often resulting in delayed care seeking and targeting of certain hospitals. CONCLUSION Drug use was experienced as a barrier at all stages of hospital care. Interventions to decrease stigma and improve our consistency and approach to pain management are necessary to improve the quality of care and care experiences of those who use drugs.
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Affiliation(s)
- Soo Chan Carusone
- Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4K1 Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON N9A 0C5 Canada
| | - Samantha Robinson
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
| | - Darrell H. Tan
- St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
| | - Curtis Cooper
- Ottawa Hospital Research Institute, 501 Smyth Box 511, Ottawa, ON K1H 8L6 Canada
| | - Bill O’Leary
- Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, ON M5S 1V4 Canada
| | | | - Grant Cobb
- AIDS Committee of Ottawa, 19 Main St, Ottawa, ON K1S 1A9 Canada
| | - Ross Upshur
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, 600 University Ave., Toronto, ON M5G 1X5 Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7 Canada
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Sacamano P, Krawczyk N, Latkin C. Emergency Department Visits in a Cohort of Persons with Substance Use: Incorporating the Role of Social Networks. Subst Use Misuse 2018; 53:2265-2269. [PMID: 29671696 PMCID: PMC6105410 DOI: 10.1080/10826084.2018.1461225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders. OBJECTIVE This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use. METHODS Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors. RESULTS Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.
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Affiliation(s)
- Paul Sacamano
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Noa Krawczyk
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carl Latkin
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Amato S, Nobay F, Amato DP, Abar B, Adler D. Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization. Am J Emerg Med 2018; 37:415-420. [PMID: 29891125 DOI: 10.1016/j.ajem.2018.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness. METHODS We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized. RESULTS Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years. CONCLUSIONS Compared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.
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Affiliation(s)
- Stas Amato
- University of Vermont Medical Center, Department of General Surgery, 111 Colchester Avenue, Burlington, VT 05401, United States; University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - Flavia Nobay
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | | | - Beau Abar
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - David Adler
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States.
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Randhawa G, Azarbar A, Dong H, Milloy MJ, Kerr T, Hayashi K. Childhood Trauma and the Inability to Access Hospital Care Among People who Inject Drugs. J Trauma Stress 2018; 31:383-390. [PMID: 29924415 PMCID: PMC6026062 DOI: 10.1002/jts.22286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 01/20/2018] [Accepted: 01/31/2018] [Indexed: 12/12/2022]
Abstract
Childhood traumatic experiences can disrupt attachment, influence personality development, and precipitate chronic disease. Although the repercussions of these experiences may also pose a barrier to healthcare, few studies have examined the association between childhood trauma and access to healthcare. Therefore, we sought to investigate whether a history of childhood trauma is associated with self-reported inability to access hospital care among persons who inject drugs (PWID). Data were derived from two prospective cohorts of PWID in Vancouver, Canada. We used multivariable generalized estimating equations to examine associations between five types of childhood trauma and self-reported inability to access hospital care, both overall and specifically due to perceived mistreatment by hospital staff. In total, 300 participants (18.3%) reported having tried but being unable to access hospital care in the previous 6 months at some point during the study period; the primary reason was perceived mistreatment by hospital staff (32.1%). In multivariable analyses, childhood emotional abuse was independently associated with self-reported inability to access hospital care, adjusted odds ratio (AOR) = 1.51, 95% CI [1.03, 2.20]. Childhood physical neglect was also independently associated with inability to access care due to perceived mistreatment by hospital staff, AOR = 1.80, 95% CI [1.11, 2.93]. This suggests potentially damaging consequences of early trauma in adult PWID populations. Further, this study emphasizes the need for trauma-informed models of care as well as the need to improve therapeutic alliances with survivors of childhood trauma in the PWID population.
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Affiliation(s)
- Gurdeeshpal Randhawa
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Ataa Azarbar
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Huiru Dong
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - MJ Milloy
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Thomas Kerr
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Implementing routine blood-borne virus testing for HCV, HBV and HIV at a London Emergency Department - uncovering the iceberg? Epidemiol Infect 2018; 146:1026-1035. [PMID: 29661260 DOI: 10.1017/s0950268818000870] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
UK guidelines recommend routine HIV testing in high prevalence emergency departments (ED) and targeted testing for HBV and HCV. The 'Going Viral' campaign implemented opt-out blood-borne virus (BBV) testing in adults in a high prevalence ED, to assess seroprevalence, uptake, linkage to care (LTC) rates and staff time taken to achieve LTC. Diagnosis status (new/known/unknown), current engagement in care, and severity of disease was established. LTC was defined as patient informed plus ⩾1 clinic visit. A total of 6211/24 981 ED attendees were tested (uptake 25%); 257 (4.1%) were BBV positive (15 co-infected), 84 (33%) required LTC. 100/147 (68%) HCV positives were viraemic; 44 (30%) required LTC (13 new, 16 disengaged). 26/54 (48%) HBV required LTC (seven new, 11 disengaged). 16/71 (23%) HIV required LTC (10 new, five disengaged). 26/84 (31%) patients requiring LTC had advanced disease (CD4 1, Fibroscan F3/F4 or liver cancer), including five with AIDS-defining conditions and three hepatocellular carcinomas. There were five BBV-related deaths. BBV prevalence was high (4.1%); most were HCV (2.4%). HIV patients were more successfully and quickly LTC than HBV or HCV patients. ED testing was valuable as one-third of those requiring LTC (new, disengaged or unknown status patients) had advanced disease.
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26
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Moore DT, Rosenheck RA. Comprehensive services delivery and emergency department use among chronically homeless adults. Psychol Serv 2018; 14:184-192. [PMID: 28481603 DOI: 10.1037/ser0000111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Homeless adults use emergency department (ED) services more frequently than other adults, but the relationships between homelessness, health status, outpatient service use, and ED utilization are poorly understood. Data from the Collaborative Initiative to Help End Chronic Homelessness (CICH) were used to compare ED use among chronically homeless adults receiving comprehensive housing, case management, mental health, addiction, and primary care services through CICH at 5 U.S. sites (n = 274) and ED use among comparison group clients receiving generally available community services (n = 116) at the same sites. Multiple imputation was used to account for missing data and differential rates of attrition between the cohorts. Longitudinal models were constructed to compare ED use between the 2 groups during the first year after initiation of CICH services. A mediation analysis was performed to determine the relative contributions of being housed, the receipt of outpatient services, and health status to group differences in ED utilization. Participants receiving CICH services were significantly less likely to report ED use (odds ratio = 0.78, 95% confidence interval [0.65, 0.93]) in the year after program entry. Decreased ED use was primarily mediated by decreased homelessness-not by increased access to other services or health status. This suggests that becoming housed is a key driver of reduced ED utilization and that efforts to provide housing for homeless adults may result in significantly decreased ED use. Further research is needed to determine the long-term effects of housing on health status and to develop services to improve health outcomes. (PsycINFO Database Record
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27
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Ostermeyer B, Baweja NUA, Schanzer B, Han J, Shah AA. Frequent Utilizers of Emergency Departments: Characteristics and Intervention Opportunities. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20171206-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Emergency medical services (EMS) and EDs in large cities are burdened with a significant number of patients with chronic disease who have limited options for receiving proper care. Despite their relatively small numbers, these "superusers" can have a significant effect on EMS, particularly in large cities. Additionally, EDs are not designed to provide chronic and continuous healthcare. This article describes how several organizations use physician assistants to manage these patients.
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Moore DT, Rosenheck RA. Factors Affecting Emergency Department Use by a Chronically Homeless Population. Psychiatr Serv 2016; 67:1340-1347. [PMID: 27417899 PMCID: PMC5133170 DOI: 10.1176/appi.ps.201500526] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Homeless adults make extensive use of emergency department (ED) services. This study examined factors associated with moderate and high ED use in a cohort of chronically homeless individuals. METHODS A cross-sectional analysis identified factors related to ED use in a cohort of 755 individuals at 11 sites at entry into the Collaborative Initiative to Help End Chronic Homelessness (CICH). Bivariate analyses identified sociodemographic, housing status, health status, and service-related factors associated with moderate and high ED use. Independent risk factors were then identified by using a multivariate multinomial model. Hierarchical regression was used to compare the strengths of association between ED use and blocks of factors composed of sociodemographic, housing, health, and service-related characteristics. RESULTS In a three-month period, 30% of participants visited the ED one or two times (moderate ED use) and 12% visited three or more times (high-ED use). ED use was most strongly associated with poor health and utilization of other non-ED services and to a lesser extent with housing status. CONCLUSIONS Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services. Thus ED use was related to high need and acuity and was not ameliorated by use of other services. Housing instability and homelessness contributed less robustly to increased ED use. More coordinated services may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.
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Affiliation(s)
- David Thomas Moore
- The authors are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Rosenheck is also with the U.S. Department of Veterans Affairs New England Mental Illness Research, Education and Clinical Center, West Haven, Connecticut
| | - Robert A Rosenheck
- The authors are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Rosenheck is also with the U.S. Department of Veterans Affairs New England Mental Illness Research, Education and Clinical Center, West Haven, Connecticut
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30
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Lam CN, Arora S, Menchine M. Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions. West J Emerg Med 2016; 17:607-12. [PMID: 27625726 PMCID: PMC5017846 DOI: 10.5811/westjem.2016.6.30690] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital. METHODS We conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients' 30-day ED revisits and hospital readmissions. RESULTS Study included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%). CONCLUSION Homeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.
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Affiliation(s)
- Chun Nok Lam
- University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Sanjay Arora
- University of Southern California, Department of Emergency Medicine, Los Angeles, California
- University of Southern California, USC Schaeffer Center for Health Policy and Economics, Los Angeles, California
| | - Michael Menchine
- University of Southern California, Department of Emergency Medicine, Los Angeles, California
- University of Southern California, USC Schaeffer Center for Health Policy and Economics, Los Angeles, California
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Thakarar K, Weinstein ZM, Walley AY. Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist. Postgrad Med J 2016; 92:356-63. [PMID: 27004476 PMCID: PMC4967553 DOI: 10.1136/postgradmedj-2015-133720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/29/2016] [Indexed: 12/20/2022]
Abstract
The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.
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Affiliation(s)
- Kinna Thakarar
- Department of Medicine/Infectious Diseases, Maine Medical Center, Portland, Maine, USA
| | - Zoe M Weinstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
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Feral-Pierssens AL, Aubry A, Truchot J, Raynal PA, Boiffier M, Hutin A, Leleu A, Debruyne G, Joly LM, Juvin P, Riou B, Freund Y. Emergency Care for Homeless Patients: A French Multicenter Cohort Study. Am J Public Health 2016; 106:893-8. [PMID: 26985613 DOI: 10.2105/ajph.2015.303038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources. METHODS We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition. RESULTS A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints. CONCLUSIONS We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Adeline Aubry
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Jennifer Truchot
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Pierre-Alexis Raynal
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Mathieu Boiffier
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Alice Hutin
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Agathe Leleu
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Geraud Debruyne
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Luc-Marie Joly
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Philippe Juvin
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Bruno Riou
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
| | - Yonathan Freund
- Anne-Laure Feral-Pierssens and Philippe Juvin are with Emergency Department, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Adeline Aubry, Geraud Debruyne, Bruno Riou, and Yonathan Freund are with Emergency Department, Hôpital Pitié-Salpêtriere, APHP, Paris. Jennifer Truchot is with Emergency Department, Hôpital Lariboisière, APHP, Paris. Pierre-Alexis Raynal is with Emergency Department, Hôpital Saint-Antoine, APHP, Paris. Mathieu Boiffier is with Emergency Department, Centre Hospitalier Universitaire de Nice, France. Alice Hutin is with Emergency Department, Hôpital Cochin, APHP, Paris. Agathe Leleu is with Emergency Department, Hôpital Bichat, APHP, Paris. Luc-Marie Joly is with Emergency Department, Hôpital Charles Nicolle, Rouen, France. Pierre-Alexis Raynal, Bruno Riou, and Yanathan Freund are also with Sorbonne Université, UPMC univ Paris 06, Paris
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Dobbins SK, Cruz M, Shah S, Abt L, Moore J, Bamberger J. Nurses in Supportive Housing are Associated With Decreased Health Care Utilization and Improved HIV Biomarkers in Formerly Homeless Adults. J Assoc Nurses AIDS Care 2016; 27:444-54. [PMID: 26861866 DOI: 10.1016/j.jana.2016.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 01/04/2016] [Indexed: 11/26/2022]
Abstract
A San Francisco study conducted in 2008 showed that the permanent supportive housing program, Direct Access to Housing, dramatically decreased the risk of death in people living with HIV. In our study, we compared the health care utilization patterns and HIV-related biological markers of formerly homeless adults with HIV before and during two types of permanent supportive housing: (a) housing with on-site nursing care for residents, and (b) housing without on-site nursing care. Using nearest-neighbor matching with propensity scoring, the difference in outcomes was calculated. In the matched analysis, adjusted for adherence to combination antiretroviral therapy, people housed at sites with nurses had 4.8 fewer emergency department visits per person (SE: 1.53, p < .01), and they had an increased mean CD4+ T cell count (101.14 cells per person [SE: 55.10, p < .05]) compared to those who lived at sites without nurses.
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Health, perceived quality of life and health services use among homeless illicit drug users. Drug Alcohol Depend 2015; 154:139-45. [PMID: 26188997 DOI: 10.1016/j.drugalcdep.2015.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/11/2015] [Accepted: 06/17/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Drug misuse has been identified as a significant problem in homeless populations. This study examines aspects of physical and mental health, perceived quality of life and health service use among homeless illicit drug users and compares these to non-drug users. METHODS Participants were recruited through health clinics across Dublin. A questionnaire assessed participants' drug use, health and well-being, health behaviours and use of health services. Descriptive statistics are presented for the entire cohort and drug users separately. Logistic regression analysis was used to examine the relationship between drug use and (i) multimorbidity, (ii) anxiety and/or depression, (iii) perceived quality of life and (iv) use of health services. RESULTS Of 105 participants recruited, 35 (33%) were current drug users. Current and previous drug users were significantly more likely to have multimorbidity than those who had never taken drugs (OR 4.86, 95% CI 1.00-23.66). There was no significant difference between drug users and non-drug users in the prevalence of anxiety and/or depression. Drug users were five times more likely than non-drug users to have a low perceived quality of life (OR 5.2, 95% CI 1.7-16.0). Health service utilization was high, although some services were used less by drug users (e.g., dentist and psychiatric outpatient services) while others were used more often (e.g., phoneline services and day care centres). CONCLUSION This study highlights the high levels of drug use in this population and the negative impact of drug use on health and perceived quality of life of a homeless population in Dublin.
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Cheung A, Somers JM, Moniruzzaman A, Patterson M, Frankish CJ, Krausz M, Palepu A. Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders. Addict Sci Clin Pract 2015; 10:17. [PMID: 26242968 PMCID: PMC4636835 DOI: 10.1186/s13722-015-0038-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 07/16/2015] [Indexed: 11/14/2022] Open
Abstract
Background Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ (HF) intervention trial. Methods The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have “high” or “moderate” levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission. Results Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62–1.17 and RR = 1.21; 95% CI 0.83–1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis. Conclusions Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders. Trial registration: ISRCTN57595077 and ISRCTN66721740
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Affiliation(s)
- Adrienne Cheung
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Julian M Somers
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | - Akm Moniruzzaman
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | | | | | - Michael Krausz
- School of Population and Public Health, Vancouver, Canada. .,Department of Psychiatry, University of British Columbia, Vancouver, Canada.
| | - Anita Palepu
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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