Antimicrobial Susceptibility of Respiratory Isolates From Homeless Population in An Urban Environment

Homelessness is believed to be a cause of health problems and high medical costs, but data supporting this association have been difficult to obtain. We compared lengths of stay and reasons for hospital admission among homeless and other low-income persons in New York City to estimate the hospitalization costs associated with homelessness. We obtained hospital-discharge data on 18,864 admissions of homeless adults to New York City's public general hospitals (excluding admissions for childbirth) and 383,986 nonmaternity admissions of other low-income adults to all general hospitals in New York City during 1992 and 1993. The differences in length of stay were adjusted for diagnosis-related group, principal diagnosis, selected coexisting illnesses, and demographic characteristics. Of the admissions of homeless people, 51.5 percent were for treatment of substance abuse or mental illness, as compared with 22.8 percent for the other low-income patients, and another 19.7 percent of the admissions of homeless people were for trauma, respiratory disorders, skin disorders, and infectious diseases (excluding the acquired immunodeficiency syndrome [AIDS]), many of which are potentially preventable medical conditions. For the homeless, 80.6 percent of the admissions involved either a principal or a secondary diagnosis of substance abuse or mental illness -- roughly twice the rates for the other patients. The homeless patients stayed 4.1 days, or 36 percent, longer per admission on average than the other patients, even after adjustments were made for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The costs of the additional days per discharge averaged $4,094 for psychiatric patients, $3,370 for patients with AIDS, and $2,414 for all types of patients. Homelessness is associated with substantial excess costs per hospital stay in New York City. Decisions to fund housing and supportive services for the homeless should take into account the potential of these services to reduce the high costs of hospitalization in this population.

Employing data from a 1987 shelter survey of 1260 homeless adults in New York City, multivariate models of emergency room (ER) use are developed which include an array of risk factors for visiting a hospital ER including health and mental health problems, victimization and injuries. The study's primary goal is to identify factors that predict ER use in this population. Multivariate logistic and linear regression models were tested separately for men and women predicting three outcomes: any use of the ER during the past 6 months, use of the ER for injuries vs all other reasons (given any ER use), and the number of ER visits (given any ER use). Lower alcohol dependence, health symptoms and injuries were strong predictors for both men and women; other significant predictors differed markedly by gender. Both models were highly significant and produced strikingly high risk profiles. A high prevalence of victimization and injuries underlies ER use among the homeless. Based upon the findings, we recommend expanded health and victim services as well as preventive measures. Until primary care becomes available for this population, we advise against policies that discourage ER use by the homeless.

The national picture of the comparative costs and diagnoses of hospitalised homeless patients are examined using the ‘no fixed abode’ flag in English hospital statistics. Comparable studies sample patients in single cities, eg New York and Toronto. The most common diagnosis is substance misuse; the share of homeless NHS patients with this diagnosis is rising, and now equals that found in North American cities. About half of the cost of homeless patients relates to diagnoses of mental illness, although these comprise a much smaller share of homeless patients than in North America. Hospital costs for homeless patients – both total and per admission – have fallen significantly in recent years, primarily because of fewer admissions and shorter lengths of stay for mentally ill patients. Aims to reduce NHS costs at the level of individual institutions have often shaped policy. Broader policy to prevent and reduce homelessness offers substantial long-term reductions in the cost of chronic care.