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      Usage of unscheduled hospital care by homeless individuals in Dublin, Ireland: a cross-sectional study

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          Abstract

          Objectives

          Homeless people lack a secure, stable place to live and experience higher rates of serious illness than the housed population. Studies, mainly from the USA, have reported increased use of unscheduled healthcare by homeless individuals.

          We sought to compare the use of unscheduled emergency department (ED) and inpatient care between housed and homeless hospital patients in a high-income European setting in Dublin, Ireland.

          Setting

          A large university teaching hospital serving the south inner city in Dublin, Ireland. Patient data are collected on an electronic patient record within the hospital.

          Participants

          We carried out an observational cross-sectional study using data on all ED visits (n=47 174) and all unscheduled admissions under the general medical take (n=7031) in 2015.

          Primary and secondary outcome measures

          The address field of the hospital’s electronic patient record was used to identify patients living in emergency accommodation or rough sleeping (hereafter referred to as homeless). Data on demographic details, length of stay and diagnoses were extracted.

          Results

          In comparison with housed individuals in the hospital catchment area, homeless individuals had higher rates of ED attendance (0.16 attendances per person/annum vs 3.0 attendances per person/annum, respectively) and inpatient bed days (0.3 vs 4.4 bed days/person/annum). The rate of leaving ED before assessment was higher in homeless individuals (40% of ED attendances vs 15% of ED attendances in housed individuals). The mean age of homeless medical inpatients was 44.19 years (95% CI 42.98 to 45.40), whereas that of housed patients was 61.20 years (95% CI 60.72 to 61.68). Homeless patients were more likely to terminate an inpatient admission against medical advice (15% of admissions vs 2% of admissions in homeless individuals).

          Conclusion

          Homeless patients represent a significant proportion of ED attendees and medical inpatients. In contrast to housed patients, the bulk of usage of unscheduled care by homeless people occurs in individuals aged 25–65 years.

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          Most cited references25

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          Factors associated with the health care utilization of homeless persons.

          Margot Kushel (2001)
          Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.
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            Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis

            Ulla Beijer, Achim Wolf, Seena Fazel (2012)
            Summary Background 100 million people worldwide are homeless; rates of mortality and morbidity are high in this population. The contribution of infectious diseases to these adverse outcomes is uncertain. Accurate estimates of prevalence data are important for public policy and planning and development of clinical services tailored to homeless people. We aimed to establish the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people. Methods We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless populations. We also searched bibliographic indices, scanned reference lists, and corresponded with authors. We explored potential sources of heterogeneity in the estimates by metaregression analysis and calculated prevalence ratios to compare prevalence estimates for homeless people with those for the general population. Findings We identified 43 eligible surveys with a total population of 63 812 (59 736 homeless individuals when duplication due to overlapping samples was accounted for). Prevalences ranged from 0·2% to 7·7% for tuberculosis, 3·9% to 36·2% for hepatitis C virus infection, and 0·3% to 21·1% for HIV infection. We noted substantial heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran's χ2 significant at p<0·0001; I 2=83%, 95% CI 76–89; 95%, 94–96; and 94%, 93–95; respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies in which diagnosis was by chest radiography than in those which used other diagnostic methods and in countries with a higher general population prevalence than in those with a lower general prevalence. Prevalence of HIV infection was lower in newer studies than in older ones and was higher in the USA than in the rest of the world. Interpretation Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests the need for local surveys to inform development of health services for homeless people. The role of targeted and population-based measures in the reduction of risks of infectious diseases, premature mortality, and other adverse outcomes needs further examination. Guidelines for screening and treatment of infectious diseases in homeless people might need to be reviewed. Funding The Wellcome Trust.
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              Geriatric syndromes in older homeless adults.

              Rebecca T. Brown, Dan K Kiely, Monica Bharel … (2012)
              The average age of the US homeless population is increasing. Little is known about the prevalence of geriatric syndromes in older homeless adults.
              Article 0 comments Cited 73 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 1 December 2017
                Volume: 7
                Issue: 11
                Electronic Location Identifier: e016420
                Affiliations
                [1 ] St James’s Hospital , Dublin, Ireland
                [2 ] Trinity College , Dublin, Ireland
                [3 ] National SpR Academic Fellowship Programme , Dublin, Ireland
                [4 ] Depaul Ireland , Dublin, Ireland
                [5 ] UCD School of Public Health, Physiotherapy and Sports Science , Dublin, Ireland
                [6 ] Partnership for Health Equity , Dublin, Ireland
                [7 ] North Dublin City GP Training Programme , Dublin, Ireland
                [8 ] Safetynet Dublin , Dublin, Ireland
                Author notes
                [Correspondence to ] Dr Clíona Ní Cheallaigh; nicheacm@ 123456tcd.ie , clionani@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-0842-425X
                Article
                Publisher ID: bmjopen-2017-016420
                DOI: 10.1136/bmjopen-2017-016420
                PMC ID: 5719262
                PubMed ID: 29196477
                SO-VID: c0d3f165-76bb-416e-bbff-e673ccc0eadd
                Copyright © © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 21 April 2017
                Date revision received : 26 August 2017
                Date accepted : 11 September 2017
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100010414, Health Research Board;
                Categories
                Subject: Epidemiology
                Subject: Research
                Subject: 1506
                Subject: 1692
                Subject: 655
                Custom metadata
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                ScienceOpen disciplines: Medicine
                Keywords: homeless,hospitalised,epidemiology
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: homeless, hospitalised, epidemiology

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