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Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients.

ABSTRACT: OBJECTIVE:Homelessness is associated with worse diabetes outcomes, but the relationship between other forms of unstable housing and diabetes is not well studied. We assessed whether unstable housing was associated with increased risk for diabetes-related emergency department use or hospitalization. RESEARCH DESIGN AND METHODS:We used data from the 2014 Health Center Patient Survey (HCPS), a cross-sectional, nationally representative survey of patients who receive care at federally funded safety-net health centers. We included nonhomeless adults (aged ≥18 years) with self-reported diabetes. Unstable housing was defined as not having enough money to pay rent or mortgage, moving two or more times in the past 12 months, or staying at a place one does not own or rent. The primary outcome was self-report of diabetes-related emergency department visit or inpatient hospitalization in the last 12 months. We also examined use of housing assistance. RESULTS:Of 1,087 participants, representing 3,277,165 adults with diabetes, 37% were unstably housed. Overall, 13.7% of participants reported a diabetes-related emergency department visit or hospitalization in the past year. In logistic regression analyses adjusted for multiple potential confounders, unstable housing was associated with greater odds of diabetes-related emergency department use or hospitalization (adjusted odds ratio 5.17 [95% CI 2.08-12.87]). Only 0.9% of unstably housed individuals reported receiving help with housing through their clinic. CONCLUSIONS:Unstable housing is common and associated with increased risk of diabetes-related emergency department and inpatient use. Addressing unstable housing in clinical settings may help improve health care utilization for vulnerable individuals with diabetes.

SUBMITTER: Berkowitz SA

PROVIDER: S-EPMC5911783 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Background and objectivesIn 2011, there were approximately 131 million visits to an emergency department in the United States. Emergency department visits have increased over time, far outpacing growth of the general population. There is a paucity of data evaluating emergency department visits among kidney transplant recipients. We sought to evaluate the incidence and risk factors for emergency department visits after initial hospital discharge after transplantation in the United States.Design, setting, participants, & measurementsWe identified 10,533 kidney transplant recipients from California, New York, and Florida between 2009 and 2012 using the State Inpatient and Emergency Department Databases included in the Healthcare Cost and Utilization Project. We used multivariable Poisson and Cox proportional hazard models to evaluate adjusted incidence rates and time to emergency department visits after transplantation.ResultsThere were 17,575 emergency department visits over 13,845 follow-up years (overall rate =126.9/100 patient-years; 95% confidence interval, 125.1 to 128.8). The cumulative incidences of emergency department visits at 1, 12, and 24 months were 12%, 40%, and 57%, respectively, with median time =19 months; 48% of emergency department visits led to hospital admission. Risk factors for higher emergency department rates included younger age, women, black and Hispanic race/ethnicity, public insurance, depression, diabetes, peripheral vascular disease, and emergency department use before transplant. There was wide variation in emergency department visits by individual transplant center (10th percentile =70.0/100 patient-years; median =124.6/100 patient-years; and 90th percentile =187.4/100 patient-years).ConclusionsThe majority of kidney transplant recipients will visit an emergency department in the first 2 years post-transplantation, with significant variation by patient characteristics and individual centers. As such, coordination of care through the emergency department is a critical component of post-transplant management, and specific acumen of transplant-related care is needed among emergency department providers. Additional research assessing best processes of care for post-transplant management and health care expenditures and outcomes associated with emergency department visits for transplant recipients are warranted.

Project description:BackgroundHousing conditions are a key driver of asthma incidence and severity. Previous studies have shown increased emergency department visits for asthma among residents living in poor-quality housing. Interventions to improve housing conditions have been shown to reduce emergency department visits for asthma, but identification and remediation of poor housing conditions is often delayed or does not occur. This study evaluates whether emergency department visits for asthma can be used to identify poor-quality housing to support proactive and early intervention.MethodsWe conducted a retrospective cohort study of children and adults living in and around New Haven, CT, USA, who were seen for asthma in an urban, tertiary emergency department between March 1, 2013, and Aug 31, 2017. We geocoded and mapped patient addresses to city parcels, and calculated a composite estimate of the incidence of emergency department use for asthma for each parcel (Nv × Np/log2[P], where Nv is the estimated mean number of visits per patient, Np is the number of patients, and P is the estimated population). To determine whether parcel-level emergency department use for asthma was associated with public housing inspection scores, we used regression analyses, adjusting for neighbourhood-level and individual-level factors contributing to emergency department use for asthma. Public housing complex inspection scores were obtained from standardised home inspections, which are conducted every 1-3 years for publicly funded housing. We used a sliding-window approach to estimate how far in advance of a failed inspection the model could identify elevated use of emergency departments for asthma, using the city-wide 90th percentile as a cutoff for elevated incidence.Findings11 429 asthma-related emergency department visits from 6366 unique patients were included in the analysis. Mean patient age was 32·4 years (SD 12·8); 3836 (60·3%) patients were female, 2530 (39·7%) were male, 3461 (57·2%) were Medicaid-insured, and 2651 (41·6%) were Black. Incidence of emergency department use for asthma was strongly correlated with lower housing inspection scores (Pearson's r=-0·55 [95% CI -0·70 to -0·35], p=3·5 × 10-6), and this correlation persisted after adjustment for patient-level and neighbourhood-level demographics using a linear regression model (r=-0·54 [-0·69 to -0·33], p=7·1 × 10-6) and non-linear regression model (r=-0·44 [-0·62 to -0·21], p=3·8 × 10-4). Elevated asthma incidence rates were typically detected around a year before a housing complex failed a housing inspection.InterpretationEmergency department visits for asthma are an early indicator of failed housing inspections. This approach represents a novel method for the early identification of poor housing conditions and could help to reduce asthma-related morbidity and mortality.FundingHarvard-National Institute of Environmental Health Sciences (NIEHS) Center for Environmental Health.

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Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients.

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