Dataset Information

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

ABSTRACT: Importance:Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. Objective:To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). Design, Setting, and Participants:This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n?=?24?890) and nonhomeless adults (n?=?1?827?900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. Main Outcomes and Measures:Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. Results:Of the 1?852?790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24?890 occurred among patients who were homeless (11?452 women and 13?438 men; mean [SD] age, 65.1 [14.8] years) and 1?827?900 occurred among patients who were not homeless (850?660 women and 977?240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P?

SUBMITTER: Wadhera RK

PROVIDER: S-EPMC6865320 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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

Wadhera Rishi K RK Khatana Sameed Ahmed M SAM Choi Eunhee E Jiang Ginger G Shen Changyu C Yeh Robert W RW Joynt Maddox Karen E KE

JAMA internal medicine 20200301 3

<h4>Importance</h4>Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes.<h4>Objective</h4>To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, st ...[more]

PMID: 31738826

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Project description:ImportanceIndividuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans.ObjectiveTo evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes.Design, setting, and participantsThis cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans.Main outcomes and measuresMain outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.ResultsThe study sample included 3?209?929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294?550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321?535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178?701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1?383?398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P?<?.001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P?<?.001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P?<?.001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P?<?.001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P?<?.001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities.Conclusions and relevanceIn this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.

Project description:ImportancePrevious studies have shown high mortality rates among homeless people in general, but little is known about the patterns of mortality among "rough sleepers," the subgroup of unsheltered urban homeless people who avoid emergency shelters and primarily sleep outside.ObjectivesTo assess the mortality rates and causes of death for a cohort of unsheltered homeless adults from Boston, Massachusetts.Design, setting, and participantsA 10-year prospective cohort study (2000-2009) of 445 unsheltered homeless adults in Boston, Massachusetts, who were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program's Street Team during 2000. Data used to describe the unsheltered homeless cohort and to document causes of death were gathered from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The study data set was linked to the death occurrence files by using a probabilistic record linkage program to confirm the deaths. Data analysis was performed from May 1, 2015, to September 6, 2016.ExposureBeing unsheltered in an urban setting.Main outcomes and measuresAge-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios that were calculated for the unsheltered adult cohort using 2 comparison groups: the nonhomeless Massachusetts adult population and an adult homeless cohort from Boston who slept primarily in shelters.ResultsOf 445 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 299 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). The most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease.Conclusions and relevanceMortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation of homeless people merits special attention to meet their unique clinical and psychosocial needs.

Project description:Thousands of physicians attend scientific meetings annually. Although hospital physician staffing and composition may be affected by meetings, patient outcomes and treatment patterns during meeting dates are unknown.To analyze mortality and treatment differences among patients admitted with acute cardiovascular conditions during dates of national cardiology meetings compared with nonmeeting dates.Retrospective analysis of 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure, or cardiac arrest from 2002 through 2011 during dates of 2 national cardiology meetings compared with identical nonmeeting days in the 3 weeks before and after conferences (AMI, 8570 hospitalizations during 82 meeting days and 57,471 during 492 nonmeeting days; heart failure, 19,282 during meeting days and 11,4591 during nonmeeting days; cardiac arrest, 1564 during meeting days and 9580 during nonmeeting days). Multivariable analyses were conducted separately for major teaching hospitals and nonteaching hospitals and for low- and high-risk patients. Differences in treatment utilization were assessed.Hospitalization during cardiology meeting dates.Thirty-day mortality, procedure rates, charges, length of stay.Patient characteristics were similar between meeting and nonmeeting dates. In teaching hospitals, adjusted 30-day mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting vs nonmeeting dates (heart failure, 17.5% [95% CI, 13.7%-21.2%] vs 24.8% [95% CI, 22.9%-26.6%]; P?<?.001; cardiac arrest, 59.1% [95% CI, 51.4%-66.8%] vs 69.4% [95% CI, 66.2%-72.6%]; P?=?.01). Adjusted mortality for high-risk AMI in teaching hospitals was similar between meeting and nonmeeting dates (39.2% [95% CI, 31.8%-46.6%] vs 38.5% [95% CI, 35.0%-42.0%]; P?=?.86), although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P?=?.02). No mortality or utilization differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals. In sensitivity analyses, cardiac mortality was not affected by hospitalization during oncology, gastroenterology, and orthopedics meetings, nor was gastrointestinal hemorrhage or hip fracture mortality affected by hospitalization during cardiology meetings.High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with AMI admitted to teaching hospitals during meetings were less likely to receive PCI, without any mortality effect.

Project description:ImportanceThere are limited data regarding sex-based differences in physical and mental health domains and health care access in adults with premature atherosclerotic cardiovascular disease (ASCVD).ObjectiveTo study the association of sex with physical and mental health domains as well as health care access-related factors among adults with self-reported premature ASCVD.Design, setting, and participantsRetrospective cohort analysis of 748 090 adults aged 18 to 55 years in the Behavioral Risk Factor Surveillance System 2016 to 2019 in the US. Data were analyzed from June to July 2021.ExposuresSelf-reported ASCVD, defined as having a history of coronary artery disease, myocardial infarction, or stroke.Main outcomes and measuresSelf-reported physical and mental health and measures of health care access, including self-reported cost-related medication nonadherence and inability to see a physician due to cost.ResultsBetween 2016 and 2019, 748 090 adults aged 18-55 years were identified, of whom 28 522 (3.3%) had self-reported premature ASCVD. Of these, 14 358 (47.0%) were women. Compared with men, women with premature ASCVD were more likely to report being clinically depressed (odds ratio [OR], 1.73; 95% CI, 1.41-2.14; P < .001), have cost-related medication nonadherence (OR, 1.42; 95% CI, 1.11-1.82; P = .005), have not seen a physician due to cost-related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001), and were more likely to report overall poor physical health (OR, 1.39; 95% CI, 1.09-1.78; P = .008) despite being more likely to have health care coverage (85.3% vs 80.8%; P = .04) and a primary care physician (84.2% vs 75.7%; P < .001).Conclusions and relevanceResults from this study indicate that women with premature ASCVD were more likely to report worse overall physical and mental health, inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.

Project description:ObjectivesEvidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals.DesignCross-sectional study.SettingData including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014.ParticipantsWe analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals.Outcome measuresRisk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects.ResultsAt safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals.ConclusionDisparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.

Project description:ImportanceDisparities in patient access and use of health care portals have been documented. Limited research has evaluated disparities in portal use during and after the COVID-19 pandemic.ObjectiveTo assess prevalence of health care portal use before, during, and after the most restrictive phase of the pandemic (2019-2022) among the COVID-19 & Chronic Conditions (C3) cohort and to investigate any disparities in use by sociodemographic factors.Design, setting, and participantsThis cohort study uses data from the C3 study, an ongoing, longitudinal, telephone-based survey of participants with multiple chronic conditions. Participants were middle aged and older-adult primary care patients who had an active portal account, recruited from a single academic medical center in Chicago, Illinois, between 2019 and 2022. Data were analyzed between March and June 2022.Main outcomes and measuresOutcomes of portal use (ie, number of days of portal login by year) were recorded for all study participants by the electronic data warehouse. All parent studies had uniform sociodemographic data and measures of social support, self-efficacy, health literacy, and health activation.ResultsOf 536 participants (mean [SD] age, 66.7 [12.0] years; 336 [62.7%] female), 44 (8.2%) were Hispanic or Latinx, 142 (26.5%) were non-Hispanic Black, 322 (60.1%) were non-Hispanic White, and 20 individuals (3.7%) identified as other race, including Asian, Native American or Alaskan Native, and self-reported other race. In multivariable analyses, portal login activity was higher during the 3 years of the COVID-19 pandemic compared with the 2019 baseline. Higher portal login activity was associated with adequate health literacy (incidence rate ratio [IRR], 1.51; 95% CI, 1.18-1.94) and multimorbidity (IRR, 1.38; 95% CI, 1.17-1.64). Lower portal activity was associated with older age (≥70 years: IRR, 0.69; 95% CI, 0.55-0.85) and female sex (IRR, 0.77; 95% CI, 0.66-0.91). Compared with non-Hispanic White patients, lower portal activity was observed among Hispanic or Latinx patients (IRR, 0.66; 95% CI, 0.49-0.89), non-Hispanic Black patients (IRR, 0.68; 95% CI, 0.56-0.83), and patients who identified as other race (IRR, 0.42; 95% CI, 0.28-0.64).Conclusions and relevanceThis cohort study using data from the C3 study identified changes in portal use over time and highlighted populations that had lower access to health information. The COVID-19 pandemic was associated with an increase in portal use. Sociodemographic disparities by sex and age were reduced, although disparities by health literacy widened. A brief validated health literacy measure may serve as a useful digital literacy screening tool to identify patients who need further support.

Dataset Information

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

Publications

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

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