Dataset Information

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness.

ABSTRACT:

Background

People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness.

Methods

Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, emergency department visits and physician visits for comparison across the 2 cohorts.

Results

During the 1-year follow-up period, a higher proportion of people in the cohort with a mental illness used any inpatient (27% vs 14%), emergency (63% vs 53%), or physician services (90% vs 76%) compared to the general homeless cohort. People from racialized groups were less likely use nearly all health services, most notably physician services. Other factors, such as reporting of a regular source of care, poor perceived general health, and diagnosed chronic conditions were associated with higher use of all health services except psychiatric inpatient care.

Conclusion

When implementing interventions for patients with the greatest health needs, we must consider the unique factors that contribute to higher healthcare use, as well as the barriers to healthcare access.

SUBMITTER: Wiens K

PROVIDER: S-EPMC9618755 | biostudies-literature | 2022

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness.

Wiens Kathryn K Rosella Laura C LC Kurdyak Paul P Chen Simon S Aubry Tim T Stergiopoulos Vicky V Hwang Stephen W SW

Health services insights 20221026

<h4>Background</h4>People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness.<h4>Methods</h4>Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, ...[more]

PMID: 36325379

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Project description:BackgroundHomelessness is associated with poor health outcomes, including lack of access to care. Homelessness experienced in rural areas is understudied but likely associated with difficulty accessing needed services. Prior studies have assessed the extent to which Veterans experiencing homelessness in rural areas "migrate" to urban areas, but have not focused on changes in services utilization following migration.ObjectiveTo determine whether Veterans with a history of homelessness experience changes in the use of homeless and health services following a migration from a rural to urban residence, and vice versa, and to assess the magnitude of those changes.DesignLongitudinal retrospective analysis of services use among Veterans identified as experiencing homelessness and migrating at least 40 miles or from an urban to a rural area or vice versa.ParticipantsA total of 81,620 Veterans with incident homelessness who experienced a migration and for whom we could establish 2 quarters of both pre-migration and post-migration service utilization.Main measuresIn addition to sociodemographic and health-related factors, we assessed index location and destination using geographic descriptors both residential address and Veteran Affairs (VA) facility where Veterans were identified as experiencing homelessness. Outcomes included continuous measures of homeless services and outpatient care and dichotomous measures of emergency department use and inpatient admissions.Key resultsRegardless of a Veteran's index location, migration to or within a rural area was associated with a significant decrease in the number of homeless and outpatient services and reduced risk of emergency department use or inpatient admission relative to migration to or within an urban area.ConclusionControlling for sociodemographic and health-related factors, Veterans experiencing homelessness who had a residential migration to or within a rural area had a significant reduction in their use of VA health and homeless services compared to those who migrated to or within an urban area.

Project description:ImportanceInterventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions.ObjectiveTo assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior.Design, setting, and participantsRetrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases.Main outcome and measuresTo assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use.ResultsCohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively).Conclusions and relevancePhysicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.

Project description:ObjectiveTo examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices.Data sourcesThis study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018.Study designWe examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level.Data collection/extraction methodsThe study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites.Principal findingsPatients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level.ConclusionsUnexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

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Dataset Information

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness.

Background

Methods

Results

Conclusion

Publications

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness.

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