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Cardiovascular Outcomes and Rehospitalization Rates in Homeless Patients Admitted With Acute Myocardial Infarction

      Abstract

      Objective

      To study the in-hospital outcomes and 30-day readmission data in homeless patients admitted with acute myocardial infarction (AMI).

      Methods

      Adult patients (>18 years of age) who were admitted with AMI between January 1, 2015, and December 31, 2016, were identified in the National Readmission Database. Patients were classified into homeless or non-homeless. Baseline characteristics, rates of invasive assessment and revascularization, mortality, 30-day readmission rates, and reasons for readmission were compared between the 2 cohorts.

      Results

      A total of 3938 of 1,100,241 (0.4%) index hospitalizations for AMI involved homeless patients. Compared with non-homeless patients, homeless patients were younger (mean age, 57±10 years vs 68±14 years; P<.001) and had a lower prevalence of atherosclerotic risk factors (hypertension, hyperlipidemia, and diabetes) but a higher prevalence of anxiety, depression, and substance abuse. Homeless patients were less likely to undergo coronary angiography (38.1% vs 54%; P<.001), percutaneous coronary intervention (24.1% vs 38.7%; P<.001), or coronary artery bypass grafting (4.9% vs 6.7%; P<.001). Among patients who underwent percutaneous coronary intervention, bare-metal stent use was higher in homeless patients (34.6% vs 12.1%; P<.001). After propensity score matching, homeless patients had similar mortality but higher rates of acute kidney injury, discharge to an intermediate care facility or against medical advice, and longer hospitalizations. Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%; P<.001). Homeless patients had more readmissions for psychiatric causes (18.0% vs 2.0%; P<.001).

      Conclusion

      Considerable differences in cardiovascular risk profile, in-hospital care, and rehospitalization rates were observed in the homeless compared with non-homeless cohort with AMI. Measures to remove the health care barriers and disparities are needed.

      Abbreviations and Acronyms:

      AMI (acute myocardial infarction), NRD (National Readmission Database), PCI (percutaneous coronary intervention)
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      References

        • Brown M.A.
        • Gellatley W.
        • Hoffman A.
        • et al.
        Medical complications of homelessness: a neglected side of men’s health.
        Intern Med J. 2019; 49: 455-460
        • Australian Bureau of Statistics
        Census of population and housing: estimating homelessness, 2016. Cat. no. 2049.0.
        (Accessed March 6, 2019.)
        • Gaetz S.
        • Dej E.
        • Richter T.
        • Redman M.
        The State of Homelessness in Canada 2016.
        Canadian Observatory on Homelessness Press, Toronto2016
        • Henry M.
        • Mahathey A.
        • Morrill T.L.
        • et al.
        Abt Associates. The 2018 Annual Homeless Assessment Report (AHAR) to Congress: Part 1: Point-in-Time Estimates of Homelessness.
        US Dept of Housing and Urban Development, Washington, DC2018
        • DiPietro B.
        • Samantha A.
        • Gates A.
        Early Impacts of the Medicaid Expansion for the Homeless Population.
        The Kaiser Commission on Medicaid and the Uninsured, Menlo Park, CA2014
        • Salit S.A.
        • Kuhn E.M.
        • Hartz A.J.
        • Vu J.M.
        • Mosso A.L.
        Hospitalization costs associated with homelessness in New York City.
        N Engl J Med. 1998; 338: 1734-1740
        • Schanzer B.
        • Dominguez B.
        • Shrout P.E.
        • Caton C.L.
        Homelessness, health status, and health care use.
        Am J Public Health. 2007; 97: 464-469
        • Krumholz H.M.
        • Wang Y.
        • Chen J.
        • et al.
        Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006.
        JAMA. 2009; 302: 767-773
        • Baggett T.P.
        • Rigotti N.A.
        • Campbell E.G.
        Cost of smoking among homeless adults.
        N Engl J Med. 2016; 374: 697-698
        • Vijayaraghavan M.
        • Apollonio D.E.
        Engaging adults experiencing homelessness in smoking cessation through large-scale community service events.
        Health Promot Pract. 2019; 20: 325-327
        • Bernstein R.S.
        • Meurer L.N.
        • Plumb E.J.
        • Jackson J.L.
        Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis.
        Am J Public Health. 2015; 105: e46-e60
        • Rosengren A.
        • Hawken S.
        • Ôunpuu S.
        • et al. for the INTERHEART investigators
        Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 953-962
        • Van der Kooy K.
        • van Hout H.
        • Marwijk H.
        • Marten H.
        • Stehouwer C.
        • Beekman A.
        Depression and the risk for cardiovascular diseases: Systematic review and meta analysis.
        Int J Geriatr Psychiatry. 2007; 22: 613-626
        • Coughlin S.S.
        Post-traumatic stress disorder and cardiovascular disease.
        Open Cardiovasc Med J. 2011; 5: 164-170
        • Lee T.C.
        • Hanlon J.G.
        • Ben-David J.
        • et al.
        Risk factors for cardiovascular disease in homeless adults.
        Circulation. 2005; 111: 2629-2635
        • Gozdzik A.
        • Salehi R.
        • O’Campo P.
        • Stergiopoulos V.
        • Hwang S.W.
        Cardiovascular risk factors and 30-year cardiovascular risk in homeless adults with mental illness.
        BMC Public Health. 2015; 15: 165
        • American Hospital Association
        Uncompensated hospital care cost fact sheet – January 2019.
        (Accessed February 26, 2019.)
        • Hannan E.L.
        • Racz M.
        • Walford G.
        • et al.
        Differences in utilization of drug-eluting stents by race and payer.
        Am J Cardiol. 2007; 100: 1192-1198
        • LaWall E.
        • Wu Y.Y.
        • Fan V.Y.
        • Ashton M.
        • Sentell T.
        Living alone and homelessness as predictors of 30-day potentially preventable hospital readmission.
        Prev Chronic Dis. 2019; 16: E16
        • Saab D.
        • Nisenbaum R.
        • Dhalla I.
        • Hwang S.W.
        Hospital readmissions in a community-based sample of homeless adults: a matched-cohort study.
        J Gen Intern Med. 2016; 31: 1011-1018
        • Rahimi A.R.
        • Spertus J.A.
        • Reid K.J.
        • Bernheim S.M.
        • Krumholz H.M.
        Financial barriers to health care and outcomes after acute myocardial infarction.
        JAMA. 2007; 297: 1063-1072
        • Kwok C.S.
        • Walsh M.N.
        • Volgman A.
        • et al.
        Discharge against medical advice after hospitalisation for acute myocardial infarction.
        Heart. 2019; 105: 315-321
        • Gelberg L.
        • Gallagher T.C.
        • Andersen R.M.
        • Koegel P.
        Competing priorities as a barrier to medical care among homeless adults in Los Angeles.
        Am J Public Health. 1997; 87: 217-220

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