HealthMay 15, 2018

Homeless veterans at increased risk of hospital readmission after surgery

For veterans undergoing surgery in the VA healthcare system, homelessness is an important risk factor for unplanned hospital readmission, reports a study in the June issue of Medical Care, published in the Lippincott portfolio by Wolters Kluwer

Homeless veterans are more likely to be discharged to a nursing home or other residential setting after surgery, and these discharge destinations are associated with a lower risk of hospital readmission. "Our findings highlight the importance of discharging homeless veterans to supportive environments where they will receive ongoing services to stabilize their medical and caregiver needs," comments senior researcher Mary D. Hawn, MD, MPH, of VA Palo Alto (Calif.) Health Care System and Stanford University School of Medicine.

Homelessness a 'Potent Risk Factor' for Readmission in Veterans

Using a VA surgery database, the researchers analyzed approximately 232,000 surgical procedures performed in 200,000 veterans at VA hospitals between 2008 and 2014. About 5,000 of the operations – 2.1 percent – were performed in homeless patients.

The homeless veterans were younger than housed veterans: average age 56 versus 64 years. Homeless veterans had lower rates of medical diseases, but higher rates of mental health problems: about 57 percent of homeless patients had one or more psychiatric disorders.

The rate of unplanned hospital readmission within one month was 13.3 percent for homeless veterans compared to 9.3 percent of housed veterans. After adjustment for other factors, homelessness was associated with a 43 percent increase in the odds of readmission. Homeless veterans were more likely to be readmitted despite undergoing less-complex surgeries and longer postoperative hospital stays during the index admission.

After leaving the hospital, homeless veterans were more likely to be sent to a nursing home or other residential setting – reflecting the lack of an appropriate place in the community to recover after surgery. Homeless veterans with these discharge destinations had lower rates of hospital readmission, compared to those discharged "to the community." In contrast, for housed veterans, discharge to a nursing home or residential setting was associated with a higher risk of readmission – reflecting poorer medical condition than those discharged home after surgery.

Other factors associated with a higher readmission rate for homeless veterans included recent alcohol abuse and being in worse health before surgery (ASA classification). Readmission risk was higher for white versus black veterans with homelessness, and for those discharged during the summer compared to other times of year.

The findings support previous studies showing a higher readmission rate for homeless patients after hospital discharge. The risk of readmission related to homelessness for veterans appears less when compared to other groups of homeless patients. That may reflect the fact that VA patients have access to more outreach programs and face fewer barriers to healthcare, compared to homeless patients at large.

"The lack of having a place to live perpetuates hospitalizations," Dr. Hawn and coauthors write. "A holistic evaluation of homeless surgical patients, to include psychosocial support and housing needs assessment, may provide opportunities to improve patient care."

The study confirms that "Homelessness is a potent, independent risk factor for readmission," according to a commentary by Margot Kushel, MD, of UCSF/Zuckerberg San Francisco General Hospital. She cites a 2017 study reporting that veterans account for nine percent of all homeless adults in the United States.

Dr. Kushel notes that while the VA has a history of pioneering services for homeless veterans, these options are limited even within the VA system. She concludes. "If the human costs of homelessness are not enough to motivate changes, perhaps studies like this can remind us of the urgency of ending homelessness and spur action."

Click here to read “Homeless Status, Postdischarge Health Care Utilization, and Readmission After Surgery.”

DOI: 10.1097/MLR.0000000000000915

Click here to read “Homelessness: A Potent Risk Factor for Readmission.”

DOI: 10.1097/MLR.0000000000000920 

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Rated as one of the top ten journals in health care administration, Medical Care is devoted to all aspects of the administration and delivery of health care. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of health care. Medical Care provides timely reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services. In addition, numerous special supplementary issues that focus on specialized topics are produced with each volume. Medical Care is the official journal of the Medical Care Section of the American Public Health Association.

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