Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study

PLOS ONE, Dec 2019

Background Little is known about homeless patients in intensive care units (ICUs). Objectives To compare clinical characteristics, treatments, and outcomes of homeless to non-homeless patients admitted to four ICUs in a large inner-city academic hospital. Methods 63 randomly-selected homeless compared to 63 age-, sex-, and admitting-ICU-matched non-homeless patients. Results Compared to matched non-homeless, homeless patients (average age 48±12 years, 90% male, 87% admitted by ambulance, 56% mechanically ventilated, average APACHE II 17) had similar comorbidities and illness severity except for increased alcohol (70% vs 17%,p<0.001) and illicit drug(46% vs 8%,p<0.001) use and less documented hypertension (16% vs 40%,p = 0.005) or prescription medications (48% vs 67%,p<0.05). Intensity of ICU interventions was similar except for higher thiamine (71% vs 21%,p<0.0001) and nicotine (38% vs 14%,p = 0.004) prescriptions. Homeless patients exhibited significantly lower Glasgow Coma Scores and significantly more bacterial respiratory cultures. Longer durations of antibiotics, vasopressors/inotropes, ventilation, ICU and hospital lengths of stay were not statistically different, but homeless patients had higher hospital mortality (29% vs 8%,p = 0.005). Review of all deaths disclosed that withdrawal of life-sustaining therapy occurred in similar clinical circumstances and proportions in both groups, regardless of family involvement. Using multivariable logistic regression, homelessness did not appear to be an independent predictor of hospital mortality. Conclusions Homeless patients, admitted to ICU matched to non-homeless patients by age and sex (characteristics most commonly used by clinicians), have higher hospital mortality despite similar comorbidities and illness severity. Trends to longer durations of life supports may have contributed to the higher mortality. Additional research is required to validate this higher mortality and develop strategies to improve outcomes in this vulnerable population.

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Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study

June Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study Orla M. Smith 0 1 2 Clarence Chant 0 1 Karen E. A. Burns 0 1 2 Maninder Kaur 0 1 2 Said Ashraf 0 1 2 Claudia C. DosSantos 0 1 2 Stephen W. Hwang 0 1 Jan O. Friedrich 0 1 2 0 Editor: Felipe Dal Pizzol, Universidade do Extremo Sul Catarinense , BRAZIL 1 a Current address: Family Medicine Department, University Hospital Conway, Louisiana, United States of America ¤b Current address: Internal Medicine Department, Detroit Medical Center - Wayne State University , Detroit, Michigan , United States of America 2 Critical Care Department, St. Michael's Hospital , Toronto , Canada , 2 Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada , 3 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto , Toronto , Canada , 4 Pharmacy Department, St. Michael's Hospital , Toronto , Canada , 5 Department of Medicine, St. Michael's Hospital and University of Toronto , Toronto , Canada , 6 Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto , Canada , 7 Centre for Urban Health Solutions, St. Michael's Hospital , Toronto , Canada - OPEN ACCESS Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Burns is supported by a Clinician Scientist Award from the Canadian Institutes of Health Research (CIHR) and an Early Researcher Award from the Ministry of Research and Innovation. Dr. Friedrich is Background Objectives Methods non-homeless patients. Results Compared to matched non-homeless, homeless patients (average age 48±12 years, 90% male, 87% admitted by ambulance, 56% mechanically ventilated, average APACHE II 17) had similar comorbidities and illness severity except for increased alcohol (70% vs 17%, p<0.001) and illicit drug(46% vs 8%,p<0.001) use and less documented hypertension (16% vs 40%,p = 0.005) or prescription medications (48% vs 67%,p<0.05). Intensity of ICU interventions was similar except for higher thiamine (71% vs 21%,p<0.0001) and nicotine (38% vs 14%,p = 0.004) prescriptions. Homeless patients exhibited significantly lower Glasgow supported by a CIHR Clinician Scientist Award. None of the funding agencies had any direct involvement in the design and conduct of this study. Competing interests: The authors have declared that no competing interests exist. Coma Scores and significantly more bacterial respiratory cultures. Longer durations of anti biotics, vasopressors/inotropes, ventilation, ICU and hospital lengths of stay were not statistically different, but homeless patients had higher hospital mortality (29% vs 8%,p = 0.005). Review of all deaths disclosed that withdrawal of life-sustaining therapy occurred in similar clinical circumstances and proportions in both groups, regardless of family involvement. Using multivariable logistic regression, homelessness did not appear to be an independent predictor of hospital mortality. Conclusions Homeless patients, admitted to ICU matched to non-homeless patients by age and sex (characteristics most commonly used by clinicians), have higher hospital mortality despite similar comorbidities and illness severity. Trends to longer durations of life supports may have contributed to the higher mortality. Additional research is required to validate this higher mortality and develop strategies to improve outcomes in this vulnerable population. Introduction Homelessness is a serious social and public health problem. Prevalence estimates indicate that at least 150,000 people were homeless in Canada in 2009 [ 1 ] and 1.5 million people were homeless in the United States in 2012 [ 2 ]. A comprehensive survey conducted by the City of Toronto, Canada in 2013 estimated a point prevalence of 5,253 homeless people in Toronto on one night, corresponding to 18.8 homeless people per 10,000 population [ 3 ]. Homeless persons have disproportionately higher rates of infectious diseases, chronic diseases, mental illness, substance use, and intentional and unintentional injuries [ 4,5,6 ]. Moreover, homelessness is associated with earlier onset of health problems that are otherwise more commonly seen in geriatric populations including hypertension [ 7 ]. Homeless individuals are admitted to hospital more often than the general population [8,9]. This may be due to suboptimal access to preventive health care and medical treatment, higher levels of comorbid conditions, and presentation for acute care when symptoms are more severe. In addition, homeless people stay in hospital longer than housed individuals, as having no residence can deter timely hospital discharge [ 8,9 ]. Homeless people admitted to hospital tend to be younger than non-homeless comparators and are more fre (...truncated)


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Orla M. Smith, Clarence Chant, Karen E. A. Burns, Maninder Kaur, Said Ashraf, Claudia C. DosSantos, Stephen W. Hwang, Jan O. Friedrich. Characteristics, clinical course, and outcomes of homeless and non-homeless patients admitted to ICU: A retrospective cohort study, PLOS ONE, 2017, Volume 12, Issue 6, DOI: 10.1371/journal.pone.0179207