Housing Status and Acute Care Use After Cancer Diagnosis.
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ABSTRACT:
SUBMITTER: Decker H
PROVIDER: S-EPMC11220561 | biostudies-literature | 2024 Jul
REPOSITORIES: biostudies-literature
Publications
Housing Status and Acute Care Use After Cancer Diagnosis.
Decker Hannah H Colom Sara S Graham-Squire Dave D Wick Elizabeth E Kushel Margot B MB Raven Maria M Kanzaria Hemal K HK
JAMA network open 20240701 7
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Project description:ImportanceCancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.ObjectiveTo characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.Design, setting, and participantsThis retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.ExposuresVeterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.Main outcomes and measuresThe major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.ResultsThis study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.Conclusions and relevanceIn this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.
| S-EPMC10739065 | biostudies-literature
Project description:ObjectivesCancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a public hospital.DesignRetrospective cohort study examining new cancer diagnoses between 1 July 2011 and 30 June 2021.SettingA public hospital in San Francisco.ExposureHousing status (housed, formerly unhoused, unhoused) was ascertained via a county-wide integrated dataset that tracks both observed and reported homelessness.MethodsWe reported univariate analyses to investigate differences in demographic and clinical characteristics by housing group. We then constructed Kaplan-Meier curves stratified by housing group to examine unadjusted all-cause mortality. Finally, we used multivariable Cox proportional hazards models to compare the hazard rate of mortality for each housing status group, adjusting for demographic and clinical factors.ResultsOur cohort included 5123 patients with new cancer diagnoses, with 4062 (79%) in housed patients, 623 (12%) in formerly unhoused patients and 438 (9%) in unhoused patients. Unhoused and formerly unhoused patients were more commonly diagnosed with stage 4 disease (28% and 27% of the time, respectively, vs 22% of housed patients). After adjusting for demographic and clinical characteristics, unhoused patients with stage 0-3 disease had a 50% increased hazard of death (adjusted HR (aHR) 1.5, 95% CI 1.1 to 1.9; p<0.004) as did formerly unhoused patients (aHR 1.5, 95% CI 1.2 to 1.9; p=0.001) compared with housed individuals 3 months after diagnosis.ConclusionsUnhoused and formerly unhoused patients diagnosed with non-metastatic cancer had substantially increased hazards of death compared with housed patients cared for in a public hospital setting. Current or former lack of housing could contribute to poor outcomes following cancer diagnoses via multiple mechanisms.
| S-EPMC11404260 | biostudies-literature
Project description:ImportanceHousing deposits and tenancy supports have become new Medicaid benefits in multiple states; however, evidence on impacts from these specific housing interventions is limited.ObjectiveTo evaluate the association of rental housing deposits and health care use among Medicaid beneficiaries receiving social needs case management as part of a Whole-Person Care (Medicaid 1115 waiver) pilot program in California.Design, setting, and participantsThis cohort study compared changes in health care use among a group of adults who received a housing deposit between October 2018 and December 2021 along with case management vs a matched comparison group who received case management only in Contra Costa County, California, a large county in the San Francisco Bay Area. All participants were enrolled in health and social needs case management based on elevated risk of acute care use. Data analysis took place from March 2023 to June 2024.ExposureRental housing deposit funds that covered 1-time moving transition costs. Funds averaged $1750 per recipient.Main outcomes and measuresChanges in hospitalizations, emergency department visits, primary care visits, specialty care visits, behavioral health visits, psychiatric emergency services, or detention intakes during the 6 months before vs 6 months after deposit receipt. Changes 12 months before and after deposit receipt were examined as a sensitivity analysis.ResultsOf 1690 case management participants, 845 received a housing deposit (362 [42.8%] <40 years old; 422 [49.9%] male) and 845 received case management only (367 [43.4%] <40 years old; 426 [50.4%] male). In adjusted analyses, deposit recipients had no statistically significant differential changes in health care use for any measure compared to participants who received case management alone. Twelve-month sensitivity analyses yielded consistent results.Conclusions and relevanceIn this cohort study, compared to case management only, housing deposits with case management were not associated with short-term changes in health care use. There may be other unmeasured health benefits or downstream benefits from greater case management engagement. States considering housing deposits as an expanded Medicaid benefit may need to temper expectations about short-term health care use impacts.
| S-EPMC11380099 | biostudies-literature
Project description:Millions of families in the United States are economically vulnerable: one shock can lead to hardship. We use data from the Fragile Families and Child Wellbeing Study to examine the association between acute healthcare utilization - emergency room visits or hospitalizations - and subsequent housing hardships, such as being evicted for financial reasons. Further, we explore whether this association differs by who in the family utilized the care and whether perceived social support protects against hardship when these experiences occur. Using lagged dependent variable regression models, we find that families that visited the emergency room or were hospitalized, regardless if it was a child or parent with this experience, were five percentage points more likely to experience any housing hardship than families that did not use acute care. Among families in which a child utilized acute care, perceived social support buffered the impact of using acute care. That perceived social support is associated with a lower likelihood of housing hardship among families that experienced acute care utilization for a child, but not parent, suggests that social support may be able to offset the challenges arising from children's, but not adults', use of acute care. In the face of economic precarity, informal safety nets may be insufficient to reduce the impact of acute care utilization on housing hardships.
| S-EPMC8955135 | biostudies-literature
Project description:This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.
| S-EPMC10637096 | biostudies-literature
Project description:BackgroundAccess to stable and affordable housing is an important social determinant of health in the United States. However, research addressing housing and cancer care, diagnosis, and outcomes has not been synthesized.MethodsWe conducted a systematic review of studies examining associations of housing and cancer care and outcomes using PubMed, Embase, Scopus, and CINAHL. Included studies were conducted in the United States and published in English between 1980 and 2021. Study characteristics and key findings were abstracted and qualitatively synthesized.ResultsA total of 31 studies were identified. Housing-related measures were reported at the individual level in 20 studies (65%) and area level in 11 studies (35%). Study populations and housing measures were heterogeneous. The most common housing measures were area-level housing discrimination (8 studies, 26%), individual-level housing status (8 studies, 26%), and individual-level housing concerns (7 studies, 23%). The most common cancer outcomes were screening (12 studies, 39%) and mortality (9 studies, 29%). Few studies assessed multiple dimensions of housing. Most studies found that exposure to housing insecurity was statistically significantly associated with worse cancer care (11 studies) or outcomes (10 studies).ConclusionsHousing insecurity is adversely associated with cancer care and outcomes, underscoring the importance of screening for housing needs and supporting systemic changes to advance equitable access to care. Additional research is needed to develop and test provider- and policy-level housing interventions that can effectively address the needs of individuals throughout the cancer care continuum.
| S-EPMC9745435 | biostudies-literature
Project description:Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.
| S-EPMC7384249 | biostudies-literature
Project description:This study examines the effects of housing difficulties on life satisfaction. By using longitudinal data from the China Family Panel Studies survey, we find strong evidence that households who experience housing difficulties are less satisfied with their lives than those who do not after controlling for a wide range of household demographic and socioeconomic characteristics and county and year fixed effects. Our estimated results are robust to unobservable household characteristics, model misspecification and selection bias. We also provide explanations for the negative effects of housing difficulties on life satisfaction through which housing difficulties are detrimental to physical and psychological health. Life satisfaction remains negatively associated with housing difficulties even after controlling for health status.
| S-EPMC9811203 | biostudies-literature
Project description:BackgroundA growing body of research has found there to be disproportionate physical restraint and chemical sedation use for historically marginalized populations in the emergency department (ED). This association has been examined with regard to patient race, ethnicity, sex, and age. Preliminary research has highlighted the ways in which unhoused status may also relate to the use of physical restraint and chemical sedation in the ED. Given the adverse health outcomes associated with these methods in the ED, further research is needed to explore the relationship between patient housing status and physical restraint/chemical sedation use in more depth.MethodsWe conducted a cross-sectional study of all ED visits among patients aged 18 years of age and older presenting to eight hospitals within a regional healthcare network in New England between January 1, 2013, and December 31, 2021. Descriptive statistics and mixed effects logistic regression models nesting by patient were used to characterize the relationship between housing status and likelihood of restraint and/or sedation use.FindingsRestraint orders were found in 3,160 (5.7%) visits by unhoused patients, compared to 44,155 (1.5%) for housed patients. Unhoused status was significantly associated with restraint/sedation use (adjusted odds ratio = 1.45, 95% CI 1.36-1.54).ConclusionOur study identified a significant association between housing status and ED restraint and sedation use after adjusting for demographic factors and chief complaints. This finding has important implications pertaining to the care of unhoused patients in the ED and for examination of structural factors like housing status and their impact on psychiatric emergency care.
| S-EPMC11906057 | biostudies-literature
Project description:IntroductionSurvival rates of cancer patients have generally improved in recent years. However, children and older adults seem to have experienced more significant clinical benefits than adolescents and young adults (AYAs). Previous studies suggest a prolonged diagnostic pathway in AYAs, but little is known about their pre-diagnostic healthcare use. This study investigates the use of primary care among AYAs during the two years preceding a cancer diagnosis.MethodsThe study is a retrospective population-based matched cohort study using Danish nationwide registry data. All persons diagnosed with cancer during 2002-2011 in the age group 15-39 years were included (N = 12,306); each participant was matched on gender, age and general practice with 10 randomly selected references (N = 123,060). The use of primary healthcare services (face-to-face contacts, blood tests and psychometric tests) was measured during the two years preceding the diagnosis (index date), and collected data were analysed in a negative binomial regression model.ResultsThe cases generally increased their use of primary care already from 8 months before a cancer diagnosis, whereas a similar trend was not found for controls. The increase was observed for all cancer types, but it started at different times: 17 months before a diagnosis of CNS tumour, 12 months before a diagnosis of soft tissue sarcoma, 9 months before a diagnosis of lymphoma, 5-6 months before a diagnosis of leukaemia, bone tumour or GCT, and 3 months before a diagnosis of malignant melanoma.ConclusionThe use of primary care among AYAs increase several months before a cancer diagnosis. The diagnostic intervals are generally short for malignant melanomas and long for brain tumours. A prolonged diagnostic pathway may indicate non-specific or vague symptomatology and low awareness of cancer among AYAs primary-care personnel. The findings suggest potential of faster cancer diagnosis in AYAs.
| S-EPMC4874574 | biostudies-literature