The experience of homelessness has been linked with developing poor health outcomes. Little is known about the risk of recurrent stroke among these individuals. This study investigated the correlates ...of developing recurrent stroke and subsequent mortality among Veterans with housing instability.
Using a national sample of Veterans from the U.S. Department of Veterans Affairs who had an indicator of housing instability between 2014–2018 (n=659,987), we identified 15,566 Veterans who experienced incident stroke. We compared characteristics of Veterans who experienced incident stroke and did and did not experience recurrent stroke and conducted logistic regressions using a discrete-time survival framework to assess two outcomes: recurrent stroke and all-cause mortality.
Among our cohort, 91.3% did not experience recurrent stroke while 8.7% did during the observation period. The receipt of any level of primary care outpatient visits was associated with a reduction in the odds of recurrent stroke. Several medical diagnoses were also associated with increased odds of recurrent stroke, including hypertension (aOR 1.35, 95% CI 1.15-1.59), diabetes (aOR 1.21, 95% CI 1.07-1.36), and renal disease (aOR 1.17, 95% CI 1.02, 1.35). Veterans who used any level of VA Homeless Programs had reduced odds of all-cause mortality (high level: aOR 0.65, 95% CI 0.60-0.71; low level: aOR 0.66, 95% CI 0.60-0.73).
Our study found several predictors of developing recurrent stroke and subsequent death in a population of Veterans experiencing housing instability. Implications include the need to monitor closely high-risk patients who have experienced incident stroke and have other co-occurring needs.
Homelessness is associated with poor health outcomes and early development of cardiovascular disease. This study investigated the correlates of incident stroke and its association with mortality ...among Veterans experiencing housing instability. Using a national sample of Veterans (n=565,608) with incident housing instability between 2014-2018, we compared characteristics of Veterans who did and did not experience incident stroke and conducted logistic regressions to assess two outcomes: incident stroke and mortality. Almost four percent experienced a first stroke and were more frequently male, older than 55 years, Black, and non-Hispanic. A higher rate of mortality was observed among those with a first stroke compared with those with no stroke (17.6% vs. 10.8%), although the difference was not statistically significant. Incident stroke was associated with triple the odds of death among unstably-housed Veterans compared with those who did not have an incident stroke. Implications include the need to screen and monitor for stroke risk among Veterans with experience of housing instability, particularly for those who are older.
Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans ...experiencing homelessness.
Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care.
Cross-sectional analysis of responses to a 2018 mailed survey.
VHA outpatients with homeless experiences.
Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey.
Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61).
Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.
More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, ...and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited.
The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients.
National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations.
A total of 5766 homeless-experienced veterans.
Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities.
H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001).
Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.
Prolonged postoperative opioid use (PPOU) is considered an unfavorable post-surgical outcome. Demographic, clinical, and psychosocial factors have been associated with PPOU, but methods to ...prospectively identify patients at increased risk are lacking.
Our objective was to determine whether an individual or a combination of several psychological factors could identify a subset of patients at increased risk for PPOU.
Observational cohort study with prospective baseline data collection and passive outcomes data collection.
A single VA medical center in the United States.
Patients were recruited from a preoperative anesthesia clinic where they were undergoing evaluation prior to elective surgery, and they completed a survey before surgery. The primary outcome was PPOU, defined as outpatient receipt of a prescribed opioid 31 to 90 days after surgery as determined from pharmacy records. Primary covariates of interest were pain catastrophizing, self-efficacy, and optimism. Additional covariates included social and demographic factors, pain severity, medication use, depression, anxiety, and surgical fear.
Of 123 patients included in the final analyses, 30 (24.4%) had PPOU. In bivariate analyses, preoperative opioid use and preoperative nonsteroidal anti-inflammatory drug use were significantly associated with PPOU. The combination of high pain catastrophizing and high preoperative pain (OR 3.32, 95% CI 1.41 - 7.79) was associated with higher odds of PPOU than either alone, and the association remained significant after adjusting for preoperative opioid use (OR 2.56, 95% CI 1.04 - 6.29).
Patients were recruited from a single site, and the sample was not large enough to include potentially important variables such as procedure type.
A combination of high pain catastrophizing and high preoperative pain has the potential to be a clinically useful means of identifying patients at elevated risk of PPOU.
Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test ...for interactions between these characteristics.
In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July–August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status.
Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0–1) to 8.4% (2–3) and to 24.2% (4–11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05).
Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.
Abstract Objective To identify organizational service features associated with positive patient ratings of primary care within primary care clinics tailored to accommodate persons with ongoing and ...recent experiences of homelessness (PEH). Data Sources and Study Setting PEH receiving primary care in 29 United States Veterans Health Administration homeless‐tailored clinics were surveyed about their primary care experience using the validated Primary Care Quality‐Homeless (PCQ‐H) survey. Characteristics of the clinics were assessed through surveys of clinic staff using a new organizational survey developed through literature review, site visits, statistical analysis, and consensus deliberation. Study Design Cross‐sectional examination of patients' ratings of care based on surveys of patients, and of clinic characteristics, analyzed with Classification and Regression Tree (CART) analysis, a form of machine learning. Data Collection Methods Patient surveys ( n = 3394) were obtained from a random sample of enrolled patients by both mail and telephone by an external survey contractor. Staff ( n = 52 from 29 clinics) were interviewed by telephone. Principal Findings This analysis identified service features that impact patient experience favorably, including aspects of patient‐centeredness, team identity, strong external leadership support, and service that reach beyond traditional primary care clinic confines. Results varied according to the patient experience scale analyzed. Individual characteristics of PEH, such as degree of social support, general health, and unsheltered status, were also correlated with how they rate care. Conclusions Organizational characteristics correlate with ratings of primary care from patients with recent and ongoing homelessness. Primary care programs serving homeless individuals can assure better care based on who they hire, how they foster team identity, what services they provide, and the strength of leadership support to protect a homeless‐focused mission.
Objectives:
Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients ...(Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences.
Methods:
We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs.
Results:
Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7).
Conclusions:
Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.
Background and Objectives
Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified ...through health record systems is unclear. Comparison of overdoses from health records to those that are self‐reported may provide insight on the proportion of nonfatal overdoses that are not identified.
Methods
We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self‐reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period.
Results
The sensitivity of diagnostic codes for overdose, compared to self‐report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self‐reported overdose (sensitivity range 17.9%–90.6%).
Discussion and Conclusions
Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self‐reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention.
Scientific Significance
This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health.
Persons who are homeless have significant health challenges and barriers accessing care. Secure messaging supports communication between patients and their providers through a web-based portal, but ...the acceptability of this technology among patients with high prevalence of substance use disorders (SUDs) is unknown. We examined secure messaging use among veterans with experiences of homelessness (VEHs), and determined factors associated with messaging use.
We conducted a cross-sectional analysis of responses to a national survey of VEHs, administered by mail from March to October 2018 (response rate = 40.2%). One item assessed secure messaging use and satisfaction. We used multivariable logistic regressions to model secure messaging use, controlling for sociodemographics, medical conditions, housing indicators, and mental health and SUD diagnoses.
Of 5072 VEHs, 21% had ever used secure messaging and 87% of the subsample found messaging to be useful. Secure messaging was more commonly used by VEHs who were female, had some college education, those with ≥3 chronic medical conditions, depression, or posttraumatic stress disorder (all P < 0.001). Messaging was much less common for VEHs ages 55 to 64 or older, non-Latino Blacks, those receiving homeless-tailored primary care, and those with SUDs (all P < 0.001). VEHs with opioid use disorder were even less likely than those with other SUDs to use secure messaging (P = 0.047).
Persons with homeless experiences might require assistance to engage with secure messaging technology. As health systems limit in-person care during a national pandemic, alternative solutions may be needed to facilitate health communications and prevent care disruptions for patients experiencing homelessness and SUDs.
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