Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study

Abstract

Background: Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations.

Objective: The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness.

Design: We conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort.

Participants: This study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005.

Main measures: The primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital.

Key results: Between 6 December 2004 and 31 March 2009, homeless participants (N = 203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR = 3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR = 2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR = 1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission.

Conclusions: Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population.

Keywords: administrative health data; homeless persons; hospital readmissions; matched-cohort.

Conflict of interest statement

Funders

The study was supported by funding from the Agency for Healthcare Research and Quality (1 R01 HS014129-01) and the Canadian Institutes of Health Research (MOP-62736). This study was also supported by the Institute for Clinical Evaluative Sciences (ICES) and the Centre for Research on Inner City Health, which are funded by annual grants from the Ontario Ministry of Health and Long-Term Care. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the article. The opinions, results, and conclusions reported in this article are the views of the authors and do not necessarily reflect the views of any of the above-named organizations. No endorsement by ICES or the Ontario Ministry of Health and Long-Term Care should be intended or inferred.

Prior Presentations

“re: Admissions among Toronto’s Homeless Population”. The Canadian Association of Health Services and Policy Research 2014 Annual Conference.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Figures

Figure 1.

Flowchart of hospitalizations and 30-day readmissions among homeless participants and low-income controls. * Among these 220 homeless participants, there were a total of 504 hospitalizations and 108 readmissions within 30 days prior to matching to low-income controls (see Table 3).