Homeless Individuals More Likely to Go On Ventilators for Respiratory Illness

Homeless individuals are more likely to be put on ventilators for respiratory infections than non-homeless individuals, according to research published in the Journal of General Internal Medicine.

Homeless populations are already at a higher risk of contracting coronavirus disease 2019 (COVID-19) and other contagious diseases, due to the fact shelters and drop-in centers are usually crowded with an active turnover of people. Homeless populations are also particularly large in urban, populated areas and are expected to grow given rising unemployment rates.

A report from the Homelessness Research Institute found one study of homeless individuals “in their 50s have been found to experience geriatric conditions (eg, memory loss, falls, functional impairments) at rates similar to members of the general population in their 70s.” Eighty-four percent of homeless adults report physical health problems, while 50% report concurrent physical, mental health and substance abuse challenges. Both older age and preexisting medical conditions are risk factors for more severe COVID-19 infections.

However, “little is understood how the outbreak of infectious diseases among the homeless population affects health systems’ resources (eg, hospital beds, ventilators),” researchers write.

Using the 2007-2012 New York State Inpatient Database, investigators identified all hospitalizations with primary or secondary diagnosis of influenza among homeless patients. They then calculated monthly trends of hospitalization rates per 1000 person-months in both the homeless and non-homeless cohorts.

Researchers derived population estimates from the US Department of Housing and Urban Development Continuum of Care data and US Census Bureau data. After adjusting for patient characteristics and year-month fixed effects, multivariable modified Poisson regression models were used to compare utilization of care and patient outcomes. Outcomes included hospitalization through emergency department (ED), mechanical ventilation (non-invasive or invasive) and in-hospital death.

In total, 1295 of 20,078 (6.4%) patients hospitalized for influenza across 214 hospitals were homeless, while the data represents 16% of the entire US homeless population. The vast majority (99.9%) of hospitalizations of homeless individuals occurred in just 10 New York hospitals. Data also revealed:

• During the 2009 H1N1 influenza pandemic, hospitalization rates were 2.9 per 1000 for homeless versus 0.1 per 1000 for non-homeless populations
• Homeless patients were more likely to be hospitalized from ED (adjusted rate ratio [aRR], 1.09; 95% CI, 1.04-1.14; P&thinsp;<&thinsp;.001) than non-homeless patients during the study period
• Homeless patients were more likely to receive mechanical ventilation (aRR, 1.58; 95% CI, 1.03-2.43; P &thinsp;= &thinsp;.04), compared with non-homeless patients
• There was no difference in in-hospital mortality rate among the 2 cohorts

Researchers note that because homeless indicators may have been under-coded, the study’s hospitalization rates may have been underestimated. As the findings were derived from New York state data, results may not be generalizable to other states.

“In the midst of the COVID-19 outbreak, these findings underscore the importance of infection control and prevention of COVID-19 among the homeless population (eg, lower threshold of virus testing, providing temporary housing to improve sanitation, and social/physical distancing),” authors conclude.

Reference

Miyawaki A, Hasegawa K, and Tsugawa Y. Lessons from influenza outbreaks for potential impact of COVID-19 outbreak on hospitalizations, ventilator use, and mortality among homeless persons in New York state. J Gen Intern Med. Published online June 4, 2020. doi:10.1007/s11606-020-05876-1