bluuebunny/crossref_metadata_2025_split huggingface dataset:
Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness
Authors: Wiens Kathryn , Nisenbaum Rosane , Sucha Ewa , Aubry Tim , Farrell Susan , Palepu Anita , Duhoux Arnaud , Gadermann Anne , Hwang Stephen W. 
Published: March 2021

Background:
Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario.

Methods:
Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs.

Results:
Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2–4.

Conclusions:
These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.
Housing Boston’s Chronically Homeless Unsheltered Population
Authors: Roncarati Jill S. , Tiemeier Henning , Tachick Rebecca , VanderWeele Tyler J. , O’Connell James J. 
Published: March 2021

Objective:
The long-term outcomes of permanent supportive housing for chronically unsheltered individuals, or rough sleepers, are largely unknown. We therefore assessed housing outcomes for a group of unsheltered individuals who were housed directly from the streets after living outside for decades.

Methods:
Using an open-cohort design, 73 chronically unsheltered individuals were enrolled and housed in permanent supportive housing directly from the streets of Boston from 2005 to 2019. Through descriptive, regression, and survival analysis, we assessed housing retention, housing stability, and predictors of survival.

Results:
Housing retention at ≥1 year was 82% yet fell to 36% at ≥5 years; corresponding Kaplan-Meier estimates for retention were 72% at ≥1, 42.5% at ≥5, and 37.5% at ≥10 years. Nearly half of the cohort (45%) died while housed. The co-occurrence of medical, psychiatric, and substance use disorder, or “trimorbidity,” was common. Moves to a new apartment were also common; 38% were moved 45 times to avoid an eviction. Each subsequent housing relocation increased the risk of a tenant returning to homelessness. Three or more housing relocations substantially increased the risk of death.

Conclusions:
Long-term outcomes for this permanent supportive housing program for chronically unsheltered individuals showed low housing retention and poor survival. Housing stability for this vulnerable population likely requires more robust and flexible and long-term medical and social supports.
Examining Sleep Disturbance Among Sheltered and Unsheltered Transition Age Youth Experiencing Homelessness
Authors: Redline Brian , Semborski Sara , Madden Danielle R. , Rhoades Harmony , Henwood Benjamin F. 
Published: March 2021

Background:
The estimated 3.5-million transition age youth (TAY) who experience homelessness in the United States annually are routinely exposed to inadequate sleep environments and other psychosocial risk factors for deficient sleep. Although staying in a shelter versus being unsheltered may facilitate sleep, research suggests that perceived safety wherever one sleeps may be just as important. In this study, which is the first known study to investigate sleep disturbances among TAY experiencing homelessness, we examine associations of sleep disturbances with sheltered status and perceived safety of usual sleep environment.

Methods:
We surveyed TAY (aged 18–25) experiencing homelessness in Los Angeles, CA about their sleep, psychosocial health, and living situations. Participants (n=103; 60% sheltered) self-reported sleep disturbances using the Patient-Reported Outcomes Measurement Information System Sleep Disturbance short form, while individual items assessed sheltered status and perceived safety where they usually slept. Regression analyses examined associations of sheltered status and perceived sleep environment safety with sleep disturbance, adjusting for age, sex, race, self-rated health, depression symptoms, serious mental illness, high-risk drinking, and severe food insecurity.

Results:
Twenty-six percent of participants reported moderate-severe sleep disturbances. Sleep disturbance was not associated with sheltered status, but was positively associated with feeling unsafe in one’s sleep environment, depression symptoms, severe food insecurity, and decreased age.

Conclusions:
Our findings suggest that sleep disturbances among TAY experiencing homelessness are associated more closely with how safe one feels rather than one’s sheltered status. This highlights the importance of providing safe places to live for sheltered and unsheltered TAY.
Trends in Trimorbidity Among Adults Experiencing Homelessness in Minnesota, 2000–2018
Authors: Vickery Katherine D. , Winkelman Tyler N.A. , Ford Becky R. , Busch Andrew , Robertshaw Danielle , Pittman Brian , Gelberg Lillian 
Published: March 2021

Background:
Earlier and more severe onset of chronic health conditions contributes to the increased risk of premature death among adults experiencing homelessness. Trimorbidity, a subset of multimorbidity representing overlap of physical health, mental health, and substance use conditions, disproportionately impacts adults experiencing homelessness. We know of no longitudinal data comparing trimorbidity trends among adults experiencing homelessness.

Objective:
To characterize 19-year trimorbidity trends among adults experiencing homelessness.

Research Design:
Repeated longitudinal, statewide survey administered every 3 years.

Subjects:
Adults living throughout Minnesota experiencing homelessness.

Measures:
Reported diagnoses of chronic health conditions within 3 categories: physical health conditions (hypertension, heart disease, asthma, diabetes); mental health conditions (depression, posttraumatic stress disorder, bipolar disorder, schizophrenia/other paranoid, and delusional disorders); and substance use conditions (alcohol and illicit substances).

Results:
A total of 25,552 surveys were completed by adults at 3-year intervals in a total of 7 waves. Participants reported increasing frequency and duration of homelessness, and more nights slept outside/in a car. 77.3% of adults experiencing homelessness in 2018 had one or more chronic health condition in any domain. From 2000 to 2018, bimorbidity and trimorbidity surpassed morbidity within a single domain. This was driven by increases in mental health conditions. In 2018, 31.7% of participants reported bimorbidity and 16.3% of adults reported trimorbidity.

Conclusions:
Adults experiencing homelessness bear a substantial and growing burden of bimorbidity and trimorbidity. Ensuring accessible, high quality care that includes robust services that can address all 3 categories of health is critical. Such care is best delivered in combination with affordable supportive housing.
Individualized Placement and Support Supported Employment for Justice-involved Homeless and Unemployed Veterans
Authors: LePage James P. , Martin William Blake , Crawford April M. , Rock Avery , Parish Johnson Julie A. , Washington Edward L. 
Published: March 2021

Background:
Homelessness is a significant issue affecting the general US population. Two subsets of the population overrepresented in the US homeless population are justice involved individuals and Veterans. However, relatively little research has addressed alleviating homelessness in justice-involved Veterans (JIV). One direction for addressing homelessness in this population is facilitating employment.

Objective:
This study examined differences in housing and employment outcomes between homeless JIV enrolled in 2 different vocational rehabilitation conditions.

Methods:
This study evaluates vocational outcomes of Veterans experiencing homelessness enrolled in a larger US Department of Veterans Affairs-funded study. Participants were randomized into 2 groups: those who participated in a job search group, the About Face Vocational Program (AFVP) and those who received AFVP plus Individualized Placement and Support, Supported Employment (AFVP+IPS-SE).

Results:
Participants who received supported employment plus group were significantly more likely to secure employment compared with group alone. This significant difference was also found in individuals who identified as chronically homeless. Furthermore, participants who secured employment were significantly more likely to exit homelessness and secure housing, suggesting group membership had an indirect effect on housing status though improved employment outcomes.

Conclusions:
Vocational rehabilitation groups combined with supported employment is appropriate and effective for homeless, JIV seeking employment and may also improve downstream housing outcomes.
Investigating Sleep Disturbance and Its Correlates Among Formerly Homeless Adults in Permanent Supportive Housing
Authors: Henwood Benjamin F. , Rhoades Harmony , Dzubur Eldin , Madden Danielle R. , Redline Brian , Brown Rebecca T. 
Published: March 2021

Background:
Adults experiencing homelessness have a high burden of sleep disturbance, which may be reduced by accessing permanent supportive housing.

Objectives:
To assess sleep disturbances and their correlates, including demographics, activity level, health status, age-related health issues (eg, functionality and cognitive impairment), substance use, and homelessness history in a sample of permanent supportive housing (PSH) tenants.

Research Design:
Cross-sectional survey design.

Subjects:
A total of 237 formerly homeless adults between 45 and 80 years old.

Measures:
The Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance short form was used to measure sleep disturbance.

Results:
Twenty-eight percent of our sample had PROMIS scores indicative of a moderate or severe sleep disturbance. Functional impairment, pain, and mental health comorbidities were associated with increased sleep disturbance in multivariable linear regression analyses. The number of years a person experienced homelessness was inversely associated with sleep disturbance.

Conclusions:
This study supports the need to screen for sleep disturbances among PSH tenants. The findings suggest that supportive services in PSH may need to include integrated physical and behavioral health care, pain management, and interventions designed to address activities of daily livings to improve tenant sleep. They also suggest that improved sleep may help reduce PSH tenant pain, impairment, and mental health symptoms among PSH tenants.
Financial Strain, Mental Illness, and Homelessness
Authors: Elbogen Eric B. , Lanier Megan , Wagner Henry R. , Tsai Jack 
Published: March 2021

Background:
Research indicates that adults with severe mental illness have lower income and employment than adults without severe mental illness. Further, mental illness has been identified as a risk factor for homelessness. However, little research has investigated the interrelationships between financial strain, mental illness, and homelessness. It is unknown whether or to what extent financial strain mediates the association between mental illness and subsequent homelessness.

Methods:
This study examined financial strain and severe mental illness (psychotic, bipolar, and depressive disorders in the past 12 months) as predictors of subsequent homelessness and financial strain as a mediator of the link between severe mental illness and homelessness by analyzing data from waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (n=34,653).

Results:
χ2 and multivariable analyses revealed that financial crises and debt, lower income, unemployment, and past homelessness at wave 1 each significantly predicted subsequent homelessness between waves 1 and 2. For participants with and without severe mental illness, risk of homelessness between waves 1 and 2 increased as a function of the number of financial strain variables at wave 1. Mediation analyses showed a direct effect of severe mental illness on future homelessness as well as an indirect effect via greater financial strain, which accounted for 39% of the link between mental illness and homelessness.

Conclusions:
The findings showing that financial strain mediated the association between severe mental illness and homelessness support assessment of financial well-being in the context of treatment of mental illness and homeless service programs. The results suggest that individuals experiencing homelessness who have severe mental illness may benefit from assistance increasing financial literacy, improving money management, and achieving financial well-being.
Hard-to-Reach Populations and Administrative Health Data
Authors: Hossain Rahat , Dai Jia Hong , Jamani Shaila , Ma Zechen , Dvorani Erind , Graves Erin , Burcul Ivana , Strobel Stephenson 
Published: March 2021

Background:
Intervention studies with vulnerable groups in the emergency department (ED) suffer from lower quality and an absence of administrative health data. We used administrative health data to identify and describe people experiencing homelessness who access EDs, characterize patterns of ED use relative to the general population, and apply findings to inform the design of a peer support program.

Methods:
We conducted a serial cross-sectional study using administrative health data to examine ED use by people experiencing homelessness and nonhomeless individuals in the Niagara region of Ontario, Canada from April 1, 2010 to March 31, 2018. Outcomes included number of visits; unique patients; group proportions of Canadian Triage and Acuity Scale (CTAS) scores; time spent in emergency; and time to see an MD. Descriptive statistics were generated with t tests for point estimates and a Mann-Whitney U test for distributional measures.

Results:
We included 1,486,699 ED visits. The number of unique people experiencing homelessness ranged from 91 in 2010 to 344 in 2017, trending higher over the study period compared with nonhomeless patients. Rate of visits increased from 1.7 to 2.8 per person. People experiencing homelessness presented later with higher overall acuity compared with the general population. Time in the ED and time to see an MD were greater among people experiencing homelessness.

Conclusions:
People experiencing homelessness demonstrate increasing visits, worse health, and longer time in the ED when compared with the general population, which may be a burden on both patients and the health care system.
Continuous Prediction of Mortality in the PICU: A Recurrent Neural Network Model in a Single-Center Dataset*
Authors: Aczon Melissa D. , Ledbetter David R. , Laksana Eugene , Ho Long V. , Wetzel Randall C. 
Published: March 2021

OBJECTIVES:
Develop, as a proof of concept, a recurrent neural network model using electronic medical records data capable of continuously assessing an individual child’s risk of mortality throughout their ICU stay as a proxy measure of severity of illness.

DESIGN:
Retrospective cohort study.

SETTING:
PICU in a tertiary care academic children’s hospital.

PATIENTS/SUBJECTS:
Twelve thousand five hundred sixteen episodes (9,070 children) admitted to the PICU between January 2010 and February 2019, partitioned into training (50%), validation (25%), and test (25%) sets.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
On 2,475 test set episodes lasting greater than or equal to 24 hours in the PICU, the area under the receiver operating characteristic curve of the recurrent neural network’s 12th hour predictions was 0.94 (CI, 0.93–0.95), higher than those of Pediatric Index of Mortality 2 (0.88; CI, [0.85–0.91]; p < 0.02), Pediatric Risk of Mortality III (12th hr) (0.89; CI, [0.86–0.92]; p < 0.05), and Pediatric Logistic Organ Dysfunction day 1 (0.85; [0.81–0.89]; p < 0.002). The recurrent neural network’s discrimination increased with more acquired data and smaller lead time, achieving a 0.99 area under the receiver operating characteristic curve 24 hours prior to discharge. Despite not having diagnostic information, the recurrent neural network performed well across different primary diagnostic categories, generally achieving higher area under the receiver operating characteristic curve for these groups than the other three scores. On 692 test set episodes lasting greater than or equal to 5 days in the PICU, the recurrent neural network area under the receiver operating characteristic curves significantly outperformed their daily Pediatric Logistic Organ Dysfunction counterparts (p < 0.005).

CONCLUSIONS:
The recurrent neural network model can process hundreds of input variables contained in a patient’s electronic medical record and integrate them dynamically as measurements become available. Its high discrimination suggests the recurrent neural network’s potential to provide an accurate, continuous, and real-time assessment of a child in the ICU.
Levetiracetam Versus Phenytoin or Fosphenytoin for Second-Line Treatment of Pediatric Status Epilepticus: A Meta-Analysis
Authors: Klowak Jennifer Ann , Hewitt Mark , Catenacci Vanessa , Duffett Mark , Rochwerg Bram , Jones Kevin , Choong Karen 
Published: March 2021

OBJECTIVE:
To synthesize the available evidence examining the efficacy and safety of levetiracetam compared with phenytoin or fosphenytoin in benzodiazepine-refractory pediatric status epilepticus.

Data Sources:
We searched (from inception until April 27, 2020) Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials.

Study Selection:
Two reviewers, independently and in duplicate, screened citations and manuscripts for eligible randomized controlled trials.

Data Extraction and Synthesis:
Independently and in duplicate, we performed data abstraction, risk of bias assessment, and certainty assessment using Grading of Recommendations, Assessment, Development, and Evaluation. We performed meta-analyses using random-effect models or, if insufficient data, presented findings narratively.

Results:
We identified seven randomized controlled trials (n = 1,575). Pooled analysis demonstrated low certainty evidence for no difference of levetiracetam on time to seizure cessation (mean difference, –3.11 min; 95% CI, –6.67 to 0.45), early seizure cessation (relative risk, 1.09, 95% CI, 0.95–1.26), or late seizure cessation (relative risk, 1.05; 95% CI, 0.93–1.18). Adverse event outcomes were limited by low event numbers. We found low certainty evidence for less respiratory depression with levetiracetam (relative risk, 0.28; 95% CI, 0.12–0.69).

Conclusions:
The efficacy of levetiracetam is comparable with phenytoin or fosphenytoin in children with benzodiazepine-refractory status epilepticus (low certainty evidence). Levetiracetam may cause less respiratory depression. Clinicians and guideline developers should weigh safety profiles when choosing between these agents.
Development of a Heart Rate Variability Risk Score to Predict Organ Dysfunction and Death in Critically Ill Children
Authors: Badke Colleen M. , Marsillio Lauren E. , Carroll Michael S. , Weese-Mayer Debra E. , Sanchez-Pinto L. Nelson 
Published: March 2021

OBJECTIVES:
Determine whether the Heart Rate Variability Dysfunction score, a novel age-normalized measure of autonomic nervous system dysregulation, is associated with the development of new or progressive multiple organ dysfunction syndrome or death in critically ill children.

DESIGN, SETTING, AND PATIENTS:
This was a retrospective, observational cohort study from 2012 to 2018. Patients admitted to the PICU with at least 12 hours of continuous heart rate data available from bedside monitors during the first 24 hours of admission were included in the analysis.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Heart rate variability was measured using the integer heart rate variability, which is the sd of the heart rate sampled every 1 second over 5 consecutive minutes. The Heart Rate Variability Dysfunction score was derived from age-normalized values of integer heart rate variability and transformed, so that higher scores were indicative of lower integer heart rate variability and a proxy for worsening autonomic nervous system dysregulation. Heart Rate Variability Dysfunction score performance as a predictor of new or progressive multiple organ dysfunction syndrome and 28-day mortality were determined using the area under the receiver operating characteristic curve. Of the 7,223 patients who met inclusion criteria, 346 patients (4.8%) developed new or progressive multiple organ dysfunction syndrome, and 103 (1.4%) died by day 28. For every one-point increase in the median Heart Rate Variability Dysfunction score in the first 24 hours of admission, there was a 25% increase in the odds of new or progressive multiple organ dysfunction syndrome and a 51% increase in the odds of mortality. The median Heart Rate Variability Dysfunction score in the first 24 hours had an area under the receiver operating characteristic curve to discriminate new or progressive multiple organ dysfunction syndrome of 0.67 and to discriminate mortality of 0.80. These results were reproducible in a temporal validation cohort.

CONCLUSIONS:
The Heart Rate Variability Dysfunction score, an age-adjusted proxy for autonomic nervous system dysregulation derived from bedside monitor data is independently associated with new or progressive multiple organ dysfunction syndrome and mortality in PICU patients. The Heart Rate Variability Dysfunction score could potentially be used as a single continuous physiologic biomarker or as part of a multivariable prediction model to increase awareness of at-risk patients and augment clinical decision-making.