Homelessness and The Outcome of Hip Fracture Surgical Management: A Nationwide Study in the US
Authors: Hoveidaei Amir Human , Pirahesh Kasra , Nejad Fatemeh Kanaani , Ghaseminejad-Raeini Amirhossein , Nwankwo Basilia Onyinyechukwu , Conway Janet D. 
Published: February 2025

OBJECTIVES:
To evaluate whether people experiencing homelessness (PEH) have more postoperative complications following hemiarthroplasty, total hip arthroplasty (THA), hip open reduction and internal fixation (ORIF), and percutaneous skeletal fixation surgeries following hip fracture in the United States.

METHODS:

Design: Retrospective cohort.

Setting:
A nationwide study in the US using the PearlDiver Patient Records Database.

Patient Selection Criteria:
Patients who underwent hemiarthroplasty, THA, ORIF, and percutaneous skeletal fixation surgeries following hip fracture from 2010 to 2022 were included. The CPT codes corresponding to surgical procedures were searched through the database. Then, the housing status was extracted using the corresponding ICD codes for homelessness. Those who did not have ICD codes assigned for homelessness were considered to be housed. PEH were matched with housed patients in a 1:3 ratio based on age, sex, and year of surgery.

Outcome Measures and Comparisons:
Baseline patient characteristics and comorbidities were accessed through ICD and CPT codes. After matching, the postoperative 30-day and 90-day rates of acute renal failure (ARF), myocardial infarction (MI), respiratory failure, sepsis, venous thromboembolism (VTE), pneumonia, urinary tract infection (UTI), surgical site infection (SSI), and readmission were compared between PEH and housed patients using two models: 1. A Chi-square test 2. A multivariate logistic regression while controlling for The Elixhauser comorbidity index (ECI), obesity, diabetes, alcohol abuse, tobacco use, and drug abuse.

RESULTS:
A total of 692,933 housed patients and 2,795 homeless patients (mean age of 59.1 ±11.6 years, 70.0% male) were evaluated. After matching the PEH to housed patients for age, sex, and year of surgery with a 1:3 ratio, a total of 8,382 housed patients (mean age of 59.1 ± 11.6, 70.0% male) were selected for the postoperative complication analysis in comparison with 2,795 PEH. In the Chi-squared analysis, it was observed that rates of postoperative 90-day ARF (1.36 [1.18 - 1.56]), sepsis (1.70 [1.44 - 1.99]), respiratory failure (1.33 [1.16 - 1.52]), UTI (1.37 [1.19-1.58]), pneumonia (1.49 [1.28-1.74]), SSI (2.03 [1.62-2.54]), and readmission (1.60 [1.45-1.77]) were significantly higher among PEH (P<0.001). In the regression model, it was found that homelessness was an independent factor for 90-day SSI (1.47 [1.13-1.91], P=0.004) and UTI (1.21 [1.03-1.43], P=0.022) following surgical management of hip fracture.

CONCLUSIONS:
This study found that homelessness was an independent risk factor for surgical complications, including SSIs and UTIs, within 90 days. Additionally, homelessness was associated with higher comorbidity rates, which were linked to increased complications and readmissions.

LEVEL OF EVIDENCE:
Level III (Investigated the results of a treatment in a retrospective cohort study)