Disparities in Care and Mortality Among Homeless Adults Hospitalized for Cardiovascular Conditions
Authors: Rishi K. Wadhera, Sameed Ahmed M. Khatana, Eunhee Choi, Ginger Jiang, Changyu Shen, Robert W. Yeh, Karen E. Joynt Maddox
Journal: JAMA Internal Medicine (2019)

<h3>Importance</h3> Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. <h3>Objective</h3> To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). <h3>Design, Setting, and Participants</h3> This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n = 24 890) and nonhomeless adults (n = 1 827 900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. <h3>Main Outcomes and Measures</h3> Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. <h3>Results</h3> Of the 1 852 790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24 890 occurred among patients who were homeless (11 452 women and 13 438 men; mean [SD] age, 65.1 [14.8] years) and 1 827 900 occurred among patients who were not homeless (850 660 women and 977 240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%;<i>P</i> &lt; .001), percutaneous coronary intervention (24.8% vs 47.4%;<i>P</i> &lt; .001), and coronary artery bypass graft (2.5% vs 7.0%;<i>P</i> &lt; .001). Among adults hospitalized with stroke, those who were homeless were less likely than nonhomeless individuals to undergo cerebral angiography (2.9% vs 9.5%;<i>P</i> &lt; .001) but were as likely to receive thrombolytic therapy (4.8% vs 5.2%;<i>P</i> = .28). In the cardiac arrest cohort, homeless adults were less likely than nonhomeless adults to undergo coronary angiography (10.1% vs 17.6%;<i>P</i> &lt; .001) and percutaneous coronary intervention (0.0% vs 4.7%;<i>P</i> &lt; .001). Risk-standardized mortality was higher for homeless persons with ST-elevation myocardial infarction compared with nonhomeless persons (8.3% vs 6.2%;<i>P</i> = .04). Mortality rates were also higher for homeless persons than for nonhomeless persons hospitalized with stroke (8.9% vs 6.3%;<i>P</i> &lt; .001) or cardiac arrest (76.1% vs 57.4%;<i>P</i> &lt; .001) but did not differ for heart failure (1.6% vs 1.6%;<i>P</i> = .83). <h3>Conclusions and Relevance</h3> There are significant disparities in in-hospital care and mortality between homeless and nonhomeless adults with cardiovascular conditions. There is a need for public health and policy efforts to support hospitals that care for homeless persons to reduce disparities in hospital-based care and improve health outcomes for this population.