When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments

摘要

Objectives. We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally. Methods. We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n?=?64?091) and nonhomeless (n?=?866?621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics. Results. Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR]?=?4.12; 95% confidence interval [CI]?=?3.97, 4.27), alcohol use disorder (OR?=?3.67; 95% CI?=?3.55, 3.79), or schizophrenia (OR?=?3.44; 95% CI?=?3.25, 3.64) in the past year. Conclusions. In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or “in” reach) services to address mental health and addictive disorders. Use of emergency departments (EDs) is of national concern because high rates of ED use are thought by many to indicate poor access to regular health care providers and failure to address preventable illness and injury. 1 Approximately 5% of patients are responsible for a quarter of all ED visits, 2 and homeless adults are among the most frequent users of ED services. 3–7 Two studies conducted in San Francisco, California, found that 40% of homeless adults used EDs at least once in the past year, a rate 3 times the US norm, 3 and that homeless people were nearly 4 times as likely as domiciled people to be frequent ED users, that is, to have visited an ED more than 4 times in the past year. 7 One large national study of homeless adults found that 32% reported having an ED visit in the past year, 4 which is much higher than the rate of 13% to 20% for US adults overall. 8,9 Several additional studies have found that homeless adults are disproportionately represented among the most frequent users of EDs. 7,10,11 In addition to using EDs more often than nonhomeless adults, homeless adults who use ED services have been reported to have higher rates of infectious diseases, substance use, and psychiatric illness. 6,10 They have also been reported to be more likely to be ED recidivists, that is, to return to the ED within a short period of time after a prior ED visit. 6,12 Among homeless adults, some identified predictors of ED use have been unstable housing, chronic medical illness, food insecurity, and victimization. 3,4,13,14 An additional factor thought to be associated with ED use is the lack of regular and accessible health care, health insurance, or both. Analyses of national ED utilization data have shown that homeless ED users are more likely to be uninsured than nonhomeless ED users. 5,6 Other studies have shown that homeless patients who use EDs often have no other source of health care, 4 especially those who are chronically homeless. 15 Thus, homeless patients may be more likely to use EDs because they do not have health insurance for ambulatory care. Moreover, even though more than half of the homeless population is enrolled in public financial assistance programs, these subsidies may not fully address the needs of those with substance use disorders or chronic medical conditions. 10 However, another series of studies have shown that frequent ED users, who are especially likely to be homeless, are more likely to be insured and less likely to be uninsured 2,3,16,17 and, rather than being disengaged from care outside of the ED, frequent ED users have been found in some studies to use outpatient primary and specialty clinic systems quite heavily. 2,18–22 One explanation for these mixed findings may be that some studies are based on health care systems that offer extensive services for the uninsured and homeless, in which insurance may be a marker for higher levels of physical and mental disability rather than an indicator of access or lack of access to ambulatory care. 3 The Veterans Affairs (VA) health care system offers a unique opportunity to examine correlates of ED use by homeless individuals. The VA is one of the largest integrated health care networks in the United States and offers veterans equal access to an array of health care services, in which insurance coverage is unrelated to access to services. 23,24 Little examination of homeless patients who use EDs within this type of health care system has occurred. Moreover, the health of homeless veterans is vital to the VA’s established goal of ending homelessness among veterans. 25 One s