Emergency General Surgery Operations in the Homeless: Marginal Access to Care and Poor Outcomes
*Michael P. DeWane, Adrian A. Maung, Kevin M. Schuster, Kimberly A. Davis, *Robert D. Becher
Yale School of Medicine, New Haven, CT
Objective: Although homelessness is a widespread problem affecting 3.5 million individuals in the United States, its effect on surgical outcomes is poorly characterized. This study assessed the impact of homelessness on emergency general surgery (EGS) outcomes in the state of California.
Design: Retrospective review of the California State Inpatient Database over a 5-year period, from 2007-2011.
Setting: Hospitals in California.
Patients: Aged 18-85 undergoing EGS operations.
Main Outcome Measures: In-hospital mortality; hospital length of stay; discharge disposition.
Results: A total of 356,322 patients underwent emergency surgery over the 5-years, of which 462 (0.13%) were homeless. In the year 2011, 0.09% of EGS operations were performed on the homeless, though that year they made up 0.36% of California’s population. Among all patients receiving EGS operations, the proportion of homeless patients undergoing unscheduled operations was 14% higher than non-homeless; the homeless were 5 times more likely to undergo repair of a perforated viscus or debridement of a necrotizing soft tissue infection (p<0.001). Multivariable logistic regression demonstrated homelessness was associated with 200% greater odds of in-hospital death (Odds Ratio [OR] 2.31, C.I. 1.33-4.00). Homelessness was also associated with length of stay >5 days (OR 1.64, C.I. 1.33-2.01) and discharge to rehabilitation or skilled nursing facility (OR 1.79, C.I. 1.31-2.45).
Conclusions: Homeless persons seem to be underrepresented among emergency surgical patients when compared to the non-homeless. When they do access surgical services, homelessness is independently associated with poorer outcomes after EGS operations, including increased risk of death. These results confirm that the homeless face multiple barriers to good surgical care and good surgical outcomes. Additional study into this unique health disparity is needed.