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Table 1 Reviewed literature on homelessness in the ED

From: Homelessness and the use of Emergency Department as a source of healthcare: a systematic review

 

Author(s), year

Study year

Country

Study aim

Study design and study duration

Setting and study population

Number and/or proportion of unique patients who are homeless

Number and/or proportion of ED visits made by homeless persons

Key reasons for presentation to the ED

Mean number of ED visits per person, per year

1

Tadros et al. 2016 [15]

2016

USA

To analyse changes in ED utilisation of homeless patients and compare that with non-homeless visits

Comparative analysis of the 2005 and 2010 NHAMCS dataset

Patients presenting to non-federal hospital ED and outpatient departments

 

In 2010, 679,854 (0.55%) out of 124,043,357 presentations to the ED were made by homeless persons

 

In 2010, homeless persons made an average of 5.8 visits per person per year compared with 1.7 by non-homeless persons

2

Oates et al. 2009 [16]

2009

USA

To analyse the national utilisation of the ED by the homeless population

Cross-sectional, secondary analysis of data using NHAMCS dataset

Patients presenting to non-federal hospital ED and outpatient departments

 

In 2005, 472,922 (0.41%) out of 115,322,815 presentations to the ED were made by homeless persons

  

3

Holtyn et al. 2017 [17]

2017

USA

To examine the relationship between ED utilisation and alcohol use in homeless alcohol-dependent adults

Analysis of self-report assessments of alcohol and emergency department use alongside random breath collections

Homeless, alcohol-dependent (met DSM-IV criteria) adults from an inpatient detoxification unit and homeless community agencies

  

Out of 86 recorded ED visits, 29.1% presented due to alcohol intoxication, 4.7% for alcohol withdrawal, 2.3% for drug/medication overdose, 11.6% for psychological problems and 18.6% for medical problems

Average of 4.4 ED visits per person per year

4

Brown et al. 2010 [18]

2010

UK

To determine whether the rate of attendance was related to the outside temperature

A retrospective study of routine ED computer records from 2003 to 2008

Patients presenting to the Northern General Hospital ED and data from the Weston Park Weather Station

 

2930 (0.55%) out of 528,573 visits to the ED were made by persons identified as homeless

  

5

Cheung et al. 2015 [19]

2015

Canada

To examine the relationship between ED use and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ intervention trial

Analysis of administrative data and findings from Vancouver At Home survey data

Homeless or precariously housed individuals who met criteria for a mental disorder with or without concurrent substance use dependence; administrative data collected from six urban hospitals in the Vancouver Coastal Health Authority

   

Average of 2.1 ED visits per person, per year

6

Brown et al. 2013 [20]

2013

USA

To compare the ED visit characteristics of younger homeless adults with those of older homeless adults

Analysis of a systematic random sample of ED visits using NHAMCS dataset from 2005 to 2009

Patients presenting to non-federal hospital ED and outpatient departments

 

2,808,000 (0.6%) out of 468,000,000 ED visits were made by homeless adults

Psychiatric issues were more frequent in younger than older homeless adults (23% vs 15%; P = 0.01). Older homeless adults were more likely to suffer injuries (28% vs 21%; P = .04) and cardiovascular complaints (11% vs 5%; P = 0.02) than younger homeless adults

 

7

Raven et al. 2017 [21]

2017

USA

To identify ED use patterns and factors associated with ED use in adults 50 and older

Initial screen for study eligibility followed by analysis of baseline interview and medical records

Random sample of adults aged 50 years and older from homeless encampments, recycling centres, overnight homeless shelters and meal programmes

  

Out of 348 recorded visits to the ED, 23.9% presented for chronic illness, 21.6% for new illness, 19.2% for pain, 16.4% for injury, 8.3% for analgesic requirement and 5.8% for mental health issues

 

8

Ku et al. 2010 [22]

2010

USA

To assess whether homelessness or associated characteristics independently predicted ED use

Descriptive, cross-sectional secondary analysis of ED visits using NHAMCS dataset for the years 2005 and 2006

Patients presenting to non-federal hospital ED and outpatient departments

 

1.1 million (0.5%) out of 234 million weighted ED attendances during the 2-year time frame were by homeless patients

Out of 550,000 recorded visits to the ED, 304,000 (55.3%) patients presented due to injuries, 100,000 (18.3%) due to alcohol or other drug use, 57,000 (10.4%) due to psychiatric diagnoses and 38,500 (7%) due to respiratory diagnoses

Average of 0.72 ED visits per person, per year

9

Feldman et al. 2017 [23]

2017

USA

To explore whether prevalence of homelessness in the ED varied between weekdays and weekends and between seasons

Prospective, 5-question homelessness screening survey of eligible participants attending the ED between May 2015 and February 2016

Patients, who are not critically ill, registered with 3 EDs in north-eastern Pennsylvania

309 (7.03%) out of 4395 participants were cited as experiencing homelessness

   

10

Jackson et al. 2019 [24]

2019

USA

To describe demographics and proportion of ED patients who have experienced homelessness

Cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016

Patients presenting to Urban Atlanta ED

475 (51.5%) out of 923 ED patients who completed the survey stated some degree of homelessness in the previous year

   

11

Lee et al. 2019 [25]

2019

Australia

To compare the prevalence of homelessness in consecutive patients presenting to the ED

Prospective screening of housing status and retrospective audit of administrative data for patients presenting to the ED during a 7-day period in 2017

Patients presenting to an inner metropolitan hospital ED in Melbourne

Sample size: 1275 ED presentations involving 1208 individual patients (7-day period)

40 (7.9%) of the 504 prospectively screened patients were identified as homeless and 16 (2.3%) of the 704 non-screened patients were identified as homeless

   

12

Tsai et al. 2013 (a) [26]

2013

USA

To examine the proportion of homeless veterans among users of Veteran Affairs EDs and compare homeless and housed VA ED users’ clinical characteristics

Cross-sectional study analysing national VA ED user’s administrative data from the fiscal year 2010

Homeless veterans presenting to VA EDs

 

64,091 (6.89%) VA ED users identified as homeless out of 930,712 veterans that utilised VA EDs

Out of 64,091 recorded visits to the ED, 13.55% presented for alcohol disorder, 11.92% for drug disorder, 37.72% for psychiatric diagnoses (35.68% for non-substance misuse related), 12.84% for any pain diagnosis, 26.30% for congestive heart failure and 7.49% for chronic pulmonary disease

Average of 3.38 (SD=4.01) ED visits per person per year compared with 2.07 (SD=1.09) for non-homeless users

13

Rodriguez et al. 2009 [27]

2009

USA

To determine the extent that people experiencing homeless present to the ED for social issues

Prospective case-control study conducting interviews between July 2006 and March 2007

Patients in the treatment areas of one urban hospital ED

 

9806 (19.5%) out of 50,172 visits to the ED in 2006

Out of 191 homeless patients, 29% stated that hunger, safety and lack of shelter were the primary reasons for presenting to the ED

Average of 5.8 ED visits per person, per year (SD= 2.2)

14

Lin et al. 2015 [28]

2015

USA

To determine which factors are associated with frequent ED visits and hospitalisations among the insured homeless population

Retrospective, cross-sectional study using BHCHP electronic database from January to December 2010

Homeless Medicaid recipients who received service from BHCHP

  

Out of 25,771 recorded visits to the ED, 15.2% of patients presented for alcohol-related disorders, 7.6% for psychiatric disorders (not including substance misuse-related conditions), 5.3% for drug-related disorders, 14% for injury and poisoning, 7% for respiratory disorders and 5% for circulatory disorders

Average of 3.97 ED visits per person, per year

15

Mackelprang et al. 2014 [29]

2014

USA

To describe injury characteristics and circumstances among individuals identified as homeless in the ED

Cross-sectional, case-control study using the NEISS database between January 2007 and December 2011

Patients with product-related injuries who presented to NEISS EDs

268 (0.0142%) out of 1,885,274 unique cases that presented to NEISS ED’s with product-related injuries involved a homeless person

 

Out of 268 recorded visits to the ED, 13.8% had alcohol involvement and 3.4% had drug/substance use involvement

 

16

Doran et al. 2016 [30]

2016

USA

To quantify the presence of housing instability, homelessness, and other selected social determinants of health in ED patients

Cross-sectional survey of a random sample of ED patients from June to August 2014

Patients presenting to an urban public hospital ED

 

Out of 625 visits to the ED, 19.6% reported homelessness or lack of stable housing in the past 2 months

  

17

Moore et al. 2011 [31]

2011

Australia

To describe patterns of service use and predict risk factors for re-presentation to an ED among homeless persons

Retrospective analysis using computerised patient administration system from January 2003 to December 2004

Patients presenting to a principal referral hospital ED

1595 (3.9%) out of 40,942 individual patients were homeless

6689 (10.4%) out of 64,177 visits to the ED were made by the homeless population

 

Average of 2.1 ED visits per person, per year

18

Hammig et al. 2014 [32]

2014

USA

To determine the clinical characteristics of homeless patients presenting to the ED, focusing on unintentional and intentional injury events and related comorbid conditions

Retrospective cohort study analysing ED visits from the NHAMCS database from 2007 to 2010

Patients presenting to non-federal hospital ED and outpatient departments

 

603,000 (0.5%) out of 119,993,000 visits to the ED annually were made by homeless patients

Out of 603,000 reorded visits to the ED, 55% were injury related and 45% were non-injury related

 

19

Mackelprang et al. 2015 [33]

2015

USA

To analyse the prevalence and characteristics of ED and inpatient admissions among homeless and unstably housed youth

Retrospective cohort study using electronic medical records from July 2009 to June 2012

Patients presenting to the ED or inpatient departments of two urban teaching hospitals

  

Out of 1151 recorded visits to the ED, 30.06% were injury related, 23.28% were due to psychiatric illness, 7.99% were alcohol related, 21.29% were drug related and 57.34% were due to a chronic medical condition

Average of 0.97 ED visits per person, per year

20

Feldman et al. 2018 [34]

2018

USA

To assess the prevalence of homelessness by gender

Retrospective survey from May 2015 to February 2016

Patients presenting to 3 EDs (a level trauma centre, a suburban hospital and an inner-city hospital)

309 (7%) out of 4395 unique participants were homeless

   

21

Tsai et al. 2013 (b) [35]

2013

USA

To determine the ED use among homeless and domiciled VA service users

Retrospective cohort study using VA administrative workload databases from fiscal year 2010

Homeless and domiciled veterans presenting to the ED

 

64,099 (6.89%) out of 930,598 visits to the ED were made by homeless people

  

22

Moulin et al. 2018 [36]

2018

USA

To determine the ED utilisation for patients with a primary mental health diagnosis

Retrospective analysis of OSHPD data from 2009 to 2014

Patients with a primary mental illness visiting acute care hospitals’ EDs

 

6153 (0.73%) out of 846,867 visits made to the ED by adult patients with mental illness were by homeless ED users

  

23

Cheallaigh et al. 2017 [37]

2017

Ireland

To compare the use of unscheduled ED and inpatient care between housed and homeless patients

Observational cross-sectional study using electronic patient data in 2015

All ED visits and unscheduled admissions to one teaching hospital

 

2966 (6.3%) out of 47,174 ED attendances were made by homeless patients

Out of 2966 recorded visits to the ED, 7.6% presented for overdose and poisoning, 6.6% for alcohol-related issues, 5.6% for head injury, 4.8% for mental illness, 3.8% for abdominal pain and 2.9% for chest pain

Average of 3 ED visits per person per year and housed individuals had an average of 0.16 ED visits per, person per year

24

Yeniocak et al. 2017 [38]

2017

Turkey

To determine the sociodemographic and clinical characteristics of Turkish homeless patients who were brought to the ED by ambulance

Retrospective cross-sectional study from January to December 2014

Homeless adult patients brought to a Tertiary Training and Research Hospital by ambulance

167 (0.0835%) homeless patients attended the ED which serves an average of 200,000 patients each year

 

Out of 167 visits to the ED, 14.7% presented due to respiratory difficulty, 12.57% due to abdominal pain, 23.35% for clouded consciousness, 15.57% for generally impaired condition, 7.78% for traffic incidents and 5.39% for sharp object injury

 

25

Lloyd et al. 2017 [39]

2017

Australia

To understand the profile and expressed needs of people seen by HEDLO in the ED in comparison to the general hospital population

Retrospective chart audit of data recorded in ED referral database and HEDLO files from October 2013 to January 2015

Homeless persons referred to HEDLOs in Queensland Health ED

117,996 presentations to the ED over 16-month period.

Of these, 221 homeless people were referred to HEDLO

 

Out of 221 recorded visits to the ED, 25% presented due to mental health, 19% due to alcohol- and other drug-related issues, 39% for chronic medical conditions and 15% for social reasons

 

26

Lombardi et al. 2019 [40]

2019

USA

To analyse national survey data to elucidate the differences between homeless and non-homeless patients’ ED visits

Retrospective study using NHAMCS dataset from 2005 to 2015

Patients presenting to non-federal hospital ED and outpatient departments

 

2750 (0.91%) out of 303, 326 visits to the ED were made by homeless persons

Out of 2750 recorded visits to the ED, 28.4% presented due to psychiatric diagnoses, (16.29% were not substance misuse related) 17.7% were drug use related, 1.2% were alcohol related, 1.78% were respiratory related and 1.09% were cardiovascular related

 

27

Hastings et al. 2013 [41]

2013

USA

To determine predictors of repeat health service use in older veterans treated and released from the ED

Retrospective cohort study analysing VHA administrative datasets and the Vitals Mini File from 1 October 2007 to 30 June 2008

Patients aged 65 or over who were treated and released from a Veterans Affairs Medical Centre ED or urgent care clinic

 

374 (1.2%) out of 31,206 visits to the ED were made by homeless veterans

  

28

Lam et al. 2016 [42]

2016

USA

To assesses the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental disorders

Secondary analysis of administrative data in the ED looking at visits made in 2012

Homeless patients presenting to the ED in an urban, safety-net hospital

4210 (4.6%) 0ut of 92,307 unique patients were homeless at any time during the study period

15,159 (10.9%) out of 139,414 visits to the ED were made by persons who were homeless at any time during the study period

Out of 15,159 recorded visits to the ED, 39.25% presentations were mental disorders and 60.75% were non-mental disorders

 

29

Stenius-Ayoade. 2017 [43]

2017

Finland

To examine the role of mental disorders in relation to the use of primary healthcare services among homeless shelters in Helsinki

Retrospective analysis of electronic health records made by physicians and nurses working in primary health care from 2005 to 2008

Homeless persons in 4 shelters operating in the Helsinki metropolitan area

  

Out of 587 recorded visits to the Primary Health Care Emergency Rooms, 11% were for mental health and substance abuse, 38% were for trauma, 11% were for infections and 19% were for intoxications and convulsions

 

30

Post et al. 2013 [44]

2013

USA

To determine the prevalence and types of ‘new media’ use among homeless patients who present to the ED

Observational cross-sectional survey from July to August 2012

Patients presenting to 3 urban, high-volume EDs in Connecticut

 

249 (4.3%) out of 5788 subjects enrolled in the study, reported episodes of homelessness in the past year.

  

31

Moore et al. 2012 [45]

2012

Australia

To evaluate the accuracy of a predictive model to identify homeless people at risk of re-presentation to the ED

Prospective cohort study conducted from 1 April 2009 to 30 April 2009

Patients presenting to an adult, tertiary referral hospital ED, excluding those who died during study period

211 (7.31%) out of 2888 unique individuals who visited the ED were homeless

327 (9.92%) out of 3298 visits to the ED were made by homeless persons

  

32

Doran et al. 2018 [46]

2018

USA

To characterise alcohol and drug use in a sample of homeless vs. non-homeless ED patients

Baseline survey interviews with patients at public hospital ED from November 2016 to September 2017

Random sample of patients who presented to an urban public hospital ED

 

316 (13.69%) out of 2309 patients were currently experiencing homelessness

Out of 316 recorded visits to the ED, 25% were substance use related

 

33

Doran et al. 2013 [47]

2013

USA

To determine what multi-dimensional patient-level factors are most strongly associated with a 6-level gradient of VHA ED use

Cross-sectional analysis of data obtained from national VHA databases for fiscal year 2010

Veterans presenting to VHA ED services

 

64,091 (6.9%) out of 930,712 patients who visited the ED were homeless

  

34

Ku et al. 2014 [48]

2014

USA

To examine the study characteristics and costs associated with homeless ED frequent users

Retrospective cross-sectional review of hospital and financial records for ED visits in 2006

Frequent users of the ED in an urban academic medical centre with a level 1 trauma and annual census of greater than 60,000 visits

74 (13.7%) out 542 frequent users were homeless

845 (15.5%) out of 5440 visits made by frequent users were made by homeless persons

Out of the 845 presentations to the ED, 12.9% were due to substance abuse, 10.9% were nervous system related, 8.9% were respiratory problems, 7.1% were cardiovascular problems and 8.3% were due to traumatic disorders

 

35

Coe et al. 2015 [49]

2015

USA

To compare homeless patients’ utilisation of the urban ED in the USA with non-homeless patients

Cross-sectional study of the NHAMCS-ED electronic database for 2009 to 2010

Patients presenting to non-federal hospital ED and outpatient departments

 

1,302,256 (0.65%) out of 200,645,347 visits to the ED were made by homeless patients

  

36

Amato et al. 2018 [50]

2018

USA

To compare emergency care utilisation between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness

Retrospective cohort study using medical chart review between for the years 2013 and 2014

Patients presenting to a single, urban, academic, tertiary care centre

 

7532 (5.17%) out of 145,662 visits to the ED were made by persons with documented homelessness

Out of 7532 recorded visits to the ED, 20.1% of patients presented for mental health disorders, 13.4% were alcohol related, 1.12% were for drug overdose, 9.3% were for abdominal pain, 8.7% were for chest pain and 7.8% were for trauma

 
  1. BHCHP, Boston Health Care for the Homeless Program; DSM, Diagnostic and Statistical Manual; ED, emergency department; HEDLO, Homeless Emergency Department Liaison Officers; DSM-IV: NEISS, National Electronic Injury Surveillance System; NHAMCS, National Hospital Ambulatory Care Survey; OSHPD, California’s Office of Statewide Health Planning and Development; VA, Veteran Affairs; VHA, Veteran Health Affairs