Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

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Abstract

Background

The health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.

Objective

This study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.

Design

An observational study was conducted using national VA administrative data from 2016 to 2019.

Participants

Data on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.

Main measures

Homelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).

Key results

The most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22–24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans. Conclusions: These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.

Introduction

Emergency departments (EDs) serve as a major source of medical care in the U.S. and thus ED utilization can reflect health needs of a local community or population that might not otherwise be met, and thus merit examination [1]. Research has shown that homeless adults frequently seek ED care [[2], [3], [4], [5], [6]] and use EDs at rates 3–4 times greater than other adults [[6], [7], [8]]. Uninsurance, underinsurance, and lack of a regular source of care contribute to emergency care-seeking [5,9], but they are not likely to be the main drivers. Even in the U.S. Department of Veterans Affairs (VA) healthcare system, which provides eligible veterans free or low-cost comprehensive healthcare services, homeless veterans are four times more likely to use EDs than their non-homeless peers [10]. One study found that 45% of homeless VA clients qualified as frequent ED users (i.e., had more than four ED visits in one year) compared to 1% of other veterans in the VA healthcare system [11]. A more recent analysis found that among VA patients who experienced any period of homelessness, 35% of them used EDs in the same year as their homeless experience. The percentage varied by age, from a low of 29% among homeless veterans in the group aged 18–29, to 38% in those aged 60–74 [12]. Compared to examinations of how much the ED is used by this population, examination of specific reasons for seeking ED care have been sparse. One older paper found heart failure and schizophrenia were risk factors for ED use [13]. A more detailed, and current, analysis of reasons for care-seeking in emergency settings could help shed light on unmet care needs and inform efforts to avert ED use when it is not necessary.

Across any population, medical and mental health needs vary by age, gender, and race/ethnicity [[14], [15], [16]], so it stands to reason that presenting diagnoses for ED use will vary in a similar manner. For example, males are more likely to present to EDs for substance use-related reasons than females [17]. There is some evidence that patient-reported stress and anxiety is higher among females reporting to EDs than males [18] and younger female patients may be more likely to present with vague, unspecific symptoms [19]. There have been fewer studies on the topic of race/ethnicity in ED use. Those that exist have often found race/ethnicity is not an independent correlate of ED use after adjusting for other factors such as age, socioeconomic status, and health insurance coverage [20,21]. These studies, however, have not consistently probed reasons for presentation, which could disclose differences. On age, a number of studies have found that older age is associated with increasing ED use, length of stay, and resource intensity in EDs [22,23]. Beyond these demographic profiles, some studies flag reasons for ED use that cross age, gender, and race/ethnicity. For example, several studies using multi-year data from the National Hospital Ambulatory Medical Care Survey have reported dramatic increases over recent time in the number of ED visits for attempted suicide or self-inflicted injury, across major demographic groups [24,25]. Whether similar patterns are evident among veterans, or to those experiencing homelessness, is not yet known.

In the current study, we used national VA administrative data on over 2 million veterans from 2016 to 2019 to examine the top 10 diagnostic categories for ED use as documented in their medical charts. We compared homeless and non-homeless veterans on diagnostic categories for ED use and further classified diagnostic categories for ED use among homeless veterans by age, gender, and race/ethnic group.

Section snippets

Materials and methods

National VA administrative data on 260,783 homeless veterans and 2,295,704 non-homeless veterans from 2016 to 2019 were analyzed. Among the sample of homeless veterans, there were 104,904 veterans in 2016; 103,248 veterans in 2017; 100,606 veterans in 2018; and 100,606 veterans in 2019. Homelessness was defined as having a documented International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic code Z59.0 Homelessness or use of any VA homeless program

Results

As presented in Table 1, the top 10 CCSR diagnostic categories for homeless veterans presenting to EDs were consistent from 2016 to 2019. Those top categories were (in order): Musculoskeletal pain, Alcohol-related disorders, Suicidal ideation/attempt/intentional self-harm, Low back pain, Other specified encounters and counseling, Nonspecific chest pain, Abdominal pain and other digestive/abdomen signs, Other specified status, Depressive disorders, and Skin and subcutaneous tissue infections.

Discussion

In a comprehensive healthcare system that does not rely on insurance payments, the top presenting diagnostic categories in EDs among homeless veterans were related to physical pain, suicidal behaviors, depressive disorders, alcohol misuse, and non-specified factors, which we presume did not reflect easily specified medical diagnoses. Pain diagnoses featured prominently among the ED visits of non-homeless veterans, as well. However non-homeless veterans did not present so frequently with

Funding

This work was supported by internal funds from the VA National Center on Homelessness among Veterans.

Declaration of Competing Interest

None of the authors report any conflicts of interest. Dr. Kertesz holds stock in CVS Caremark, Thermo Fisher, and Zimmer Biomet, not exceeding 5% of his assets. Dr. Kertesz reports his spouse holds equity in Merck, Abbot, Thermo Fisher, and Johnson and Johnson, in her private assets, not exceeding 10% of her assets. Dr. Kertesz also receives income from UpToDate, Inc.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to

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