Predictors of Emergency Department Utilization by Homeless Persons: A National Study Clarilee Hauser PhD, RN

Homelessness and ED Overcrowding: A Health Care Crisis Study Purpose: To determine the extent to which homeless persons in the United States use the ED for non- urgent care To determine the factors that are predictive of ED use for non-urgent care

Research Questions What is the relationship between housing status and ED use? What is the relationship between housing status and urgent versus non-urgent use of the ED? What are the predictors of ED utilization for non- urgent visits?

Background Homelessness has a negative effect on health The use of the ED as a regular source of health care results in poor health outcomes ED overcrowding contributes to a delay in emergency care that results in increased morbidity and mortality for ED patients ED overcrowding contributes to the increasing cost of health care in the United States

Methodology Secondary analysis of the National Hospital Ambulatory Care Survey 2005 (NHAMCS 2005)  A national sample  A public-use database  Demographic characteristics of the patient population  In 2005, housing status was added to the Patient Record Form for the first time

Hierarchy of NHAMCS 2005 Survey Design PSU Hospital ESA ESA ESA ESA Visit Visit Visit Visit Visit Visit Visit Visit

Variables Dependent Variables Use of ED Number of patient visits Type of Use Triage category Independent Variables Predisposing Housing status Age Gender Race/Ethnicity Geographic location Month/day/time of day

Independent Variables Enabling Insurance status Hospital ownership Need Presenting complaint Drug/alcohol use/abuse Level of pain Injury/poisoning intentional Admit to hospital Physician diagnosis

What is the Relationship Between Housing Status and ED Use? Homeless persons have a significantly higher likelihood of visiting the ED than not homeless (p = 0.007)

What is the Relationship Between Housing Status and Urgent Versus Non-Urgent Use of the ED? Homelessness and Urgency N=24,311 Non-Urgent Urgent Not Homeless16.89% 83.11% Homeless18.92% 81.08% Total 16.90% 83.10% p = 0.763

What Are the Predictors of ED Utilization for Non-Urgent Visits? Overall Tests for the Likelihood of Non-Urgent Visit N=24, 311 Variable Wald F Significance Gender *.012 Race/Ethnicity **.003 Season *.030 Insurance ***.000 Diagnosis ***.000 Age ***.000

Summary of Results Greater proportion of the homeless population than the not homeless population used the ED in 2005 (p = 0.007) There was no statistically significant difference in non-urgent use (p = 0.763) Non-urgent ED visits were 1.4 times more likely to be made by persons without health insurance than by those with health insurance

Implications for Policy, Practice and Delivery Are there adequate health care services for homeless persons? What is the role of the ED? Universal health care could result in less use of the ED and lower health care costs

Predictors of Emergency Department Utilization by Homeless Persons: A National Study Clarilee Hauser PhD, RN