Homelessness associated with a dramatic increase in A&E attendance

Posted on: 25 January 2018

Homeless people use emergency department 20 times more than their housed counterparts and have 10 times more inpatient bed days, according to a new study carried out by researchers at Trinity College Dublin.

The research, which analysed all 54,205 emergency department visits and unscheduled admissions to St James’s Hospital in Dublin’s south inner city in 2015, illustrates the toll that Ireland’s homelessness crisis is having on people’s health and on hospital overcrowding, according to its authors.

“Previous work done in Dublin and elsewhere had shown that homeless people are much sicker and die at a much younger age than those who have homes. We’ve now demonstrated the impact that the ill-health associated with homelessness has on the need for care in the ED and in admissions to the hospital. Our ongoing failure to address the structural causes of homelessness is making people sick and resulting in increased use of costly unscheduled acute healthcare and adding to the existing strains on the healthcare system” explained lead author of the study Dr Clíona Ní Cheallaigh, Senior Lecturer in Medical Gerontology at Trinity’s School of Medicine; Consultant in General Medicine and Infectious Diseases, St James’s Hospital; and faculty member of the Global Brain Health Institute, a joint venture between Trinity College Dublin and the University of California, San Francisco.

The research, which has recently been published in the journal BMJ Open, found that homeless people need hospital care at a much younger age than housed people. It also found that homeless people attending the emergency department were much more likely to leave the hospital before their assessment and/or treatment was completed. Previous work in the UK and US had also shown that homeless people use more emergency care than others, but the increase seen in Dublin was even more dramatic than what they had reported.

Key findings:

• Homeless people in the catchment area of St James’s Hospital had a 20-times higher rate of attendance at the emergency department compared to their housed counterparts with on average 3 attendances per year compared to a rate of 0.16 attendances per person per annum among the housed population.
• Homeless individuals required 10 times more unscheduled medical inpatient beds than their housed counterparts with on average 4.4 inpatient bed days a year in comparison with housed people in the hospital catchment area who had just 0.3 inpatient bed days a year.
• Homeless people need hospital care at a much younger age. The average age of homeless emergency department attendees was 39 years, whereas that of housed attendees was 45 years. The average age of homeless medical inpatients was 44 and that of the housed patients was 61 years
• 15% of homeless people terminated inpatient admissions prematurely compared to 2% of housed patients.

Dr Ní Cheallaigh added: “Clinicians working in acute hospitals can clearly see the impact that homelessness has on health. Homelessness represents an extreme form of social exclusion, and many homeless people have experienced severe trauma in childhood and adulthood. Homeless leads to a dramatic increase in ill-health and adds to the existing pressures on acute hospitals. This needs to be factored into government decisions on housing, social care and addiction supports.”

“Health services should recognise that homeless, and other socially excluded people, represent a significant proportion of their patients, and services may need to be adapted to suit their needs. An approach called Inclusion Health has been demonstrated to improve outcomes. Our experience in St James’s shows that it also reduces hospital admissions.”

“As our policymakers and politicians try to grapple with the current homeless crisis it is important that they also factor in ill-health as both a cause and consequence of homelessness and factor in healthcare costs as another way in which homelessness and social exclusion affect all in Ireland.   Healthcare providers and planners need to directly address health inequity in order to improve outcomes and reduce the burden on acute hospitals.”

The paper “Usage of unscheduled hospital care by homeless individuals in Dublin, Ireland: a cross-sectional study” can be viewed and downloaded here:

http://bmjopen.bmj.com/content/7/11/e016420