文章基本信息

标题：A Comprehensive Assessment of Health Care Utilization Among Homeless Adults Under a System of Universal Health Insurance
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作者：Stephen W. Hwang ; Catharine Chambers ; Shirley Chiu 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2013
卷号：103
期号：Suppl 2
页码：S294-S301
DOI：10.2105/AJPH.2013.301369
语种：English
出版社：American Public Health Association
摘要：Objectives. We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. Methods. We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). Results. Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical–surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical–surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. Conclusions. In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services. Homelessness is a serious problem in North America. High rates of unemployment and mortgage foreclosures resulting from the recent global economic downturn have further perpetuated this crisis. 1 Approximately 650 000 people will experience homelessness each night in the United States, of whom more than one third are people in families. 2 More than 1.6 million Americans spend at least 1 night in an emergency shelter or transitional housing each year. 2 In Toronto, Ontario, more than 4000 individuals experience homelessness on any given night, and approximately 27 000 people use emergency shelters each year. 3,4 Compared with the general population, homeless people have higher rates of chronic and acute health conditions and are at increased risk for all-cause mortality. 5–8 Despite their increased need for health services, homeless people are a marginalized population who frequently encounter barriers to accessing primary or preventive health care. 6,9–17 In addition, they often face competing priorities for basic subsistence needs, 18 factors that may result in delays in health care seeking, deterioration in health status, unmet needs for care, increased mortality, and use of more expensive forms of health care delivery. 6,11,19–21 Evidence has suggested that homeless people can be more intensive users of health services than the general population, 12,22–26 yet no comprehensive assessment of health care utilization among homeless persons is available. Such data are difficult to obtain in the United States using administrative databases because more than 50% of homeless adults lack any health insurance. 12 Many previous studies have relied solely on self-reports, 11,12,27–29 assessed only 1 type of health service (e.g., emergency department [ED] visits), 22,26,30 lacked a comparison group in the general population, 11,19 or exclusively assessed utilization for homeless individuals who had contact with the health care system. 22,25,26,30 In this study, we examined health care utilization by a population-based cohort of homeless single men, single women, and adults in families using administrative data in a setting in which all residents, regardless of their housing, employment, or income status, are covered under a publicly funded universal health insurance system. We compared health care utilization rates of homeless individuals and age- and gender-matched low-income controls from the general population and examined patterns of health care utilization, with a focus on those considered to be frequent users of health services.