In the Journals

In acute MI, care of homeless differs from general population

Mohamad Alkhouli

Researchers observed several significant differences regarding in-hospital care, CV risk profile and rehospitalization rates in patients with acute MI who were homeless vs. those who were not, according to a study published in Mayo Clinic Proceedings.

“These findings should raise awareness that managing cardiovascular disease in homeless patients has its unique challenges due to the high burden of psychiatric illnesses among them and the clear disparities in provision of care for the homeless in the medical system,” Mohamad Alkhouli, MD, interventional cardiologist and senior associate consultant at Mayo Clinic, told Healio.

Patients with acute MI

Sudarshan Balla, MD, program director of the cardiology fellowship program and assistant professor in the division of cardiology at West Virginia University in Morgantown, and colleagues analyzed data from 1,100,241 patients from the National Readmission Database who were admitted for acute MI from 2015 to 2016. Patients were then classified as homeless or nonhomeless.

Several study endpoints were assessed including rates of revascularization and invasive assessment, baseline characteristics, readmission rates at 30 days and in-hospital cost, morbidity and mortality.

Homeless patients accounted for 0.4% of the study population. Compared with the nonhomeless group, the homeless group was more likely to be men (82.5% vs. 40.5%; P < .001), younger (57 vs. 68 years; P < .001) and have a lower prevalence of atherosclerotic risk factors including hyperlipidemia (8.7% vs. 13.3%; P < .001), hypertension (73.4% vs. 79%; P < .001) and diabetes (37.1% vs. 42.8%; P < .001).

Homeless patients were also more likely to have major depression (15.5% vs. 9.1%; P < .001), anxiety disorders (13.7% vs. 9.5%; P < .001) and substance abuse disorders including alcohol (7% vs. 1.1%; P < .001) and drugs (15.7% vs. 1.7%; P < .001).

Compared with nonhomeless patients, homeless patients were less likely to undergo PCI (24.1% vs. 38.7%; P< .001), coronary angiography (38.1% vs. 54%; P < .001) or CABG (4.9% vs. 6.7%; P < .001). Bare-metal stents were more often used in homeless patients vs. nonhomeless patients (34.6% vs. 12.1%; P < .001).

Researchers also performed propensity score matching, which determined that homeless patients had similar rates of mortality (5.7% vs. 6.6%; P = .21) but higher rates of discharge against medical advice or to an intermediate care facility (16.7% vs. 13.4%; P < .001), acute kidney injury (28.7% vs. 25.8%; P = .04) and longer hospitalizations (4 vs. 3 days; P < .001). This group also had higher 30-day readmission rates (22.5% vs. 10%; P < .001).

More readmissions for psychiatric causes occurred in homeless patients vs. nonhomeless patients (18% vs. 2%; P < .001).

“Additional research is needed to understand the reasons for the documented disparities in care among the homeless and to devise a ‘holistic approach’ to address CV and non-CV risks among these patients,” Alkhouli said in an interview.

Focus on homeless population

In a related editorial, R. Scott Wright, MD, consultant in the division of structural heart disease and in the division of preventive cardiology and professor of medicine at Mayo Clinic, and Joseph G. Murphy, MD, consultant in the division of ischemic heart disease and critical care and in the division of structural heart disease and professor of medicine at Mayo Clinic, wrote: “We need to better address the health and living conditions of America’s homeless population, some of whom as veterans have risked their lives for us in foreign wars. And we need to more fully invest in their care during and after hospitalization for acute MI to ensure better long-term health outcomes for them and, ultimately, lower costs for our society at large.” – by Darlene Dobkowski

For more information:

Mohamad Alkhouli, MD, can be reached at alkhouli.mohamad@mayo.edu.

Disclosures: The authors of the study and of the editorial report no relevant financial disclosures.

Mohamad Alkhouli

Researchers observed several significant differences regarding in-hospital care, CV risk profile and rehospitalization rates in patients with acute MI who were homeless vs. those who were not, according to a study published in Mayo Clinic Proceedings.

“These findings should raise awareness that managing cardiovascular disease in homeless patients has its unique challenges due to the high burden of psychiatric illnesses among them and the clear disparities in provision of care for the homeless in the medical system,” Mohamad Alkhouli, MD, interventional cardiologist and senior associate consultant at Mayo Clinic, told Healio.

Patients with acute MI

Sudarshan Balla, MD, program director of the cardiology fellowship program and assistant professor in the division of cardiology at West Virginia University in Morgantown, and colleagues analyzed data from 1,100,241 patients from the National Readmission Database who were admitted for acute MI from 2015 to 2016. Patients were then classified as homeless or nonhomeless.

Several study endpoints were assessed including rates of revascularization and invasive assessment, baseline characteristics, readmission rates at 30 days and in-hospital cost, morbidity and mortality.

Homeless patients accounted for 0.4% of the study population. Compared with the nonhomeless group, the homeless group was more likely to be men (82.5% vs. 40.5%; P < .001), younger (57 vs. 68 years; P < .001) and have a lower prevalence of atherosclerotic risk factors including hyperlipidemia (8.7% vs. 13.3%; P < .001), hypertension (73.4% vs. 79%; P < .001) and diabetes (37.1% vs. 42.8%; P < .001).

Homeless patients were also more likely to have major depression (15.5% vs. 9.1%; P < .001), anxiety disorders (13.7% vs. 9.5%; P < .001) and substance abuse disorders including alcohol (7% vs. 1.1%; P < .001) and drugs (15.7% vs. 1.7%; P < .001).

Compared with nonhomeless patients, homeless patients were less likely to undergo PCI (24.1% vs. 38.7%; P< .001), coronary angiography (38.1% vs. 54%; P < .001) or CABG (4.9% vs. 6.7%; P < .001). Bare-metal stents were more often used in homeless patients vs. nonhomeless patients (34.6% vs. 12.1%; P < .001).

Researchers also performed propensity score matching, which determined that homeless patients had similar rates of mortality (5.7% vs. 6.6%; P = .21) but higher rates of discharge against medical advice or to an intermediate care facility (16.7% vs. 13.4%; P < .001), acute kidney injury (28.7% vs. 25.8%; P = .04) and longer hospitalizations (4 vs. 3 days; P < .001). This group also had higher 30-day readmission rates (22.5% vs. 10%; P < .001).

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More readmissions for psychiatric causes occurred in homeless patients vs. nonhomeless patients (18% vs. 2%; P < .001).

“Additional research is needed to understand the reasons for the documented disparities in care among the homeless and to devise a ‘holistic approach’ to address CV and non-CV risks among these patients,” Alkhouli said in an interview.

Focus on homeless population

In a related editorial, R. Scott Wright, MD, consultant in the division of structural heart disease and in the division of preventive cardiology and professor of medicine at Mayo Clinic, and Joseph G. Murphy, MD, consultant in the division of ischemic heart disease and critical care and in the division of structural heart disease and professor of medicine at Mayo Clinic, wrote: “We need to better address the health and living conditions of America’s homeless population, some of whom as veterans have risked their lives for us in foreign wars. And we need to more fully invest in their care during and after hospitalization for acute MI to ensure better long-term health outcomes for them and, ultimately, lower costs for our society at large.” – by Darlene Dobkowski

For more information:

Mohamad Alkhouli, MD, can be reached at alkhouli.mohamad@mayo.edu.

Disclosures: The authors of the study and of the editorial report no relevant financial disclosures.