Care disparities, barriers common in homeless patients hospitalized for acute MI

Coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting were done less frequently in homeless patients, and homeless patients who did undergo PCI were more likely to receive bare-metal stents, according to a recent study.

Patients with acute myocardial infarction (MI) who are homeless may receive less optimal in-hospital care and have higher rehospitalization rates than nonhomeless patients.

Researchers used the National Readmission Database to identify homeless and nonhomeless adults admitted to the hospital with acute MI between Jan. 1, 2015, and Dec. 31, 2016. The two cohorts were compared for baseline characteristics, rates of invasive assessment and revascularization, mortality rates, 30-day readmission rates, and readmission reasons. Results were published March 19 by Mayo Clinic Proceedings.

Of 1,100,241 index hospitalizations for acute MI, 3,938 (0.4%) were in patients who were homeless. Homeless patients were younger (mean age, 57 years vs. 68 years) and were less likely to have atherosclerotic risk factors such as hypertension, hyperlipidemia, and diabetes but more likely to have anxiety, depression, and substance abuse compared with nonhomeless patients. The homeless cohort included fewer women than the nonhomeless cohort (17.5% vs. 40.5%, respectively). Coronary angiography, percutaneous coronary intervention, and coronary artery bypass grafting were done less frequently in homeless patients, and homeless patients who did undergo percutaneous coronary intervention were more likely to receive bare-metal stents. Mortality rates were similar in homeless and nonhomeless patients after propensity score matching, but homeless patients were more likely to have acute kidney injury, to be discharged to an intermediate care facility or against medical advice, and to have longer hospital stays. Significantly higher 30-day readmission rates were seen in homeless versus nonhomeless patients (22.5% vs. 10.0%; P<0.001), and readmissions for psychiatric causes were also more common (18.0% vs. 2.0%; P<0.001).

The researchers noted that homelessness might have been underreported in National Readmission Database and that it does not include data on deaths outside the hospital, among other limitations. They concluded that homeless patients who are admitted to the hospital for acute MI have a different risk profile than nonhomeless patients, experience disparities in care, and have worse short-term outcomes and higher readmission rates. “Stakeholders need to collaborate on policies and interventions to improve the psychosocial profile, health care delivery, and outcomes in homeless patients,” the authors wrote. They called for additional research on the potential effects of a housing intervention in this cohort.