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Original research
Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients
  1. Dan Lewer1,2,3,
  2. Dee Menezes1,
  3. Michelle Cornes4,
  4. Ruth M Blackburn1,
  5. Richard Byng5,
  6. Michael Clark6,
  7. Spiros Denaxas1,7,
  8. Hannah Evans1,
  9. James Fuller4,
  10. Nigel Hewett8,
  11. Alan Kilmister4,
  12. Serena April Luchenski1,
  13. Jill Manthorpe4,
  14. Martin McKee9,
  15. Joanne Neale10,
  16. Alistair Story11,
  17. Michela Tinelli6,
  18. Martin Whiteford12,
  19. Fatima Wurie3,
  20. Alexei Yavlinsky1,
  21. Andrew Hayward2,3,
  22. Robert Aldridge1
  1. 1 Institute of Health Informatics, University College London, London, UK
  2. 2 Collaborative Centre for Inclusion Health, University College London, London, UK
  3. 3 Institute of Epidemiology and Health Care, University College London, London, UK
  4. 4 NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
  5. 5 Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
  6. 6 Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
  7. 7 Alan Turing Institute, British Library, London, UK
  8. 8 Pathway Charity, London, UK
  9. 9 Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
  10. 10 National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
  11. 11 Find & Treat, University College London Hospitals NHS Foundation Trust, London, UK
  12. 12 Department of Nursing & Community Health, Glasgow Caledonian University, Glasgow, UK
  1. Correspondence to Dan Lewer, Institute of Epidemiology and Healthcare, University College London, London, UK; d.lewer{at}ucl.ac.uk

Abstract

Background Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission.

Methods We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios.

Results After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients.

Conclusions Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.

  • homelessness
  • access to hlth care
  • health inequalities
  • record linkage

Data availability statement

Data may be obtained from a third party and are not publicly available. As part of the approvals and information governance frameworks, we are unable to share the underlying data for this research study. Our approval only allowed researchers involved in this specific project to access data for the prespecified and approved analyses. Therefore, data collection and linkage would have to be repeated with new approvals sought by anyone wanting access to the underlying data used in this analysis. Application for access should be directed to the CAG of the Health Research Authority. Information regarding the application process and relevant links for applications are available from the CAG website.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/jech-2020-215204

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. As part of the approvals and information governance frameworks, we are unable to share the underlying data for this research study. Our approval only allowed researchers involved in this specific project to access data for the prespecified and approved analyses. Therefore, data collection and linkage would have to be repeated with new approvals sought by anyone wanting access to the underlying data used in this analysis. Application for access should be directed to the CAG of the Health Research Authority. Information regarding the application process and relevant links for applications are available from the CAG website.

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    Footnotes

    • Twitter @danlewer, @martinmckee, @rob_aldridge

    • Presented at The analysis presented in this paper was outlined in our previously published study protocol.

    • Contributors MCo, AH and RA—conceptualisation. DL, DM, RMB, HE and RA—methodology. DL and DM—software. DL—formal analysis. DM, RMB, HE, AY and RA—data curation. DL and JF—writing (original draft). DL, DM, MCo, RMB, RB, MC, SD, HE, JF, NH, AK, SAL, JM, MM, JN, AS, MT, MW, FW, AY, AH and RA—writing (review and editing). DL—visualisation. MCo, AH and RA—supervision. DM and RA—project administration. MCo, AH and RA—funding acquisition.

    • Funding This study was supported by the National Institute for Health Research (NIHR) (Project number: 13/156/10 to HS & DR). We also acknowledge the support from the Health Data Research (HDR) UK which receives its funding from HDR UK funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust. AH’s salary is provided by Central and North West London NHS Community Trust. AS is funded by UCLH Foundation Trust. DL is funded by an NIHR Doctoral Research Fellowship (DRF-2018-11-ST2-016). JN is part-funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. RMB is supported by a UK Research and Innovation Fellowship funded by a grant from the Medical Research Council (MR/S003797/1). SL is funded by NIHR (ICA-CDRF-2016-02-042). RB is supported by the NIHR Applied Research Collaboration (ARC) South West Peninsula and JM is supported by the NIHR ARC South London. RWA is supported by Wellcome through a Wellcome Clinical Research Career Development Fellowship (206602). This article is based on independent research commissioned and funded by the NIHR Health Service and Delivery Programme.

    • Disclaimer The views expressed in the publication are those of the authors and not necessarily those of the NHS, the NIHR, the Wellcome Trust, the Department of Health and Social Care, Public Health England or its arm’s length bodies or other government departments.

    • Competing interests NH is medical director, and AH is a trustee of the charity ‘Pathway: Healthcare for homeless people’. AS is clinical lead and manager for the ‘Find and Treat’ service at University College London Hospitals.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.