People who are homeless are less likely to receive appropriate interventions for cardiovascular conditions compared to individuals who are not homeless, which may indicate significant barriers to care in patients who are homeless, study results in JAMA Internal Medicine reports.

Researchers performed a retrospective cross-sectional analysis of cardiovascular-related hospitalizations data from the Florida, Massachusetts, and New York State Inpatient Databases of the Healthcare Cost and Utilization Project. For the purposes of this study, hospitalizations of adults who were (n=24,890) and adults were not (n=1,827,900) homeless  for various cardiovascular conditions in Florida, Massachusetts, and New York between January 1, 2010, and September 30, 2015. The primary study outcomes included risk-standardized diagnostic rates, intervention rates, and in-hospital mortality rates.

The mean age in the homeless and non-homeless cohorts was 65.1±14.8 years and 72.1±14.6 years, respectively. Characteristics associated with a higher likelihood of being homeless included black race (38.6% vs 15.6%, respectively) and having Medicaid insurance (49.3% vs 8.5%, respectively).

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In analyses adjusted for demographics, insurance payer, and clinical comorbidities, adults who were homeless and hospitalized for acute myocardial infarction (AMI) were significantly less likely to undergo coronary angiography than adults who were not homeless (39.5% vs 70.9%; P <.001). Adults in the homeless cohort were also less likely to undergo percutaneous coronary intervention than adults in the non-homeless cohort (24.8% vs 47.4%; P <.001) and coronary artery bypass graft (2.5% vs 7.0%; P <.001) if they were hospitalized for an acute myocardial infarction.

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In adults hospitalized with stroke, patients who were homeless at time of admission were significantly less likely to undergo cerebral angiography (2.9% vs 9.5%; P <.001). Despite this difference, adults who were homeless had similar rates of thrombolytic therapy receipt as hospitalized adults who were not homeless (4.8% vs 5.2%, respectively; P =.28).

Adults who were homeless and hospitalized for cardiac arrest were also less likely to undergo coronary angiography (10.1% vs 17.6%; P <.001) and PCI (0.0% vs 4.7%; P <.001) compared with adults who were not homeless. In addition, patients with ST-elevation myocardial infarction had a higher risk-standardized mortality if they were homeless vs if they were not homeless (8.3% vs 6.2%, respectively; P =.04). While there was no difference in mortality associated with heart failure between patients who were and were not homeless (1.6% vs 1.6%, respectively; P =.83), patients who were homeless had higher mortality rates if they were hospitalized with stroke (8.9% vs 6.3%; P <.001) or cardiac arrest (76.1% vs 57.4%; P <.001).

Study limitations included its retrospective and observational nature, the focus on hospitalizations in only 3 states, and the lack of assessment of differences between the 2 groups with regard to illness acuity.

The researchers concluded that their “findings suggest a need for public health and policy efforts to focus on reducing disparities in hospital-based acute care” in individuals who are homeless to optimize outcomes in this population.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Wadhera RK, Khatana SAM, Choi E, et al. Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions [published online November 18, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.6010