Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations: A Position Paper From the American College of Physicians.

Access to safe and stable housing has both a direct and indirect effect on health. Experiencing homelessness and housing instability can induce stress and trauma, worsening behavioral health and substance use. The absence of safe and stable living conditions can make it challenging to rest, recuperate, and recover from health ailments and can pose barriers to treatment adherence. Homelessness and housing instability is associated with high rates of numerous diseases and chronic conditions. Its cyclical relationship with other social drivers of health can exacerbate health disparities. As a result, unhoused persons experience unique health challenges and require a health care system and professionals designed to meet their distinct needs. Physicians and other health professionals have a role in educating themselves about the needs of unhoused patients as well as making themselves aware of community and government resources available to these populations. Policymakers must support health professionals in these efforts by supporting the data infrastructure needed to facilitate these referrals to resources, supporting research into best practices for caring for these populations, and investing in community-based organization capacity. Policy action is needed to address the underlying drivers of homelessness, including a dearth of affordable housing, while also addressing the short-term need for safe shelter now. In this position paper, the American College of Physicians (ACP) recognizes the need to address universal access to housing to fulfill one's right to health. ACP offers several recommendations to prevent homelessness and promote the necessary health care and social needs of unhoused populations.

Geospatial, Clinical, and Social Determinants of Hospital Readmissions.

Unnecessary hospital readmissions increase patient burden, decrease health care quality and efficiency, and raise overall costs. This retrospective cohort study sought to identify high-risk patients who may serve as targets for interventions aiming at reducing hospital readmissions. The authors compared geospatial, social demographic, and clinical characteristics of patients with or without a 90-day readmission. Electronic health records of 42 330 adult patients admitted to 2 Midwestern hospitals during 2013 to 2016 were used, and logistic regression was performed to determine risk factors for readmission. The 90-day readmission percentage was 14.9%. Two main groups of patients with significantly higher odds of a 90-day readmission included those with severe conditions, particularly those with a short length of stay at incident admission, and patients with Medicare but younger than age 65. These findings expand knowledge of potential risk factors related to readmissions. Future interventions to reduce hospital readmissions may focus on the aforementioned high-risk patient groups.

Prospective Randomized Evaluation of Preoperative Angiotensin-Converting Enzyme Inhibition (PREOP-ACEI).

BACKGROUND: Intraoperative hypotension is associated with an increased risk of end organ damage and death. The transient preoperative interruption of angiotensinconverting enzyme inhibitor (ACEI) therapy prior to cardiac and vascular surgeries decreases the occurrence of intraoperative hypotension. OBJECTIVE: We sought to compare the effect of two protocols for preoperative ACEI management on the risk of intraoperative hypotension among patients undergoing noncardiac, nonvascular surgeries. DESIGN: Prospective, randomized study. SETTING: Midwestern urban 489-bed academic medical center. PATIENTS: Patients taking an ACEI for at least six weeks preoperatively were considered for inclusion. INTERVENTIONS: Randomization of the final preoperative ACEI dose to omission (n = 137) or continuation (n = 138). MEASUREMENTS: The primary outcome was intraoperative hypotension, which was defined as any systolic blood pressure (SBP) < 80 mm Hg. Postoperative hypotensive (SBP < 90 mm Hg) and hypertensive (SBP >> 180 mm Hg) episodes were also recorded. Outcomes were compared using Fisher's exact test. RESULTS: Intraoperative hypotension occurred less frequently in the omission group (76 of 137 [55%]) than in the continuation group (95 of 138 [69%]) (RR: 0.81, 95% CI: 0.67 to 0.97, P = .03, NNH 7.5). Postoperative hypotensive events were also less frequent in the ACEI omission group (RR: 0.49, 95% CI: 0.28 to 0.86, P = .02) than in the continuation group. However, postoperative hypertensive events were more frequent in the omission group than in the continuation group (RR: 1.95, 95%: CI: 1.14 to 3.34, P = .01). CONCLUSIONS: The transient preoperative interruption of ACEI therapy is associated with a decreased risk of intraoperative hypotension. REGISTRATION: ClinicalTrials.gov: NCT01669434.

A Clinical Process Change and Educational Intervention to Reduce the Use of Unnecessary Preoperative Tests.

BACKGROUND: Internal medicine residents receive limited training on how to be good stewards of health care dollars while preserving high-quality care. INTERVENTION: We implemented a clinical process change and an educational intervention focused on the appropriate use of preoperative diagnostic testing by residents at a Veterans Administration (VA) medical center. METHODS: The clinical process change consisted of reducing routine ordering of preoperative tests in the absence of specific indications. Residents received a short didactic session, which included algorithms for determining the appropriate use of perioperative diagnostic testing. One outcome was the average cost savings on preoperative testing for a continuous cohort of patients referred for elective knee or hip surgery. Resident knowledge and confidence prior to and after the intervention was measured by pre- and posttest. RESULTS: The mean cost of preoperative testing decreased from $74 to $28 per patient after the dual intervention (P < .001). The bulk of cost savings came from elimination of unnecessary blood and urine tests, as well as reduced numbers of electrocardiograms and chest radiographs. Among residents who completed the pretest and posttest, the mean score on the pretest was 54%, compared with 80% on the posttest (P  =  .027). Following the educational intervention, 70% of residents stated they felt "very comfortable" ordering appropriate preoperative testing (P  =  .006). CONCLUSIONS: This initiative required few resources, and it simultaneously improved the educational experience for residents and reduced costs. Other institutions may be able to adopt or adapt this intervention to reduce unnecessary diagnostic expenditures.