The co-occurrence of AIDS and homelessness: results from the integration of administrative databases for AIDS surveillance and public shelter utilisation in Philadelphia.

STUDY OBJECTIVE: Administrative databases from the City of Philadelphia that track public shelter utilisation (n=44 337) and AIDS case reporting (n=7749) were merged to identify rates and risk factors for co-occurring homelessness and AIDS. DESIGN: Multiple decrement life tables analyses were conducted, and logistic regression analyses used to identify risk factors associated with AIDS among the homeless, and homelessness among people with AIDS. SETTING: City of Philadelphia, Pennsylvania, USA. MAIN RESULTS: People admitted to public shelters had a three year rate of subsequent AIDS diagnosis of 1.8 per 100 person years; nine times the rate for the general population of Philadelphia. Logistic regression results show that substance abuse history (OR = 3.14), male gender (OR = 2.05), and a history of serious mental disorder (OR = 1.62) were significantly related to the risk for AIDS diagnosis among shelter users. Among people with AIDS, results show a three year rate of subsequent shelter admission of 6.9 per 100 person years, and a three year rate of prior shelter admission of 9%, three times the three year rate of shelter admission for the general population. Logistic regression results show that intravenous drug user history (OR = 3.14); no private insurance (OR = 2.93); black race (OR = 2.82); pulmonary or extra-pulmonary TB (OR = 1.43); and pneumocystis pneumonia (OR = 0.56) were all related to the risk for shelter admission. CONCLUSIONS: Homelessness prevention programmes should target people with HIV risk factors, and HIV prevention programmes should be targeted to homeless persons, as these populations have significant intersection. Reasons and implications for this intersection are discussed.

Connections between AIDS and homelessness.

Although the links between health and environment are well known, interventions that target these associations in order to improve health are rare. Health and social service agencies often function independently of one another, maintaining separate, unlinked databases. For example, relationships among homelessness, AIDS, and tuberculosis have been noted, but services have not focused on the intersecting populations these conditions affect. This Issue Brief summarizes efforts to merge databases and provide policymakers with information to guide housing, social service, and health care resources. The investigators identify risk factors associated with AIDS among the homeless, and homelessness among people with AIDS.

Assessing homeless population size through the use of emergency and transitional shelter services in 1998: results from the analysis of administrative data from nine US jurisdictions.

OBJECTIVES: This study reports findings from the first-ever systematic enumeration of homeless population size using data previously collected from administrative records of homeless services providers in nine US jurisdictions over a one year period. As such, it provides the basis for establishing an ongoing measure of the parameters of the homeless population and for tracking related trends on the use of homeless services over time. METHODS: Each participating jurisdiction collected data through its homeless services management information systems for persons and families who use emergency shelter and transitional housing. The jurisdictions organized the data by a standardized reporting format. These data form the basis for reporting homeless population size, both in raw numbers and as adjusted for each jurisdiction's overall population size, as well as the rate of turnover and average annual length of stay in emergency shelters and transitional housing. RESULTS: Individual jurisdictions had annual rates of sheltered homelessness ranging from 0.1% to 2.1% of their overall population, and 1.3% to 10.2% of their poverty population. Annual population size was 2.5 to 10.2 times greater than the point-prevalent population size. Results are broken down for adults and families. CONCLUSIONS: The prevalence of homelessness varies greatly among the jurisdictions included in this study, and possible factors for this diversity are discussed. Future reports of this nature will furnish similar series of homeless enumerations across a growing number of jurisdictions, thereby providing a basis for exploring the effects of different contextual factors on local prevalence rates of homelessness.

Homelessness among persons with serious mental illness in an enhanced community-based mental health system.

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.

Staging non-small cell lung cancer with whole-body PET.

PURPOSE: To compare the accuracies of whole-body 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) and conventional imaging (thoracic computed tomography [CT], bone scintigraphy, and brain CT or magnetic resonance [MR] imaging) in staging bronchogenic carcinoma. MATERIALS AND METHODS: Within 20 months, 100 patients with newly diagnosed bronchogenic carcinoma underwent whole-body FDG PET and chest CT. Ninety of these patients underwent radionuclide bone scintigraphy, and 70 patients underwent brain CT or MR imaging. For each patient, all examinations were completed within 1 month. A radiologic stage was assigned by using PET and conventional imaging independently and was compared with the pathologic stage. The accuracy, sensitivity, specificity, and negative and positive predictive values were calculated. RESULTS: PET staging was accurate in 83 (83%) patients; conventional imaging staging was accurate in 65 (65%) patients (P < .005). Staging with mediastinal lymph nodes was correct by using PET in 67 (85%) patients and by using CT in 46 (58%) patients (P < .001). Nine (9%) patients had metastases demonstrated by using PET that were not found with conventional imaging, whereas 10 (10%) patients suspected of having metastases because of conventional imaging findings were correctly shown with PET to not have metastases. CONCLUSION: Whole-body PET was more accurate than thoracic CT, bone scintigraphy, and brain CT or MR imaging in staging bronchogenic carcinoma.

Timing of sentinel lymph node mapping after lymphoscintigraphy.

BACKGROUND: Sentinel lymph node (SLN) mapping is an effective technique for staging patients with melanoma. In an attempt to avoid reinjection of radiolabeled colloid and facilitate SLN mapping at the time of surgery, we examined whether residual radioactivity from preoperative lymphoscintigraphy could be used to accurately identify SLNs during surgery 18 to 24 hours later. METHODS: Forty-six patients with newly diagnosed melanoma underwent injection of 0.22-micron filtered technetium 99m-labeled sulfur colloid followed by lymphoscintigraphy. Patients returned the next day for SLN biopsy with Isosulfan blue dye and the hand-held gamma-probe to identify SLNs. Thirty of 46 patients underwent repeat imaging before operation. No patient had reinjection of radiocolloid. RESULTS: Ninety-five SLNs were identified on initial lymphoscintigraphy, and repeat imaging on the day of surgery confirmed all SLNs previously identified. A total of 122 SLNs (2.65 per patient) were resected from 58 basins. Eighty-four (69%) of 122 SLNs stained blue, and 118 (97%) of 122 SLNs had in vivo gamma-counts greater than 4 times background. Microscopic metastases were present in 13 (10.7%) of 122 SLNs in 12 (26.1%) of 46 patients. There have been no recurrences over a mean follow-up time of 320 days. CONCLUSIONS: Intraoperative gamma-probe detection combined with blue dye injection is highly effective in identifying SLNs 18 to 24 hours after injection of 0.22-micron filtered 99mTc-sulfur colloid. Reinjection of radiocolloid is not required. This technique avoids radiopharmaceutical administration in the operating room, minimizes radiation exposure, and increases scheduling flexibility.

Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: results from the analysis of administrative data.

This study tests a typology of homelessness using administrative data on public shelter use in New York City (1988-1995) and Philadelphia (1991-1995). Cluster analysis is used to produce three groups (transitionally, episodically, and chronically homeless) by number of shelter days and number of shelter episodes. Results show that the transitionally homeless, who constitute approximately 80% of shelter users in both cities, are younger, less likely to have mental health, substance abuse, or medical problems, and to overrepresent Whites relative to the other clusters. The episodically homeless, who constitute 10% of shelter users, are also comparatively young, but are more likely to be non-White, and to have mental health, substance abuse, and medical problems. The chronically homeless, who account for 10% of shelter users, tend to be older, non-White, and to have higher levels of mental health, substance abuse, and medical problems. Differences in health status between the episodically and chronically homeless are smaller, and in some cases the chronically homeless have lower rates (substance abuse in New York; serious mental illness in Philadelphia). Despite their relatively small number, the chronically homeless consume half of the total shelter days. Results suggest that program planning would benefit from application of this typology, possibly targeting the transitionally homeless with preventive and resettlement assistance, the episodically homeless with transitional housing and residential treatment, and the chronically homeless with supported housing and long-term care programs.

Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage.

BACKGROUND: Malignant pleural effusions are a common problem for patients with metastatic disease. Most patients are treated with tube thoracostomy and sclerotherapy, although there remains no standard approach. The purpose of this study was to compare the efficacy of bleomycin with doxycycline sclerotherapy for the treatment of malignant pleural effusions using small-bore catheters. METHODS: All patients with a symptomatic malignant pleural effusion referred for chest tube drainage and sclerotherapy over a 2-year period were considered eligible. Using image guidance, a 14F self-retaining catheter was inserted into the pleural space and connected to continuous wall suction. When drainage fell below 200 mL/d, patients were randomized to 60 U of bleomycin or 500 mg of doxycycline sclerotherapy. Response at 30 days was determined. RESULTS: One hundred six patients were enrolled in the study. Fifteen men (29%) and 37 women (71%) with a mean age of 57 years received bleomycin sclerotherapy. Twenty-one of the 29 patients (72%) alive and evaluable at 30 days had successful sclerotherapy. Twenty-three men (43%) and 31 women (57%) with a mean age of 61 years received doxycycline sclerotherapy. Twenty-three of the 29 patients (79%) alive and evaluable at 30 days had successful sclerotherapy. There was no significant difference in response rates between doxycycline and bleomycin (p=0.760). CONCLUSIONS: These data continue to support a role for small-bore chest drainage and sclerotherapy, although there was no significant difference in 30-day response rates between doxycycline and bleomycin.

Thoracic imaging features of patients with antiphospholipid antibodies.

PURPOSE: Our aim was to determine the thoracic manifestations of patients with antiphospholipid antibodies (APAs). METHOD: We performed a retrospective review of the clinical records and thoracic imaging studies of 88 patients (63 women, 25 men; mean age 47 years) with APAs to determine the spectrum of thoracic disease. RESULTS: Nine patients (10%) had thoracic abnormalities, including eight with pulmonary embolism (PE) and one with aortic thrombus. One patient with PE had subclavian vein thrombosis. Coexistent thromboses included deep venous thrombosis of the leg in six patients. CONCLUSION: PE was the most common thoracic abnormality in our patients. The presence of these antibodies should be suspected in patients with PE of otherwise unexplained etiology.

Prevalence of treated behavioral disorders among adult shelter users: a longitudinal study.

Of 27,638 homeless adults admitted to Philadelphia public shelters in the years 1990 through 1992, 20.1% received treatment for a mental health disorder, and 25.3% for a substance use disorder in the years 1985 through 1993. An additional 20.7% were identified as having untreated substance use problems. Overall, a total of 65.5% of adult shelter users were identified as ever having had a mental health or substance use problem, treated or untreated.

The rate of public shelter admission among Medicaid-reimbursed users of behavioral health services.

This study examined the rate of admission to public shelters between 1990 and 1992 among persons who received Medicaid-reimbursed inpatient and outpatient psychiatric services and inpatient substance abuse services in Philadelphia between 1985 and 1993. Results show that 7.5 percent of such persons were admitted to public shelters during the three-year period, nearly 2.7 times the rate of shelter use by the general population (2.8 percent). Medicaid recipients treated for serious mental disorders had a three-year rate of shelter use of 8.4 percent. Those receiving inpatient treatment for substance use disorders, including detoxification services, had a three-year rate of shelter admission of 10.2 percent.

For-profit versus non-profit freestanding psychiatric inpatient facilities: an update.

Although several studies have examined the trend toward the decreasing differentiation of non-profit from for-profit general hospitals, few have focused on freestanding psychiatric hospitals. This study updates previous research that used psychiatric hospital data from calendar year 1986 with data from 1990. In addition, a preliminary examination of the influence of market competition on the behavior of non-profit psychiatric facilities was conducted. Results confirm a converging trend between for-profit and non-profit facilities that is related, in part, to competition.

Old and new: a comparison of state psychiatric hospitals.

The study examined whether state hospitals in operation before deinstitutionalization still carry vestiges of older models of psychiatric care. Using a national database, the authors compared 166 state hospitals built before 1949 with 80 state hospitals built after that time. The old hospitals treated fewer children and adolescents, received more state funding and less third-party funding, had fewer professional clinical staff, spent less on salaries and maintenance, and had more beds, a lower turnover rate, and a longer average length of stay. Findings suggest that planners and policymakers should take into account a facility's history when attempting to introduce innovations.

The current practice of child and adolescent partial hospitalization: results of a national survey.

OBJECTIVE: In 1992, the American Association for Partial Hospitalization initiated a national survey of partial hospitalization providers to investigate their present status (programming, staffing, and pricing), to track market trends, and to improve advocacy for appropriate utilization and reimbursement. METHOD: Instrument development and field testing preceded widespread distribution of the survey. From survey data, a description of child and adolescent partial hospital services based on statistical averages is reported as are analyses of program differences by length of stay and for-profit/not-for-profit status. RESULTS: Of the 580 programs responding, 95 indicated that at least 50% of their patient population consisted of children and adolescents. Descriptive statistics on this subsample suggest continued variability in child and adolescent partial hospital programming. Program differences in referral and discharge patterns, population and programming, and utilization and funding patterns based on length of stay and profit status are presented. CONCLUSIONS: The pattern of significant program differences between acute-care and long-term child and adolescent partial hospital programs and for-profit/not-for-profit programs (along with the absence of for-profit programs treating children and adolescents in long-term programs) points to an evolving system of care.

A reexamination of the reported decline in partial hospitalization.

This study examines recent trends in the organization of partial-hospitalization services in the United States. Contrary to two recent reports describing declining support for partial hospitalization, data from the National Institute of Mental Health's Inventory of Mental Health Organizations reveal that the number of "partial-care" providers increased by 20% between 1984 and 1988, with increases occurring among privately and publicly funded programs. However, there has been a 56% decline in the average length of stay, with both privately and publicly funded programs showing proportional shifts to more acute care. An increase in the number of long-stay "day care" programs may be attributable to educational and rehabilitation programs that report as partial-care providers. Future study is proposed to create a better typology of partial-hospitalization programs.

The status of community mental health centers ten years into Block Grant Financing.

This study tracks the 761 community mental health centers which received federal grants as of 1981 and assesses their status 10 years after the shift to Block Grant financing. Contrary to what had been predicted (Biegel, 1982), the vast majority of centers remained open (88.3%), a small proportion were involved in mergers (8.5%) and an even smaller percentage closed (3.3%). No pattern was evident as to which centers closed or merged by type of initial funding, although some states showed a concentration of mergers and closures. Data from the 1988 Inventory of Mental Health Organizations are used to characterize the centers still in operation by facility type, ownership, service mix and revenue mix. In 1988, federally funded CMHCs accounted for 34% of the total patient episodes treated and 22.7% of the total revenues reported by specialty mental health providers in the United States.

The discriminating characteristics of for-profit versus not-for-profit freestanding psychiatric inpatient facilities.

This study examines the characteristics that discriminate between ownership types among private, freestanding psychiatric inpatient facilities in the United States. Use of data from the Inventory of Mental Health Organizations (National Institute of Mental Health 1983, 1986), revealed that not-for-profits provide more services and serve more of the underinsured, while for-profits serve the better insured, concentrate primarily on inpatient services, and serve more children, adolescents, and substance abusers. A surplus bed capacity among for-profit psychiatric hospitals is presumed to contribute to lower occupancy rates and less turnover in the for-profit sector. Not-for-profit psychiatric facilities are also found to be more involved in professional training and to be more accessible through emergency services. However, the misclassification test in the discriminant procedure reveals that a significant group of not-for-profit facilities looks more like its for-profit counterpart group than like other not-for-profits. Study findings are interpreted both in terms of debates over the tax-exempt status of not-for-profit hospitals and the potential negative service effects of proprietization.

Prehospital patients refusing care.

In summary, many of the complex medicolegal and ethical issues surrounding the prehospital patient who refuses all or part of the care offered by the EMS system have been reviewed. The best outcome can be achieved using a sliding scale of capacity and a conservative approach to treatment rather than releasing the patient at the scene. Finally, the roles of collateral history, inquiries as to the origin of the patient's refusal of care, direct physician interaction with the patient, a spirit of creativity and compromise in dealing with the patient, meticulous documentation, and policy issues have been discussed.

Subclavian vein catheterization in the emergency department: a comparison of guidewire and nonguidewire techniques.

Guidewire catheters have been used with increasing frequency during the last several years for placement of central venous lines. No data exist comparing success and complication rates of guidewire and nonguidewire catheterization in the emergency setting. A prospective, randomized study was conducted to compare GW and NGW central venous catheterization (CVC) by the infraclavicular subclavian approach. The study consisted of 210 patients (87 trauma, 123 medical) requiring a CVC as part of their emergency department care. Catheter placement and complications were determined by immediate chest radiograph, two-day followup, and chart review after discharge. Results demonstrated no statistically significant differences in success rates or complications, with the exception of catheter malfunction due to extrathoracic vascular placement or catheter kinkage. This complication occurred more frequently when the guidewire technique was used. The guidewire CVC technique does not appear to offer any improvement of complication rates when compared to the nonguidewire technique.