Quality improvement in the era of boarding and burnout: A postpandemic blueprint.

The COVID-19 pandemic led to unprecedented challenges to healthcare quality in the emergency department, including directly impacting quality metrics and worsening barriers to the quality improvement process such as burnout, staff turnover, and boarding. We aimed to develop a blueprint for postpandemic quality improvement to address these specific barriers, focused on prioritizing frontline staff engagement from idea generation to implementation and assessment. Drawing from teamwork literature, we constructed a process that emphasized egalitarian conversations, psychological safety, and creating an environment where staff could feel heard at every step of the process. We applied this blueprint to improving rates of patients who leave without being seen and achieved a four percentage point reduction (9% vs. 5%, p < 0.001), with high rates of staff satisfaction with the process. We conclude that while postpandemic quality improvement presents significant challenges, we can rise to meet those challenges by adapting existing quality improvement processes to increase frontline staff engagement.

Housing Status and Acute Care Use After Cancer Diagnosis.

This cohort study examines housing status and acute care use after a cancer diagnosis among individuals treated at a public hospital in San Francisco, California.

Association of Homelessness with Before Medically Advised Discharge After Surgery.

BACKGROUND: Before medically advised (BMA) discharge, which refers to patients leaving the hospital at their own discretion, is associated with higher rates of readmission and death in other settings. It is not known if housing status is associated with this phenomenon after surgery. METHODS: We identified all admitted adults who underwent an operation by one of 11 different surgical services at a single tertiary care hospital between January 2013 and June 2022. Chi-square tests and t-tests were used to compare demographic and clinical features between BMA discharges and standard discharges. Multivariable logistic regression was used to evaluate the association between housing status and BMA discharge, adjusting for demographic and admission characteristics. Documented reasons for BMA discharge were also abstracted from the medical record. RESULTS: Of 111,036 patient admissions, 242 resulted in BMA discharge (0.2%). After adjusting for observable confounders, patients experiencing homelessness had substantially higher odds of BMA discharge after surgery (adjusted odds ratio 4.4, 95% confidence interval 3.0-6.4; p < 0.001) when compared to housed. Patients who underwent emergency surgery, patients with a documented substance use disorder, and those insured by Medicaid also had significantly higher odds of BMA discharge. System- or provider-related reasons (including patient frustration with the hospital environment, challenges in managing substance dependence, and perceived inadequacy of paint control) were documented in 96% of BMA discharges for patients experiencing homelessness (vs. 66% in housed patients). CONCLUSION: BMA discharge is more common in patients experiencing homelessness after surgery even after adjusting for observable confounding characteristics. Deeper understanding of the drivers of BMA discharge in patients experiencing homelessness through qualitative methods are critical to promote more equitable and effective care.

Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America.

Importance: Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective: To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants: This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures: People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures: Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results: Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance: The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.

Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans.

Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.

Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness.

BACKGROUND: Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH. METHODS: This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs. RESULTS: Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH. CONCLUSIONS: PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.

Provider perceptions of challenges and facilitators to surgical care in unhoused patients: A qualitative analysis.

BACKGROUND: Unhoused patients have worse surgical outcomes than the general population. However, the drivers of this inequity have not been studied. METHODS: We conducted 26 semi-structured interviews of clinicians who care for patients with surgical disease, using a purposive sampling strategy to intentionally recruit participants with significant experience caring for unhoused patients across different roles. We used thematic analysis to analyze the resulting data. RESULTS: We conducted 26 interviews: 11 with surgeons (42%), 8 with internal medicine physicians (30%), 2 with surgical advanced practice providers (8%), 3 with social workers or case managers (11%), and 2 with registered nurses (8%). One-third of the participants worked in either medical respite or street medicine programs. We identified 5 themes, each of which was most relevant at a distinct point along the spectrum of surgical care: (1) patients and clinicians face multiple challenges meeting preoperative requirements, (2) although surgeons do not make major operative decisions based on housing status, some take it into consideration for minor care decisions, (3) clinicians perceive that unhoused patients have negative postoperative experiences in the hospital, (4) discharge options for unhoused patients are commonly imperfect, which can lead to inadequate postoperative care, (5) challenges with formal communication between surgeons and non-surgeons are amplified when caring for unhoused patients. CONCLUSION: Clinicians who care for unhoused patients with surgical disease relayed multiple challenges throughout all phases of surgical care and relied on both formal and informal mechanisms to mitigate these challenges. There may be opportunities to intervene and improve access to surgical care for this vulnerable group.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans.

Importance: Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. Objective: To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Design, Setting, and Participants: This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Exposures: Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. Main Outcomes and Measures: The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. Results: This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. Conclusions and Relevance: In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness.

Importance: Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale. Objective: To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission. Design, Setting, and Participants: This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022. Exposures: PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable. Main Outcomes and Measures: The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment). Results: A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19). Conclusions and Relevance: Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.

Association of Housing Status With Types of Operations and Postoperative Health Care Utilization.

OBJECTIVE: To analyze the association between housing status and the nature of surgical care provided, health care utilization, and operational outcomes. BACKGROUND: Unhoused patients have worse outcomes and higher health care utilization across multiple clinical domains. However, little has been published describing the burden of surgical disease in unhoused patients. METHODS: We conducted a retrospective cohort study of 111,267 operations from 2013 to 2022 with housing status documented at a single, tertiary care institution. We conducted unadjusted bivariate and multivariate analyses adjusting for sociodemographic and clinical characteristics. RESULTS: A total of 998 operations (0.8%) were performed for unhoused patients, with a higher proportion of emergent operations than housed patients (56% vs 22%). In unadjusted analysis, unhoused patients had longer length of stay (18.7 vs 8.7 days), higher readmissions (9.5% vs 7.5%), higher in-hospital (2.9% vs 1.8%) and 1-year mortality (10.1% vs 8.2%), more in-hospital reoperations (34.6% vs 15.9%), and higher utilization of social work, physical therapy, and occupational therapy services. After adjusting for age, sex, comorbidities, insurance status, and indication for operation, as well as stratifying by emergent versus elective operation, these differences went away for emergent operations. CONCLUSIONS: In this retrospective cohort analysis, unhoused patients more commonly underwent emergent operations than their housed counterparts and had more complex hospitalizations on an unadjusted basis that largely disappeared after adjustment for patient and operative characteristics. These findings suggest issues with upstream access to surgical care that, when unaddressed, may predispose this vulnerable population to more complex hospitalizations and worse longer term outcomes.

Characterizing patients hospitalized without an acute care indication: A retrospective cohort study.

BACKGROUND: Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays. OBJECTIVE: To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs. DESIGNS, SETTINGS, AND PARTICIPANTS: A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital. MAIN OUTCOME AND MEASURES: Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics. RESULTS: Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001). CONCLUSIONS: Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.

Hospital variability in adoption of alcohol and drug screening in adult trauma patients.

BACKGROUND: Despite recommendations to screen all injured patients for substance use, single-center studies have reported underscreening. This study sought to determine if there was significant practice variability in adoption of alcohol and drug screening of injured patients among hospitals participating in the Trauma Quality Improvement Program. METHODS: This was a retrospective observational cross-sectional study of trauma patients 18 years or older in Trauma Quality Improvement Program 2017-2018. Hierarchical multivariable logistic regression modeled the odds of screening for alcohol and drugs via blood/urine test while controlling for patient and hospital variables. We identified statistically significant high and low-screening hospitals based on hospitals' estimated random intercepts and associated confidence intervals (CIs). RESULTS: Of 1,282,111 patients at 744 hospitals, 619,423 (48.3%) were screened for alcohol, and 388,732 (30.3%) were screened for drugs. Hospital-level alcohol screening rates ranged from 0.8% to 99.7%, with a mean rate of 42.4% (SD, 25.1%). Hospital-level drug screening rates ranged from 0.2% to 99.9% (mean, 27.1%; SD, 20.2%). A total of 37.1% (95% CI, 34.7-39.6%) of variance in alcohol screening and 31.5% (95% CI, 29.2-33.9%) of variance in drug screening were at the hospital level. Level I/II trauma centers had higher adjusted odds of alcohol screening (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.41) and drug screening (aOR, 1.16; 95% CI, 1.08-1.25) than Level III and nontrauma centers. We found 297 low-screening and 307 high-screening hospitals in alcohol after adjusting for patient and hospital variables. There were 298 low-screening and 298 high-screening hospitals for drugs. CONCLUSION: Overall rates of recommended alcohol and drug screening of injured patients were low and varied significantly between hospitals. These results underscore an important opportunity to improve the care of injured patients and reduce rates of substance use and trauma recidivism. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Cluster Analysis of the Highest Users of Medical, Behavioral Health, and Social Services in San Francisco.

BACKGROUND: In the City and County of San Francisco, frequent users of emergent and urgent services across different settings (i.e., medical, mental health (MH), substance use disorder (SUD) services) are referred to as high users of multiple systems (HUMS). While often grouped together, frequent users of the health care system are likely a heterogenous population composed of subgroups with differential management needs. OBJECTIVE: To identify subgroups within this HUMS population using a cluster analysis. DESIGN: Cross-sectional study of HUMS patients for the 2019-2020 fiscal year using the Coordinated Care Management System (CCMS), San Francisco Department of Public Health's integrated data system. PARTICIPANTS: We calculated use scores based on nine types of urgent and emergent medical, MH, and SUD services and identified the top 5% of HUMS patients. Through k-medoids cluster analysis, we identified subgroups of HUMS patients. MAIN MEASURES: Subgroup-specific demographic, comorbidity, and service use profiles. KEY RESULTS: The top 5% of HUMS patients in the study period included 2657 individuals; 69.7% identified as men and 66.5% identified as non-White. We detected 5 subgroups: subgroup 1 (N = 298, 11.2%) who were relatively younger with prevalent MH and SUD comorbidities, and MH services use; subgroup 2 (N = 478, 18.0%), who were experiencing homelessness, with multiple comorbidities, and frequent use of medical services; subgroup 3 (N = 449, 16.9%), who disproportionately self-identified as Black, with prolonged homelessness, multiple comorbidities, and persistent HUMS status; subgroup 4 (N = 690, 26.0%), who were relatively older, disproportionately self-identified as Black, with prior homelessness, multiple comorbidities, and frequent use of medical services; and subgroup 5 (N=742, 27.9%), who disproportionately self-identified as Latinx, were housed, with medical comorbidities and frequent medical service use. CONCLUSIONS: Our study highlights the heterogeneity of HUMS patients. Interventions must be tailored to meet the needs of these diverse patient subgroups.

Perspectives of COVID-19 vaccine-hesitant emergency department patients to inform messaging platforms to promote vaccine uptake.

OBJECTIVES: Efforts to promote COVID-19 vaccine acceptance must consider the critical role of the emergency department (ED) in providing health care to underserved patients. Focusing on patients who lacked primary care, we sought to elicit the perspectives of unvaccinated ED patients regarding COVID-19 vaccination concerns and potential approaches that might increase their vaccine acceptance. METHODS: We conducted this qualitative interview study from August to November 2021 at four urban EDs in San Francisco, California; Seattle, Washington; Durham, North Carolina; and Philadelphia, Pennsylvania. We included ED patients who were ≥18 years old, fluent in English or Spanish, had not received a COVID-19 vaccine, and did not have primary care physicians or clinics. We excluded patients who were unable to complete an interview, in police custody, under suspicion of active COVID-19 illness, or presented with a psychiatric chief complaint. We enrolled until we reached thematic saturation in relevant domains. We analyzed interview transcripts with a content analysis approach focused on identifying concerns about COVID-19 vaccines and ideas regarding the promotion of vaccine acceptance and potential trusted messengers. RESULTS: Of 65 patients enrolled, 28 (43%) identified as female, their median age was 36 years (interquartile range 29-49), and 12 (18%) interviews were conducted in Spanish. Primary concerns about COVID-19 vaccines included risk of complications, known and unknown side effects, and fear of contracting COVID-19 from vaccines. Trust played a major role for patients in deciding which sources to use for vaccine information and in engendering vaccine acceptance. Health care providers and family or friends were commonly cited as trusted messengers of information. CONCLUSIONS: We characterized concerns about COVID-19 vaccines, uncovered themes that may promote vaccine acceptance, and identified trusted messengers-primarily health care professionals. These data may inform the development of nuanced COVID-19 vaccine messaging platforms to address COVID-19 vaccine hesitancy among underserved ED populations.

Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic.

Importance: Although the general US population had fewer emergency department (ED) visits during the COVID-19 pandemic, patterns of use among high users are unknown. Objectives: To examine natural trends in ED visits among high users of health and social services during an extended period and assess whether these trends differed during COVID-19. Design, Setting, and Participants: This retrospective cohort study combined data from 9 unique cohorts, 1 for each fiscal year (July 1 to June 30) from 2012 to 2021, and used mixed-effects, negative binomial regression to model ED visits over time and assess ED use among the top 5% of high users of multiple systems during COVID-19. Data were obtained from the Coordinated Care Management System, a San Francisco Department of Public Health platform that integrates medical and social information with service use. Exposures: Fiscal year 2020 was defined as the COVID-19 year. Main Outcomes and Measures: Measured variables were age, gender, language, race and ethnicity, homelessness, insurance status, jail health encounters, mental health and substance use diagnoses, and mortality. The main outcome was annual mean ED visit counts. Incidence rate ratios (IRRs) were used to describe changes in ED visit rates both over time and in COVID-19 vs non-COVID-19 years. Results: Of the 8967 participants, 3289 (36.7%) identified as White, 3005 (33.5%) as Black, and 1513 (16.9%) as Latinx; and 7932 (88.5%) preferred English. The mean (SD) age was 46.7 (14.2) years, 6071 (67.7%) identified as men, and 7042 (78.5%) had experienced homelessness. A statistically significant decrease was found in annual mean ED visits among high users for every year of follow-up until year 8, with the largest decrease occurring in the first year of follow-up (IRR, 0.41; 95% CI, 0.40-0.43). However, during the pandemic, ED visits decreased 25% beyond the mean reduction seen in prepandemic years (IRR, 0.75; 95% CI, 0.72-0.79). Conclusions and Relevance: In this study, multiple cohorts of the top 5% of high users of multiple health care systems in San Francisco had sustained annual decreases in ED visits from 2012 to 2021, with significantly greater decreases during COVID-19. Further research is needed to elucidate pandemic-specific factors associated with these findings and understand how this change in use was associated with health outcomes.

Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic.

Importance: Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. Objective: To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. Design, Setting, and Participants: This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. Exposures: SIP hotel placement with on-site supportive services. Main Outcomes and Measures: The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. Results: Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001). Conclusions and Relevance: These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.

Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic.

Importance: There has been recent media attention on the risk of excess mortality among homeless individuals during the COVID-19 pandemic, yet data on these deaths are limited. Objectives: To quantify and describe deaths among people experiencing homelessness in San Francisco during the COVID-19 pandemic and to compare the characteristics of these deaths with those in prior years. Design, Setting, and Participants: A cross-sectional study tracking mortality among people experiencing homelessness from 2016 to 2021 in San Francisco, California. All deceased individuals who were homeless in San Francisco at the time of death and whose deaths were processed by the San Francisco Office of the Chief Medical Examiner were included. Data analysis was performed from August to October 2021. Exposure: Homelessness, based on homeless living status in an administrative database. Main Outcomes and Measures: Descriptive statistics were used to understand annual trends in demographic characteristics, cause and manner of death (based on autopsy), substances present in toxicology reports, geographic distribution of deaths, and use of health and social services prior to death. Total estimated numbers of people experiencing homelessness in San Francisco were assessed through semiannual point-in-time counts. The 2021 point-in-time count was postponed owing to the COVID-19 pandemic. Results: In San Francisco, there were 331 deaths among people experiencing homelessness in the first year of the COVID-19 pandemic (from March 17, 2020, to March 16, 2021). This number was more than double any number in previous years (eg, 128 deaths in 2016, 128 deaths in 2017, 135 deaths in 2018, and 147 deaths in 2019). Most individuals who died were male (268 of 331 [81%]). Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury. COVID-19 was not listed as the primary cause of any deaths. The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic). Fewer decedents had contacts with health services in the year prior to their death during the pandemic than in prior years (13% used substance use disorder services compared with 20% in 2019). Conclusions and Relevance: In this cross-sectional study, the number of deaths among people experiencing homelessness in San Francisco increased markedly during the first year of the COVID-19 pandemic. These findings may guide future interventions to reduce mortality among individuals experiencing homelessness.

Understanding the association between frequent emergency department use and jail incarceration: A cross-sectional analysis.

BACKGROUND: Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration. METHODS: We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters. RESULTS: The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest. CONCLUSIONS: Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.