Risk factors for unplanned hospital admission in a specialist homeless general practice population: case-control study to investigate the relationship with tri-morbidity.

BACKGROUND: 'Tri-morbidity' describes the complex comorbidity of chronic physical illness, mental illness, and alcohol and/or drug misuse within the homeless population. Poor health outcomes of homeless people are reflected by the higher rate of unplanned hospital admissions compared with the non-homeless population. AIM: To identify whether tri-morbidity is a risk factor for unplanned hospital admissions in the homeless population. DESIGN AND SETTING: A case-control study of patients who were registered with a specialist homeless GP surgery in Brighton (72 cases and 72 controls). METHOD: Cases were defined as those who had ≥1 overnight hospital admission within a 12-month period. Controls were matched for demographics but with no hospital admission. The primary care record was analysed, and tri-morbidity entered into binomial logistic regression with admission as the dichotomous dependent variable. RESULTS: The logistic regression analysis demonstrated that other enduring mental health disorders and/or personality disorder (odds ratio [OR] 3.84, 95% confidence interval [CI] = 1.56 to 9.44), alcohol use (OR 2.92, 95% CI = 1.42 to 5.98), and gastrointestinal disorder (OR 2.90, 95% CI = 1.06 to 7.98) were independent risk factors for admission. Tri-morbidity increased odds of admission by more than four-fold (OR 4.19, 95% CI = 1.90 to 9.27). CONCLUSION: This study shows that tri-morbidity is an important risk factor for unplanned hospital admissions among the homeless population, and provides an interesting starting point for the development of a risk stratification tool to identify those at risk of unplanned admission in this population.

Randomised controlled trial of GP-led in-hospital management of homeless people ('Pathway').

Homeless people have complex problems. GP enhanced care (Pathway) has shown benefits. We performed a randomised, -parallel arm trial at two large inner city hospitals. Inpatient homeless adults were randomly allocated to either standard care (all management by the hospital-based clinical team) or enhanced care with input from a homeless care team. The hospital data system provided healthcare usage information, and we used questionnaires to assess quality of life. 206 patients were allocated to enhanced care and 204 to usual care. Length of stay (up to 90 days after admission) did not differ between groups (standard care 14.0 days, enhanced care 13.3 days). Average reattendance at the emergency department within a year was 5.8 visits in the standard care group and 4.8 visits with enhanced care, but this decrease was not significant. -Quality of life scores after discharge (in 108 patients) improved with enhanced care (EQ-5D-5L score increased by 0.12 [95% CI 0.032 to 0.22] compared wtih 0.03 [-0.1 to 0.15; p=0.076] with standard care). The proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm (p=0.034). The quality-of-life cost per quality-adjusted life-year was £26,000. The Pathway approach doesn't alter length of stay but improves quality of life and reduces street -homelessness.

Floodplain ecohydrology: Climatic, anthropogenic, and local physical controls on partitioning of water sources to riparian trees.

Seasonal and annual partitioning of water within river floodplains has important implications for ecohydrologic links between the water cycle and tree growth. Climatic and hydrologic shifts alter water distribution between floodplain storage reservoirs (e.g., vadose, phreatic), affecting water availability to tree roots. Water partitioning is also dependent on the physical conditions that control tree rooting depth (e.g., gravel layers that impede root growth), the sources of contributing water, the rate of water drainage, and water residence times within particular storage reservoirs. We employ instrumental climate records alongside oxygen isotopes within tree rings and regional source waters, as well as topographic data and soil depth measurements, to infer the water sources used over several decades by two co-occurring tree species within a riparian floodplain along the Rhône River in France. We find that water partitioning to riparian trees is influenced by annual (wet versus dry years) and seasonal (spring snowmelt versus spring rainfall) fluctuations in climate. This influence depends strongly on local (tree level) conditions including floodplain surface elevation and subsurface gravel layer elevation. The latter represents the upper limit of the phreatic zone and therefore controls access to shallow groundwater. The difference between them, the thickness of the vadose zone, controls total soil moisture retention capacity. These factors thus modulate the climatic influence on tree ring isotopes. Additionally, we identified growth signatures and tree ring isotope changes associated with recent restoration of minimum streamflows in the Rhône, which made new phreatic water sources available to some trees in otherwise dry years. KEY POINTS: Water shifts due to climatic fluctuations between floodplain storage reservoirsAnthropogenic changes to hydrology directly impact water available to treesEcohydrologic approaches to integration of hydrology afford new possibilities.