The Association Between Homelessness and Key Liver-Related Outcomes in Veterans With Cirrhosis.
Journal
The American journal of gastroenterology
ISSN: 1572-0241
Titre abrégé: Am J Gastroenterol
Pays: United States
ID NLM: 0421030
Informations de publication
Date de publication:
27 Oct 2023
27 Oct 2023
Historique:
received:
03
04
2023
accepted:
06
09
2023
pubmed:
2
10
2023
medline:
2
10
2023
entrez:
2
10
2023
Statut:
aheadofprint
Résumé
Homelessness adversely affects patient outcomes in broad cohort studies; however, its impact on key liver-related outcomes in patients with cirrhosis is understudied. We aimed to address this knowledge gap using data from the Veterans Health Administration, a cohort disproportionately affected by homelessness. This was a retrospective cohort study of the Veterans Health Administration patients with incident cirrhosis diagnosis between January 2008 and February 2022. Homeless status was classified at baseline and as time-updating variable during follow-up. Inverse probability treatment weighted Cox regression was performed to evaluate the association between homelessness and outcomes of all-cause mortality, cirrhosis decompensation, and hepatocellular carcinoma. A total of 117,698 patients were included in the cohort, of whom 14,243 (12.1%) were homeless at baseline. In inverse probability treatment weighted Cox regression, homelessness was associated with a 24% higher hazard of all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.22-1.26, P < 0.001). However, in competing risk regression models, homelessness was associated with a reduced subhazard of decompensation (subhazard ratio 0.86, 95% CI 0.84-0.88, P < 0.001) and hepatocellular carcinoma (subhazard ratio 0.86, 95% CI 0.83-0.89, P < 0.001). In cause-specific mortality analysis, homeless patients had significantly increased non-liver-related and liver-related mortality; however, the magnitude of effect size was greater for non-liver-related mortality (csHR 1.38, 95% CI 1.35-1.40, P < 0.001). Homelessness in veterans with cirrhosis is associated with increased all-cause mortality; however, this is likely mediated primarily through non-liver-related factors. Future studies are needed to explore drivers of mortality and improve mitigation strategies in these patients.
Identifiants
pubmed: 37782293
doi: 10.14309/ajg.0000000000002535
pii: 00000434-990000000-00892
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Subventions
Organisme : Foundation for the National Institutes of Health
ID : K08-DK124577
Organisme : Foundation for the National Institutes of Health
ID : K08-DK117013
Organisme : Foundation for the National Institutes of Health
ID : R01-AG079911
Organisme : U.S. Department of Veterans Affairs
ID : I01-CX-002010
Organisme : U.S. Department of Veterans Affairs
ID : I01-CX-001933
Informations de copyright
Copyright © 2023 by The American College of Gastroenterology.
Références
De Sousa T, Andrichik A, Cuellar M, et al. The 2022 Annual Homelessness Assessment Report (AHAR) to Congress part 1: Point-in-Time Estimates of Homelessness December 2022 Acknowledgements. The U.S. Department of Housing and Urban Development: Washington, DC, 2022.
Nichter B, Tsai J, Pietrzak RH. Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans. Psychol Med. 2023;53(9):3952–62.
Carbonneau M, Davyduke T, Congly SE, et al. Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization. Can Liver J 2021;4(1):38–50.
Cohen-Mekelburg S, Waljee AK, Kenney BC, et al. Coordination of care is associated with survival and health care utilization in a population-based study of patients with cirrhosis. Clin Gastroenterol Hepatol 2020;18(10):2340–8.e3.
Beste LA, Ioannou GN. Prevalence and treatment of chronic hepatitis C virus infection in the US department of veterans affairs. Epidemiol Rev 2015;37(1):131–43.
Beste LA, Leipertz SL, Green PK, et al. Trends in burden of cirrhosis and hepatocellular carcinoma by underlying liver disease in US veterans, 2001-2013. Gastroenterology 2015;149(6):1471–82.e5; quiz e17-8.
Mahmud N, Fricker Z, Panchal S, et al. External validation of the VOCAL-penn cirrhosis surgical risk score in 2 large, independent health systems. Liver Transpl 2021;27(7):961–70.
Peterson R, Gundlapalli AV, Metraux S, et al. Identifying homelessness among veterans using VA administrative data: Opportunities to expand detection criteria. PLoS One 2015;10(7):e0132664.
Homeless incidence and risk factors for becoming homeless in veterans ( http://www.va.gov/oig/hotline/default.asp ) (2012). Accessed February 15, 2023.
Marrie RA, Walker JR, Graff LA, et al. Performance of administrative case definitions for depression and anxiety in inflammatory bowel disease. J Psychosom Res 2016;89:107–13.
Marrie RA, Fisk JD, Yu BN, et al. Mental comorbidity and multiple sclerosis: Validating administrative data to support population-based surveillance. BMC Neurol 2013;13:16.
Lurie N, Popkin M, Dysken M, et al. Accuracy of diagnoses of schizophrenia in Medicaid claims. Hosp Community Psychiatry 1992;43(1):69–71.
Pang JXQ, Ross E, Borman MA, et al. Validation of coding algorithms for the identification of patients hospitalized for alcoholic hepatitis using administrative data. BMC Gastroenterol 2015;15(1):116–8.
McGrew KM, Carabin H, Garwe T, et al. Validity of ICD-based algorithms to estimate the prevalence of injection drug use among infective endocarditis hospitalizations in the absence of a reference standard. Drug Alcohol Depend 2020;209:107906.
Afshar M, Sharma B, Dligach D, et al. Development and multimodal validation of a substance misuse algorithm for referral to treatment using artificial intelligence (SMART-AI): A retrospective deep learning study. Lancet Digital Health 2022;4(6):e426–e435.
Fazel S, Yoon IA, Hayes AJ. Substance use disorders in prisoners: An updated systematic review and meta-regression analysis in recently incarcerated men and women. Addiction (Abingdon, England) 2017;112(10):1725–39.
Kaplan DE, Dai F, Aytaman A, et al. Development and performance of an algorithm to estimate the child-turcotte-pugh score from a national electronic healthcare database. Clin Gastroenterol Hepatol 2015;13(13):2333–41.e1-6.
Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory care quality improvement project (ACQUIP). Alcohol use disorders identification test. Arch Intern Med 1998;158(16):1789–95.
Sohn MW, Arnold N, Maynard C, et al. Accuracy and completeness of mortality data in the department of veterans affairs. Popul Health Metrics 2006;4(1):2–8.
Mahmud N, Kaplan DE, Taddei TH, et al. Incidence and mortality of acute-on-chronic liver failure using two definitions in patients with compensated cirrhosis. Hepatology 2019;69(5):2150–63.
Mahmud N, Fricker Z, Hubbard RA, et al. Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology 2021;73(1):204–18.
Brown RT, Evans JL, Valle K, et al. Factors associated with mortality among homeless older adults in California: The HOPE HOME study. JAMA Intern Med 2022;182(10):1052–60.
Baggett TP, Hwang SW, O'Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med 2013;173(3):189–95.
Cawley C, Kanzaria HK, Zevin B, et al. Mortality among people experiencing homelessness in San Francisco during the COVID-19 pandemic. JAMA Netw Open 2022;5(3):e221870.
Baggett TP, Liauw SS, Hwang SW. Cardiovascular disease and homelessness. J Am Coll Cardiol 2018;71(22):2585–97.
Determinants of regular source of care among homeless adults in Los Angeles on JSTOR ( https://www.jstor.org/stable/3766492 ). Accessed December 4, 2022.
Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA 2001;285(2):200–6.
Kushel MB, Perry S, Bangsberg D, et al. Emergency department use among the homeless and marginally housed: Results from a community-based study. Am J Public Health 2002;92(5):778–84.
Hwang SW, Chambers C, Chiu S, et al. A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. Am J Public Health 2013;103(Suppl 2):S294–S301.
Bharel M, Lin WC, Zhang J, et al. Health care utilization patterns of homeless individuals in Boston: Preparing for Medicaid expansion under the Affordable Care Act. Am J Public Health 2013;103(Suppl 2):S311–S317.
Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: National comparison of homeless and nonhomeless US veterans who use veterans affairs emergency departments. Am J Public Health 2013;103(Suppl 2):S225–S231.
Henry M, De Sousa T, Roddey C, et al. The 2020 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development: Washington, DC, 2020.
2021 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point in Time Estimates of Sheltered Homelessness|Enhanced Reader. The U.S. Department of Housing and Urban Development: Washington, DC, 2021.
Levitt AJ, Culhane DP, DeGenova J, et al. Health and social characteristics of homeless adults in Manhattan who were chronically or not chronically unsheltered. Psychiatr Serv 2009;60(7):978–81.
Flaming D, Burns P, Carlen J. Escape routes: Meta-analysis of homelessness in L.A. SSRN Electron J 2018. 10.2139/SSRN.3202467
doi: 10.2139/SSRN.3202467
Byrne T, Montgomery AE, Fargo JD. Unsheltered homelessness among veterans: Correlates and profiles. Community Ment Health J 2016;52(2):148–57.
Henry M, De Sousa T, Tano C, et al. 2021 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point in Time Estimates of Sheltered Homelessness. The U.S. Department of Housing and Urban Development: Washington, DC, 2021.
Veterans Health Administration. Homeless programs office. US Department of Veterans Affairs: Washington, DC, 2022, pp 1–19.
Wang PL, Djerboua M, Flemming JA. Cause-specific mortality among patients with cirrhosis in a population-based cohort study in Ontario (2000–2017). Hepatol Commun 2023;7(7):e00194.