Publications by authors named "Kelly M Doran"

41 Publications

National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness.

J Subst Abuse Treat 2021 May 29;132:108504. Epub 2021 May 29.

Department of Population Health, NYU School of Medicine, 550 First Avenue, New York, NY 10016, United States of America.

Objective: People experiencing homelessness (PEH) have high rates of substance use, and homelessness may be an important driver of health disparities in the opioid overdose epidemic. However, few studies focus on homelessness among the opioid use disorder (OUD) treatment population. We examine national-level trends in substance use treatment admissions among PEH with OUD.

Methods: This study used data from first-time treatment admissions in the United States from the Treatment Episode Data Set: Admissions (TEDS-A) to examine characteristics and trends of adults experiencing homelessness who entered state-licensed substance use treatment programs for OUD from 2013 to 2017. We used chi-squared analyses to examine changes in characteristics of this population over time and logistic regression to assess characteristics associated with receipt of medications for opioid use disorder (MOUD) among PEH.

Results: Among all adults with OUD entering specialty treatment from 2013 to 2017, 12.5% reported experiencing homelessness. Compared to individuals not experiencing homelessness, PEH were more likely to be male, inject opioids, use cocaine or methamphetamine, and enter into residential detoxification treatment. PEH were less likely to enter outpatient treatment or receive MOUD. From 2013 to 2017, significant increases occurred in the proportion of PEH who had co-occurring psychiatric problems and used methamphetamines. Over time, treatment type shifted significantly from residential detoxification to outpatient treatment. Receipt of MOUD increased among PEH over time (13.7% to 25.2%), but lagged behind increases among individuals not experiencing homelessness. Among PEH, being older was associated with receiving MOUD, while concurrent methamphetamine use [adjusted odds ratio (AOR) 0.63; 95% CI 0.58, 0.69] and living in the southern United States (AOR 0.27; 95% CI 0.25, 0.30) were associated with not receiving MOUD.

Discussion: The proportion of PEH with OUD who receive medications as part of treatment increased over time, but three quarters of PEH entering treatment still do not receive this highest standard in evidence-based care. The sharp increase observed in concomitant methamphetamine use in this population is concerning and has implications for treatment.
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http://dx.doi.org/10.1016/j.jsat.2021.108504DOI Listing
May 2021

Screening Discordance and Characteristics of Patients With Housing-Related Social Risks.

Am J Prev Med 2021 Mar 27. Epub 2021 Mar 27.

Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts.

Introduction: Healthcare systems are increasingly interested in identifying patients' housing-related risks, but minimal information exists to inform screening question selection. The primary study aim is to evaluate discordance among 5 housing-related screening questions used in health care.

Methods: This was a cross-sectional multisite survey of social risks used in a convenience sample of adults seeking care for themselves or their child at 7 primary care clinics and 4 emergency departments across 9 states (2018-2019). Housing-related risks were measured using 2 questions from the Accountable Health Communities screening tool (current/anticipated housing instability, current housing quality problems) and 3 from the Children's HealthWatch recommended housing instability screening measures (prior 12-month: rent/mortgage strain, number of moves, current/recent homelessness). The 2-sided Fisher's exact tests analyzed housing-related risks and participant characteristics; logistic regression explored associations with reported health (2019-2020).

Results: Of 835 participants, 52% screened positive for ≥1 housing-related risk (n=430). Comparing the tools, 32.8% (n=274) screened discordant: 11.9% (n=99) screened positive by Children's HealthWatch questions but negative by Accountable Health Communities, and 21.0% (n=175) screened positive by the Accountable Health Communities tool but negative by Children's HealthWatch (p<0.001). Worse health was associated with screening positive for current/anticipated housing instability (AOR=0.56, 95% CI=0.32, 0.96) or current/recent homelessness (AOR=0.57, 95% CI=0.34, 0.96).

Conclusions: The 5 housing questions captured different housing-related risks, contributed to different health consequences, and were relevant to different subpopulations. Before implementing housing-related screening initiatives, health systems should understand how specific measures surface distinct housing-related barriers. Measure selection should depend on program goals and intervention resources.
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http://dx.doi.org/10.1016/j.amepre.2021.01.027DOI Listing
March 2021

Health Care for People Experiencing Homelessness-What Outcomes Matter?

JAMA Netw Open 2021 03 1;4(3):e213837. Epub 2021 Mar 1.

Department of Emergency Medicine, UCSF School of Medicine, San Francisco, California.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.3837DOI Listing
March 2021

The Joint Effect of Childhood Abuse and Homelessness on Substance Use in Adulthood.

Subst Use Misuse 2021 7;56(5):660-667. Epub 2021 Mar 7.

Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.

Background: Childhood abuse and homelessness are independently associated with substance use. Though childhood abuse and homelessness are strongly correlated, research on the joint effect of exposure to both traumatic life events on substance use is limited. To estimate independent and joint effects of childhood abuse and homelessness on substance use risk during emerging adulthood and adulthood. Using the National Longitudinal Study of Adolescent to Adult Health ( = 12,288), we measured associations between exposure to physical or sexual abuse in childhood, homelessness in childhood or emerging adulthood, or exposure to both traumas and outcomes of binge drinking, marijuana use, cocaine use, methamphetamine use, and prescription opioid misuse during emerging adulthood (Wave III, ages 18-26 years) and adulthood (Wave IV, ages 24-32 years). : In adjusted analyses, exposure to childhood abuse alone, homelessness alone, and both childhood abuse and homelessness were significant correlates of most substance use indicators in emerging adulthood. Those jointly exposed to childhood abuse and homelessness had disproportionate risk of substance use, particularly use of cocaine (adjusted odds ratio (AOR)=4.25, 95% confidence interval (CI): 2.70, 6.71) and methamphetamine (AOR = 6.59, 95% CI: 3.87, 11.21). The independent and combined effects of abuse and homelessness generally persisted into adulthood though associations tended to weaken. : Those with exposure to abuse, homelessness, and both adverse outcomes constitute a high-risk population for substance use. Addressing abuse and homelessness should be a component of preventing drug risk for screening, treatment, and prevention efforts.
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http://dx.doi.org/10.1080/10826084.2021.1887249DOI Listing
March 2021

Health-Related Social Needs Among Emergency Department Patients with HIV.

AIDS Behav 2021 Jun 1;25(6):1968-1974. Epub 2021 Jan 1.

Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.
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http://dx.doi.org/10.1007/s10461-020-03126-3DOI Listing
June 2021

Comparing methods of performing geographically targeted rural health surveillance.

Emerg Themes Epidemiol 2020 Nov 23;17(1). Epub 2020 Nov 23.

Department of Population Health, NYU School of Medicine, New York, NY, USA.

Background: Worsening socioeconomic conditions in rural America have been fueling increases in chronic disease and poor health. The goal of this study was to identify cost-effective methods of deploying geographically targeted health surveys in rural areas, which often have limited resources. These health surveys were administered in New York's rural Sullivan County, which has some of the poorest health outcomes in the entire state.

Methods: Comparisons were made for response rates, estimated costs, respondent demographics, and prevalence estimates of a brief health survey delivered by mail and phone using address-based sampling, and in-person using convenience sampling at a sub-county level in New York's rural Sullivan County during 2017.

Results: Overall response rates were 27.0% by mail, 8.2% by phone, and 71.4% for convenience in-person surveys. Costs to perform phone surveys were substantially higher than mailed or convenience in-person surveys. All modalities had lower proportions of Hispanic respondents compared to Census estimates. Unadjusted and age-adjusted prevalence estimates were similar between mailed and in-person surveys, but not for phone surveys.

Conclusions: These findings are consistent with declining response rates of phone surveys, which obtained an inadequate sample of rural residents. Though in-person surveys had higher response rates, convenience sampling failed to obtain a geographically distributed sample of rural residents. Of modalities tested, mailed surveys provided the best opportunity to perform geographically targeted rural health surveillance.
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http://dx.doi.org/10.1186/s12982-020-00090-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686693PMC
November 2020

Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis.

Ann Emerg Med 2020 10 21;76(4):462-467. Epub 2020 Apr 21.

Department of Applied Statistics, Social Sciences, and Humanities, NYU Steinhardt School, New York, NY.

Study Objective: Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless.

Methods: We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline.

Results: Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use.

Conclusion: In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.
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http://dx.doi.org/10.1016/j.annemergmed.2020.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541602PMC
October 2020

The Development Of Health And Housing Consortia In New York City.

Health Aff (Millwood) 2020 04;39(4):631-638

Kelly M. Doran is an assistant professor in the Departments of Emergency Medicine and Population Health, New York University School of Medicine.

Health and housing consortia in New York City offer a model for bridging the divide between the health care and housing sectors. While staff in these sectors often recognize the need to better integrate their services, there are few models for doing so. In this article we describe the formation of a health and housing consortium in the Bronx, New York City, as well as the successful replication of its model in Brooklyn. While each consortium has some features specific to its service area, the primary goal of both is the same: to provide a neutral space for health care and housing organizations to collaborate in what is otherwise often competitive and fragmented territory. In addition, the work of both consortia coalesces around training and resource development, cross-sector communication, and research and advocacy. We provide examples of the Bronx Consortium's activities in each of these core areas, highlight tangible results to date, and offer recommendations for people interested in undertaking similar efforts.
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http://dx.doi.org/10.1377/hlthaff.2019.01580DOI Listing
April 2020

Community Health Worker Intervention in Subsidized Housing: New York City, 2016-2017.

Am J Public Health 2020 05 19;110(5):689-692. Epub 2020 Mar 19.

Amy L. Freeman, Tianying Li, Sue A. Kaplan, and Marc N. Gourevitch are with the Department of Population Health, New York University (NYU) School of Medicine, New York, NY. Ingrid Gould Ellen is with NYU Furman Center, NYU Wagner School, New York, NY. Ashley Young is with Neighborhood Resource Center, Henry Street Settlement, New York, NY. Kelly M. Doran is with Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, NYU School of Medicine.

From April 2016 to June 2017, the Health + Housing Project employed four community health workers who engaged residents of two subsidized housing buildings in New York City to address individuals' broadly defined health needs, including social and economic risk factors. Following the intervention, we observed significant improvements in residents' food security, ability to pay rent, and connection to primary care. No immediate change was seen in acute health care use or more narrowly defined health outcomes.
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http://dx.doi.org/10.2105/AJPH.2019.305544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144437PMC
May 2020

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

Am J Prev Med 2019 12;57(6 Suppl 1):S38-S46

Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California.

Introduction: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.

Methods: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.

Results: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.

Conclusions: Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.

Supplement Information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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http://dx.doi.org/10.1016/j.amepre.2019.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876708PMC
December 2019

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

Am J Prev Med 2019 12;57(6 Suppl 1):S25-S37

Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California.

Introduction: Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

Methods: This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

Results: Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

Conclusions: A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

Supplement Information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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http://dx.doi.org/10.1016/j.amepre.2019.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336892PMC
December 2019

Commentary: How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine.

Authors:
Kelly M Doran

Ann Emerg Med 2019 11;74(5S):S41-S44

NYU School of Medicine, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.annemergmed.2019.08.442DOI Listing
November 2019

When Crises Converge: Hospital Visits Before And After Shelter Use Among Homeless New Yorkers.

Health Aff (Millwood) 2019 09;38(9):1458-1467

Kelly M. Doran ( ) is an assistant professor in the Departments of Emergency Medicine and Population Health, New York University School of Medicine.

People who are homeless use more hospital-based care than average, yet little is known about how hospital and shelter use are interrelated. We examined the timing of emergency department (ED) visits and hospitalizations relative to entry into and exit from New York City homeless shelters, using an analysis of linked health care and shelter administrative databases. In the year before shelter entry and the year following shelter exit, 39.3 percent and 43.3 percent, respectively, of first-time adult shelter users had an ED visit or hospitalization. Hospital visits-particularly ED visits-began to increase several months before shelter entry and declined over several months after shelter exit, with spikes in ED visits and hospitalizations in the days immediately before shelter entry and following shelter exit. We recommend cross-system collaborations to better understand and address the co-occurring health and housing needs of vulnerable populations.
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http://dx.doi.org/10.1377/hlthaff.2018.05308DOI Listing
September 2019

"It Wasn't Just One Thing": A Qualitative Study of Newly Homeless Emergency Department Patients.

Acad Emerg Med 2019 09 16;26(9):982-993. Epub 2019 Aug 16.

NYU Silver School of Social Work, New York, NY.

Objectives: Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions that attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions.

Methods: We conducted in-depth, one-on-one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semistructured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line by line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion.

Results: Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected.

Conclusions: These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.
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http://dx.doi.org/10.1111/acem.13677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732033PMC
September 2019

Health-related material needs and substance use among emergency department patients.

Subst Abus 2020 1;41(2):196-202. Epub 2019 Aug 1.

Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA.

Emergency department (ED) visits related to substance use are common. ED patients also have high levels of health-related material needs (HRMNs), such as homelessness and food insecurity. However, little research has examined the intersection between ED patient HRMNs and substance use. We surveyed a random sample of public hospital ED patients. Surveys included validated single-item screeners for unhealthy alcohol and any drug use and questions on self-reported past-year material needs. We compared individual HRMNs and cumulative number of HRMNs by substance use screening status using bivariate and multivariable analyses. A total of 2312 surveys were completed. Nearly one third of patients (32.3%,  = 747) screened positive for unhealthy alcohol use, and 21.8% ( = 503) screened positive for drug use. Prevalence of HRMNs for all patients-including food insecurity (50.8%), inability to meet essential expenses (40.8%), cost barriers to medical care (24.6%), employment issues (23.8%), and homelessness (21.4%)-was high and was significantly higher for patients with unhealthy alcohol use or drug use. In multivariable analyses, homelessness was independently associated with unhealthy alcohol use (adjusted odds ratio [aOR]: 1.61, 95% confidence interval [CI]: 1.24-2.09) and drug use (aOR: 2.30, 95% CI: 1.74-3.05). There was a significant stepwise increase in the odds of patient unhealthy alcohol or drug use as number of HRMNs increased. ED patients with unhealthy alcohol or drug use have higher prevalence of HRMNs than those without. Our findings suggest that HRMNs may act additively and that homelessness is particularly salient. Patients' comorbid HRMNs may affect the success of ED-based substance use interventions.
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http://dx.doi.org/10.1080/08897077.2019.1635960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994322PMC
August 2019

Opioid Overdose Protocols in the Emergency Department: Are We Asking the Right Questions?

Ann Emerg Med 2018 07;72(1):12-15

National Clinician Scholars Program and Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.

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http://dx.doi.org/10.1016/j.annemergmed.2018.05.024DOI Listing
July 2018

Substance use and homelessness among emergency department patients.

Drug Alcohol Depend 2018 Jul 22;188:328-333. Epub 2018 May 22.

Department of Family Medicine, David Geffen School of Medicine at UCLA, Department of Health Policy and Management, UCLA Fielding School of Public Health, Office of Healthcare Transformation and Innovation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, 90024, USA.

Background: Homelessness and substance use often coexist, resulting in high morbidity. Emergency department (ED) patients have disproportionate rates of both homelessness and substance use, yet little research has examined the overlap of these issues in the ED setting. We aimed to characterize alcohol and drug use in a sample of homeless vs. non-homeless ED patients.

Methods: A random sample of urban hospital ED patients were invited to complete an interview regarding housing, substance use, and other health and social factors. We compared substance use characteristics among patients who did vs. did not report current literal (streets/shelter) homelessness. Additional analyses were performed using a broader definition of homelessness in the past 12-months.

Results: Patients who were currently homeless (n = 316, 13.7%) versus non-homeless (n = 1,993, 86.3%) had higher rates of past year unhealthy alcohol use (44.4% vs. 30.5%, p < .0001), any drug use (40.8% vs. 18.8%, p < .0001), heroin use (16.7% vs. 3.8%, p < .0001), prescription opioid use (12.5% vs. 4.4%, p < .0001), and lifetime opioid overdose (15.8% vs. 3.7%, p < .0001). In multivariable analyses, current homelessness remained significantly associated with unhealthy alcohol use, AUDIT scores among unhealthy alcohol users, any drug use, heroin use, and opioid overdose; past 12-month homelessness was additionally associated with DAST-10 scores among drug users and prescription opioid use.

Conclusions: Patients experiencing homelessness have higher rates and greater severity of alcohol and drug use than other ED patients across a range of measures. These findings have implications for planning services for patients with concurrent substance use and housing problems.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.04.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478031PMC
July 2018

Undocumented Latino Immigrants and Research: New Challenges in Changing Times.

J Health Care Poor Underserved 2018 ;29(2):645-650

Latinos are the largest immigrant group in the United States, representing 17.6% of the total U.S. population, and are therefore critical to include in research. However, Latino immigrants-and particularly those who are undocumented residents-may be increasingly wary of participating in research amidst hostile anti-immigrant rhetoric and high profile cases of deportation. In this commentary we discuss challenges of conducting research with undocumented Latino immigrants in the current sociopolitical climate. We provide suggestions for data collection, data protection, and research recruitment techniques that may mitigate some of these challenges.
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http://dx.doi.org/10.1353/hpu.2018.0048DOI Listing
March 2019

Homelessness and Emergency Medicine: Where Do We Go From Here?

Acad Emerg Med 2018 05 20;25(5):598-600. Epub 2018 Apr 20.

Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA.

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http://dx.doi.org/10.1111/acem.13392DOI Listing
May 2018

Material Needs of Emergency Department Patients: A Systematic Review.

Acad Emerg Med 2018 03 5;25(3):330-359. Epub 2018 Feb 5.

Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY.

Background: Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.

Methods: We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.

Results: Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.

Conclusions: Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.
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http://dx.doi.org/10.1111/acem.13370DOI Listing
March 2018

Vulnerability of Older Adults in Disasters: Emergency Department Utilization by Geriatric Patients After Hurricane Sandy.

Disaster Med Public Health Prep 2018 04 2;12(2):184-193. Epub 2017 Aug 2.

1Ronald O. Perelman Department of Emergency Medicine,New York University School of Medicine,New York,New York.

Objective: Older adults are a potentially medically vulnerable population with increased mortality rates during and after disasters. To evaluate the impact of a natural disaster on this population, we performed a temporal and geospatial analysis of emergency department (ED) use by adults aged 65 years and older in New York City (NYC) following Hurricane Sandy's landfall.

Methods: We used an all-payer claims database to analyze demographics, insurance status, geographic distribution, and health conditions for post-disaster ED visits among older adults. We compared ED patterns of use in the weeks before and after Hurricane Sandy throughout NYC and the most afflicted evacuation zones.

Results: We found significant increases in ED utilization by older adults (and disproportionately higher in those aged ≥85 years) in the 3 weeks after Hurricane Sandy, especially in NYC evacuation zone one. Primary diagnoses with notable increases included dialysis, electrolyte disorders, and prescription refills. Secondary diagnoses highlighted homelessness and care access issues.

Conclusions: Older adults display heightened risk for worse health outcomes with increased ED visits after a disaster. Our findings suggest the need for dedicated resources and planning for older adults following a natural disaster by ensuring access to medical facilities, prescriptions, dialysis, and safe housing and by optimizing health care delivery needs to reduce the burden of chronic disease. (Disaster Med Public Health Preparedness. 2018;12:184-193).
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http://dx.doi.org/10.1017/dmp.2017.44DOI Listing
April 2018

Geographic variation in the demand for emergency care: A local population-level analysis.

Healthc (Amst) 2016 Jun 11;4(2):98-103. Epub 2015 Jun 11.

Department of Emergency Medicine, Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States.

Background: Geographic variation in healthcare has been traditionally studied in large areas such as hospital referral regions or service areas. These analyses are limited by variation that exists within local communities.

Materials And Methods: Using a New York claims database, we analyzed variation in emergency department use using 35 million visits from 2008 to 2012 among 4797 Census tracts, a smaller unit than usually studied. Using multivariate analysis, we studied associations between population characteristics and proximity to healthcare with rates of emergency department use. We analyzed how factors associated with emergency department utilization differed among urban, suburban, and rural regions.

Results: We found significant geographic variation in emergency department use among Census tracts. Public insurance and uninsurance were correlated with high emergency department utilization across all types of regions. We found that race, ethnicity, and poverty were only associated with high emergency department use in urban regions. In suburban and rural regions, a lower proportion of elderly residents and shorter distances to the nearest ED were correlated with high emergency department use.

Conclusions: Significant variation in emergency department use exists locally when studied within small geographic areas. Insurance type is significantly associated with variation in emergency department use across urban, suburban, and rural regions, whereas the significance of other factors depended on urbanicity.

Implications: Studying geographic variation at a more granular level can lead to better understanding of local population health, drivers of healthcare utilization, and inform targeted interventions. Given heterogeneity in emergency department use by Census tract, policies directed at shaping acute care utilization must consider these local geographic differences.
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http://dx.doi.org/10.1016/j.hjdsi.2015.05.003DOI Listing
June 2016

Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy.

J Urban Health 2016 Apr;93(2):331-44

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.
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http://dx.doi.org/10.1007/s11524-016-0035-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835349PMC
April 2016

Geographic Distribution of Disaster-Specific Emergency Department Use After Hurricane Sandy in New York City.

Disaster Med Public Health Prep 2016 06 9;10(3):351-61. Epub 2016 Feb 9.

1Ronald O. Perelman Department of Emergency Medicine,New York University School of Medicine,New York,New York.

Objective: We aimed to characterize the geographic distribution of post-Hurricane Sandy emergency department use in administrative flood evacuation zones of New York City.

Methods: Using emergency claims data, we identified significant deviations in emergency department use after Hurricane Sandy. Using time-series analysis, we analyzed the frequency of visits for specific conditions and comorbidities to identify medically vulnerable populations who developed acute postdisaster medical needs.

Results: We found statistically significant decreases in overall post-Sandy emergency department use in New York City but increased utilization in the most vulnerable evacuation zone. In addition to dialysis- and ventilator-dependent patients, we identified that patients who were elderly or homeless or who had diabetes, dementia, cardiac conditions, limitations in mobility, or drug dependence were more likely to visit emergency departments after Hurricane Sandy. Furthermore, patients were more likely to develop drug-resistant infections, require isolation, and present for hypothermia, environmental exposures, or administrative reasons.

Conclusions: Our study identified high-risk populations who developed acute medical and social needs in specific geographic areas after Hurricane Sandy. Our findings can inform coherent and targeted responses to disasters. Early identification of medically vulnerable populations can help to map "hot spots" requiring additional medical and social attention and prioritize resources for areas most impacted by disasters. (Disaster Med Public Health Preparedness. 2016;10:351-361).
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http://dx.doi.org/10.1017/dmp.2015.190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7112993PMC
June 2016

Improving post-hospital care for people who are homeless: Community-based participatory research to community-based action.

Healthc (Amst) 2015 Dec 25;3(4):238-44. Epub 2015 Aug 25.

Robert Wood Johnson Foundation Clinical Scholars Program and Department of Pediatrics, Yale School of Medicine, United States.

This article discusses how community-based participatory research (CBPR) on hospital care transitions in New Haven, Connecticut led to the development of a new medical respite program to better serve patients who are homeless. Key insights include: • Homelessness is an important driver of hospital utilization and must be addressed in efforts to decrease hospital readmissions. • Hospitals and community organizations often serve a shared patient/client base and can work together to develop innovative programs that are beneficial to all parties. • Community-based participatory research methods are particularly conducive to producing research that is translatable to policy and new programs. • Targeted dissemination of research results played a pivotal role in securing resources and funding for the new program.
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http://dx.doi.org/10.1016/j.hjdsi.2015.07.006DOI Listing
December 2015

Homelessness and ED use: myths and facts.

Authors:
Kelly M Doran

Am J Emerg Med 2016 Feb 9;34(2):307. Epub 2015 Oct 9.

Departments of Emergency Medicine and Population Health, NYU School of Medicine/Bellevue Hospital Center, New York, NY 10016. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2015.10.001DOI Listing
February 2016

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission.

Am Heart J 2014 Dec 8;168(6):901-8.e1. Epub 2014 Aug 8.

Department of Medicine, NYU School of Medicine, New York, NY.

Background: Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits.

Methods: We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

Results: The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission.

Conclusions: The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.
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http://dx.doi.org/10.1016/j.ahj.2014.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254520PMC
December 2014

Correlates of hospital use in homeless and unstably housed women: the role of physical health and pain.

Womens Health Issues 2014 Sep-Oct;24(5):535-41

Department of Medicine, University of California, San Francisco, San Francisco, California.

Purpose: To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical health and pain.

Methods: We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used.

Results: Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio [OR], 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations.

Conclusions: Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.
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http://dx.doi.org/10.1016/j.whi.2014.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163010PMC
April 2015

"Rewarding and challenging at the same time": emergency medicine residents' experiences caring for patients who are homeless.

Acad Emerg Med 2014 Jun;21(6):673-9

The Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine and the U.S. Department of Veterans Affairs, the Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.

Objectives: The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians.

Methods: We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content-relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved.

Results: Three recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of "misses," in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence.

Conclusions: Caring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and resources to improve the ability of residents to care for this vulnerable population. Future research is needed to determine if such interventions improve EM resident education and, ultimately, result in improved care for ED patients who are homeless.
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http://dx.doi.org/10.1111/acem.12388DOI Listing
June 2014

Reasons for emergency department use: do frequent users differ?

Am J Manag Care 2014 Nov 1;20(11):e506-14. Epub 2014 Nov 1.

Department of Emergency Medicine, Bellevue Hospital Center Room A-345, First Ave and 27th St, New York, NY 10016. E-mail:

Objectives: To examine patients' reasons for using the emergency department (ED) for low-acuity health complaints, and determine whether reasons differed for frequent ED users versus nonfrequent ED users.

Study Design: Prospective cross-sectional survey.

Methods: Patients presenting to an urban public hospital for low-acuity health complaints were surveyed about their reasons for visiting the ED rather than a private doctor's office or clinic. Patients with 3 or more visits to the study hospital ED over the past year were classified as frequent ED users. Multivariable logistic regression was used to determine if frequent ED users gave different reasons for ED use than nonfrequent ED users, while controlling for differences in other baseline patient characteristics.

Results: 940 patients, including 163 frequent ED users, completed the study questionnaire. Commonly cited reasons for using the ED were that coming to the ED was easier than making a clinic appointment (82.3% agreed); the problem could not wait (78.8%); they didn't know how to make a clinic appointment (66.7%); they felt the ED provided better care (56.7%); and they believed the clinic would cost more (54.8%). After controlling for other patient characteristics, there were no significant differences found in reasons for ED use given by frequent versus nonfrequent ED users.

Conclusions: Frequent ED users gave similar reasons for using the ED for low-acuity health complaints compared with nonfrequent ED users. Access, convenience, cost, and quality concerns, as well as feeling that ED care was needed, were all commonly cited as reasons for using the ED.
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November 2014