Critical Illness and Homelessness

Transcription

1 Critical Illness and Homelessness Jan O Friedrich, MD DPhil Associate Professor of Medicine, University of Toronto Medical Director, MSICU St. Michael s Hospital, Toronto, Canada Critical Care Canada Forum 2 October 2017

2 None to report Conflicts of Interest

3 Introduction Homelessness is a serious social and public health issue 1.5 million in USA and 150,000 in Canada Comprehensive survey in Toronto in one night identified 5,232 homeless individuals (19/10,000 population) marginalized population who frequently present to hospital in advanced disease states with serious and potentially life-threatening illness Higher rates of infectious diseases, mental illness, substance abuse, chronic diseases, injuries Associated with earlier onset of chronic health problems which frequently are under treated Refs: 2012 Annual Homeless Assessment Report, US Dept Housing & Urban Development. Homeless Shelters and Beds/Housing/Indicators of Well Being in Canada, Human Resources and Skills Development Canada Street Needs Assessment, City of Toronto.

4 Introduction Homeless that are hospitalized are Younger than non-homeless patients More frequently admitted for medical or psychiatric vs surgical conditions Hospitalized for longer as having no residence can delay timely discharge which leads to higher costs However, the course of illness and use of health care resources of homeless patients admitted to ICU is largely unknown

5 Published Literature Systematic review to July 2012 screening 2653 citations for studies of critically-ill homeless patients No studies in which more than 50% of participants were homeless Only 5 studies addressed critical illness related issues in which any participants were homeless Ref: Chant, Wang, Burns, dos Santos, Hwang, Friedrich, Smith. Inten Care Med 2014; 40: 123-5

6 Published Literature Topic Bacteremic Pneumonia Bacteremic Pneumonia Trauma Treatment Preferences Research Consent Study Type Prospect. Cohort Retrospect. Cohort Retrospec. Database No (%) Homeless 73 (57%) No (%) Critical Ill Main Findings 5 (4%) Homeless have 27-fold increase in bacterial pneumococcal pneumonia 3 (7%) N/R Homelessness not mortality predictor in bacterial pneumococcal pneumonia 326,073 (21%) Survey 229 (100%) Retrospec. Database 67 (13%) 310,784 (20%) Higher age/gender adjusted injury risk for certain mechanisms of injury 0 (0%) Homeless want more aggressive care than either physicians or COPD pts on oxygen N/R Less likely to be enrolled acute lung injury trial due to lack of SDM Refs: 1) Shariatzadeh et al, Medicine 2005; 84:147. 2) Rioseco et al, Rev Med Chile 2004, 132:588. 3) Frencher et al, J Trauma Inj Infect Crit Care 2010; 69: S191. 4) Norris et al, Chest 2005; 127: ) Glassberg et al, Chest 2008; 134:719.

7 Reasons that homelessness in critical illness is understudied Represent vulnerable patient cohort, and while Ethics and Review Boards seek to prevent exploitation, this protection may exclude them from participating in studies By virtue of critical illness, they typically require substitute decision maker (SDM) but often are estranged from family Publically appointed SDM typically do not provide consent for research studies May be excluded from studies requiring follow up owing to concerns regarding their ability to attend future appointments Stigma associated with homelessness may make it less attractive for researchers or funding agencies Concentrated within urban centres necessitating use of specific study designs or collaborative research structures Ref: Chant, Wang, Burns, dos Santos, Hwang, Friedrich, Smith. Inten Care Med 2014; 40: 123-5

8 Two More Detailed Examinations of Homeless Patients Admitted to ICU Recently Published Propensity-Matched Cohort Study (Paris, France) 421 homeless compared to 9,353 non-homeless Matched 1:4 age, sex, admission diagnosis and date Focused on lengths of stay and outcomes Case-Control Study (Toronto, Canada) 63 pairs: matched 1:1 age, sex, admission ICU and date Detailed clinical course, treatments and end of life decision making Ref: Bigé et al, CCM 2015; 43:1246. Smith... Friedrich, PLoS ONE 2017; 12:e

9 Propensity-Matched Cohort Study (Paris, France) Consecutive admissions July 2000-Dec bed MSICU, tertiary care university hospital, Paris, France (674 hospital beds) 421 homeless v 9,353 non-homeless Male: 89% v 57% p<0.001 Median Age: 49 v 62 p<0.001 Readmission: 12% v 7% p<0.001 Ref: Bigé N, Hejblum G, Baudel JL, Carron A, Chevalier S, Pichereau C, Maury E, Guidet B. CCM 2015; 43:1246

10 Propensity-Matched Cohort Study (Paris, France) 421 homeless v 9,353 non-homeless HTN: 5% v 22% Diabetes: 6% v 12% Heart Disease: 10% v 20% Cancer: 5% v 16% CKD: 1% v 4% Obesity: 0% v 3% Mental Illness: 14% v 16% Substance Use: 7% v 2% Alcoholism: 50% v 8% Cirrhosis: 14% v 6% Ref: Bigé et al, CCM 2015; 43:1246

11 Propensity-Matched Cohort Study (Paris, France) 421 homeless v 9,353 non-homeless SAPS II: 37 v 37 p=n.s. No. Organ Supports similar p=0.49 Mech Vent 44% v 37% p=0.003 Resp Failure 33% v 34% p=n.s. Sepsis 6% v 8% p=n.s. Coma 34% v 21% p<0.001 Non-EtOH acute intox. 25% v 42% EtOH 34% v 13% Seizure 43% v 26% Ref: Bigé N, Hejblum G, Baudel JL, Carron A, Chevalier S, Pichereau C, Maury E, Guidet B. CCM 2015; 43:1246

12 Propensity-Matched Cohort Study (Paris, France) Matched Homeless Non-Homeless p ICU Mortality 19% 18% 0.62 Hosp Mortality 21% 21% 0.95 Mean ICU LoS 6.5 d 5.6 d Mean Hosp LoS 19 d 15 d Survivor Disposition Home, street 68% 60% Other hospital/rehab 32% 40% Ref: Bigé et al, CCM 2015; 43:1246

13 Case-Control Study (Toronto, Canada) Any of 4 ICUs at St. Michael s Hospital MSICU [medical-surgical] 24 beds NTICU [neurosurgical-trauma] 19 beds CVICU [cardiac/vascular surgery] 15 beds CICU [cardiac] 10 beds tertiary care university hospital 462 hospital beds 63 randomly-selected homeless patients admitted Ref: Smith OM, Chant C, Burns KEA, Kaur M, Ashraf S, DosSantos CC, Hwang SW, Friedrich JO. PLoS ONE 2017; 12(6):e

14 Case-Control Study (Toronto, Canada) 63 homeless patients matched to 63 non-homeless patients by Admit Year: all 79% admitted within 60d of each other Age: all except 2 patients One was 1 year younger and the other was 1 year older Sex: all Admitting ICU: all except one patient MSICU v TNICU Ref: Smith OM, Chant C, Burns KEA, Kaur M, Ashraf S, DosSantos CC, Hwang SW, Friedrich JO. PLoS ONE 2017; 12(6):e

15 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Age (y) 48 ±12, ±12, Male 90% 90% p-value Weight (kg) Comorbidities HTN 16% 40% Diabetes 8% 8% 1.00 COPD 11% 5% 0.32 Cancer 3% 10% 0.27 Depression 17% 11% 0.45 Schizophrenia 8% 2% 0.21 Severe Liver Disease 1% 0% 1.00 Ref: Smith... Friedrich. PLoS ONE 2017; 12:e

16 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Prescription Meds 48% 67% Anti-seizure 14% 3% Thyroid 0% 8% Substance Use Alcohol 70% 17% <0.001 Illicit Drugs 46% 8% <0.001 Smoking 40% 21% 0.03 SDM at admission 38% 83% <0.001 Ref: Smith... Friedrich. PLoS ONE 2017; 12:e

17 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Tox Screen Done 75% 38% <0.001 Tox Screen +ve 72% 71% 1.00 Toxin Detected Alcohol 41% 10% <0.001 Benzodiazepines 27% 16% 0.19 Opioid 10% 3% 0.27 Cannaboid 10% 3% 0.27 Cocaine 8% 2% 0.21 Acetominophen 10% 0% 0.03 Ref: Smith... Friedrich. PLoS ONE 2017; 12:e

18 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Arrival via EMS 87% 65% Admitted to ICU from Emergency Room 76% 56% Operating Room 13% 22% Hospital Ward 8% 9% Referring Hospital 0% 13% APACHE II 18 ±8 16 ± MV on admission 56% 43% 0.21 Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

19 Case-Control Study (Toronto, Canada) Glascow Coma Scale Homeless p<0.01 * ICU Day 1 Non-Homeless p=0.04 * ICU Day 3 p=0.11 ICU Day Heart Rate p=0.02 * ICU Day 1 ICU Day 3 p=0.09 ICU Day 7 Mean BP ICU Day 1 ICU Day 3 p=0.01 * ICU Day 7 (No Differences: P/F Ratio, No. on Vasopressors, No. Transfused, Creatinine, Platelets, Bilirubin)

20 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Specialist Consults 3.5 ± ± Diagnostic Tests CT 54% 48% 0.59 Echocardiogram 33% 32% 1.00 Ultrasound 19% 14% 0.63 MRI 13% 11% 1.00 Invasive Procedures Bronchoscopy 14% 11% 0.79 Angiography 6% 14% 0.24 Lumbar Puncture 5% 3% 1.00 Upper Endoscopy 2% 6% 0.36 Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

21 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Dialysis 8% 10% 0.99 Blood transfusion 22% 22% 1.00 Parental Nutrition 2% 2% 1.00 Medications Sedatives 95% 90% 0.49 Thiamine 71% 21% <0.001 Nicotine Replacement 38% 14% Corticosteroids 22% 27% 0.68 Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

22 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Microbiology Testing 52% 41% 0.28 Any Positive Culture 51% 37% 0.15 Blood 14% 10% 0.54 Respiratory 38% 21% <0.05 (S.pneumo, MRSA, MSSA, H.flu, E.coli) Urinary 10% 11% 1.00 Antibiotics 59% 59% 1.00 Days, median [IQR] 5 [3-9] 3 [2-6] 0.06 Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

23 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Vasoactive 27% 19% 0.40 Days, median [IQR] 3 [2-6] 2 [1-2] 0.06 Ventilator Days 1 [0-5] 0.5 [0-2] ICU days 6 ±8 4 ± Median [IQR] 3 [2-8] 2 [1-5] 0.07 Hospital days 19 ±25 13 ± Median [IQR] 11 [5-24] 8 [5-19] 0.17 Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

24 Case-Control Study (Toronto, Canada) Homeless (n=63) Non-Homeless (n=63) Hospital Mortality 18 (27%) 5 (8%) Process 1.00 Withdrawal 11/18 (61%) 3/5 (60%) Non-resuscitated arrest 5/18 (28%) 1/5 (20%) No limitations 2/18 (11%) 1/5 (20%) End-of-Life Decision Making 0.15 Family involved 9/18 (50%) 5/5 (100%) Family not involved 8/18 (44%) Known wishes 1/18 (6%) Survivor Disposition 0.20 Home/shelter/jail 35/45 (78%) 38/58 (66%) Hospital/Long-Term Care 10/45 (22%) 20/58 (34%) Ref: Smith... Friedrich JO. PLoS ONE 2017; 12:e

25 Summary Paris & Toronto Detailed Studies Pre-Admission Mean age ~50 years old 90% Male Lower prevalence many comorbidities (e.g. HTN) Possibly due to younger age, but since also present after matching by age, likely also due to under diagnosis Higher alcohol and substance abuse history At Admission More emergent vs elective (operative) admissions Similar acuity of illness More mechanical ventilation Due to coma (EtOH, seizures) rather than respiratory failure Ref: Bigé CCM 2015; 43:1246. Smith...Friedrich, PLoS ONE 2017; 12:e

26 Summary Paris & Toronto Detailed Studies During Admission Similar intensity investigations and treatments More thiamine and more nicotine replacement Lower GCS up to at least ICU Day 7-?substance use Direct effect on level of consciousness Sedatives required to treat withdrawal symptoms More respiratory cultures positive pathogenic organisms Trend to more antibiotics Trends to longer duration of ventilation and vasopressors Ref: Bigé CCM 2015; 43:1246. Smith...Friedrich, PLoS ONE 2017; 12:e

27 Summary Paris & Toronto Detailed Studies At Discharge Longer ICU and hospital lengths of stay Lower proportion discharged to rehabilitation or other hospitals Effect on mortality unclear Paris similar mortality Toronto higher mortality (small numbers) Higher mortality not due to higher withdrawal of life support Ref: Bigé CCM 2015; 43:1246. Smith...Friedrich, PLoS ONE 2017; 12:e

28 Challenges/Limitations Identifying patients as homeless within studies of ICU patients is typically challenging Often identified as low socioeconomic status, poor, disadvantaged, or experiencing social deprivation without referencing housing status Accurately identifying patients as homeless within hospital databases is similarly challenging Both the Paris and Toronto studies discussed these difficulties Homelessness is a dynamic state and patients may be homeless at and for different time periods Binary classification based on index hospitalization may be too simplistic E.g. chronically homeless patients likely have different outcomes than the transiently homeless patients

29 Summary Homeless patients admitted to ICU are difficult to study resulting in limited published data Acuity of illness at ICU admission, and intensity of treatment were similar At least within the context of public health care systems Overall, outcomes appear to be somewhat worse than matched controls Additional research in other health care settings to validate the findings of these single-centre studies are needed with an aim of trying to develop strategies that improve outcomes in this vulnerable population

30 The End Thank you for your attention Questions?