Abstract P260: Patients Experiencing Homelessness Have Longer Hospital Lengths of Stay After Admission for Ischemic Stroke or TIA

Abstract

Introduction: There is little information available regarding stroke care and outcomes specific to patients experiencing homelessness. This study assesses the provision of stroke care and outcomes for these patients and identifies opportunities to improve their care. Methods: Data was obtained from a large, multi-state health system’s Get With The Guidelines registry for patients discharged between January 2009 and September 2016. Patients with an ischemic stroke or transient ischemic attack (TIA) were included. Patients with time of last known well (LKW) to hospital arrival of more than two weeks or hospital arrival to CT times of more than two days were excluded. Homeless patients were matched to non-homeless patients with a 1:5 ratio using case control matching on age, stroke type, gender and year. Patient characteristics between homeless and housed patients were compared before and after matching using t-tests, Mann Whitney tests, or chi-squared tests, as appropriate. Primary outcomes were discharge modified Rankin score (mRs), with disability categorized as none/slight (mRs≤2) or moderate or greater (mRS > 3) and length of stay (LOS). Logistic regression was used to analyze the relationship between homeless status and mRs, and Cox proportional hazards regression was used to assess the effect of homelessness on LOS. LKW to hospital arrival time and admit National Institutes of Health Stroke Scale (NIHSS) score were added as covariates to both models. Adjusted odds ratios (AOR) and hazards ratios (AHR), and their corresponding p-values were reported. Results: A total of 20,516 patients met inclusion criteria with 28 experiencing homelessness. Prior to matching, homeless patients were more likely to be male (78.6% vs 48.9%, p=.007), younger (58 vs 72 years, p<.001) and have longer median LKW to arrival times (921 vs 386 minutes, p=.066). After matching, the analytic sample size was 168 patients with 16.7% (n=28) experiencing homelessness and 83.3% (n=140) housed. Multivariable analyses indicated that homeless patients leave the hospital at a slower rate compared to the non-homeless (AHR=0.666, p=.056). They also had lower disability scores at discharge (AOR=0.104, p=.095); however, this result only approached significance. Conclusion: Patients experiencing homelessness had longer LKW to hospital arrival times indicating an opportunity for targeted intervention around the need for quick arrival after symptoms. In addition, homeless patients also had longer LOS which is likely related to challenges in safely discharging this population. Further research with a larger number of patients is needed in order to compare other aspects of acute stroke care, including treatment rates and time to treatment, and assess ways to address the challenges of shortening last known well to arrival times and safe discharge.