Delivery of inpatient cancer care varies greatly based on housing status
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Key takeaways:
- People with cancer experiencing homelessness appeared less likely to undergo surgery or receive systemic therapy.
- They also got discharged against medical advice more frequently.
Inpatient management of people with cancer varied considerably based on their housing status, according to results of a cross-sectional study.
Patients experiencing homelessness underwent procedures and received systemic therapy — such as chemotherapy or immunotherapy — less often than housed patients.
They also had a substantially higher likelihood of getting discharged against medical advice.
The findings are not entirely unexpected, according to researcher Kanan Shah, MD, resident physician at NYU Langone Health.
“I think that part of this is driven by the fact that [patients experiencing homelessness] present at a later stage,” Shah told Healio. “Procedures may not be as easy to do at that point, or [these patients] may not benefit as much.”
Background and methods
Approximately 550,000 individuals experience homelessness daily in the United States, and between 2.3 and 3.5 million experience homelessness per year, according to study background.
Homelessness has increased since 2016, with a 16% jump between 2020 and 2022 due to the COVID-19 pandemic.
“The care that we give to people who are experiencing homelessness — not just in cancer — is so different from the care that we give to those who are not experiencing homelessness,” Shah said. “It’s not because we want to give different care, but because there’s a lot of barriers that we have to think about when patients do leave the hospital. This led me to think in cancer, which can take up all aspects of a patient’s life, how different must this care be?”
Shah and colleagues used the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project National Inpatient Sample — which includes 20% of all discharge records in the U.S.— to identify 13,838,612 hospitalized adults with cancer admitted between 2016 and 2020.
The most common cancer types in the cohort included lung cancer (17.3%), hematologic malignancies (16.9%) and upper gastrointestinal cancer (15.3%).
The cohort included 13,793,462 housed adults (median age, 68 years; range, 58-77; 52.9% men) and 45,150 adults experiencing homelessness (median age, 58 years; range, 52-64; 74.8% men).
Researchers defined homelessness as, “lacking permanent or reliable shelter ... due to poverty, lack of affordable housing, mental illness, substance abuse, juvenile alienation or other factor” or “inadequate housing, not otherwise specified.”
Rates of invasive procedures, systemic therapy and radiotherapy served as primary endpoints. Invasive procedures included surgeries, biopsies, mechanical ventilation, and placement of arterial access. Systemic therapies included chemotherapy and immunotherapy.
Inpatient mortality, cost of hospital stays and discharge against medical advice served as secondary endpoints.
Results
A higher percentage of patients experiencing homelessness had moderate or major illness (80.1% vs. 74%).
They were less likely to undergo invasive procedures [adjusted OR (aOR) = 0.53; 95% CI, 0.49-0.56] or receive systemic therapies (aOR = 0.73; 95% CI, 0.63-0.85) but more likely to receive radiotherapy (aOR = 1.38; 95% CI, 1.05-1.82).
Individuals experiencing homelessness appeared more than four times as likely to be discharged against medical advice (aOR = 4.29; 95% CI, 3.63-5.06).
They had lower odds of dying during inpatient care (aOR = 0.79; 95% CI, 0.68-0.92) or having a higher-than-median cost of hospital stay (aOR = 0.71; 95% CI, 0.65-0.77).
Researchers acknowledged study limitations, including lack of data on variables such as cancer stage that may have affected clinical decision-making.
’Best personalized care’
Clinicians may not give systemic therapy or perform invasive procedures as a personalized approach to care for individuals experiencing homelessness, Shah said.
For example, these individuals may not be able to take care of their surgical site after a surgery, they may not be able to organize transportation for follow-up treatments for chemotherapy or adhere to post-treatment care, or they may experience adverse events that require monitoring, Shah said.
The higher use of radiotherapy for patients experiencing homeless may be due to the fact it can be given in shorter intervals with less follow-up and may have more palliative benefits.
“We don’t have access to the intent or the thought process,” Shah said. “A lot of this is me hypothesizing. But the other part of that is, even if we are delivering personalized care, how can we deliver the best personalized care that’s closest to standard-of-care recommendations?”
Hospital-at-home models could benefit individuals experiencing homelessness, Shah said.
“Patients who have cancers with lower side effects — [such as] prostate cancer or breast cancer — are able to receive some of their chemotherapy infusions or shots at home in some parts of the country,” she said. “What if we could take this and apply it to people experiencing homelessness — use mobile health clinics to go to the shelters, go to the hotels, go to the single-room occupancies to administer these treatments? And, if our major barriers are stable housing or private bathrooms, then [is there a way] to provide more longer-term care facilities for people who are diagnosed with cancer so that we’re giving them a way to receive their care?”
However, true improvement may not occur until “systemic-level changes” are made, she said.
“How can we design a better health care system that doesn't let these patients fall through the cracks?” Shah said. “We broke up our population into patients who are living in urban areas vs. patients who are living in non-urban areas, and we still saw this trend uphold even when we controlled for that. [This] tells me that this is going beyond something that’s a phenomenon in places where there may not be as many people experiencing homelessness. It’s happening everywhere.”
For more information:
Kanan Shah, MD, can be reached at kanan.shah@nyulangone.org.
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