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Homeless Patients in the ICU

An Observational Propensity-Matched Cohort Study*

Bigé, Naïke MD, PhD1,2; Hejblum, Gilles PhD3,4,5; Baudel, Jean-Luc MD1; Carron, Annie6; Chevalier, Sophie7; Pichereau, Claire MD, PharmD1,2; Maury, Eric MD, PhD1,3,4; Guidet, Bertrand MD1,3,4

doi: 10.1097/CCM.0000000000000944
Clinical Investigations

Objective: To describe epidemiology and outcome of critically ill homeless patients, as compared with those of nonhomeless patients.

Design: Homeless and nonhomeless admissions were matched on the basis of a 1:4 ratio, using a propensity score-based procedure involving age, sex, date, and main diagnosis at ICU admission.

Setting: A 18-bed closed medical ICU of a French tertiary care university hospital.

Patients: All consecutive admissions from July 2000 to December 2012.

Interventions: None.

Measurements and Main Results: There were 421 homeless and 9,353 nonhomeless admissions. Considering homeless admissions, 50% patients had no health insurance, 56% had no financial resource, 91% were socially isolated, and 69% lived in street. In a multivariable analysis of homeless admissions including age, sex, and Simplified Acute Physiology Score II, living in street was significantly associated with hospital mortality (odds ratio = 2.94; 95% CI, 1.30–7.10; p = 0.012). As compared with nonhomeless, homeless admissions more frequently concerned men (89% vs 57%; p < 0.0001) and younger patients (49 yr [43–57] vs 62 yr [46–76]; p < 0.0001), whereas Simplified Acute Physiology Score II (37 [24–50] vs 37 [25–52]; p = 0.99) and distribution of the number of organ supports (p = 0.49) were similar. ICU mortality concerned 19.1% and 18% of matched homeless and nonhomeless admissions, respectively. The corresponding figures for hospital mortality were 20.8% and 20.6%. In multivariable analysis, homeless status was associated with neither ICU (odds ratio = 1.27 [0.92–1.73]; p = 0.14) nor hospital mortality (odds ratio = 1.07 [0.77–1.49]; p = 0.68), while it was independently associated with longer ICU (means ratio = 1.16 [1.01–1.34]; p = 0.035) and hospital (means ratio = 1.30 [1.12–1.49]; p = 0.0002) stay of survivors.

Conclusions: Critically ill homeless patients benefit from the same level of care and have globally the same prognosis than housed patients but experience longer lengths of stay. Most precarious patients living in street have a higher mortality rate. The study perspective is not ICU centered but also concerns the global organization of healthcare since homeless patients are referred by numerous sources and discharged to different wards.

1Service de Réanimation Médicale, AP–HP, Hôpital Saint-Antoine, Paris, France.

2Faculté de Médecine Pierre et Marie Curie, UPMC Univ Paris 06, Sorbonne Universités, Paris, France.

3U1136, INSERM, Paris, France.

4UMR_S 1136, UPMC Univ Paris 06, Sorbonne Universités, Paris, France.

5Unité de Santé Publique, Hôpital Saint-Antoine, AP–HP, Paris, France.

6Service Social Hospitalier, Hôpital Saint-Antoine, AP–HP, Paris, France.

7Département de l’Information Médicale, Hôpital Saint-Antoine, AP–HP, Paris, France.

* See also p.1339.

Dr. Bigé, Dr. Hejblum, Dr. Guidet, and Dr. Baudel contributed to the design of the study. Dr. Guidet coded all the patients with International Classification of Diseases, Tenth Revision including code Z59.0. Dr. Guidet, Dr. Baudel, Ms. Carron, Dr. Bigé, and Ms. Chevalier managed data collection. Dr. Guidet, Dr. Hejblum, and Dr. Bigé had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr. Hejblum designed and carried out the statistical analysis. Dr. Hejblum, Dr. Guidet, and Dr. Bigé analyzed data. Dr. Guidet, Dr. Hejblum, and Dr. Bigé wrote the draft of the report and are the guarantors. All authors contributed to the final writing of the report and approved the final version. The lead author affirms that the article is an honest, accurate, and transparent account of the study being reported and that no important aspects of the study have been omitted.

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Dr. Guidet lectured for Laboratoire Français des Biotechnologies (LFB), Griffols, and Fresenius Kabi, and he received support for the development of educational presentations from LFB, but no conflict of interest related to this article. All authors have completed the Unified Competing Interest form at (available on request from the corresponding author). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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