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Hospital Costs and Length of Stay Among Homeless Patients Admitted to Medical, Surgical, and Psychiatric Services

Hwang, Stephen W., MD, MPH*,†; Weaver, James, MPH*; Aubry, Tim, PhD; Hoch, Jeffrey S., PhD*,§

doi: 10.1097/MLR.0b013e318206c50d
Brief Report

Background Homeless individuals often suffer from serious health conditions and are frequently hospitalized. This study compares hospitalization costs for homeless and housed patients, with and without adjustment for patient and service characteristics.

Methods Administrative data on 93,426 admissions at an academic teaching hospital in Toronto, Canada, were collected over a 5-year period. These data included an identifier for patients who were homeless. Each admission was allocated a cost in Canadian dollars based on Ontario Case Costing methodology. Associations between homeless status and cost were examined for the entire sample and stratified by medical, surgical, and psychiatric services.

Results Data were analyzed for 90,345 housed patient admissions (mean cost, $12,555) and 3081 homeless patient admissions (mean cost, $13,516). After adjustment for age, gender, and resource intensity weight, homeless patient admissions cost $2559 more than housed patient admissions (95% CI, $2053, $3066). For patients on medical and surgical services, much of this difference was explained by more alternate level of care days spent in the hospital, during which patients did not require the level of services provided in an acute care facility. Homeless patient admissions on the psychiatric service cost $1058 more than housed patient admissions (95% CI, $480, $1635) even after adjustment for length of stay.

Conclusions Homeless patients on medical and surgical services remain hospitalized longer than housed patients, resulting in substantial excess costs. Homeless patients admitted for psychiatric conditions have higher costs not explained by prolonged length of stay. These observations may help guide development of community-based interventions for homeless individuals and reduce their use of inpatient care.

*Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada

Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Centre for Research on Educational and Community Services, School of Psychology, University of Ottawa, Ottawa, Ontario, Canada

§Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Reprints: Stephen W. Hwang, MD, MPH, Centre for Research on Inner City Health, St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada. e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.