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Vascular Surgical Care Of Patients With Housing Insecurity: Demographics And Disparities
Mikayla Kricfalusi, BA
1, Sai Divya Yadavalli, MD
1, Elisa Caron, MD
1, Daniel Colome, BS
1, Jeremy D. Darling, MD
1, Christina L. Marcaccio, MD, MPH
1, Jeffery J. Siracuse
2, Carla C. Moriera, MD, RPVI
3, Marc L. Schermerhorn, MD
1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA,
2Boston University, Boston, MA, USA,
3Brown University, Providence, RI, USA.
OBJECTIVES: Housing insecurity is rising in the United States, with more than 653,000 individuals experiencing homelessness on any night in 2023. The surgical care of these patients is complex, yet few previous studies have described housing insecurity in the vascular patient population. This work reports the demographics, operative management, and outcomes of patients with housing insecurity undergoing vascular surgery compared with their housed counterparts.
METHODS:The Vascular Quality Initiative (VQI) was queried for patients undergoing endovascular aortic repair (EVAR), thoracic endovascular aortic repair (TEVAR), open aortic repair (OAR), carotid endarterectomy (CEA), carotid artery stenting (CAS), peripheral vascular intervention (PVI), infrainguinal bypass (IIB), suprainguinal bypass (SIB) or lower extremity amputation (LEA) from 2003 to 2023. Patients were divided into housed (home/nursing home) or unhoused. Demographic characteristics, presentation, and discharge location were reported for all procedures. Multivariable logistic regression analyzed perioperative death, in-hospital reintervention, any complication, and extended length of stay (LOS) (>75th percentile); adjusted Cox regression analyzed 5-year mortality.
RESULTS:There were 934,926 patients undergoing EVAR, TEVAR, OAR, CEA, CAS, PVI, IIB, SIB, or LEA, of which 2028 (0.2%) were unhoused at time of surgery. Unhoused patients were younger (59 years vs 69 years), more likely to be male (85%vs64%), non-white race (40%vs21%), and undergo urgent (35%vs15%) or emergent (8%vs4%) procedures. Unhoused patients were treated most often with PVI (46%). They had a higher LEA rate than housed patients (10%vs3%) and underwent proportionally more TFCAS (5%vs3%) than TCAR (2%vs6%). Unhoused patients were more often discharged to a facility (72%vs14%), with 23% returning to homelessness. On multivariable analysis, there were no differences in perioperative mortality (OR.98,95%CI[0.73-1.28]) or 5-year mortality (HR.99[.87-1.12]) between groups for all procedures. Homelessness was associated with higher odds of extended LOS (>75th percentile) (OR3.66[3.31-4.04],P<0.001), reintervention (OR1.58[1.33-1.86],P<0.001) and any complication (OR1.50[1.29-1.73],P<0.001) for all procedures (Table).
CONCLUSIONS:Unhoused patients differ significantly from their housed counterparts, undergoing more urgent and emergent procedures, and experiencing higher rates of reintervention and complications. As rates of housing insecurity continue to rise, targeted efforts at earlier screening for vascular disease, coordination with community care centers, and equitable discharge practices are imperative to providing high-quality care to this vulnerable population.
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