Housing Instability and its Impact on Hospital Resource Utilization

ADA Guidelines highlight importance of social stability in diabetes management.

The American Diabetes Association: Standards of Medical Care in Diabetes 2018 recommends that each patient who has diabetes be assessed for social stability, which are needs that include financial, housing, and food aid. Any patients requiring support should be provided with social assistance resources.

In general, optimal diabetes management requires meeting essential basic needs like food or housing. Current evidence shows that homelessness is associated with poor diabetes outcomes. However, one area that is not well studied is the more commonly occurring transient housing instability (i.e. staying with friends/relatives, recurrent moving in the past 12 months, inability to pay for rent, etc.). Housing instability is troublesome as it can affect  optimal diabetes management from attending medical appointments to blood glucose monitoring and beyond.

The objective of this cross-sectional study was to determine the primary outcome if unstable housing is associated with increased utilization of the emergency department (ED) or hospitalization; additionally, they sought to determine the use of social assistance programs and/or treatment at safety net health clinics. September 2014 to April 2015, using data from annual Health Center Patient Survey (HCPS), 1,087 individuals classified as having  type 1 or 2 diabetes and age ≥18 years old were enrolled in the study. Any participants identified as being homeless or stably housed were excluded from the study.

Statistical analyses by way of t-tests and chi square tests were used. Logistic regression was used to analyze the association between unstable housing and ED/hospitalizations. Confounding variables were accounted for during this step.

Study results showed 13.7% of subjects required ED visit/hospitalization during study duration, 26% had unstable housing (p = 0.005) while 7% had stable housing. Several areas were identified as significant during the unmet need analysis; these include clothes help, medication help, and home visits. Unmet needs areas where unstably housed individuals required more assistance than those with stable housing included appointment help and medication help. This observation does not lessen the importance of other needs areas analyzed like food or transportation. Housing assistance was required in approximately 2% (p = 0.05) of participants either stably or unstably housed. Only 0.89% of unstably housed participants received housing help from clinic staff. Utilization of government assistance programs was reduced and underused while use rates between stably and unstably housed were similar.

Limitations were noted upon study completion. First, the selected study design, cross-sectional, has inherent weaknesses; it is too difficult to conclude causation indicating the need for longitudinal studies. Second, self-reported data was used to answer the primary outcome indicating potential bias in conclusions drawn. Third, confounding variables were accounted for, however some unidentified variables may have been missed; still, investigators believe the sensitivity analysis performed could counter this argument.

Previous studies have identified the association between housing instability and use of hospital resources. However, these studies differ in the fact that they focused solely on a small subset of the population. This study is unique in its use of the HCPS survey, which is said to be representative of the population. Overall, culmination of the data shows that housing instability and ED visit/hospitalization is an issue. Furthermore, to better diabetes management, improvements must be made to identify people with  social concerns. Directing at-risk patients to appropriate assistance programs and resources can hopefully reduce the burden for these patients and help them achieve optimal control of their disease.

Practice Pearls:

• Unstable housing, defined as inability to pay for rent, high frequency of moving, staying with relatives, etc., is associated with increased utilization of hospital resources.
• Patients with diabetes should be regularly assessed for unmet needs and social concerns (i.e. financial, housing, food, and medical).
• Only 2% of patients, with varying degrees of housing stability, requested housing assistance.

References:

Berkowitz, S.A., Kalkhoran, S., Edwards, S.T., Essien, U.R., and Baggett, T.P. Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients. Diabetes Care. 41.5 (2018): 933-939. https://doi.org/10.2337/dc17-1812.

American Diabetes Association. 1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2018. Diabetes Care. 41.Supplement 1 (2018): S7-S12. https://doi.org/10.2337/dc18-S001.

Kaytie A. Weierstahl, Pharm.D. Candidate, LECOM School of Pharmacy