Beyond Injury: Length of Stay and Rehabilitation Disparities in Houseless Trauma Patients

Houseless trauma patients (HTPs) face triple the complications and nearly double the mortality of nonhouseless trauma patients (nHTPs), which may be related to a higher burden of undiagnosed or untreated chronic conditions. This study aims to explore whether HTPs have a longer length of stay (LOS) and encounter more difficulties in accessing rehabilitation services compared to nHTPs. We hypothesize that HTPs, as compared to nHTPs, have longer LOS and decreased access to rehabilitation services.

The 2021-2023 Trauma Quality Improvement Program database was queried for admitted adult HTPs. HTPs were compared to nHTPs. The LOS for surviving HTPs and nHTPs was compared in a variety of clinical scenarios. Chi-square and Mann-Whitney U tests were performed. A multivariable logistic regression analysis was used to determine risk of prolonged LOS (defined as ≥5 d).

From 2,474,565 patients, 26,349 (1.1%) were HTPs. HTPs exhibited higher rates of alcohol use (22.6% versus 7.4%, P < 0.001) and mental health disorders (25.1% versus 12.3%, P < 0.001). After adjusting for age, injury severity, and comorbidities, HTPs continued to have a higher risk for prolonged LOS (odds ratio 1.49, 95% confidence interval 1.44-1.54, P < 0.001). HTPs had a longer median LOS in all scenarios, most notably with severe lower extremity fractures (19 versus 10 d, P < 0.001) and severe trauma (injury severity score >15) (12 versus 8 d, P < 0.001). HTPs also had decreased discharges to short-term/intermediate/long-term care rehabilitation (6% versus 13.2%, P < 0.001) but increased rates of leaving against medical advice (10.7% vs. 1.8%, P < 0.001).

This prognostic and epidemiological analyses highlight significant disparities faced by HTPs, including longer LOS and lower rates of discharge to rehabilitation services. By focusing on integrated care models and advocating for policies that address houselessness and health disparities, hopefully we can move closer to a health-care system that serves all individuals with equity and compassion.