Prevalence And Correlates of Patient-Directed Discharges Among Admitted Patients Experiencing Homelessness: A Cross-Sectional Study

Abstract

BACKGROUND: Patient-directed discharge (PDD) from the hospital occurs more frequently among people experiencing homelessness (PEH), exacerbating already worse outcomes and higher costs. To our knowledge there are no descriptive studies of PEH who perform PDDs and little is known about the population of PEH admitted to Harborview Medical Center (HMC). This exploratory descriptive analysis aims to describe PEH admitted to HMC and identify the prevalence of and factors associated with PDD. METHODS: This cross-sectional study examined HMC EHR data of adult patients registered as homeless within 1 year of their admission to any hospital unit from 2023-2024. ED visits without admission and records missing information related to the outcome variable of PDD were excluded. Descriptive analysis was performed and strength of association for selected predictors was evaluated via modified Poisson regression with robust standard errors. RESULTS: Of 1,637 PEH admitted to HMC, 183 performed a patient-directed discharge (11% prevalence). Younger age (≤ 45 years) (aPR 1.47; 95% CI: 1.07–2.04); OUD diagnosis (aPR 1.46; 95% CI: 1.09–1.94); patient-reported daily opioid use (aPR 1.45; 95% CI: 1.05–2.01) and infectious disease admission (aPR 1.76; 95% CI: 1.34–2.31) were all independently associated with higher prevalence of PDD. Being uninsured was associated with an adjusted prevalence more than twice that of insured patients (aPR 2.36; 95% CI: 1.19–4.18). Medical/surgical boarding bed placement was associated with higher PDD prevalence (aPR 1.85; 95% CI: 1.32–2.59). Conversely, psychiatric admission diagnosis (aPR 0.25; 95% CI: 0.13-0.46) and history of psychiatric diagnosis (aPR 0.64; 95% CI: 0.47-0.86) were both protective against PDD. Previously reported associations of male sex and Medicaid insurance with PDD were not replicated in this study population. CONCLUSIONS: This study showed that PDD is highly prevalent among PEH at HMC and confirmed younger age, OUD and insurance status as risk factors. Medical/surgical boarding placement was identified as a hospital-level factor and a potentially worthwhile target for future study and intervention. Additional study is required to better understand the structural risk factors for PDD, and future studies would benefit from evaluating these factors within a multi-level context.