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Med Care. 2018 Jun;56(6):460-469. doi: 10.1097/MLR.0000000000000915.

Homeless Status, Postdischarge Health Care Utilization, and Readmission After Surgery.

Titan A1,2, Graham L3,4, Rosen A5,6, Itani K5,6,7, Copeland LA8,9,10, Mull HJ5,6, Burns E11,12, Richman J3,4, Kertesz S3, Wahl T3,4, Morris M3,4, Whittle J11,12, Telford G11, Wilson M13, Hawn M1,2.

Author information

VA Palo Alto Health Care System.
Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
Birmingham Health Services Research and Development Unit, Birmingham VA Medical Center.
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System.
Department of Surgery, Boston University School of Medicine.
Harvard University School of Medicine, Boston.
Boston, Veterans Affairs Central Western Massachusetts Healthcare System, Leeds, MA.
Baylor Scott & White Health, Center for Applied Health Research.
Texas A&M Health Science Center, College of Medicine, Temple, TX.
Milwaukee Veterans Affairs Medical Center.
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, PA.



Homeless Veterans are vulnerable to poor care transitions, yet little research has examined their risk of readmission following inpatient surgery. This study investigates the predictors of surgical readmission among homeless relative to housed Veteran patients.


Inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration from 2008 to 2014 were identified. Administrative International Classification of Diseases, Ninth Revision, Clinical Modification codes and Veterans Health Administration clinic stops were used to identify homeless patients. Bivariate analyses examined characteristics and predictors of readmission among homeless patients. Multivariate logistic models were used to estimate the association between homeless experience and housed patients with readmission following surgery.


Our study included 232,373 surgeries: 43% orthopedic, 39% general, and 18% vascular with 5068 performed on homeless patients. Homeless individuals were younger (56 vs. 64 y, P<0.01), more likely to have a psychiatric comorbidities (51.3% vs. 19.4%, P<0.01) and less likely to have other medical comorbidities such as hypertension (57.1% vs. 70.8%, P<0.01). Homeless individuals were more likely to be readmitted [odds ratio (OR), 1.43; confidence interval (CI), 1.30-1.56; P<0.001]. Discharge destination other than community (OR, 0.57; CI, 0.44-0.74; P<0.001), recent alcohol abuse (OR, 1.45; CI, 1.15-1.84; P<0.01), and elevated American Society Anesthesiologists classification (OR, 1.86; CI, 1.30-2.68; P<0.01) were significant risk factors associated with readmissions within the homeless cohort.


Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.

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