Introduction Homelessness can limit access to preventive medical care, especially for the homeless with chronic disease. Although national data describe reduced access to a regular source of care among homeless individuals generally, no studies compare utilization for homeless and housed outpatients in systems that serve both groups. Many veterans are homeless. We used Veterans Health Administration (VHA) data to compare outpatient utilization for homeless and housed veterans with diabetes.
Methods Using a 5% random sample of the national VHA outpatient database (FY2003), we identified 35,721 patients with diabetes-related diagnostic codes for two or more encounters. Utilization indicators were proportions of patients visiting each of the following clinic types: primary care with a diabetes diagnostic code (≥ 4 visits/year), diabetes/endocrinology (≥ 1), eye(≥ 1), and podiatry/foot-care (≥ 1). Separate logistic regressions modeled factors associated with failure to achieve each utilization indicator, including age, race, mental illness, alcohol and drug abuse as predictors.
Results Homeless persons were 1.2% (n = 417) of the sample. The percentages of homeless versus housed failing to achieve each utilization indicator were primary care (72% vs. 79%, p < .01), diabetes/endocrinology (71% vs. 82%, p < .01), eye (73% vs. 74%, p = .76), and podiatry/foot-care (71% vs.74%, p = .15). The homeless had marginally significantly lower odds of failing to have 4 diabetes-related Primary care visits (odds ratio [OR] 0.8 [95% confidence interval (CI) 0.6-1.0]). Drug abuse was associated with greater likelihood of failure to have 4 diabetes-related primary care visits for homeless (OR 2.0 [95%CI 1.2-3.7]), but not housed subjects (1.0 [0.7-1.5]) (interaction p = .04). Alcohol abuse and mental illness were associated with slightly lower likelihood of failure to have 4 diabetes-related primary care visits (0.8 [0.7-1.0] and 0.7 [0.7-0.8], respectively).
Conclusions Many veterans with diabetes did not utilize important VHA outpatient services at recommended levels. Unexpectedly, veterans who were homeless, abused alcohol or had recognized mental illness utilized these outpatient services equally or slightly more than otherwise similar diabetic veterans. Only homeless diabetic veterans with recognized drug abuse were prone to underutilize diabetes-related primary care services. In this outpatient sample, homeless veterans with diabetes demonstrated remarkably similar access to VHA care as those who were housed.
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