TJA: Homeless Patients 15x More Likely to Visit ER…But

A team of researchers from New England Baptist Hospital, Massachusetts General Hospital, Boston University School of Medicine, and Boston Medical Center have found that homeless patients are 15x more likely to visit the emergency room…but, importantly…did NOT have significantly higher rates of readmission when compared to a non-homeless population.

Their work, “Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital,” appears in the March 15, 2022, edition of the Journal of the American Academy of Orthopaedic Surgeons.

“Homelessness is a growing situation across the United States co-author Eric Smith, M.D., chief of arthroplasty at New England Baptist Hospital, told OTW, “and providing safe and effective health care to those individuals experiencing homelessness is important for society now and in the future.”

“Even though total joint arthroplasty [TJA] is among the most successful and frequently performed procedures to improve quality of life, homelessness is often a contraindication to these procedures due to risks of infection, readmission, and poor outcomes.”

“There is very little evidence in the literature that supports or refutes performing TJA in this patient population. This study begins to describe the outcomes of TJA in this patient group as well as the challenges of providing such care.”

The researchers did a retrospective review of 442 patients who had primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. The study group consisted of 28 self-identified homeless patients and 414 control non-homeless patients.

Dr. Smith described the results of the study and the surprising result to OTW, “Patients who describe themselves as homeless were 15 times more likely to visit an emergency room in the study period yet did not have a significantly higher readmission rate vs the non-homeless cohort.”

“We interpreted this as a function of the safety-net delivery of health care where homeless individuals will often seek care in an emergency department [ED] versus their primary care provider. Surgeons who perform TJA in this patient population should expect their patients to have frequent visits to the ED, but not necessarily for diagnoses related to their TJA.”

What, we wondered, were some the “unique challenges” of serving this particular patient population. According to co-author Ruijia Niu, M.P.H. “The individuals in the homeless cohort reported higher rates of alcohol, illicit drug use and smoking, all risks factors for poor outcomes after TJA.”

“All patients in this study (both cohorts) underwent preoperative clearance using a robust 22-point pre-screening process to modify risk factors before surgery. We believe that this results in a lower complication rate among our patients in both cohorts. Our results may not be applicable to other institutions who do not have such a robust clearance process prior to TJA. We believe that not only the patient factors represent unique challenges but the necessary resources to clear and care for this patient population is also a unique challenge.”