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. 2017 Jul;62(7):482-492.
doi: 10.1177/0706743717693781. Epub 2017 Feb 15.

The Hotel Study-Clinical and Health Service Effectiveness in a Cohort of Homeless or Marginally Housed Persons

William G Honer  1 , Alejandro Cervantes-Larios  2 , Andrea A Jones  1 , Fidel Vila-Rodriguez  1 , Julio S Montaner  1 , Howard Tran  3 , Jimmy Nham  3 , William J Panenka  1 , Donna J Lang  4 , Allen E Thornton  5 , Talia Vertinsky  4 , Alasdair M Barr  6 , Ric M Procyshyn  1 , Geoffrey N Smith  1 , Tari Buchanan  1 , Mel Krajden  7 , Michael Krausz  1 , G William MacEwan  1 , Kristina M Gicas  5 , Olga Leonova  1 , Verena Langheimer  1 , Alexander Rauscher  1 , Krista Schultz  1
Affiliations

The Hotel Study-Clinical and Health Service Effectiveness in a Cohort of Homeless or Marginally Housed Persons

William G Honer et al. Can J Psychiatry. 2017 Jul.

Abstract
in English, French

Objective: The Hotel Study was initiated in Vancouver's Downtown East Side (DTES) neighborhood to investigate multimorbidity in homeless or marginally housed people. We evaluated the clinical effectiveness of existing, illness-specific treatment strategies and assessed the effectiveness of health care delivery for multimorbid illnesses.

Method: For context, we mapped the housing locations of patients presenting for 552,062 visits to the catchment hospital emergency department (2005-2013). Aggregate data on 22,519 apprehensions of mentally ill people were provided by the Vancouver Police Department (2009-2015). The primary strategy was a longitudinal cohort study of 375 people living in the DTES (2008-2015). We analysed mortality and evaluated the clinical and health service delivery effectiveness for infection with human immunodeficiency virus or hepatitis C virus, opioid dependence, and psychosis.

Results: Mapping confirmed the association between poverty and greater number of emergency visits related to substance use and mental illness. The annual change in police apprehensions did not differ between the DTES and other policing districts. During 1581 person-years of cohort observation, the standardized mortality ratio was 8.43 (95% confidence interval, 6.19 to 11.50). Physician visits were common (84.3% of participants over 6 months). Clinical treatment effectiveness was highest for HIV/AIDS, intermediate for opioid dependence, and lowest for psychosis. Health service delivery mechanisms provided examples of poor access, poor treatment adherence, and little effect on multimorbid illnesses.

Conclusions: Clinical effectiveness was variable, and illness-specific service delivery appeared to have little effect on multimorbidity. New models of care may need to be implemented.

Objectif:: L’étude Hotel a débuté dans le quartier Downtown East Side (DTES) de Vancouver pour mener une recherche sur la multi-morbidité chez les personnes sans abri ou ayant un logement précaire. Nous avons évalué l’efficacité clinique des stratégies existantes de traitement de maladies spécifiques et évalué l’efficacité de la prestation des soins de santé pour les maladies multi-morbides.

Méthode:: Pour le contexte, nous avons configuré les lieux où logent des patients qui se sont présentés 552 062 fois au service d’urgence de l’hôpital de la zone couverte (2005-2013). Les données agrégées de 22 519 arrestations de personnes souffrant de maladie mentale ont été fournies par le service de police de Vancouver (2009-2015). La stratégie principale était une étude de cohorte longitudinale de 375 personnes vivant dans le DTES (2008-2015). Nous avons analysé la mortalité, et évalué l’efficacité de la prestation des services de santé et cliniques pour : l’infection à virus de l’immunodéficience humaine ou à virus de l’hépatite C, la dépendance aux opioïdes, et la psychose.

Résultats:: La configuration a confirmé l’association entre la pauvreté et le plus grand nombre de visites à l’urgence liées à l’utilisation de substances et à la maladie mentale. Le changement annuel des arrestations de la police ne différait pas entre le DTES et d’autres districts de police. Durant 1581 années-personnes d’observation de cohorte, le taux de mortalité normalisé était de 8,43 (intervalle de confiance à 95 % 6,19 à 11,50). Les visites à un médecin étaient fréquentes (84,3 % des participants sur 6 mois). L’efficacité du traitement clinique était la plus élevée pour le VIH/sida, intermédiaire pour la dépendance aux opioïdes, et faible pour la psychose. Les mécanismes de la prestation de services ont présenté des exemples de mauvais accès, de médiocre observance du traitement, et de peu d’effet sur les maladies multi-morbides.

Conclusions:: L’efficacité clinique était variable, et la prestation de services pour les maladies spécifiques semblait avoir peu d’effet sur la multi-morbidité. Il faut peut-être mettre en œuvre de nouveaux modèles de soins.

Keywords: HCV; HIV; heroin; mortality; multimorbidity; police; psychosis.

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Conflict of interest statement

Declaration of Conflicting Interests: Dr. Honer has received consulting fees or sat on advisory boards for In Silico, Eli Lilly, Roche, Lundbeck, and Otsuka. Dr. Montaner has received grant support from Abbott, Biolytical, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiV Healthcare. Dr. Barr has received consulting fees or sat on advisory boards for Bristol-Myers Squibb, Eli Lilly, and Roche. Dr. Procyshyn has received speaking and advisory board fees from Janssen, Lundbeck, Otsuka, and Sunovion and was a member of speaker’s bureaus for AstraZeneca, Janssen, Lundbeck, and Otsuka. Dr. Krausz has received grant support from Bell Canada, CIHR, the Mental Health Commission of Canada, the Canadian Center of Substance Abuse, and the Innerchange Foundation. Dr. MacEwan has received speaking or consulting fees or sat on advisory boards for Apotex, AstraZeneca, Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Pfizer, and Sunovion and has received research grant support from Janssen. Dr. Rauscher has received advisory board fees from Hofmann-La Roche. Mr. Tran, Mr. Nham, Mr. Cervantes-Larios, Ms. Jones, Ms. Gicas, and Ms. Buchanan declare no conflict of interest. Drs. Vila-Rodriguez, Leonova, Langheimer, Panenka, Lang, Thornton, Vertinsky, Schultz, Krajden, and Smith declare no conflict of interest.

Figures

Figure 1.
Figure 1.
Relationship of measures of poverty and emergency department utilization for specific disorders. Statistics are kept for local health authorities (LHA), 2 of which are depicted in the figure. Emergency department visits are illustrated for the St. Paul’s Hospital (SPH, “H”) in the center of the northern part of LHA 161. This hospital serves the northern part of LHA 161 and LHA 162; a different hospital is closer to the southern part of LHA 161. The ring in LHA 162 delineates the area of recruitment where 95% of participants in the Hotel Study lived. The distribution of measures of poverty includes (A) the median after-tax income assessed in the National Household Survey (NHS) in 2011, (B) dwellings in disrepair, and (C) the percentage of subsidized housing. The distribution of people seeking emergency department care (per 100 living in a census dissemination area) includes (D) neurological disorder visits, (E) substance misuse visits, and (F) mental health related visits, with an insert map placing the region within the lower mainland area of British Columbia.
Figure 2.
Figure 2.
Trends in police apprehensions related to mental illness. (A) Numbers of unique individuals with a single apprehension in a year are shown with the gray line and the left y-axis. Numbers of unique individuals with more than 1 apprehension in the same year are shown as black bars and the right y-axis. (B) Data for total apprehensions, apprehensions initiated by police (s28), and apprehensions initiated by mental health care providers (F4, 10, 21). The left panel shows the relative increase in care provider-initiated apprehensions in the Downtown Eastside (DTES) relative to other policing districts.
Figure 3.
Figure 3.
Multimorbid illness and hepatitis C virus (HCV) active infection. Percentage of participants in HCV nonexposed group (N = 116) and HCV active infection group (N = 180) with multimorbid illnesses (11 possible, excludes HCV). Multimorbid illnesses assessed were psychosis, alcohol dependence, stimulant dependence, opioid dependence, movement disorder, traumatic brain injury, clinical cognitive impairment, seizures, cerebral infarction, HIV, hepatitis B virus (HBV), surface antigen positive.
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