Association of homelessness and unstable housing with cardiovascular care utilization among Veterans

Abstract: Background: US military Veterans account for a disproportionate share of adults experiencing homelessness. Individuals experiencing homelessness and unstable housing (HUH) carry an increased burden of cardiovascular (CV) risk factors and disease. We examined rates of cardiovascular care utilization among Veterans with established CV disease by HUH status. Methods: We identified Veterans with coronary artery disease, heart failure, peripheral artery disease, atrial fibrillation, or stroke/ cerebrovascular disease between 2016 and 2019 and determined their HUH status. The primary outcomes were the annual number of outpatient visits for CV disease management and prescription of recommended medications for CV conditions. Secondary outcomes were the number of CV disease procedures or diagnostic testing, ED visits, and hospitalizations. Inverse probability of treatment weighting was used to balance clinical, demographic, and area-level variables. Results: A total of 2,134,650 Veterans with CV disease were identified, with 128,197 experiencing HUH during the study period. HUH status was associated with an 8.7% (95% CI 7.6% to 9.8%, p<0.001) lower rate of outpatient visits for CV disease management. There was no statistically significant difference in the odds of receiving recommended CV medications between the two groups. Veterans in the HUH group also had lower rates of carotid artery stenting or endarterectomy and pacemaker/implantable cardioverter-defibrillator implantations, and higher rates CV-specific ED visits and hospitalizations (23.7% (95% CI 21.0% to 26.5%) and 15.7% (95% CI 13.7% to 17.8%) respectively). Conclusion: Veterans with chronic CV disease experiencing HUH had fewer outpatient visits for CV disease management, similar rates of CV disease medication prescriptions, lower rates of certain CV procedures, but higher rates of ED visits and hospitalizations.