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Homeless status and associations with treatment disparities for common skin conditions

Year: 2020
Type: article
Study design: Observational Study
Abstract: Dear Editor, Over 500 000 people experience homelessness in the USA on any given night.1 Skin disease is prevalent in homeless individuals, and increased morbidity has been attributed to environmental exposures, lack of resource access and inconsistent health care.1 2 In this case–control study, we identify differences in dermatologists’ management of common conditions in homeless relative to nonhomeless patients that might contribute to healthcare disparities in the homeless. In Salt Lake City, Utah, free primary and specialty care is provided by Fourth Street Clinic (FSC) to homeless persons. Since 2000, dermatologists from the University of Utah (UU) Department of Dermatology voluntarily staff FSC's twice‐monthly referral‐based dermatology clinic. Homeless FSC patients have similar access to medications, procedures and follow‐up as UU clinics, albeit free‐of‐charge. The management practices of seven UU dermatologists who volunteer regularly at FSC (attending at least seven clinics between 2011 and 2017) were analysed. Adult (> 17 years) homeless (FSC clinics) and nonhomeless patients (UU clinics) diagnosed with actinic keratosis (AK), dermatitis, nongenital verrucae or acne between May 2011 and July 2017 were included. Demographic and treatment information were obtained via electronic health records. Five nonhomeless patients were matched to each homeless patient based on diagnosis, sex, age ± 3 years, treating dermatologist and clinic visit date ± 3 years using Greedy matching (SAS macro: %gmatch).3 Matched‐control patients (n = 98) with duplicate entries, no clinic note, nonmatching diagnosis or no evidence of skin disease were excluded. Dermatitis diagnoses included atopic, seborrhoeic, contact and not‐otherwise‐specified subtypes. Procedures for dermatitis included biopsy, potassium hydroxide preparation, intralesional steroid injection and culture. Acne severity was determined using the Global Acne Grading System.4 We compared homeless with nonhomeless matched‐control patients using t‐tests, Kruskal–Wallis tests or chi‐squared tests, as appropriate. Analyses were performed in SAS version 9·4 (SAS, Cary, NC, USA). Fifty‐seven homeless patients with AKs were matched to 283 nonhomeless patients and had comparable numbers of AKs (P = 0·25). Overall, medications were prescribed in 7·4% and cryotherapy was performed in 89·4% of patients. Comparing homeless and nonhomeless patients, no significant differences existed between the number of prescriptions or treatment with cryotherapy (P = 0·51 and P = 0·06, respectively, Table 1). However, stratifying by number of AKs, in those with fewer (< 5) AKs, cryotherapy was more common for nonhomeless compared with homeless patients (93·8% vs. 81·3%, P = 0·02). In addition, follow‐up was more commonly recommended for non‐homeless patients (86·9% vs. 36·8%, P < 0·001). Comparison of treatment for common skin conditions, overall and by homeless status P‐values are considered statistically significant at a threshold of 0·05 and are marked in bold. Comparison of treatment for common skin conditions, overall and by homeless status P‐values are considered statistically significant at a threshold of 0·05 and are marked in bold. Sixty‐two homeless patients with dermatitis were matched to 241 nonhomeless patients with comparable numbers of body sites affected (average, n = 2; P = 0·73); 96·8% of patients were prescribed medications. High‐potency topical steroids were less commonly prescribed in homeless patients (17·7% vs. 41·9%), whereas mid‐potency topical steroids were more frequently prescribed (69·4% vs. 37·3%, P < 0·001). Procedures were performed less often in homeless than nonhomeless patients (1·6% vs. 22·0%, P < 0·001), notably, biopsies (0% vs. 10·8%, P = 0·007). Although follow‐up was recommended less frequently for homeless patients, this did not reach statistical significance (25·8% vs. 39·0%, P = 0·054). Twenty‐eight homeless patients with nongenital verrucae matched to 199 nonhomeless patients did not differ in verruca counts (average, n = 1; P = 0·161). Cryotherapy was performed in 89·3% of homeless and 79·9% of nonhomeless patients. Homeless patients were less commonly prescribed medications (7·1% vs. 29·1%, P = 0·01) and were less commonly recommended follow‐up (21·4% vs. 41·2%, P = 0·04). Twenty‐seven homeless patients with acne were matched to 126 nonhomeless patients. No differences existed in distribution of acne severity (P = 0·64). Homeless patients were more commonly prescribed one or more topical medications compared with nonhomeless patients (92·6% vs. 72·2%, P = 0·001). Nonhomeless patients were prescribed more acne medications at the same visit (more complicated regimen) compared with homeless patients (P = 0·005). Follow‐up was less frequently recommended for homeless patients (44·4% vs. 73·8%, P = 0·003). This study highlights patterns in less diagnostic inquiry, less aggressive intervention and fewer recommendations for follow‐up for common skin conditions in homeless populations vs. nonhomeless populations, despite the same dermatologists treating both groups. As we reported previously, these trends may contribute to disparities associated with homelessness.5 Potential explanations for these differing dermatologist behaviours may include lack of knowledge of available resources at the homeless clinic, implicit biases, concern for patient adherence or resource stewardship, or tendency to over‐medicalize nonhomeless patients.6 7 Adopting available guidelines for treating common skin conditions or improving physician training about homelessness and its effects may reduce treatment disparities. Although limited by sample size, single geographic location and potential confounding comparisons between the homeless community clinic and ‘nonhomeless’ academic medical centre clinics, our findings demonstrate that healthcare disparities exist in the dermatological care given to homeless compared with nonhomeless patients. This is particularly apparent in dermatologists’ diagnostic and treatment approaches towards common skin conditions. Underlying causes for these disparities need to be explored and mitigated. Funding sources: A.M.S. receives support from a Dermatology Foundation Public Health Career Development Award. A.T. is supported by a National Institutes of Health predoctoral fellowship, F30CA235964. Conflicts of interest: The authors declare they have no conflicts of interest.
DOI: 10.1111/bjd.19051
Language: English
Open Access status: green
OpenAlex ID: W3013553467
FWCI: 1.304
Cites: 5
Cited by: 10
Related to: 10