To the Editor:
Skin disease is prevalent in homeless populations and contributes to significant morbidity.1,2,3 However, data are lacking on the unique factors that influence dermatologic care for homeless persons. To determine demographics and factors associated with failure to follow-up, we performed a retrospective analysis of patients seen between May 2009 and July 2017 at a referral-based dermatology clinic (IRB# 00096567). The clinic is located in Salt Lake City, Utah, a large urban center in a rural, mountainous state, and provides free medical care, specifically for the homeless. Dermatologists volunteer in twice monthly clinics following referral from primary care providers.
Medical data from patients ≥18 years old were obtained from electronic health records (EHR) and included demographics, diagnostic information, treatment, recommendations, follow-up information, and comorbidities. Demographics were compared by gender using t-tests for continuous variables and chi-squared tests for nominal variables. Generalized estimated equations with exchangeable covariance structure were used to determine variables associated with follow-up. SAS (Version 9.4) was used for all analyses.
One hundred forty-one dermatology clinics were held during the study period, totaling 507 individuals. Average age at first visit was 48.9 years. Male patients were more common and were more likely to be older at first visit compared to females (p<0.001). 73% of patients identified as Caucasian/White. The majority of patients (86.2%) had a Charlson Comorbidity Index (CCI) of ≤1. 66.9% of patients had ≥1 mental health diagnosis and was more common in females (p=0.048) (Table 1). Infectious and premalignant/malignant diagnoses were more commonly diagnosed in males, whereas acne/rosacea were more commonly diagnosed in females.
Table 1. Demographics of patients, overall and by gender, at the dermatology homeless clinic.
SD: Standard deviation
| Total | Female | Male | p-value | |
|---|---|---|---|---|
| Number of patients | 507 | 158 | 349 | |
| Average age in years at first visit (SD) | 48.9 (10.5) | 46.0 (10.6) | 50.2 (10.1) | < 0.001 |
| Average number of diagnoses per patient (SD) | 2.0 (1.5) | .8 (1.2) | 2.0 (1.6) | 0.126 |
| Average number of clinic visits per patient (SD) | 1.2 (0.6) | 1.2 (0.6) | 1.2 (0.7) | 0.603 |
| Race, n (%) | 0.74 | |||
| Caucasian/White | 370 (73.0) | 111 (70.3) | 259 (74.2) | |
| Hispanic/Latino | 68 (13.4) | 25 (15.8) | 43 (12.3) | |
| Black/African-American | 37 (7.3) | 12 (7.6) | 25 (7.2) | |
| Other | 32 (6.3) | 10 (6.3) | 22 (6.3) | |
| Charlson Comorbidity Index, n (%) | 0.387 | |||
| 0 | 306 (60.4) | 87 (55.1) | 219 (62.8) | |
| 1 | 131 (25.8) | 45 (28.5) | 86 (24.6) | |
| 2 | 32 (6.3) | 14 (8.9) | 18 (5.2) | |
| 3 | 24 (4.7) | 8 (5.1) | 16 (4.6) | |
| 4+ | 14 (2.8) | 4 (2.5) | 10 (2.9) | |
| Mental Health Diagnoses, n (%) | 0.048 | |||
| 0 | 168 (33.1) | 43 (27.2) | 125 (35.8) | |
| 1 | 146 (28.8) | 47 (29.7) | 99 (28.4) | |
| 2 | 98 (19.3) | 27 (17.1) | 71 (20.3) | |
| 3 | 68 (13.4) | 30 (19.0) | 38 (10.9) | |
| 4+ | 27 (5.3) | 11 (7.0) | 16 (4.6) | |
| Dermatologic Diagnosis Category, n (%) | ||||
| Benign | 216 (42.6) | 74 (46.8) | 142 (40.7) | 0.195 |
| Dermatitis/Psoriasis | 135 (26.6) | 37 (23.4) | 98 (28.1) | 0.271 |
| Infection | 110 (21.7) | 21 (13.3) | 89 (25.5) | 0.002 |
| Premalignant/malignant | 104 (20.5) | 23 (14.6) | 81 (23.2) | 0.025 |
| Acne/Rosacea | 38 (7.5) | 19 (12.0) | 19 (5.4) | 0.009 |
| Other | 143 (28.2) | 46 (29.1) | 97 (27.8) | 0.760 |
Average time to most recent follow-up was 1.0 years. Of the 246 (39.4%) patients who were recommended to follow-up, 49.6% followed up as recommended. Patient demographics associated with increased likelihood of follow-up included older age (p=0.03), male (p=0.001), more skin diagnoses (p=0.03), premalignant/malignant diagnoses (p=0.025), in-clinic procedure performed (p=0.001), shorter recommended follow-up intervals (p=0.001), and lower number of mental health diagnoses (p=0.02) (Table 2).
Table 2. Comparison of follow-up variables between patients who did and did not follow up among visits in which follow-up was recommended (n visits=246).
SD: standard deviation; OTC: Over the counter
| Patient followed up? | |||
|---|---|---|---|
| Variable | No (n = 96) |
Yes (n = 150) |
P-value |
| Age, mean (SD) | 47.6 (11.0) | 50.3 (9.2) | 0.0314 |
| Average number of diagnoses per visit (SD) | 1.8 (1.4) | 2.5 (2.1) | 0.0287 |
| Gender, n (%) | |||
| Male | 48 (57.1) | 104 (78.8) | 0.0013 |
| Female | 36 (42.9) | 28 (21.2) | |
| Race, n (%) | 0.1728 | ||
| White | 64 (76.2) | 105 (79.5) | |
| Hispanic/Latino | 12 (14.3) | 15 (11.4) | |
| Black/African-American | 2 (2.4) | 9 (6.8) | |
| Other | 6 (7.1) | 3 (2.3) | |
| Charlson Comorbidity index, n (%) | 0.7593 | ||
| 0 | 50 (59.5) | 78 (59.1) | |
| 1 | 21 (25.0) | 36 (27.3) | |
| 2 | 5 (6.0) | 10 (7.6) | |
| 3 | 5 (6.0) | 4 (3.0) | |
| 4+ | 3 (3.6) | 4 (3.0) | |
| Number of mental health diagnoses, n (%) | 0.0194 | ||
| 0 | 27 (32.1) | 55 (41.7) | |
| 1 | 18 (21.4) | 44 (33.3) | |
| 2+ | 39 (46.4) | 33 (25.0) | |
| Dermatologic Diagnostic Category | |||
| Benign | 31 (32.3) | 62 (41.3) | 0.154 |
| Dermatitis/Psoriasis | 29 (30.2) | 40 (26.7) | 0.546 |
| Infection | 18 (18.8) | 37 (24.7) | 0.277 |
| Premalignant/malignant | 28 (29.2) | 65 (43.3) | 0.025 |
| Acne/Rosacea | 13 (13.5) | 19 (12.7) | 0.842 |
| Other | 26 (27.1) | 42 (28.0) | 0.875 |
| In-clinic procedure, n (%) | 0.0010 | ||
| Yes | 34 (35.4) | 85 (56.7) | |
| No | 62 (64.6) | 65 (43.3) | |
| Prescribed medication, n (%) | 0.2991 | ||
| Yes | 57 (59.4) | 79 (52.7) | |
| No | 39 (40.6) | 71 (47.3) | |
| Recommended follow up time interval | 0.0013 | ||
| ≤1 month | 30 (33.0) | 80 (55.2) | |
| >1 month to 6 months | 45 (49.5) | 53 (36.6) | |
| >6 months | 16 (17.6) | 12 (8.3) | |
These findings can aid clinicians in altering recommendations or identifying at-risk patient populations for potential non-adherence. Given the transience of homeless populations, following through on commitments to follow-up care is understandably difficult. Interestingly, although our patient population is largely physically health as measured by CCI, mental health burden is higher than national averages of 18.5% of the general U.S. population and 46% of homeless U.S. adults.5 The inverse correlation of mental health diagnoses with the likelihood of follow-up points to the compounded difficulty of patient compliance when grappling with psychiatric disease.
Although this study has several limitations, including limited sample size, reliance on the accuracy of the EHR, and generalizability to the U.S. homeless population, our results aim to better inform dermatology providers on the management of this unique and vulnerable population. Future studies should characterize barriers to dermatologic care for homeless persons to develop effective interventions and treatment strategies.
Acknowledgments
This study was granted exemption by the University of Utah Institutional Review Board (IRB No. 00096567).
Funding sources: A.S. is funded by the University of Utah Vice President’s Clinical Translational Research Scholars and the Dermatology Foundation. A.T. is supported by NIH grants 5T32HD007491-22 (Former) and F30CA235964 (Current).
ABBREVIATIONS
- EHR
electronic health record
- CCI
Charlson Comorbidity Index
Footnotes
Conflict of Interest Disclosure: None Declared
REFERENCES
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