The homeless population is a complex patient cohort that orthopaedic surgeons will undoubtedly face. According to the U.S. Department of Housing and Urban Development, there were 649,917 sheltered and unsheltered homeless persons nationwide as of January 2010. Additionally, about 1.59 million people used an emergency shelter or a transitional housing program during the 12-month period between Oct.1, 2009, and Sept. 30, 2010. This number suggests that roughly 1 in every 200 persons in the United States used the shelter system at some point during that period.

A homeless individual is one who lacks a fixed, regular, and adequate nighttime residence or whose primary nighttime residence is a public or privately operated shelter to provide temporary living accommodations, or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. The general homeless population has higher incidences of mental health problems, drug abuse, alcohol abuse, and chronic medical conditions than the general public and presents unique challenges for healthcare providers.

Moreover, homeless individuals generally suffer from malnutrition and social isolation, which are exacerbated by a high level of distress, riskier living conditions, and lower levels of economic stability. Education regarding this patient population is critical for improving the care of orthopaedic injuries among the homeless.

Social issues
Various studies demonstrate that the health problems of homeless individuals can be largely attributed to their social isolation, low levels of social support and functioning, and lack of social resources, which produce a high stress and high risk environment. Considerable evidence suggests that social support has protective effects on physical health outcomes (eg, cardiovascular disease, mortality) and is associated with lower rates of depression, anxiety, suicidal ideation, and substance abuse.

Homelessness itself is a source of distress and, coupled with lower levels of economic and social support, is related to the frequency of severe and chronic mental illness being as high as 30 percent in the homeless patient population. Depression is prevalent among the homeless; many homeless people display depressive symptoms commensurate with a clinical diagnosis. Interestingly, level of education has been strongly associated with the level of depressive symptomatology. One hypothesis is that education and literacy help “inoculate” a person against the stressful circumstances of being homeless.

This is noteworthy because not only does the average homeless individual have considerably fewer years of education than the average non-homeless person, but both lower educational level and depression independently have been shown to have detrimental effects on postoperative recovery.

These effects are often magnified by the well-documented prevalence of substance abuse among the homeless, which is associated with the lack of social support characteristic of homelessness, and has been linked to poorer postoperative outcomes. Thus, in treating homeless patients, orthopaedic surgeons should keep in mind the increased likelihood of social stressors, mental illness, and substance abuse, as well as the lack of significant education.

Nutritional issues
The nutritional status of homeless people is another area of concern. A 1990 study among 96 New York City homeless individuals found a diet that consisted almost entirely of foods high in saturated fat and cholesterol and low in nutrient density. Similarly, a 2008 study of 81 homeless women living in transitional living centers in the southern United States had a diet that fell considerably short of USDA recommendations, consisting predominantly of high-fat foods with few fruits and vegetables. This resulted in health problems, including depression, edema, weight gain, and uncontrolled diabetes.

Some studies have even suggested that homeless individuals, many of whom are recovering from substance abuse and who have experienced trauma, crave carbohydrates as a symptom of their postacute withdrawal process and/or trauma recovery. Thus, the nutritional vulnerability of this patient population can have substantial effects on their trauma care, as the resultant chronic diet-related health conditions can detrimentally affect postoperative recovery.

Management issues
Homeless individuals often experience diseases and disorders that normally afflict the geriatric population, aggravating their social and nutritional problems. Extreme poverty, substance abuse, and poor mental and physical health increase the risk of development of conditions such as severe coronary artery disease and peripheral vascular disease. These patients can also demonstrate problems with bone healing secondary to endocrine abnormalities in the setting of malnutrition.

When these conditions develop in younger homeless individuals, who are ineligible for Medicare benefits, they can have a detrimental effect on the medical care the individuals receive. Because of these unique challenges, homeless individuals are admitted to inpatient units five times more often and have longer average lengths of stay than non-homeless individuals. The orthopaedic surgeon must therefore carefully consider surgical versus nonsurgical management of injuries in this population.

Follow-up issues
Another significant factor for orthopaedic surgeons in managing care of homeless patients is the difficulty in follow-up. Most homeless patients have no health insurance, and government assistance, including Medicaid, is difficult to obtain without a permanent residence. Inability to pay, lack of transportation, and mistrust or fear of healthcare professionals have often been cited by homeless people as barriers to obtaining health care. These issues may have a significant impact on follow-up and should be considered when treating homeless patients with orthopaedic injuries.

Surgical management and specific health issues
Surgical care of the homeless patient is also complicated by various comorbidities. Increased rates of infectious diseases as well as chronic medical conditions have been reported, ranging from community-acquired pneumonia, tuberculosis, and HIV to cardiovascular disease and chronic obstructive pulmonary disease. Certain cancer risk factors, such as sun exposure, cigarette smoking, and alcoholism, are also higher among the homeless than in the general population.

Moreover, although respiratory infections are usually self-limiting, they can be disabling for homeless patients who face greater obstacles in procuring adequate shelter, food, and health care and may not have a place to rest and recuperate. Furthermore, although the prevalence of diabetes is not substantially higher among homeless adults, evidence exists of inadequate diagnosis, treatment, and management among this population.

The long-term effect of these chronic conditions was exemplified in a study among New York City’s homeless individuals, who had an age-adjusted mortality rate nearly four times higher than the average U.S. population. Thus, postoperative outcomes are significantly affected in the homeless population by various comorbidities, and surgeons must assume that successful postoperative treatment without complication will be more difficult in the homeless patient.

Conclusions
The practicing orthopaedic surgeon often comes in contact with homeless patients in non elective settings such as after traumatic injury. Although specific surgical or conservative treatments for an injury are often applied across a broad spectrum of patients, optimal care of the homeless individual may require an alternative approach based on a nuanced understanding of the complex medical and social challenges presented by this patient population.

Overall, homeless individuals are extremely complex patients to treat in both a medical and social context. The social, nutritional, and medical difficulties experienced by this patient population affect the course of treatment and increase the risk of complications. A thorough understanding by orthopaedic surgeons of the unique challenges of treating homeless patients is critical and may improve health outcomes.

Neil M. Issar, BSc; Alex A. Jahangir, MD; Mallory Powell; William T. Obremskey, MD, MPH; and Manish K. Sethi, MD, are all associated with the Vanderbilt Orthopaedic Institute Center for Health Policy.

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