Incarcerated and Homeless People Disproportionately Affected by COVID-19

Martha P. Montgomery, MD, MHS

A new investigation into the intricacies of COVID-19 hospitalizations for people experiencing incarceration or homelessness in the United States suggested that expanding medical respite could reduce hospitalization or shorten the length of stay in populations who are disproportionately affected by the pandemic.

Investigators led by Martha P. Montgomery, MD, MHS, COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia, noted that people experiencing incarceration (PEI) and people experiencing homelessness (PEH) have an increased risk of COVID-19 exposure from congregate living.

However, data on the hospitalization course of PEI and PEH are limited.

With their cross-sectional study, Montgomery and colleagues compared hospitalizations from COVID-19 for PEI and PEH among those recorded in the general population.

The Methods

The investigators analyzed data from an all-payer, hospital-based administrative database called the Premier Healthcare Database Special COVID-19 Release. The database contained discharge records from over 800 for-profit and non-profit, community, and teaching hospitals across the US.

The study included all adults 18 years or older with COVID-19 who were evaluated in the emergency department or hospitalized and discharged during April 1, 2020, through June 30, 2021.

People experiencing incarceration and people experiencing homelessness were identified using ICD-10-CM codes. These conditions were listed as either the primary or secondary diagnosis code during any emergency department visit or hospitalization during the study period.

Montgomery and colleagues defined hospitalization proportion as the number of patients hospitalized for COVID-19 out of the total number evaluated in the emergency department for COVID-19.

Patient race and ethnicity were determined as recorded in the electronic health record, and underlying medical conditions were defined using ICD-10-CM codes listed as a primary or secondary diagnosis code during any inpatient or outpatient encounter during the period from January 1, 2019, through the initial COVID-19 encounter.

Several outcomes were examined during the study, including acute in-hospital complications, laboratory test results, intensive care unit admission, invasive mechanical ventilation (IMV), in-hospital mortality, length of stay, and 30-day readmission for COVID-19.

The Findings

In total, 3415 PEI (2952 men [86.4%]; mean [SD] age, 50.8 [15.7] years) and 9434 PEH (6776 men [71.8%]; mean [SD] age, 50.1 [14.5] years) were evaluated in the emergency department for COVID-19.

During this time, investigators observed that both groups were hospitalized more often (2170 of 3415 [63.5%] PEI; 6088 of 9434 [64.5%] PEH) than the general population (624 470 of 1 257 250 [49.7%]) (P < .001).

Additionally, both PEI and PEH patients hospitalized for COVID-19 were more likely to be younger, male, and non-Hispanic Black than the general population.

A higher frequency of invasive mechanical ventilation (IMV) was seen in hospitalized PEI (410 [18.9%]; adjusted risk ratio [aRR], 1.16; 95% CI, 1.04-1.30), in addition to a higher frequency of mortality (308 [14.2%]; aRR, 1.28; 95% CI, 1.11-1.47) than the general population (IMV, 88 897 [14.2%]; mortality, 84 725 [13.6%]).

Conversly, hospitalized PEH had a lower frequency of IMV (606 [10.0%]; aRR, 0.64; 95% CI, 0.58-0.70) and mortality (330 [5.4%]; aRR, 0.53; 95% CI, 0.47-0.59) than the general population.

However, both PEI and PEH had longer mean (SD) lengths of stay (PEI, 9 [10] days; PEH, 11 [26] days) and a higher frequency of readmission (PEI, 128 [5.9%]; PEH, 519 [8.5%]) than the general population (mean [SD] length of stay, 8 [10] days; readmission, 28 493 [4.6%]).

The team concluded that the results of the study reinforced the importance of COVID-19 prevention measures for disproportionately affected populations such as PEI and PEH.

“In the long term, reducing COVID-19 hospitalizations among PEI and PEH will require continued partnerships among homeless services, correctional facilities and agencies, health care professionals, and public health agencies to ensure that COVID-19 vaccinations and other prevention measures are implemented equitably for PEI and PEH,” the team wrote.

The study, "Hospitalizations for COVID-19 Among US People Experiencing Incarceration or Homelessness," was published online in JAMA Open Network.