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OBJECTIVES: This study reports findings from the first-ever systematic enumeration of homeless population size using data previously collected from administrative records of homeless services providers in nine US jurisdictions over a one year period. As such, it provides the basis for establishing an ongoing measure of the parameters of the homeless population and for tracking related trends on the use of homeless services over time. METHODS: Each participating jurisdiction collected data through its homeless services management information systems for persons and families who use emergency shelter and transitional housing. The jurisdictions organized the data by a standardized reporting format. These data form the basis for reporting homeless population size, both in raw numbers and as adjusted for each jurisdiction's overall population size, as well as the rate of turnover and average annual length of stay in emergency shelters and transitional housing. RESULTS: Individual jurisdictions had annual rates of sheltered homelessness ranging from 0.1% to 2.1% of their overall population, and 1.3% to 10.2% of their poverty population. Annual population size was 2.5 to 10.2 times greater than the point-prevalent population size. Results are broken down for adults and families. CONCLUSIONS: The prevalence of homelessness varies greatly among the jurisdictions included in this study, and possible factors for this diversity are discussed. Future reports of this nature will furnish similar series of homeless enumerations across a growing number of jurisdictions, thereby providing a basis for exploring the effects of different contextual factors on local prevalence rates of homelessness. [ABSTRACT FROM AUTHOR]

Use of administrative data to inform decision making is now commonplace throughout the public sector, including program and policy evaluation. While reuse of these data can reduce costs, improve methodologies, and shorten timelines, challenges remain. This article informs evaluators about the growing field of Integrated Data Systems (IDS), and how to leverage cross-sector administrative data in evaluation work. This article is informed by three sources: a survey of current data integration efforts in the United States (U.S.) (N=63), informational interviews with experts, and internal knowledge cultivated through Actionable Intelligence for Social Policy's (AISP) 12+ years of work in the field. A brief discussion of the U.S. data integration context and history is provided, followed by discussion of tangible recommendations for evaluators, examples of evaluations relying on integrated data, and a list of U.S. IDS sites with publicly available processes for external data requests. Despite the challenges associated with reusing administrative data for program evaluation, IDS offer evaluators a new set of tools for leveraging data across institutional silos., Competing Interests: Conflict of interest statement The authors declare they have no conflicts of interest., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: Despite increasing interest in assessing patient social needs in health care settings, there has been little research examining the performance of housing-related screening questions., Objective: To examine the performance of 2 single-item screening questions assessing emergency department (ED) patients' self-perceived risk of future homelessness., Design, Setting, and Participants: This prospective cohort study was conducted among a randomly selected sample of adult ED patients from 2016 to 2017 in a public hospital ED in New York City. Data were analyzed from September 2019 through October 2021., Exposures: Responses on patient surveys conducted at the baseline ED visit for 2 single-item screening questions on self-perceived risk for future housing instability and homelessness were collected. One question asked patients if they were worried about having stable housing in the next 2 months, and the other question asked them to rate the likelihood that they would enter a homeless shelter in the next 6 months., Outcomes: Homeless shelter entry 2, 6, and 12 months after an ED visit, assessed using shelter administrative data in the study city, which was linked with participant baseline survey responses., Results: There were 1919 study participants (976 [51.0%] men and 931 [48.6%] women among 1915 individuals with gender data; 700 individuals aged 31-50 years [36.5%] among 1918 individuals with age data; 1126 Hispanic or Latinx individuals [59.0%], 368 non-Hispanic Black individuals [19.3%], and 225 non-Hispanic White individuals [11.8%] among 1908 individuals with race and ethnicity data). Within 2, 6, and 12 months of the ED visit, 45 patients (2.3%), 66 patients (3.4%), and 95 patients (5.0%) had entered shelter, respectively. For both single-item screening questions, participants who answered affirmatively had significantly higher likelihood of future shelter entry at each time point examined (eg, at 2 months: 31 participants responding yes [6.5%] vs 14 participants responding no [1.0%] to the question concerning being worried about having stable housing in the next 2 months). Sensitivity of the screening questions ranged from 0.27 to 0.69, specificity from 0.76 to 0.97, positive predictive value from 0.07 to 0.27, and area under the receiver operating characteristic curve from 0.62 to 0.72., Conclusions and Relevance: This study found that 2 single-item screening questions assessing ED patient self-perceived risk of future housing instability and homelessness had adequate to good performance in identifying risk for future shelter entry. Such single-item screening questions should be further tested before broad adoption.

Objective: To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes., Data Sources: Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database., Study Design: Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires., Data Collection/extraction Methods: Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching., Principal Findings: Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry., Conclusions: Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs., (© 2021 Health Research and Educational Trust.)

Background: It is estimated that around 160,000 households in Britain experience homelessness each year, although no definitive statistics exist. Between March and September 2020, as part of the initial 'Everyone In' government response to COVID-19 in England, 10,566 people were living in emergency accommodation and nearly 18,911 people had been moved into settled accommodation. However, some forms of temporary accommodation may not be suitable as shared facilities make it impossible for people to adhere to government guidelines to reduce the spread of COVID-19., Methods: This is parallel group, pilot randomised controlled trial. The target is to recruit three local authorities, each of which will recruit 50 participants (thus a total of approximately 150 participants). Individuals are eligible if they are aged 18 and over, in a single-person homeless household, temporarily accommodated by the LA with recourse to public funds. Participants will be randomised to receive settled accommodation (intervention group) or temporary accommodation (control group). The intervention group includes settled housing such as Private Rented Sector (low and medium support), Social Housing (low and medium support), and Housing First (High support). The control group will maintain treatment as usual. The follow-up period will last 6 months. The primary outcome is to assess the feasibility of recruitment, retention, and acceptability of trial processes against progression criteria laid out in a traffic light system (green: all criteria are met, the trial should progress as designed in this pilot; amber: the majority of criteria are met and with adaptations to methods all criteria could be met; red: the minority of criteria are met and the pilot RCT should not proceed). Secondary outcomes include assessment of completeness of data collection at 3 and 6 months and percentage of participants consenting to data linkage, as well as a process evaluation and economic evaluation., Discussion: This trial will address feasibility questions associated with progression to a fully powered effectiveness trial of models of housing to reduce risk of COVID-19 infection and homelessness., Trial Registration: ISRCTN69564614 . Registered on December 16, 2020., (© 2022. The Author(s).)

We provide an overview of the pilot and evaluation measures used for an independent evaluation of the Encampment Resolution Pilot (ERP) wherein the City of Philadelphia closed two homeless encampments in May 2018 and sought to assist those displaced by the closures with housing and treatment services. The evaluation used the Rapid Assessment, Response, and Evaluation method to collect qualitative findings on service use barriers and facilitators from open-ended interviews with people staying in the encampments (N = 27) and service providers (N = 10). We assessed how the ERP allowed providers to "push the system" by removing access barriers, and providing amenable, effective, and accessible housing and drug treatment services that led to more widely adopted best practices. However, there was a clear need for additional supportive services and aftercare for those exiting treatment. Providers also cited a need for more integrated medical and mental health services.

Study Objective: Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless., Methods: We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline., Results: Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use., Conclusion: In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the temporal sequencing of a first-recorded episode of homelessness and treatment for suicidal ideation or attempt., Methods: Data were from the U.S. Department of Veterans Affairs Corporate Data Warehouse and contained medical records of service use dates and associated ICD codes for care provided by the Veterans Health Administration. The analysis examined treatment for suicidality before and after a first record of homelessness ("onset") among 152,519 veterans. The second analysis examined the rate of treatment for suicidality among 156,288 veterans with any indication of homelessness. The third analysis examined the rate of homelessness among 145,770 veterans with indication of suicidality., Results: Among newly homeless veterans, treatment for suicidality peaked just before onset of homelessness. Thirteen percent of homeless veterans had evidence of suicidality. Twenty-nine percent of veterans with evidence of suicidality appeared to have concurrent homelessness., Conclusions: Homelessness should be considered a primary risk factor for suicidality.

Background: Among individuals experiencing homelessness, unsheltered status is associated with poor health and access to care and an increased risk for premature death. Insufficient research has explored gender differences in these outcomes; the objective of this study was to address this gap in the research., Methods: This study used survey data collected during the 100,000 Homes Campaign. Chi-square tests identified differences in the characteristics of women, men, and transgender individuals. Generalized linear mixed models fit with demographic, homelessness, mental/behavioral health, institutional, and income characteristics were run separately for women and men to assess correlates of unsheltered status and increased risk of premature mortality., Results: Men reported more frequently experiencing unsheltered homelessness while women and transgender participants more frequently met the criteria for risk of premature mortality. Women reported less frequently than men a history of or current substance use, but it significantly increased their likelihood of unsheltered homelessness; reports of mental health issues were rarer among men but significantly increased their odds of unsheltered homelessness. The experience of a violent attack while homeless was most strongly related to increased risk of premature mortality for both women and men., Conclusions: Interventions to reduce unsheltered homelessness among men should be particularly sensitive to mental health issues while for women there may need to be increased attention to substance use. A focus on experience of trauma and the provision of trauma-informed care is essential to address the increased risk of premature mortality among both men and women experiencing homelessness., (Published by Elsevier Inc.)

Objective: Among homeless veterans and those at risk of homelessness currently enrolled in Veterans Affairs (VA) health care, this study examined the proportion likely to become eligible for Medicaid in 2014 and their health needs., Methods: A total of 114,497 homeless and at-risk veterans were categorized into three groups: currently covered by Medicaid, likely to become eligible for Medicaid, and not likely., Results: Seventy-eight percent of the sample was determined to be likely to become eligible for Medicaid in states that expand Medicaid. Compared with veterans not likely to become eligible for Medicaid, those likely to become eligible were less likely to have general medical and psychiatric conditions and to have a VA service-connected disability but more likely to have substance use disorders., Conclusions: Programs serving homeless and at-risk veterans should anticipate the potential interplay between VA health care and the expansion of Medicaid in states that implement the expansion.

Firearm violence is the end result of a causative web of individual-level and geographic risk factors. Few, if any, studies of firearm violence have been able to simultaneously determine the population-based relative risks that individuals experience as a result of what they were doing at a specific point in time and where they were, geographically, at a specific point in time. This paper describes the linkage of individual and geographic data that was undertaken as part of a population-based case-control study of firearm violence in Philadelphia. New methods and applications of these linked data relevant to researchers and policymakers interested in firearm violence are also discussed.

Although the links between health and environment are well known, interventions that target these associations in order to improve health are rare. Health and social service agencies often function independently of one another, maintaining separate, unlinked databases. For example, relationships among homelessness, AIDS, and tuberculosis have been noted, but services have not focused on the intersecting populations these conditions affect. This Issue Brief summarizes efforts to merge databases and provide policymakers with information to guide housing, social service, and health care resources. The investigators identify risk factors associated with AIDS among the homeless, and homelessness among people with AIDS.

Objective: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system., Methods: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness., Results: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission., Conclusions: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.

Purpose: To compare the accuracies of whole-body 2-[fluorine 18]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) and conventional imaging (thoracic computed tomography [CT], bone scintigraphy, and brain CT or magnetic resonance [MR] imaging) in staging bronchogenic carcinoma., Materials and Methods: Within 20 months, 100 patients with newly diagnosed bronchogenic carcinoma underwent whole-body FDG PET and chest CT. Ninety of these patients underwent radionuclide bone scintigraphy, and 70 patients underwent brain CT or MR imaging. For each patient, all examinations were completed within 1 month. A radiologic stage was assigned by using PET and conventional imaging independently and was compared with the pathologic stage. The accuracy, sensitivity, specificity, and negative and positive predictive values were calculated., Results: PET staging was accurate in 83 (83%) patients; conventional imaging staging was accurate in 65 (65%) patients (P < .005). Staging with mediastinal lymph nodes was correct by using PET in 67 (85%) patients and by using CT in 46 (58%) patients (P < .001). Nine (9%) patients had metastases demonstrated by using PET that were not found with conventional imaging, whereas 10 (10%) patients suspected of having metastases because of conventional imaging findings were correctly shown with PET to not have metastases., Conclusion: Whole-body PET was more accurate than thoracic CT, bone scintigraphy, and brain CT or MR imaging in staging bronchogenic carcinoma.

Background: Sentinel lymph node (SLN) mapping is an effective technique for staging patients with melanoma. In an attempt to avoid reinjection of radiolabeled colloid and facilitate SLN mapping at the time of surgery, we examined whether residual radioactivity from preoperative lymphoscintigraphy could be used to accurately identify SLNs during surgery 18 to 24 hours later., Methods: Forty-six patients with newly diagnosed melanoma underwent injection of 0.22-micron filtered technetium 99m-labeled sulfur colloid followed by lymphoscintigraphy. Patients returned the next day for SLN biopsy with Isosulfan blue dye and the hand-held gamma-probe to identify SLNs. Thirty of 46 patients underwent repeat imaging before operation. No patient had reinjection of radiocolloid., Results: Ninety-five SLNs were identified on initial lymphoscintigraphy, and repeat imaging on the day of surgery confirmed all SLNs previously identified. A total of 122 SLNs (2.65 per patient) were resected from 58 basins. Eighty-four (69%) of 122 SLNs stained blue, and 118 (97%) of 122 SLNs had in vivo gamma-counts greater than 4 times background. Microscopic metastases were present in 13 (10.7%) of 122 SLNs in 12 (26.1%) of 46 patients. There have been no recurrences over a mean follow-up time of 320 days., Conclusions: Intraoperative gamma-probe detection combined with blue dye injection is highly effective in identifying SLNs 18 to 24 hours after injection of 0.22-micron filtered 99mTc-sulfur colloid. Reinjection of radiocolloid is not required. This technique avoids radiopharmaceutical administration in the operating room, minimizes radiation exposure, and increases scheduling flexibility.

Background: Malignant pleural effusions are a common problem for patients with metastatic disease. Most patients are treated with tube thoracostomy and sclerotherapy, although there remains no standard approach. The purpose of this study was to compare the efficacy of bleomycin with doxycycline sclerotherapy for the treatment of malignant pleural effusions using small-bore catheters., Methods: All patients with a symptomatic malignant pleural effusion referred for chest tube drainage and sclerotherapy over a 2-year period were considered eligible. Using image guidance, a 14F self-retaining catheter was inserted into the pleural space and connected to continuous wall suction. When drainage fell below 200 mL/d, patients were randomized to 60 U of bleomycin or 500 mg of doxycycline sclerotherapy. Response at 30 days was determined., Results: One hundred six patients were enrolled in the study. Fifteen men (29%) and 37 women (71%) with a mean age of 57 years received bleomycin sclerotherapy. Twenty-one of the 29 patients (72%) alive and evaluable at 30 days had successful sclerotherapy. Twenty-three men (43%) and 31 women (57%) with a mean age of 61 years received doxycycline sclerotherapy. Twenty-three of the 29 patients (79%) alive and evaluable at 30 days had successful sclerotherapy. There was no significant difference in response rates between doxycycline and bleomycin (p=0.760)., Conclusions: These data continue to support a role for small-bore chest drainage and sclerotherapy, although there was no significant difference in 30-day response rates between doxycycline and bleomycin.

This study tests a typology of homelessness using administrative data on public shelter use in New York City (1988-1995) and Philadelphia (1991-1995). Cluster analysis is used to produce three groups (transitionally, episodically, and chronically homeless) by number of shelter days and number of shelter episodes. Results show that the transitionally homeless, who constitute approximately 80% of shelter users in both cities, are younger, less likely to have mental health, substance abuse, or medical problems, and to overrepresent Whites relative to the other clusters. The episodically homeless, who constitute 10% of shelter users, are also comparatively young, but are more likely to be non-White, and to have mental health, substance abuse, and medical problems. The chronically homeless, who account for 10% of shelter users, tend to be older, non-White, and to have higher levels of mental health, substance abuse, and medical problems. Differences in health status between the episodically and chronically homeless are smaller, and in some cases the chronically homeless have lower rates (substance abuse in New York; serious mental illness in Philadelphia). Despite their relatively small number, the chronically homeless consume half of the total shelter days. Results suggest that program planning would benefit from application of this typology, possibly targeting the transitionally homeless with preventive and resettlement assistance, the episodically homeless with transitional housing and residential treatment, and the chronically homeless with supported housing and long-term care programs.

Purpose: Our aim was to determine the thoracic manifestations of patients with antiphospholipid antibodies (APAs)., Method: We performed a retrospective review of the clinical records and thoracic imaging studies of 88 patients (63 women, 25 men; mean age 47 years) with APAs to determine the spectrum of thoracic disease., Results: Nine patients (10%) had thoracic abnormalities, including eight with pulmonary embolism (PE) and one with aortic thrombus. One patient with PE had subclavian vein thrombosis. Coexistent thromboses included deep venous thrombosis of the leg in six patients., Conclusion: PE was the most common thoracic abnormality in our patients. The presence of these antibodies should be suspected in patients with PE of otherwise unexplained etiology.

Of 27,638 homeless adults admitted to Philadelphia public shelters in the years 1990 through 1992, 20.1% received treatment for a mental health disorder, and 25.3% for a substance use disorder in the years 1985 through 1993. An additional 20.7% were identified as having untreated substance use problems. Overall, a total of 65.5% of adult shelter users were identified as ever having had a mental health or substance use problem, treated or untreated.

This study examined the rate of admission to public shelters between 1990 and 1992 among persons who received Medicaid-reimbursed inpatient and outpatient psychiatric services and inpatient substance abuse services in Philadelphia between 1985 and 1993. Results show that 7.5 percent of such persons were admitted to public shelters during the three-year period, nearly 2.7 times the rate of shelter use by the general population (2.8 percent). Medicaid recipients treated for serious mental disorders had a three-year rate of shelter use of 8.4 percent. Those receiving inpatient treatment for substance use disorders, including detoxification services, had a three-year rate of shelter admission of 10.2 percent.

Although several studies have examined the trend toward the decreasing differentiation of non-profit from for-profit general hospitals, few have focused on freestanding psychiatric hospitals. This study updates previous research that used psychiatric hospital data from calendar year 1986 with data from 1990. In addition, a preliminary examination of the influence of market competition on the behavior of non-profit psychiatric facilities was conducted. Results confirm a converging trend between for-profit and non-profit facilities that is related, in part, to competition.

The study examined whether state hospitals in operation before deinstitutionalization still carry vestiges of older models of psychiatric care. Using a national database, the authors compared 166 state hospitals built before 1949 with 80 state hospitals built after that time. The old hospitals treated fewer children and adolescents, received more state funding and less third-party funding, had fewer professional clinical staff, spent less on salaries and maintenance, and had more beds, a lower turnover rate, and a longer average length of stay. Findings suggest that planners and policymakers should take into account a facility's history when attempting to introduce innovations.

Objective: In 1992, the American Association for Partial Hospitalization initiated a national survey of partial hospitalization providers to investigate their present status (programming, staffing, and pricing), to track market trends, and to improve advocacy for appropriate utilization and reimbursement., Method: Instrument development and field testing preceded widespread distribution of the survey. From survey data, a description of child and adolescent partial hospital services based on statistical averages is reported as are analyses of program differences by length of stay and for-profit/not-for-profit status., Results: Of the 580 programs responding, 95 indicated that at least 50% of their patient population consisted of children and adolescents. Descriptive statistics on this subsample suggest continued variability in child and adolescent partial hospital programming. Program differences in referral and discharge patterns, population and programming, and utilization and funding patterns based on length of stay and profit status are presented., Conclusions: The pattern of significant program differences between acute-care and long-term child and adolescent partial hospital programs and for-profit/not-for-profit programs (along with the absence of for-profit programs treating children and adolescents in long-term programs) points to an evolving system of care.

This study examines recent trends in the organization of partial-hospitalization services in the United States. Contrary to two recent reports describing declining support for partial hospitalization, data from the National Institute of Mental Health's Inventory of Mental Health Organizations reveal that the number of "partial-care" providers increased by 20% between 1984 and 1988, with increases occurring among privately and publicly funded programs. However, there has been a 56% decline in the average length of stay, with both privately and publicly funded programs showing proportional shifts to more acute care. An increase in the number of long-stay "day care" programs may be attributable to educational and rehabilitation programs that report as partial-care providers. Future study is proposed to create a better typology of partial-hospitalization programs.

This study tracks the 761 community mental health centers which received federal grants as of 1981 and assesses their status 10 years after the shift to Block Grant financing. Contrary to what had been predicted (Biegel, 1982), the vast majority of centers remained open (88.3%), a small proportion were involved in mergers (8.5%) and an even smaller percentage closed (3.3%). No pattern was evident as to which centers closed or merged by type of initial funding, although some states showed a concentration of mergers and closures. Data from the 1988 Inventory of Mental Health Organizations are used to characterize the centers still in operation by facility type, ownership, service mix and revenue mix. In 1988, federally funded CMHCs accounted for 34% of the total patient episodes treated and 22.7% of the total revenues reported by specialty mental health providers in the United States.

This study examines the characteristics that discriminate between ownership types among private, freestanding psychiatric inpatient facilities in the United States. Use of data from the Inventory of Mental Health Organizations (National Institute of Mental Health 1983, 1986), revealed that not-for-profits provide more services and serve more of the underinsured, while for-profits serve the better insured, concentrate primarily on inpatient services, and serve more children, adolescents, and substance abusers. A surplus bed capacity among for-profit psychiatric hospitals is presumed to contribute to lower occupancy rates and less turnover in the for-profit sector. Not-for-profit psychiatric facilities are also found to be more involved in professional training and to be more accessible through emergency services. However, the misclassification test in the discriminant procedure reveals that a significant group of not-for-profit facilities looks more like its for-profit counterpart group than like other not-for-profits. Study findings are interpreted both in terms of debates over the tax-exempt status of not-for-profit hospitals and the potential negative service effects of proprietization.

Guidewire catheters have been used with increasing frequency during the last several years for placement of central venous lines. No data exist comparing success and complication rates of guidewire and nonguidewire catheterization in the emergency setting. A prospective, randomized study was conducted to compare GW and NGW central venous catheterization (CVC) by the infraclavicular subclavian approach. The study consisted of 210 patients (87 trauma, 123 medical) requiring a CVC as part of their emergency department care. Catheter placement and complications were determined by immediate chest radiograph, two-day followup, and chart review after discharge. Results demonstrated no statistically significant differences in success rates or complications, with the exception of catheter malfunction due to extrathoracic vascular placement or catheter kinkage. This complication occurred more frequently when the guidewire technique was used. The guidewire CVC technique does not appear to offer any improvement of complication rates when compared to the nonguidewire technique.

In summary, many of the complex medicolegal and ethical issues surrounding the prehospital patient who refuses all or part of the care offered by the EMS system have been reviewed. The best outcome can be achieved using a sliding scale of capacity and a conservative approach to treatment rather than releasing the patient at the scene. Finally, the roles of collateral history, inquiries as to the origin of the patient's refusal of care, direct physician interaction with the patient, a spirit of creativity and compromise in dealing with the patient, meticulous documentation, and policy issues have been discussed.