Many pediatric hospitalizations are of short duration, and more than half of short‐stay hospitalizations are designated as observation status.[1, 2] Observation status is an administrative label assigned to patients who do not meet hospital or payer criteria for inpatient‐status care. Short‐stay observation‐status patients do not fit in traditional models of emergency department (ED) or inpatient care. EDs often focus on discharging or admitting patients within a matter of hours, whereas inpatient units tend to measure length of stay (LOS) in terms of days[3] and may not have systems in place to facilitate rapid discharge of short‐stay patients.[4] Observation units (OUs) have been established in some hospitals to address the unique care needs of short‐stay patients.[5, 6, 7]

Single‐site reports from children's hospitals with successful OUs have demonstrated shorter LOS and lower costs compared with inpatient settings.[6, 8, 9, 10, 11, 12, 13, 14] No prior study has examined hospital‐level effects of an OU on observation‐status patient outcomes. The Pediatric Health Information System (PHIS) database provides a unique opportunity to explore this question, because unlike other national hospital administrative databases,[15, 16] the PHIS dataset contains information about children under observation status. In addition, we know which PHIS hospitals had a dedicated OU in 2011.⁷

We hypothesized that overall observation‐status stays in hospitals with a dedicated OU would be of shorter duration with earlier discharges at lower cost than observation‐status stays in hospitals without a dedicated OU. We compared hospitals with and without a dedicated OU on secondary outcomes including rates of conversion to inpatient status and return care for any reason.

METHODS

We conducted a cross‐sectional analysis of hospital administrative data using the 2011 PHIS databasea national administrative database that contains resource utilization data from 43 participating hospitals located in 26 states plus the District of Columbia. These hospitals account for approximately 20% of pediatric hospitalizations in the United States.

For each hospital encounter, PHIS includes patient demographics, up to 41 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) diagnoses, up to 41 ICD‐9‐CM procedures, and hospital charges for services. Data are deidentified prior to inclusion, but unique identifiers allow for determination of return visits and readmissions following an index visit for an individual patient. Data quality and reliability are assured jointly by the Children's Hospital Association (formerly Child Health Corporation of America, Overland Park, KS), participating hospitals, and Truven Health Analytics (New York, NY). This study, using administrative data, was not considered human subjects research by the policies of the Cincinnati Children's Hospital Medical Center Institutional Review Board.

RESULTS

Hospital Characteristics

Dedicated OUs were present in 14 of the 31 hospitals that reported observation‐status patient data to PHIS (Figure 1). Three of these hospitals had OUs that were open for 5 months or less in 2011; 1 unit opened, 1 unit closed, and 1 hospital operated a seasonal unit. The remaining 17 hospitals reported no OU that admitted unscheduled patients from the ED during 2011. Hospitals with a dedicated OU had more inpatient beds and higher median number of inpatient admissions than those without (Table 1). Hospitals were statistically similar in terms of total volume of ED visits, percentage of ED visits resulting in admission, total number of observation‐status stays, percentage of admissions under observation status, and payer mix.

Figure 1

Table 1.Hospitals* With and Without Dedicated Observation Units

	Overall, Median (IQR)	Hospitals With a Dedicated Observation Unit, Median (IQR)	Hospitals Without a Dedicated Observation Unit, Median (IQR)	P Value
NOTE: Abbreviations: ED, emergency department; IQR, interquartile range. *Among hospitals that reported observation‐status patient data to the Pediatric Health Information System database in 2011. Hospitals reporting the presence of at least 1 dedicated observation unit that admitted unscheduled patients from the ED in 2011. Percent of ED visits resulting in admission=number of ED visits admitted to inpatient or observation status divided by total number of ED visits in 2011. Percent of admissions under observation status=number of observation‐status stays divided by the total number of admissions (observation and inpatient status) in 2011.
No. of hospitals	31	14	17
Total no. of inpatient beds	273 (213311)	304 (269425)	246 (175293)	0.006
Total no. ED visits	62971 (47,50497,723)	87,892 (55,102117,119)	53,151 (4750470,882)	0.21
ED visits resulting in admission, %	13.1 (9.715.0)	13.8 (10.5, 19.1)	12.5 (9.714.5)	0.31
Total no. of inpatient admissions	11,537 (9,26814,568)	13,206 (11,32517,869)	10,207 (8,64013,363)	0.04
Admissions under observation status, %	25.7 (19.733.8)	25.5 (21.431.4)	26.0 (16.935.1)	0.98
Total no. of observation stays	3,820 (27935672)	4,850 (3,309 6,196)	3,141 (2,3654,616)	0.07
Government payer, %	60.2 (53.371.2)	62.1 (54.9, 65.9)	59.2 (53.373.7)	0.89

DISCUSSION

Counter to our hypothesis, we did not find hospital‐level differences in length of stay or costs for observation‐status patients cared for in hospitals with and without a dedicated OU, though hospitals with dedicated OUs did have more same‐day discharges and more morning discharges. The lack of observed differences in LOS and costs may reflect the fact that many children under observation status are treated throughout the hospital, even in facilities with a dedicated OU. Access to a dedicated OU is limited by factors including small numbers of OU beds and specific low acuity/low complexity OU admission criteria.[7] The inclusion of all children admitted under observation status in our analyses may have diluted any effect of dedicated OUs at the hospital level, but was necessary due to the inability to identify location of care for children admitted under observation status. Location of care is an important variable that should be incorporated into administrative databases to allow for comparative effectiveness research designs. Until such data are available, chart review at individual hospitals would be necessary to determine which patients received care in an OU.

We did find that discharges for observation‐status patients occurred earlier in the day in hospitals with a dedicated OU when compared with observation‐status patients in hospitals without a dedicated OU. In addition, the percentage of same‐day discharges was higher among observation‐status patients treated in hospitals with a dedicated OU. These differences may stem from policies and procedures that encourage rapid discharge in dedicated OUs, and those practices may affect other care areas. For example, OUs may enforce policies requiring family presence at the bedside or utilize staffing models where doctors and nurses are in frequent communication, both of which would facilitate discharge as soon as a patient no longer required hospital‐based care.[7] A retrospective chart review study design could be used to identify discharge processes and other key characteristics of highly performing OUs.

We found conflicting results in our main and sensitivity analyses related to conversion to inpatient status. Lower percentages of observation‐status patients converting to inpatient status indicates greater success in the delivery of observation care based on established performance metrics.[19] Lower rates of conversion to inpatient status may be the result of stricter admission criteria for some diagnosis and in hospitals with a continuously open dedicate OU, more refined processes for utilization review that allow for patients to be placed into the correct status (observation vs inpatient) at the time of admission, or efforts to educate providers about the designation of observation status.[7] It is also possible that fewer observation‐status patients convert to inpatient status in hospitals with a continuously open dedicated OU because such a change would require movement of the patient to an inpatient bed.

These analyses were more comprehensive than our prior studies[2, 20] in that we included both patients who were treated first in the ED and those who were not. In addition to the APR‐DRGs representative of conditions that have been successfully treated in ED‐based pediatric OUs (eg, asthma, seizures, gastroenteritis, cellulitis),[8, 9, 21, 22] we found observation‐status was commonly associated with procedural care. This population of patients may be relevant to hospitalists who staff OUs that provide both unscheduled and postprocedural care. The colocation of medical and postprocedural patients has been described by others[8, 23] and was reported to occur in over half of the OUs included in this study.[7] The extent to which postprocedure observation care is provided in general OUs staffed by hospitalists represents another opportunity for further study.

Hospitals face many considerations when determining if and how they will provide observation services to patients expected to experience short stays.[7] Some hospitals may be unable to justify an OU for all or part of the year based on the volume of admissions or the costs to staff an OU.[24, 25] Other hospitals may open an OU to promote patient flow and reduce ED crowding.[26] Hospitals may also be influenced by reimbursement policies related to observation‐status stays. Although we did not observe differences in overall payer mix, we did find higher percentages of observation‐status patients in hospitals with dedicated OUs to have public insurance. Although hospital contracts with payers around observation status patients are complex and beyond the scope of this analysis, it is possible that hospitals have established OUs because of increasingly stringent rules or criteria to meet inpatient status or experiences with high volumes of observation‐status patients covered by a particular payer. Nevertheless, the brief nature of many pediatric hospitalizations and the scarcity of pediatric OU beds must be considered in policy changes that result from national discussions about the appropriateness of inpatient stays shorter than 2 nights in duration.[27]

CONCLUSION

Observation status patients are similar in hospitals with and without dedicated observation units that admit children from the ED. The presence of a dedicated OU appears to have an influence on same‐day and morning discharges across all observation‐status stays without impacting other hospital‐level outcomes. Inclusion of location of care (eg, geographically distinct dedicated OU vs general inpatient unit vs ED) in hospital administrative datasets would allow for meaningful comparisons of different models of care for short‐stay observation‐status patients.

Many pediatric hospitalizations are of short duration, and more than half of short‐stay hospitalizations are designated as observation status.[1, 2] Observation status is an administrative label assigned to patients who do not meet hospital or payer criteria for inpatient‐status care. Short‐stay observation‐status patients do not fit in traditional models of emergency department (ED) or inpatient care. EDs often focus on discharging or admitting patients within a matter of hours, whereas inpatient units tend to measure length of stay (LOS) in terms of days[3] and may not have systems in place to facilitate rapid discharge of short‐stay patients.[4] Observation units (OUs) have been established in some hospitals to address the unique care needs of short‐stay patients.[5, 6, 7]

Single‐site reports from children's hospitals with successful OUs have demonstrated shorter LOS and lower costs compared with inpatient settings.[6, 8, 9, 10, 11, 12, 13, 14] No prior study has examined hospital‐level effects of an OU on observation‐status patient outcomes. The Pediatric Health Information System (PHIS) database provides a unique opportunity to explore this question, because unlike other national hospital administrative databases,[15, 16] the PHIS dataset contains information about children under observation status. In addition, we know which PHIS hospitals had a dedicated OU in 2011.⁷

We hypothesized that overall observation‐status stays in hospitals with a dedicated OU would be of shorter duration with earlier discharges at lower cost than observation‐status stays in hospitals without a dedicated OU. We compared hospitals with and without a dedicated OU on secondary outcomes including rates of conversion to inpatient status and return care for any reason.

METHODS

We conducted a cross‐sectional analysis of hospital administrative data using the 2011 PHIS databasea national administrative database that contains resource utilization data from 43 participating hospitals located in 26 states plus the District of Columbia. These hospitals account for approximately 20% of pediatric hospitalizations in the United States.

For each hospital encounter, PHIS includes patient demographics, up to 41 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) diagnoses, up to 41 ICD‐9‐CM procedures, and hospital charges for services. Data are deidentified prior to inclusion, but unique identifiers allow for determination of return visits and readmissions following an index visit for an individual patient. Data quality and reliability are assured jointly by the Children's Hospital Association (formerly Child Health Corporation of America, Overland Park, KS), participating hospitals, and Truven Health Analytics (New York, NY). This study, using administrative data, was not considered human subjects research by the policies of the Cincinnati Children's Hospital Medical Center Institutional Review Board.

RESULTS

Hospital Characteristics

Dedicated OUs were present in 14 of the 31 hospitals that reported observation‐status patient data to PHIS (Figure 1). Three of these hospitals had OUs that were open for 5 months or less in 2011; 1 unit opened, 1 unit closed, and 1 hospital operated a seasonal unit. The remaining 17 hospitals reported no OU that admitted unscheduled patients from the ED during 2011. Hospitals with a dedicated OU had more inpatient beds and higher median number of inpatient admissions than those without (Table 1). Hospitals were statistically similar in terms of total volume of ED visits, percentage of ED visits resulting in admission, total number of observation‐status stays, percentage of admissions under observation status, and payer mix.

Figure 1

Table 1.Hospitals* With and Without Dedicated Observation Units

	Overall, Median (IQR)	Hospitals With a Dedicated Observation Unit, Median (IQR)	Hospitals Without a Dedicated Observation Unit, Median (IQR)	P Value
NOTE: Abbreviations: ED, emergency department; IQR, interquartile range. *Among hospitals that reported observation‐status patient data to the Pediatric Health Information System database in 2011. Hospitals reporting the presence of at least 1 dedicated observation unit that admitted unscheduled patients from the ED in 2011. Percent of ED visits resulting in admission=number of ED visits admitted to inpatient or observation status divided by total number of ED visits in 2011. Percent of admissions under observation status=number of observation‐status stays divided by the total number of admissions (observation and inpatient status) in 2011.
No. of hospitals	31	14	17
Total no. of inpatient beds	273 (213311)	304 (269425)	246 (175293)	0.006
Total no. ED visits	62971 (47,50497,723)	87,892 (55,102117,119)	53,151 (4750470,882)	0.21
ED visits resulting in admission, %	13.1 (9.715.0)	13.8 (10.5, 19.1)	12.5 (9.714.5)	0.31
Total no. of inpatient admissions	11,537 (9,26814,568)	13,206 (11,32517,869)	10,207 (8,64013,363)	0.04
Admissions under observation status, %	25.7 (19.733.8)	25.5 (21.431.4)	26.0 (16.935.1)	0.98
Total no. of observation stays	3,820 (27935672)	4,850 (3,309 6,196)	3,141 (2,3654,616)	0.07
Government payer, %	60.2 (53.371.2)	62.1 (54.9, 65.9)	59.2 (53.373.7)	0.89

DISCUSSION

Counter to our hypothesis, we did not find hospital‐level differences in length of stay or costs for observation‐status patients cared for in hospitals with and without a dedicated OU, though hospitals with dedicated OUs did have more same‐day discharges and more morning discharges. The lack of observed differences in LOS and costs may reflect the fact that many children under observation status are treated throughout the hospital, even in facilities with a dedicated OU. Access to a dedicated OU is limited by factors including small numbers of OU beds and specific low acuity/low complexity OU admission criteria.[7] The inclusion of all children admitted under observation status in our analyses may have diluted any effect of dedicated OUs at the hospital level, but was necessary due to the inability to identify location of care for children admitted under observation status. Location of care is an important variable that should be incorporated into administrative databases to allow for comparative effectiveness research designs. Until such data are available, chart review at individual hospitals would be necessary to determine which patients received care in an OU.

We did find that discharges for observation‐status patients occurred earlier in the day in hospitals with a dedicated OU when compared with observation‐status patients in hospitals without a dedicated OU. In addition, the percentage of same‐day discharges was higher among observation‐status patients treated in hospitals with a dedicated OU. These differences may stem from policies and procedures that encourage rapid discharge in dedicated OUs, and those practices may affect other care areas. For example, OUs may enforce policies requiring family presence at the bedside or utilize staffing models where doctors and nurses are in frequent communication, both of which would facilitate discharge as soon as a patient no longer required hospital‐based care.[7] A retrospective chart review study design could be used to identify discharge processes and other key characteristics of highly performing OUs.

We found conflicting results in our main and sensitivity analyses related to conversion to inpatient status. Lower percentages of observation‐status patients converting to inpatient status indicates greater success in the delivery of observation care based on established performance metrics.[19] Lower rates of conversion to inpatient status may be the result of stricter admission criteria for some diagnosis and in hospitals with a continuously open dedicate OU, more refined processes for utilization review that allow for patients to be placed into the correct status (observation vs inpatient) at the time of admission, or efforts to educate providers about the designation of observation status.[7] It is also possible that fewer observation‐status patients convert to inpatient status in hospitals with a continuously open dedicated OU because such a change would require movement of the patient to an inpatient bed.

These analyses were more comprehensive than our prior studies[2, 20] in that we included both patients who were treated first in the ED and those who were not. In addition to the APR‐DRGs representative of conditions that have been successfully treated in ED‐based pediatric OUs (eg, asthma, seizures, gastroenteritis, cellulitis),[8, 9, 21, 22] we found observation‐status was commonly associated with procedural care. This population of patients may be relevant to hospitalists who staff OUs that provide both unscheduled and postprocedural care. The colocation of medical and postprocedural patients has been described by others[8, 23] and was reported to occur in over half of the OUs included in this study.[7] The extent to which postprocedure observation care is provided in general OUs staffed by hospitalists represents another opportunity for further study.

Hospitals face many considerations when determining if and how they will provide observation services to patients expected to experience short stays.[7] Some hospitals may be unable to justify an OU for all or part of the year based on the volume of admissions or the costs to staff an OU.[24, 25] Other hospitals may open an OU to promote patient flow and reduce ED crowding.[26] Hospitals may also be influenced by reimbursement policies related to observation‐status stays. Although we did not observe differences in overall payer mix, we did find higher percentages of observation‐status patients in hospitals with dedicated OUs to have public insurance. Although hospital contracts with payers around observation status patients are complex and beyond the scope of this analysis, it is possible that hospitals have established OUs because of increasingly stringent rules or criteria to meet inpatient status or experiences with high volumes of observation‐status patients covered by a particular payer. Nevertheless, the brief nature of many pediatric hospitalizations and the scarcity of pediatric OU beds must be considered in policy changes that result from national discussions about the appropriateness of inpatient stays shorter than 2 nights in duration.[27]

CONCLUSION

Observation status patients are similar in hospitals with and without dedicated observation units that admit children from the ED. The presence of a dedicated OU appears to have an influence on same‐day and morning discharges across all observation‐status stays without impacting other hospital‐level outcomes. Inclusion of location of care (eg, geographically distinct dedicated OU vs general inpatient unit vs ED) in hospital administrative datasets would allow for meaningful comparisons of different models of care for short‐stay observation‐status patients.

Many pediatric hospitalizations are of short duration, and more than half of short‐stay hospitalizations are designated as observation status.[1, 2] Observation status is an administrative label assigned to patients who do not meet hospital or payer criteria for inpatient‐status care. Short‐stay observation‐status patients do not fit in traditional models of emergency department (ED) or inpatient care. EDs often focus on discharging or admitting patients within a matter of hours, whereas inpatient units tend to measure length of stay (LOS) in terms of days[3] and may not have systems in place to facilitate rapid discharge of short‐stay patients.[4] Observation units (OUs) have been established in some hospitals to address the unique care needs of short‐stay patients.[5, 6, 7]

Single‐site reports from children's hospitals with successful OUs have demonstrated shorter LOS and lower costs compared with inpatient settings.[6, 8, 9, 10, 11, 12, 13, 14] No prior study has examined hospital‐level effects of an OU on observation‐status patient outcomes. The Pediatric Health Information System (PHIS) database provides a unique opportunity to explore this question, because unlike other national hospital administrative databases,[15, 16] the PHIS dataset contains information about children under observation status. In addition, we know which PHIS hospitals had a dedicated OU in 2011.⁷

We hypothesized that overall observation‐status stays in hospitals with a dedicated OU would be of shorter duration with earlier discharges at lower cost than observation‐status stays in hospitals without a dedicated OU. We compared hospitals with and without a dedicated OU on secondary outcomes including rates of conversion to inpatient status and return care for any reason.

METHODS

We conducted a cross‐sectional analysis of hospital administrative data using the 2011 PHIS databasea national administrative database that contains resource utilization data from 43 participating hospitals located in 26 states plus the District of Columbia. These hospitals account for approximately 20% of pediatric hospitalizations in the United States.

For each hospital encounter, PHIS includes patient demographics, up to 41 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) diagnoses, up to 41 ICD‐9‐CM procedures, and hospital charges for services. Data are deidentified prior to inclusion, but unique identifiers allow for determination of return visits and readmissions following an index visit for an individual patient. Data quality and reliability are assured jointly by the Children's Hospital Association (formerly Child Health Corporation of America, Overland Park, KS), participating hospitals, and Truven Health Analytics (New York, NY). This study, using administrative data, was not considered human subjects research by the policies of the Cincinnati Children's Hospital Medical Center Institutional Review Board.

RESULTS

Hospital Characteristics

Dedicated OUs were present in 14 of the 31 hospitals that reported observation‐status patient data to PHIS (Figure 1). Three of these hospitals had OUs that were open for 5 months or less in 2011; 1 unit opened, 1 unit closed, and 1 hospital operated a seasonal unit. The remaining 17 hospitals reported no OU that admitted unscheduled patients from the ED during 2011. Hospitals with a dedicated OU had more inpatient beds and higher median number of inpatient admissions than those without (Table 1). Hospitals were statistically similar in terms of total volume of ED visits, percentage of ED visits resulting in admission, total number of observation‐status stays, percentage of admissions under observation status, and payer mix.

Figure 1

Table 1.Hospitals* With and Without Dedicated Observation Units

	Overall, Median (IQR)	Hospitals With a Dedicated Observation Unit, Median (IQR)	Hospitals Without a Dedicated Observation Unit, Median (IQR)	P Value
NOTE: Abbreviations: ED, emergency department; IQR, interquartile range. *Among hospitals that reported observation‐status patient data to the Pediatric Health Information System database in 2011. Hospitals reporting the presence of at least 1 dedicated observation unit that admitted unscheduled patients from the ED in 2011. Percent of ED visits resulting in admission=number of ED visits admitted to inpatient or observation status divided by total number of ED visits in 2011. Percent of admissions under observation status=number of observation‐status stays divided by the total number of admissions (observation and inpatient status) in 2011.
No. of hospitals	31	14	17
Total no. of inpatient beds	273 (213311)	304 (269425)	246 (175293)	0.006
Total no. ED visits	62971 (47,50497,723)	87,892 (55,102117,119)	53,151 (4750470,882)	0.21
ED visits resulting in admission, %	13.1 (9.715.0)	13.8 (10.5, 19.1)	12.5 (9.714.5)	0.31
Total no. of inpatient admissions	11,537 (9,26814,568)	13,206 (11,32517,869)	10,207 (8,64013,363)	0.04
Admissions under observation status, %	25.7 (19.733.8)	25.5 (21.431.4)	26.0 (16.935.1)	0.98
Total no. of observation stays	3,820 (27935672)	4,850 (3,309 6,196)	3,141 (2,3654,616)	0.07
Government payer, %	60.2 (53.371.2)	62.1 (54.9, 65.9)	59.2 (53.373.7)	0.89

DISCUSSION

Counter to our hypothesis, we did not find hospital‐level differences in length of stay or costs for observation‐status patients cared for in hospitals with and without a dedicated OU, though hospitals with dedicated OUs did have more same‐day discharges and more morning discharges. The lack of observed differences in LOS and costs may reflect the fact that many children under observation status are treated throughout the hospital, even in facilities with a dedicated OU. Access to a dedicated OU is limited by factors including small numbers of OU beds and specific low acuity/low complexity OU admission criteria.[7] The inclusion of all children admitted under observation status in our analyses may have diluted any effect of dedicated OUs at the hospital level, but was necessary due to the inability to identify location of care for children admitted under observation status. Location of care is an important variable that should be incorporated into administrative databases to allow for comparative effectiveness research designs. Until such data are available, chart review at individual hospitals would be necessary to determine which patients received care in an OU.

We did find that discharges for observation‐status patients occurred earlier in the day in hospitals with a dedicated OU when compared with observation‐status patients in hospitals without a dedicated OU. In addition, the percentage of same‐day discharges was higher among observation‐status patients treated in hospitals with a dedicated OU. These differences may stem from policies and procedures that encourage rapid discharge in dedicated OUs, and those practices may affect other care areas. For example, OUs may enforce policies requiring family presence at the bedside or utilize staffing models where doctors and nurses are in frequent communication, both of which would facilitate discharge as soon as a patient no longer required hospital‐based care.[7] A retrospective chart review study design could be used to identify discharge processes and other key characteristics of highly performing OUs.

We found conflicting results in our main and sensitivity analyses related to conversion to inpatient status. Lower percentages of observation‐status patients converting to inpatient status indicates greater success in the delivery of observation care based on established performance metrics.[19] Lower rates of conversion to inpatient status may be the result of stricter admission criteria for some diagnosis and in hospitals with a continuously open dedicate OU, more refined processes for utilization review that allow for patients to be placed into the correct status (observation vs inpatient) at the time of admission, or efforts to educate providers about the designation of observation status.[7] It is also possible that fewer observation‐status patients convert to inpatient status in hospitals with a continuously open dedicated OU because such a change would require movement of the patient to an inpatient bed.

These analyses were more comprehensive than our prior studies[2, 20] in that we included both patients who were treated first in the ED and those who were not. In addition to the APR‐DRGs representative of conditions that have been successfully treated in ED‐based pediatric OUs (eg, asthma, seizures, gastroenteritis, cellulitis),[8, 9, 21, 22] we found observation‐status was commonly associated with procedural care. This population of patients may be relevant to hospitalists who staff OUs that provide both unscheduled and postprocedural care. The colocation of medical and postprocedural patients has been described by others[8, 23] and was reported to occur in over half of the OUs included in this study.[7] The extent to which postprocedure observation care is provided in general OUs staffed by hospitalists represents another opportunity for further study.

Hospitals face many considerations when determining if and how they will provide observation services to patients expected to experience short stays.[7] Some hospitals may be unable to justify an OU for all or part of the year based on the volume of admissions or the costs to staff an OU.[24, 25] Other hospitals may open an OU to promote patient flow and reduce ED crowding.[26] Hospitals may also be influenced by reimbursement policies related to observation‐status stays. Although we did not observe differences in overall payer mix, we did find higher percentages of observation‐status patients in hospitals with dedicated OUs to have public insurance. Although hospital contracts with payers around observation status patients are complex and beyond the scope of this analysis, it is possible that hospitals have established OUs because of increasingly stringent rules or criteria to meet inpatient status or experiences with high volumes of observation‐status patients covered by a particular payer. Nevertheless, the brief nature of many pediatric hospitalizations and the scarcity of pediatric OU beds must be considered in policy changes that result from national discussions about the appropriateness of inpatient stays shorter than 2 nights in duration.[27]

CONCLUSION

Observation status patients are similar in hospitals with and without dedicated observation units that admit children from the ED. The presence of a dedicated OU appears to have an influence on same‐day and morning discharges across all observation‐status stays without impacting other hospital‐level outcomes. Inclusion of location of care (eg, geographically distinct dedicated OU vs general inpatient unit vs ED) in hospital administrative datasets would allow for meaningful comparisons of different models of care for short‐stay observation‐status patients.

Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

RESULTS

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

RESULTS

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

Gender disparities still exist for women in academic medicine.[1, 2, 3, 4, 5, 6, 7, 8, 9] The most recent data from the Association of American Medical Colleges (AAMC) show that although gender disparities are decreasing, women are still under‐represented in the assistant, associate, and full‐professor ranks as well as in leadership positions.[1]

Some studies indicate that gender differences are less evident when examining younger cohorts.[1, 10, 11, 12, 13] Hospital medicine emerged around 1996, when the term hospitalist was first coined.[14] The gender distribution of academic hospitalists is likely nearly equal,[15, 16] and they are generally younger physicians.[15, 17, 18, 19, 20] Accordingly, we questioned whether gender disparities existed in academic hospital medicine (HM) and, if so, whether these disparities were greater than those that might exist in academic general internal medicine (GIM).

METHODS

This study consisted of both prospective and retrospective observation of data collected for academic adult hospitalists and general internists who practice in the United States. It was approved by the Colorado Multiple Institutional Review Board.

Gender distribution was assessed with respect to: (1) academic HM and GIM faculty, (2) leadership (ie, division or section heads), and (3) scholarly work (ie, speaking opportunities and publications). Data were collected between October 1, 2012 and August 31, 2014.

RESULTS

DISCUSSION

The important findings of this study are that, despite an equal gender distribution of academic HM and GIM faculty, fewer women were HM division/section chiefs, fewer women were speakers at the 2 selected national meetings, and fewer women were first or last authors of publications in 2 selected journals in comparison with general internists.

Previous studies have found that women lag behind their male counterparts with respect to academic productivity, leadership, and promotion.[1, 5, 7] Some studies suggest, however, that gender differences are reduced when younger cohorts are examined.[1, 10, 11, 12, 13] Surveys indicate that that the mean age of hospitalists is younger than most other specialties.[15, 19, 20, 24] The mean age of academic GIM physicians is unknown, but surveys of GIM (not differentiating academic from nonacademic) suggest that it is an older cohort than that of HM.[24] Despite hospitalists being a younger cohort, we found gender disparities in all areas investigated.

Our findings with respect to gender disparities in HM division or section leadership are consistent with the annual AAMC Women in US Academic Medicine and Science Benchmarking Report that found only 22% of all permanent division or section heads were women.[1]

Gender disparities with respect to authorship of medical publications have been previously noted,[3, 6, 15, 25] but to our knowledge, this is the first study to investigate the gender of authors who were hospitalists. Although we found a higher proportion of women hospitalists who were first or last authors than was observed by Jagsi and colleagues,[3] women hospitalists were still under‐represented with respect to this measure of academic productivity. Erren et al. reviewed 6 major journals from 2010 and 2011, and found that first authorship of original research by women ranged from 23.7% to 46.7%, and for last authorship from 18.3% to 28.8%.[25] Interestingly, we found no significant gender difference for first authors who were general internists, and there was a trend toward more women general internists being first authors than men for original research, reviews, and brief reports (data not shown).

Our study did not attempt to answer the question of why gender disparities persist, but many previous studies have explored this issue.[4, 8, 12, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] Issues raised by others include the quantity of academic work (ie, publications and grants obtained), differences in hours worked and allocation of time, lack of mentorship, family responsibilities, discrimination, differences in career motivation, and levels of institutional support, to name a few.

The under‐representation of women hospitalists in leadership, authorship, and speaking opportunities may be consistent with gender‐related differences in research productivity. Fewer publications could lead to fewer national presentations, which could lead to fewer leadership opportunities. Our findings with respect to general internists are not consistent with this idea, however, as whereas women were under‐represented in GIM leadership positions, we found no disparities with respect to the gender of first authors or speakers at national meetings for general internists. The finding that hospitalists had gender disparities with respect to first authors and national speakers but general internists did not, argues against several hypotheses (ie, that women lack mentorship, have less career motivation, fewer career building opportunities).

One notable hypothesis, and perhaps one that is often discussed in the literature, is that women shoulder the majority of family responsibilities, and this may result in women having less time for their careers. Jolly and colleagues studied physician‐researchers and noted that women were more likely than men to have spouses or domestic partners who were fully employed, spent 8.5 more hours per week on domestic activities, and were more likely to take time off during disruptions of usual child care.[33] Carr and colleagues found that women with children (compared to men with children) had fewer publications, slower self‐perceived career progress, and lower career satisfaction, but having children had little effect on faculty aspirations and goals.[2] Kaplan et al., however, found that family responsibilities do not appear to account for sex differences in academic advancement.[4] Interestingly, in a study comparing physicians from Generation X to those of the Baby Boomer age, Generation X women reported working more than their male Generation X counterparts, and both had more of a focus on worklife balance than the older generation.[12]

The nature the of 2 specialties' work environment and job requirements could have also resulted in some of the differences seen. Primary care clinical work is typically conducted Monday through Friday, and hospitalist work frequently includes some weekend, evening, night, and holiday coverage. Although these are known differences, both specialties have also been noted to offer many advantages to women and men alike, including collaborative working environments and flexible work hours.[16]

Finally, finding disparity in leadership positions in both specialties supports the possibility that those responsible for hiring could have implicit gender biases. Under‐representation in entry‐level positions is also not a likely explanation for the differences we observed, because nearly an equal number of men and women graduate from medical school, pursue residency training in internal medicine, and become either academic hospitalists or general internists at university settings.[1, 15, 24] This hypothesis could, however, explain why disparities exist with respect to senior authorship and leadership positions, as typically, these individuals have been in practice longer and the current trends of improved gender equality have not always been the case.

Our study has a number of limitations. First, we only examined publications in 2 journals and presentations at 2 national conferences, although the journals and conferences selected are considered to be the major ones in the 2 specialties. Second, using Internet searches may have resulted in inaccurate gender and specialty assignment, but previous studies have used similar methodology.[3, 43] Additionally, we also attempted to contact individuals for direct confirmation when the information we obtained was not clear and had a second investigator independently verify the gender and specialty data. Third, we utilized division/department websites when available to determine the gender of HM divisions/sections. If not recently updated, these websites may not have reflected the most current leader of the unit, but this concern would seemingly pertain to both hospitalists and general internists. Fourth, we opted to only study faculty and division/section heads at university hospitals, as typically these institutions had GIM and hospitalist groups and also typically had websites. Because we only studied faculty and leadership at university hospitals, our data are not generalizable to all hospitalist and GIM groups. Finally, we excluded pediatric hospitalists, and thus, this study is representative of adult hospitalists only. Including pediatric hospitalists was out of the scope of this project.

Our study also had a number of strengths. To our knowledge, this is the first study to provide an estimate of the gender distribution in academic HM, of hospitalists as speakers at national meetings, as first and last authors, and of HM division or section heads, and is the first to compare these results with those observed for general internists. In addition, we examined 7 years of data from 2 of the major journals and national conferences for these specialties.

In summary, despite HM being a newer field with a younger cohort of physicians, we found that gender disparities exist for women with respect to authorship, national speaking opportunities, and division or section leadership. Identifying why these gender differences exist presents an important next step.

Disclosures: Nothing to report. Marisha Burden, MD and Maria G. Frank, MD are coprincipal authors.

People who use illicit drugs (PWUDs) experience a wide range of health‐related harms and consequently often rely on acute and emergency services for care.[1, 2] Specifically, the poor health status of many PWUDs is often attributable to infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C virus.[3, 4] Soft‐tissue infections associated with injection drug use are also common, and have increasingly accounted for the majority of hospitalizations among this population.[5] Many of these adverse health outcomes may require lengthy in‐patient hospital admissions and constitute a substantial financial burden for the healthcare system.[6]

PWUDs frequently experience barriers to conventional healthcare services. For example, negative experiences with healthcare providers and the healthcare system have often deterred PWUDs from accessing these services.[7, 8] Given that most hospitals operate under an abstinence‐based policy, PWUDs have minimal access to drug‐using paraphernalia while hospitalized, making it difficult for these individuals to safely manage their active drug use. As a result, many PWUDs may resort to high‐risk drug‐using practices (eg, syringe sharing, injecting alone) in the hospital that may lead to further adverse health outcomes, such as infectious disease transmission and overdose, respectively.[9] Past studies have also shown that many PWUDs do not complete hospital‐based treatments.[10, 11] Specifically, many PWUDs leave the hospital against medical advice (AMA) possibly because they are unable to continue their drug use practices in this setting,[10, 12] thus contributing to an increase in readmission rates and mortality among this population.[13] Past studies have indicated that approximately 30% of patients who inject drugs left the hospital AMA,[12, 14] and these individuals have shown to be as high as 4 times more likely to leave the hospital AMA compared to their nondrug‐using counterparts.[11]

Supervised injection facilities (SIFs) are sanctioned environments where PWUDs can inject preobtained illicit drugs under the supervision of healthcare staff. Internationally, SIFs have been shown to improve public health and public order within surrounding communities.[15, 16, 17] For example, a dramatic decline in fatal overdoses in Vancouver's Downtown Eastside neighborhood was attributed to the implementation of a SIF in the area.[15] Changes in risk‐injecting behavior have also been observed among individuals who access SIFs.[18] Although a large body of evidence supports SIFs as an effective approach for minimizing the drug‐ and health‐related harms within street‐based drug scenes,[17, 19] little is known about whether there is a role for SIFs within hospital settings. Currently in Vancouver, Canada, harm reduction services are generally not being provided within hospital settings. Therefore, we sought to conduct a needs assessment to identify the prevalence and correlates of willingness to access an in‐hospital SIF among PWUDs in Vancouver. These data may be crucial for planning appropriate programs and services to reduce health‐related harms and leaving the hospital AMA among PWUDs in hospital settings.

METHODS

The Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) are 2 prospective cohort studies of PWUDs who have been recruited through self‐referral and street outreach since May 1996. These cohorts have been described in detail previously.[20, 21] In brief, persons were eligible to enter the VIDUS study if they had injected illicit drugs at least once in the previous month and resided in the Greater Vancouver region at enrollment. Persons were eligible to enter the ACCESS study if they were HIV infected and used illicit drugs other than cannabinoids in the previous month. Individuals who seroconvert following recruitment are transferred from the VIDUS study into the ACCESS study. All eligible participants provided written informed consent. At baseline and semiannually, study participants complete a harmonized interviewer‐administered questionnaire (ie, participants in the VIDUS and ACCESS studies completed an identical questionnaire) and provide blood samples for HIV and hepatitis C virus testing, and HIV disease monitoring. At the conclusion of each visit, study participants receive Can$20 for their time. The study has received ethical approval from Providence Health Care/University of British Columbia's research ethics board.

The primary outcome of interest for this analysis was willingness to access an in‐hospital SIF (yes vs no or unsure), ascertained by asking participants the following hypothetical question: If you were admitted into a hospital, and if a supervised safe injection site was available in that hospital, would you use it? Given the existence of 2 SIFs in the local environment, PWUDs in Vancouver are familiar with the design and operation of such programs. We compared PWUDs who were and were not willing to access an in‐hospital SIF using bivariable and multivariable logistic regression analyses. Given that the variable measure was based on a hypothetical scenario, participants who completed the survey between June 2013 and November 2013 were eligible for inclusion regardless of their current injection drug use behavior. A complete case approach was used to analyze the data given that the extent of missingness was not significant (<5%). Variables considered included: age (per year increase); gender (male vs female); HIV serostatus (positive vs negative); heroin injection ( daily vs

To identify factors independently associated with willingness to access an in‐hospital SIF, a multivariable logistic regression model was constructed using an a prioridefined statistical protocol based on examination of the Akaike information criterion (AIC) and P values. First, we constructed a full model that included all variables significant at P<0.10 in bivariable analyses. After noting the AIC of the model, we removed the variable with the largest P value and built a reduced model. We continued this iterative process until no variables remained. We selected the multivariable model with the lowest AIC score. All P values were 2 sided. As a subanalysis, we asked participants who would be willing to access an in‐hospital SIF to indicate reasons why they would be willing to access such a facility.

RESULTS

Of the total 769 participants who were eligible for inclusion in the study, 732 PWUDs provided complete data and participated in the study; 37 (4.8%) were excluded due to missing data. In our study sample, 250 (34.2%) were female, the median age was 48 years (interquartile range: 4153 years), and 307 (41.5%) were HIV‐positive. Among our study sample, 499 (68.2%) participants would be willing to access an in‐hospital SIF if it were available. Bivariable analyses of factors associated with willingness to access an in‐hospital SIF are presented in Table 1.

As indicated in Table 2, in multivariable analyses, factors that remained significantly and positively associated with willingness to access an in‐hospital SIF included: daily heroin injection (adjusted odds ratio [AOR]=1.90; 95% confidence interval [CI]: 1.20‐3.11), ever used illicit drugs in the hospital (AOR=1.63; 95% CI: 1.18‐2.26), and previously used an SIF (AOR=1.53; 95% CI: 1.10‐2.15).

Among participants who would be willing to access an in‐hospital SIF, the most common reasons included: to be able to stay in the hospital (229/499=45.9%), to reduce their drug‐related risks (189/499=37.9%), and to reduce stress associated with being kicked out of the hospital because they were using drugs (97/499=19.4%).

DISCUSSION

We found that over two‐thirds of PWUDs participating in our study would be willing to access an in‐hospital SIF if such a service was available. This finding is encouraging given that a large proportion of PWUDs are hospitalized annually for acute and chronic diseases.[5, 6] Previous studies have documented the positive impact of incorporating a harm reduction model within hospital settings, resulting in more comprehensive care for PWUDs.[22, 23] For example, the Dr. Peter Centre Day Health Program provides a SIF for HIV‐positive PWUDs to safely use illicit drugs under the supervision of trained nurses and was once located at St. Paul's Hospital.[24] Although the Dr. Peter Centre currently operates outside of St. Paul's Hospital, it may be advantageous to model an in‐hospital SIF after the Dr. Peter Centre's harm‐reduction room given their success in facilitating access and delivery of comprehensive care for PWUDs.[23] Specifically, nurses at the Dr. Peter Centre directly observe injections of preobtained illicit drugs for the purposes of preventing illness and promoting health. Our findings support recent calls to implement harm‐reduction services within hospital settings in an effort to minimize the harms associated with illicit drug use.[25, 26]

Previous studies have identified various high‐risk locations where PWUDs use illicit drugs to maintain their established drug‐use habits, including in locked washrooms in hospitals.[9] We found a positive association among PWUDs who had used illicit drugs in the hospital and a willingness to use an in‐hospital SIF. Our finding is reassuring given that studies have shown that these individuals are at a higher risk of negative health consequences (eg, fatal overdose) from using drugs in the hospital.[9] Harm reduction services within the hospital settings can play an important role in reducing this drug‐ and health‐related harm among PWUDs.

Our study also found that high‐frequency heroin injection was associated with a willingness to access an in‐hospital SIF. This relationship may be a result of the complex nature of treating opioid‐dependent patients for pain. For instance, some opioid‐dependent PWUDs may have already established a high tolerance for opioids due to the concomitant use of opioid substitution therapies and ongoing drug use, making it difficult to appropriately prescribe pain medication to these individuals.[27] High‐frequency heroin users may also face severe withdrawal given the unavailability of illicit opioids in hospital settings, resulting in their increased willingness to access an in‐hospital SIF. Furthermore, inadequate pain management may contribute to the continued need to use opioids, as some healthcare providers may be reluctant to provide pain medication out of fear that they would contribute to an existing addiction or relapse.[28, 29] Further, requests for pain mediation may be misinterpreted as drug‐seeking behavior.[30, 31] Given the complexities arising from high‐intensity heroin use, pain management, and healthcare professionals' perceptions regarding PWUDs, further research should seek to untangle the causal relationships underlying these associations.

We found an association between recent use of an SIF and willingness to access an in‐hospital SIF. As mentioned previously, earlier research has shown improvements in various health outcomes and reductions in related harm in surrounding communities where SIFs were implemented.[15, 17] It is unfortunate that although progress in reducing the harm of injection drug use has been seen in community settings globally, the same cannot be said about hospitals. Given that many PWUDs often present to emergency care late in the course of illness and require admission to a hospital bed,[2] it is important to ensure that harm reduction services that are available in the community are also made available in hospitals. However, given the lack of knowledge on in‐hospital SIFs, future research should seek to understand the benefits and consequences of implementing such a facility in a hospital from different perspectives. For example, it may be of interest to assess the attitudes and perceptions of healthcare providers toward an in‐hospital SIF.

A large body of evidence has documented the health harms associated with leaving the hospital AMA, including readmission for a worsened illness and mortality.[13, 32] However, when faced with the abstinence‐based policies that exist in most hospital settings, it is not uncommon for PWUDs to leave the hospital to maintain their active addiction or to address their drug withdrawal.[9] Although we failed to find a statistically significant association between being discharged AMA and willingness to access an in‐hospital SIF, it is noteworthy that in our subanalysis we found that PWUD who were more likely to access an in‐hospital SIF reported doing so because they wanted to stay in the hospital and reduce their drug‐related risks. Given that we observed low counts of reported AMA discharge events, further exploration of this topic is warranted.

Our study suggests that in‐hospital SIFs have the potential to minimize health harms among patients who use illicit drugs in hospitals; however, there are some legal issues that warrant consideration. Specifically, for the successful operation of SIFs, there is a need for changes to regulatory frameworks, including drug laws, to allow for the possession of illicit drugs by individuals accessing an SIF. Such frameworks have been developed in a range of settings and in a manner that is consistent with international drug control treaties. In hospitals, additional regulatory changes may be needed to address issues unique to these settings, such as the use of opioids among PWUDs being treated for pain.

There are several limitations to this study. First, the cross‐sectional design of the study limited our ability to determine a temporal or causal relationship between the explanatory and outcome variables. Second, it is noteworthy that the chosen mode of interviewer‐based questionnaire administration may have influenced our results by relying on self‐reported data that are susceptible to reporting biases, including socially desirable reporting and recall bias. However, we believe we have minimized response bias and maximized reliability in our data by placing sensitive questions toward the end of the interview to allow rapport to be established between the interviewer and participant. Last, given that the participants in the present study were not randomly selected, the interpretation of these results may not be representative or generalizable to other PWUD populations outside of Vancouver. However, it is noteworthy that over the past few decades, community‐based SIFs have been successfully operating in international settings such as Europe and Australia[33, 34]; thus, the concept of an in‐hospital SIF may not be far from actual inpatient practice in these settings. It is also important to acknowledge the progress made toward the implementation of community‐based SIFs in other settings, including the United States. For example, feasibility studies have been conducted in San Francisco and New York and have shown increasing support for the implementation of SIFs in these areas.[35, 36]

We found that a substantial proportion of PWUDs in our sample would be willing to access an in‐hospital SIF if this service was available. Those PWUDs who expressed a willingness to use an in‐hospital SIF were more likely to be high‐intensity heroin users, to have previously used illicit drugs in the hospital, and were more likely to have previously used an SIF. Our findings highlight the potential of in‐hospital SIFs to complement existing harm‐reduction programs that serve people who inject drugs.

People who use illicit drugs (PWUDs) experience a wide range of health‐related harms and consequently often rely on acute and emergency services for care.[1, 2] Specifically, the poor health status of many PWUDs is often attributable to infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C virus.[3, 4] Soft‐tissue infections associated with injection drug use are also common, and have increasingly accounted for the majority of hospitalizations among this population.[5] Many of these adverse health outcomes may require lengthy in‐patient hospital admissions and constitute a substantial financial burden for the healthcare system.[6]

PWUDs frequently experience barriers to conventional healthcare services. For example, negative experiences with healthcare providers and the healthcare system have often deterred PWUDs from accessing these services.[7, 8] Given that most hospitals operate under an abstinence‐based policy, PWUDs have minimal access to drug‐using paraphernalia while hospitalized, making it difficult for these individuals to safely manage their active drug use. As a result, many PWUDs may resort to high‐risk drug‐using practices (eg, syringe sharing, injecting alone) in the hospital that may lead to further adverse health outcomes, such as infectious disease transmission and overdose, respectively.[9] Past studies have also shown that many PWUDs do not complete hospital‐based treatments.[10, 11] Specifically, many PWUDs leave the hospital against medical advice (AMA) possibly because they are unable to continue their drug use practices in this setting,[10, 12] thus contributing to an increase in readmission rates and mortality among this population.[13] Past studies have indicated that approximately 30% of patients who inject drugs left the hospital AMA,[12, 14] and these individuals have shown to be as high as 4 times more likely to leave the hospital AMA compared to their nondrug‐using counterparts.[11]

Supervised injection facilities (SIFs) are sanctioned environments where PWUDs can inject preobtained illicit drugs under the supervision of healthcare staff. Internationally, SIFs have been shown to improve public health and public order within surrounding communities.[15, 16, 17] For example, a dramatic decline in fatal overdoses in Vancouver's Downtown Eastside neighborhood was attributed to the implementation of a SIF in the area.[15] Changes in risk‐injecting behavior have also been observed among individuals who access SIFs.[18] Although a large body of evidence supports SIFs as an effective approach for minimizing the drug‐ and health‐related harms within street‐based drug scenes,[17, 19] little is known about whether there is a role for SIFs within hospital settings. Currently in Vancouver, Canada, harm reduction services are generally not being provided within hospital settings. Therefore, we sought to conduct a needs assessment to identify the prevalence and correlates of willingness to access an in‐hospital SIF among PWUDs in Vancouver. These data may be crucial for planning appropriate programs and services to reduce health‐related harms and leaving the hospital AMA among PWUDs in hospital settings.

METHODS

The Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) are 2 prospective cohort studies of PWUDs who have been recruited through self‐referral and street outreach since May 1996. These cohorts have been described in detail previously.[20, 21] In brief, persons were eligible to enter the VIDUS study if they had injected illicit drugs at least once in the previous month and resided in the Greater Vancouver region at enrollment. Persons were eligible to enter the ACCESS study if they were HIV infected and used illicit drugs other than cannabinoids in the previous month. Individuals who seroconvert following recruitment are transferred from the VIDUS study into the ACCESS study. All eligible participants provided written informed consent. At baseline and semiannually, study participants complete a harmonized interviewer‐administered questionnaire (ie, participants in the VIDUS and ACCESS studies completed an identical questionnaire) and provide blood samples for HIV and hepatitis C virus testing, and HIV disease monitoring. At the conclusion of each visit, study participants receive Can$20 for their time. The study has received ethical approval from Providence Health Care/University of British Columbia's research ethics board.

The primary outcome of interest for this analysis was willingness to access an in‐hospital SIF (yes vs no or unsure), ascertained by asking participants the following hypothetical question: If you were admitted into a hospital, and if a supervised safe injection site was available in that hospital, would you use it? Given the existence of 2 SIFs in the local environment, PWUDs in Vancouver are familiar with the design and operation of such programs. We compared PWUDs who were and were not willing to access an in‐hospital SIF using bivariable and multivariable logistic regression analyses. Given that the variable measure was based on a hypothetical scenario, participants who completed the survey between June 2013 and November 2013 were eligible for inclusion regardless of their current injection drug use behavior. A complete case approach was used to analyze the data given that the extent of missingness was not significant (<5%). Variables considered included: age (per year increase); gender (male vs female); HIV serostatus (positive vs negative); heroin injection ( daily vs

To identify factors independently associated with willingness to access an in‐hospital SIF, a multivariable logistic regression model was constructed using an a prioridefined statistical protocol based on examination of the Akaike information criterion (AIC) and P values. First, we constructed a full model that included all variables significant at P<0.10 in bivariable analyses. After noting the AIC of the model, we removed the variable with the largest P value and built a reduced model. We continued this iterative process until no variables remained. We selected the multivariable model with the lowest AIC score. All P values were 2 sided. As a subanalysis, we asked participants who would be willing to access an in‐hospital SIF to indicate reasons why they would be willing to access such a facility.

RESULTS

Of the total 769 participants who were eligible for inclusion in the study, 732 PWUDs provided complete data and participated in the study; 37 (4.8%) were excluded due to missing data. In our study sample, 250 (34.2%) were female, the median age was 48 years (interquartile range: 4153 years), and 307 (41.5%) were HIV‐positive. Among our study sample, 499 (68.2%) participants would be willing to access an in‐hospital SIF if it were available. Bivariable analyses of factors associated with willingness to access an in‐hospital SIF are presented in Table 1.

As indicated in Table 2, in multivariable analyses, factors that remained significantly and positively associated with willingness to access an in‐hospital SIF included: daily heroin injection (adjusted odds ratio [AOR]=1.90; 95% confidence interval [CI]: 1.20‐3.11), ever used illicit drugs in the hospital (AOR=1.63; 95% CI: 1.18‐2.26), and previously used an SIF (AOR=1.53; 95% CI: 1.10‐2.15).

Among participants who would be willing to access an in‐hospital SIF, the most common reasons included: to be able to stay in the hospital (229/499=45.9%), to reduce their drug‐related risks (189/499=37.9%), and to reduce stress associated with being kicked out of the hospital because they were using drugs (97/499=19.4%).

DISCUSSION

We found that over two‐thirds of PWUDs participating in our study would be willing to access an in‐hospital SIF if such a service was available. This finding is encouraging given that a large proportion of PWUDs are hospitalized annually for acute and chronic diseases.[5, 6] Previous studies have documented the positive impact of incorporating a harm reduction model within hospital settings, resulting in more comprehensive care for PWUDs.[22, 23] For example, the Dr. Peter Centre Day Health Program provides a SIF for HIV‐positive PWUDs to safely use illicit drugs under the supervision of trained nurses and was once located at St. Paul's Hospital.[24] Although the Dr. Peter Centre currently operates outside of St. Paul's Hospital, it may be advantageous to model an in‐hospital SIF after the Dr. Peter Centre's harm‐reduction room given their success in facilitating access and delivery of comprehensive care for PWUDs.[23] Specifically, nurses at the Dr. Peter Centre directly observe injections of preobtained illicit drugs for the purposes of preventing illness and promoting health. Our findings support recent calls to implement harm‐reduction services within hospital settings in an effort to minimize the harms associated with illicit drug use.[25, 26]

Previous studies have identified various high‐risk locations where PWUDs use illicit drugs to maintain their established drug‐use habits, including in locked washrooms in hospitals.[9] We found a positive association among PWUDs who had used illicit drugs in the hospital and a willingness to use an in‐hospital SIF. Our finding is reassuring given that studies have shown that these individuals are at a higher risk of negative health consequences (eg, fatal overdose) from using drugs in the hospital.[9] Harm reduction services within the hospital settings can play an important role in reducing this drug‐ and health‐related harm among PWUDs.

Our study also found that high‐frequency heroin injection was associated with a willingness to access an in‐hospital SIF. This relationship may be a result of the complex nature of treating opioid‐dependent patients for pain. For instance, some opioid‐dependent PWUDs may have already established a high tolerance for opioids due to the concomitant use of opioid substitution therapies and ongoing drug use, making it difficult to appropriately prescribe pain medication to these individuals.[27] High‐frequency heroin users may also face severe withdrawal given the unavailability of illicit opioids in hospital settings, resulting in their increased willingness to access an in‐hospital SIF. Furthermore, inadequate pain management may contribute to the continued need to use opioids, as some healthcare providers may be reluctant to provide pain medication out of fear that they would contribute to an existing addiction or relapse.[28, 29] Further, requests for pain mediation may be misinterpreted as drug‐seeking behavior.[30, 31] Given the complexities arising from high‐intensity heroin use, pain management, and healthcare professionals' perceptions regarding PWUDs, further research should seek to untangle the causal relationships underlying these associations.

We found an association between recent use of an SIF and willingness to access an in‐hospital SIF. As mentioned previously, earlier research has shown improvements in various health outcomes and reductions in related harm in surrounding communities where SIFs were implemented.[15, 17] It is unfortunate that although progress in reducing the harm of injection drug use has been seen in community settings globally, the same cannot be said about hospitals. Given that many PWUDs often present to emergency care late in the course of illness and require admission to a hospital bed,[2] it is important to ensure that harm reduction services that are available in the community are also made available in hospitals. However, given the lack of knowledge on in‐hospital SIFs, future research should seek to understand the benefits and consequences of implementing such a facility in a hospital from different perspectives. For example, it may be of interest to assess the attitudes and perceptions of healthcare providers toward an in‐hospital SIF.

A large body of evidence has documented the health harms associated with leaving the hospital AMA, including readmission for a worsened illness and mortality.[13, 32] However, when faced with the abstinence‐based policies that exist in most hospital settings, it is not uncommon for PWUDs to leave the hospital to maintain their active addiction or to address their drug withdrawal.[9] Although we failed to find a statistically significant association between being discharged AMA and willingness to access an in‐hospital SIF, it is noteworthy that in our subanalysis we found that PWUD who were more likely to access an in‐hospital SIF reported doing so because they wanted to stay in the hospital and reduce their drug‐related risks. Given that we observed low counts of reported AMA discharge events, further exploration of this topic is warranted.

Our study suggests that in‐hospital SIFs have the potential to minimize health harms among patients who use illicit drugs in hospitals; however, there are some legal issues that warrant consideration. Specifically, for the successful operation of SIFs, there is a need for changes to regulatory frameworks, including drug laws, to allow for the possession of illicit drugs by individuals accessing an SIF. Such frameworks have been developed in a range of settings and in a manner that is consistent with international drug control treaties. In hospitals, additional regulatory changes may be needed to address issues unique to these settings, such as the use of opioids among PWUDs being treated for pain.

There are several limitations to this study. First, the cross‐sectional design of the study limited our ability to determine a temporal or causal relationship between the explanatory and outcome variables. Second, it is noteworthy that the chosen mode of interviewer‐based questionnaire administration may have influenced our results by relying on self‐reported data that are susceptible to reporting biases, including socially desirable reporting and recall bias. However, we believe we have minimized response bias and maximized reliability in our data by placing sensitive questions toward the end of the interview to allow rapport to be established between the interviewer and participant. Last, given that the participants in the present study were not randomly selected, the interpretation of these results may not be representative or generalizable to other PWUD populations outside of Vancouver. However, it is noteworthy that over the past few decades, community‐based SIFs have been successfully operating in international settings such as Europe and Australia[33, 34]; thus, the concept of an in‐hospital SIF may not be far from actual inpatient practice in these settings. It is also important to acknowledge the progress made toward the implementation of community‐based SIFs in other settings, including the United States. For example, feasibility studies have been conducted in San Francisco and New York and have shown increasing support for the implementation of SIFs in these areas.[35, 36]

We found that a substantial proportion of PWUDs in our sample would be willing to access an in‐hospital SIF if this service was available. Those PWUDs who expressed a willingness to use an in‐hospital SIF were more likely to be high‐intensity heroin users, to have previously used illicit drugs in the hospital, and were more likely to have previously used an SIF. Our findings highlight the potential of in‐hospital SIFs to complement existing harm‐reduction programs that serve people who inject drugs.

People who use illicit drugs (PWUDs) experience a wide range of health‐related harms and consequently often rely on acute and emergency services for care.[1, 2] Specifically, the poor health status of many PWUDs is often attributable to infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C virus.[3, 4] Soft‐tissue infections associated with injection drug use are also common, and have increasingly accounted for the majority of hospitalizations among this population.[5] Many of these adverse health outcomes may require lengthy in‐patient hospital admissions and constitute a substantial financial burden for the healthcare system.[6]

PWUDs frequently experience barriers to conventional healthcare services. For example, negative experiences with healthcare providers and the healthcare system have often deterred PWUDs from accessing these services.[7, 8] Given that most hospitals operate under an abstinence‐based policy, PWUDs have minimal access to drug‐using paraphernalia while hospitalized, making it difficult for these individuals to safely manage their active drug use. As a result, many PWUDs may resort to high‐risk drug‐using practices (eg, syringe sharing, injecting alone) in the hospital that may lead to further adverse health outcomes, such as infectious disease transmission and overdose, respectively.[9] Past studies have also shown that many PWUDs do not complete hospital‐based treatments.[10, 11] Specifically, many PWUDs leave the hospital against medical advice (AMA) possibly because they are unable to continue their drug use practices in this setting,[10, 12] thus contributing to an increase in readmission rates and mortality among this population.[13] Past studies have indicated that approximately 30% of patients who inject drugs left the hospital AMA,[12, 14] and these individuals have shown to be as high as 4 times more likely to leave the hospital AMA compared to their nondrug‐using counterparts.[11]

Supervised injection facilities (SIFs) are sanctioned environments where PWUDs can inject preobtained illicit drugs under the supervision of healthcare staff. Internationally, SIFs have been shown to improve public health and public order within surrounding communities.[15, 16, 17] For example, a dramatic decline in fatal overdoses in Vancouver's Downtown Eastside neighborhood was attributed to the implementation of a SIF in the area.[15] Changes in risk‐injecting behavior have also been observed among individuals who access SIFs.[18] Although a large body of evidence supports SIFs as an effective approach for minimizing the drug‐ and health‐related harms within street‐based drug scenes,[17, 19] little is known about whether there is a role for SIFs within hospital settings. Currently in Vancouver, Canada, harm reduction services are generally not being provided within hospital settings. Therefore, we sought to conduct a needs assessment to identify the prevalence and correlates of willingness to access an in‐hospital SIF among PWUDs in Vancouver. These data may be crucial for planning appropriate programs and services to reduce health‐related harms and leaving the hospital AMA among PWUDs in hospital settings.

METHODS

The Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) are 2 prospective cohort studies of PWUDs who have been recruited through self‐referral and street outreach since May 1996. These cohorts have been described in detail previously.[20, 21] In brief, persons were eligible to enter the VIDUS study if they had injected illicit drugs at least once in the previous month and resided in the Greater Vancouver region at enrollment. Persons were eligible to enter the ACCESS study if they were HIV infected and used illicit drugs other than cannabinoids in the previous month. Individuals who seroconvert following recruitment are transferred from the VIDUS study into the ACCESS study. All eligible participants provided written informed consent. At baseline and semiannually, study participants complete a harmonized interviewer‐administered questionnaire (ie, participants in the VIDUS and ACCESS studies completed an identical questionnaire) and provide blood samples for HIV and hepatitis C virus testing, and HIV disease monitoring. At the conclusion of each visit, study participants receive Can$20 for their time. The study has received ethical approval from Providence Health Care/University of British Columbia's research ethics board.

The primary outcome of interest for this analysis was willingness to access an in‐hospital SIF (yes vs no or unsure), ascertained by asking participants the following hypothetical question: If you were admitted into a hospital, and if a supervised safe injection site was available in that hospital, would you use it? Given the existence of 2 SIFs in the local environment, PWUDs in Vancouver are familiar with the design and operation of such programs. We compared PWUDs who were and were not willing to access an in‐hospital SIF using bivariable and multivariable logistic regression analyses. Given that the variable measure was based on a hypothetical scenario, participants who completed the survey between June 2013 and November 2013 were eligible for inclusion regardless of their current injection drug use behavior. A complete case approach was used to analyze the data given that the extent of missingness was not significant (<5%). Variables considered included: age (per year increase); gender (male vs female); HIV serostatus (positive vs negative); heroin injection ( daily vs

To identify factors independently associated with willingness to access an in‐hospital SIF, a multivariable logistic regression model was constructed using an a prioridefined statistical protocol based on examination of the Akaike information criterion (AIC) and P values. First, we constructed a full model that included all variables significant at P<0.10 in bivariable analyses. After noting the AIC of the model, we removed the variable with the largest P value and built a reduced model. We continued this iterative process until no variables remained. We selected the multivariable model with the lowest AIC score. All P values were 2 sided. As a subanalysis, we asked participants who would be willing to access an in‐hospital SIF to indicate reasons why they would be willing to access such a facility.

RESULTS

Of the total 769 participants who were eligible for inclusion in the study, 732 PWUDs provided complete data and participated in the study; 37 (4.8%) were excluded due to missing data. In our study sample, 250 (34.2%) were female, the median age was 48 years (interquartile range: 4153 years), and 307 (41.5%) were HIV‐positive. Among our study sample, 499 (68.2%) participants would be willing to access an in‐hospital SIF if it were available. Bivariable analyses of factors associated with willingness to access an in‐hospital SIF are presented in Table 1.

As indicated in Table 2, in multivariable analyses, factors that remained significantly and positively associated with willingness to access an in‐hospital SIF included: daily heroin injection (adjusted odds ratio [AOR]=1.90; 95% confidence interval [CI]: 1.20‐3.11), ever used illicit drugs in the hospital (AOR=1.63; 95% CI: 1.18‐2.26), and previously used an SIF (AOR=1.53; 95% CI: 1.10‐2.15).

Among participants who would be willing to access an in‐hospital SIF, the most common reasons included: to be able to stay in the hospital (229/499=45.9%), to reduce their drug‐related risks (189/499=37.9%), and to reduce stress associated with being kicked out of the hospital because they were using drugs (97/499=19.4%).

DISCUSSION

We found that over two‐thirds of PWUDs participating in our study would be willing to access an in‐hospital SIF if such a service was available. This finding is encouraging given that a large proportion of PWUDs are hospitalized annually for acute and chronic diseases.[5, 6] Previous studies have documented the positive impact of incorporating a harm reduction model within hospital settings, resulting in more comprehensive care for PWUDs.[22, 23] For example, the Dr. Peter Centre Day Health Program provides a SIF for HIV‐positive PWUDs to safely use illicit drugs under the supervision of trained nurses and was once located at St. Paul's Hospital.[24] Although the Dr. Peter Centre currently operates outside of St. Paul's Hospital, it may be advantageous to model an in‐hospital SIF after the Dr. Peter Centre's harm‐reduction room given their success in facilitating access and delivery of comprehensive care for PWUDs.[23] Specifically, nurses at the Dr. Peter Centre directly observe injections of preobtained illicit drugs for the purposes of preventing illness and promoting health. Our findings support recent calls to implement harm‐reduction services within hospital settings in an effort to minimize the harms associated with illicit drug use.[25, 26]

Previous studies have identified various high‐risk locations where PWUDs use illicit drugs to maintain their established drug‐use habits, including in locked washrooms in hospitals.[9] We found a positive association among PWUDs who had used illicit drugs in the hospital and a willingness to use an in‐hospital SIF. Our finding is reassuring given that studies have shown that these individuals are at a higher risk of negative health consequences (eg, fatal overdose) from using drugs in the hospital.[9] Harm reduction services within the hospital settings can play an important role in reducing this drug‐ and health‐related harm among PWUDs.

Our study also found that high‐frequency heroin injection was associated with a willingness to access an in‐hospital SIF. This relationship may be a result of the complex nature of treating opioid‐dependent patients for pain. For instance, some opioid‐dependent PWUDs may have already established a high tolerance for opioids due to the concomitant use of opioid substitution therapies and ongoing drug use, making it difficult to appropriately prescribe pain medication to these individuals.[27] High‐frequency heroin users may also face severe withdrawal given the unavailability of illicit opioids in hospital settings, resulting in their increased willingness to access an in‐hospital SIF. Furthermore, inadequate pain management may contribute to the continued need to use opioids, as some healthcare providers may be reluctant to provide pain medication out of fear that they would contribute to an existing addiction or relapse.[28, 29] Further, requests for pain mediation may be misinterpreted as drug‐seeking behavior.[30, 31] Given the complexities arising from high‐intensity heroin use, pain management, and healthcare professionals' perceptions regarding PWUDs, further research should seek to untangle the causal relationships underlying these associations.

We found an association between recent use of an SIF and willingness to access an in‐hospital SIF. As mentioned previously, earlier research has shown improvements in various health outcomes and reductions in related harm in surrounding communities where SIFs were implemented.[15, 17] It is unfortunate that although progress in reducing the harm of injection drug use has been seen in community settings globally, the same cannot be said about hospitals. Given that many PWUDs often present to emergency care late in the course of illness and require admission to a hospital bed,[2] it is important to ensure that harm reduction services that are available in the community are also made available in hospitals. However, given the lack of knowledge on in‐hospital SIFs, future research should seek to understand the benefits and consequences of implementing such a facility in a hospital from different perspectives. For example, it may be of interest to assess the attitudes and perceptions of healthcare providers toward an in‐hospital SIF.

A large body of evidence has documented the health harms associated with leaving the hospital AMA, including readmission for a worsened illness and mortality.[13, 32] However, when faced with the abstinence‐based policies that exist in most hospital settings, it is not uncommon for PWUDs to leave the hospital to maintain their active addiction or to address their drug withdrawal.[9] Although we failed to find a statistically significant association between being discharged AMA and willingness to access an in‐hospital SIF, it is noteworthy that in our subanalysis we found that PWUD who were more likely to access an in‐hospital SIF reported doing so because they wanted to stay in the hospital and reduce their drug‐related risks. Given that we observed low counts of reported AMA discharge events, further exploration of this topic is warranted.

Our study suggests that in‐hospital SIFs have the potential to minimize health harms among patients who use illicit drugs in hospitals; however, there are some legal issues that warrant consideration. Specifically, for the successful operation of SIFs, there is a need for changes to regulatory frameworks, including drug laws, to allow for the possession of illicit drugs by individuals accessing an SIF. Such frameworks have been developed in a range of settings and in a manner that is consistent with international drug control treaties. In hospitals, additional regulatory changes may be needed to address issues unique to these settings, such as the use of opioids among PWUDs being treated for pain.

There are several limitations to this study. First, the cross‐sectional design of the study limited our ability to determine a temporal or causal relationship between the explanatory and outcome variables. Second, it is noteworthy that the chosen mode of interviewer‐based questionnaire administration may have influenced our results by relying on self‐reported data that are susceptible to reporting biases, including socially desirable reporting and recall bias. However, we believe we have minimized response bias and maximized reliability in our data by placing sensitive questions toward the end of the interview to allow rapport to be established between the interviewer and participant. Last, given that the participants in the present study were not randomly selected, the interpretation of these results may not be representative or generalizable to other PWUD populations outside of Vancouver. However, it is noteworthy that over the past few decades, community‐based SIFs have been successfully operating in international settings such as Europe and Australia[33, 34]; thus, the concept of an in‐hospital SIF may not be far from actual inpatient practice in these settings. It is also important to acknowledge the progress made toward the implementation of community‐based SIFs in other settings, including the United States. For example, feasibility studies have been conducted in San Francisco and New York and have shown increasing support for the implementation of SIFs in these areas.[35, 36]

We found that a substantial proportion of PWUDs in our sample would be willing to access an in‐hospital SIF if this service was available. Those PWUDs who expressed a willingness to use an in‐hospital SIF were more likely to be high‐intensity heroin users, to have previously used illicit drugs in the hospital, and were more likely to have previously used an SIF. Our findings highlight the potential of in‐hospital SIFs to complement existing harm‐reduction programs that serve people who inject drugs.