title: The Hotel Study-Clinical and Health Service Effectiveness in a Cohort of Homeless or Marginally Housed Persons.
abstract: The Hotel Study was initiated in Vancouver's Downtown East Side (DTES) neighborhood to investigate multimorbidity in homeless or marginally housed people. We evaluated the clinical effectiveness of existing, illness-specific treatment strategies and assessed the effectiveness of health care delivery for multimorbid illnesses.
  
  
  
  For context, we mapped the housing locations of patients presenting for 552,062 visits to the catchment hospital emergency department (2005-2013). Aggregate data on 22,519 apprehensions of mentally ill people were provided by the Vancouver Police Department (2009-2015). The primary strategy was a longitudinal cohort study of 375 people living in the DTES (2008-2015). We analysed mortality and evaluated the clinical and health service delivery effectiveness for infection with human immunodeficiency virus or hepatitis C virus, opioid dependence, and psychosis.
  
  
  
  Mapping confirmed the association between poverty and greater number of emergency visits related to substance use and mental illness. The annual change in police apprehensions did not differ between the DTES and other policing districts. During 1581 person-years of cohort observation, the standardized mortality ratio was 8.43 (95% confidence interval, 6.19 to 11.50). Physician visits were common (84.3% of participants over 6 months). Clinical treatment effectiveness was highest for HIV/AIDS, intermediate for opioid dependence, and lowest for psychosis. Health service delivery mechanisms provided examples of poor access, poor treatment adherence, and little effect on multimorbid illnesses.
  
  
  
  Clinical effectiveness was variable, and illness-specific service delivery appeared to have little effect on multimorbidity. New models of care may need to be implemented.
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: William G
authors.initials: WG
authors.lastname: Honer
authors.affiliation: 2 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Cervantes-Larios
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Andrea A
authors.initials: AA
authors.lastname: Jones
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Fidel
authors.initials: F
authors.lastname: Vila-Rodriguez
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Julio S
authors.initials: JS
authors.lastname: Montaner
authors.affiliation: 3 Youth Services Section and Mental Health Portfolio, Vancouver Police Department, Vancouver, British Columbia.
authors.forename: Howard
authors.initials: H
authors.lastname: Tran
authors.affiliation: 3 Youth Services Section and Mental Health Portfolio, Vancouver Police Department, Vancouver, British Columbia.
authors.forename: Jimmy
authors.initials: J
authors.lastname: Nham
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: William J
authors.initials: WJ
authors.lastname: Panenka
authors.affiliation: 4 Department of Radiology, University of British Columbia, Vancouver, British Columbia.
authors.forename: Donna J
authors.initials: DJ
authors.lastname: Lang
authors.affiliation: 5 Department of Psychology, Simon Fraser University, Burnaby, British Columbia.
authors.forename: Allen E
authors.initials: AE
authors.lastname: Thornton
authors.affiliation: 4 Department of Radiology, University of British Columbia, Vancouver, British Columbia.
authors.forename: Talia
authors.initials: T
authors.lastname: Vertinsky
authors.affiliation: 6 Department of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia.
authors.forename: Alasdair M
authors.initials: AM
authors.lastname: Barr
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Ric M
authors.initials: RM
authors.lastname: Procyshyn
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Geoffrey N
authors.initials: GN
authors.lastname: Smith
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Tari
authors.initials: T
authors.lastname: Buchanan
authors.affiliation: 7 Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia.
authors.forename: Mel
authors.initials: M
authors.lastname: Krajden
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Michael
authors.initials: M
authors.lastname: Krausz
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: G William
authors.initials: GW
authors.lastname: MacEwan
authors.affiliation: 5 Department of Psychology, Simon Fraser University, Burnaby, British Columbia.
authors.forename: Kristina M
authors.initials: KM
authors.lastname: Gicas
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Olga
authors.initials: O
authors.lastname: Leonova
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Verena
authors.initials: V
authors.lastname: Langheimer
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Alexander
authors.initials: A
authors.lastname: Rauscher
authors.affiliation: 1 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.
authors.forename: Krista
authors.initials: K
authors.lastname: Schultz
mesh_terms: D000328:Adult; D001955:British Columbia / Q000453:epidemiology; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000401:mortality / Q000628:therapy; D006526:Hepatitis C / Q000453:epidemiology / Q000401:mortality / Q000628:therapy; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006798:Housing / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D000076322:Multimorbidity; D009293:Opioid-Related Disorders / Q000453:epidemiology / Q000401:mortality / Q000628:therapy; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D016495:Police / Q000706:statistics & numerical data*; D011618:Psychotic Disorders / Q000453:epidemiology*
keywords: HCV; HIV; heroin; mortality; multimorbidity; police; psychosis