Marcel Slockers

114 Chapter 8 impact on the health of homeless people, our reported mortality and lower life expectancy may be an underestimate compared to the current situation. However, it is also possible that there is actually less excess mortality now because the increased size of the group of homeless people has, in general, a less extreme profile. Data on health problems The population of patients visiting the street doctor's consultation hours described in this thesis does not include all homeless people in Rotterdam. The registration of patients of the Rotterdam street doctor's consultation hours was only expanded from 2016 to include (sometimes homeless) undocumented immigrants who report to the Pauluskerk. We did not include this group in our study. Our results therefore only apply to legally residing homeless people who visit the street doctor’s consultation hours. Additional analyses for 2016 and 2017, which do include data from the Pauluskerk, show that the total population of homeless people includes more women and has a smaller proportion of street doctor visits due to psychological complaints and trauma, than the population of documented homeless people we studied. Under-registration may also have caused some bias in the study results. In a street doctor population, possible under-registration must be taken into account even more than in a regular practice. Street doctors and nurses are inundated with problems during their contacts with homeless people and must establish a good report in a relatively short time while helping to disentangle medical and social problems. Furthermore, substance abuse and addiction complicates the registration of diagnoses. A relatively high proportion of intellectual disabilities in this population can also lead to underreporting, and inadequate information from a large number of other care workers makes reporting less certain. 3 Underreporting in the street doctor population may vary per diagnosis group and may have biased the pattern in recorded diagnoses we found. In addition, the question arises as to whether "health problems as presented during the street doctor consultation" provide a valid picture of the health problems as they occur in the population of homeless people, or only of the use of care. Our comparison with patients from a regular GP practice suggests the latter. For most ICPC main groups, except for mental health problems and trauma, the share of patients who have visited consultation hours with the relevant condition at least once, is substantially higher, namely two to four times, in a regular GP practice than in the street doctor's consultation hours. Homeless people thus seem to have a relatively high threshold for visiting a doctor for common complaints, such as respiratory infections, gastrointestinal problems and musculoskeletal disorders.