Mortality Among Homeless Adults in Boston Shifts in Causes of Death Over a 15-Year Period

JAMA Internal Medicine (Impact Factor: 13.12). 01/2013; 173(3):1-7. DOI: 10.1001/jamainternmed.2013.1604
Source: PubMed


Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death. To our knowledge, no studies have examined shifts in causes of death for this population over time.

We assessed all-cause and cause-specific mortality rates in a cohort of 28 033 adults 18 years or older who were seen at Boston Health Care for the Homeless Program from January 1, 2003, through December 31, 2008. Deaths were identified through probabilistic linkage to the Massachusetts death occurrence files. We compared mortality rates in this cohort with rates in the 2003-2008 Massachusetts population and a 1988-1993 cohort of homeless adults in Boston using standardized rate ratios with 95% confidence intervals.

A total of 1302 deaths occurred during 90 450 person-years of observation. Drug overdose (n = 219), cancer (n = 206), and heart disease (n = 203) were the major causes of death. Drug overdose accounted for one-third of deaths among adults younger than 45 years. Opioids were implicated in 81% of overdose deaths. Mortality rates were higher among whites than nonwhites. Compared with Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25- to 44-year-olds and 4.5-fold higher in 45- to 64-year-olds. In comparison with 1988-1993 rates, reductions in deaths from human immunodeficiency virus (HIV) were offset by 3- and 2-fold increases in deaths owing to drug overdose and psychoactive substance use disorders, resulting in no significant difference in overall mortality.

The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988 to 1993 despite a major interim expansion in clinical services. Drug overdose has replaced HIV as the emerging epidemic. Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness.

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    • "Overall, the homeless population has a three to four times greater mortality rate than the general population (O'Connell, 2005). One study with homeless adults revealed that drug overdose, cancer, and heart disease were the major causes of death (Baggett et al., 2013). Homeless patients who had been hospitalized for a drugrelated issue have a sevenfold higher risk of death from drugs as compared to the general population (Morrison, 2009). "
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    ABSTRACT: This qualitative study explored perspectives toward a good or bad death among twenty-one older homeless adults residing in transitional housing. Using grounded theory approach, the themes for a good death were: 1) dying peacefully; 2) not suffering; 3) experiencing spiritual connection; and 4) making amends with significant others. Themes for a bad death were: 1) experiencing death by accident or violence; 2) prolonging life with life supports; 3) becoming dependent while entering a dying trajectory; and 4) dying alone. Healthcare professionals need to develop a culturally sensitive approach for end-of-life care grounded in understanding unique needs of older homeless adults.
    Full-text · Article · Feb 2015 · Death Studies
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    • "Thus, the present study provides the evidence that in the 21st century homelessness is still associated with a large excess mortality, even in a country like the Netherlands with an extensive social security system. The high excess mortality in the current century is in line with a recent study reporting that in 2003–2008 the mortality rate of 18–64 year-old homeless in Boston has not changed as compared to 1988–1993 [15]. "
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    ABSTRACT: Data on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city. Based on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy. During follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95-7.82) as compared to men (RR 3.31, 95% CI 2.91-3.77), and decreased with age (RR 7.67, 95% CI 6.87-8.56 for the age group 20-44 and RR 1.63, 95% CI 1.41-1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1-12.9) and 15.9 (95% CI 10.3-21.5) years lower for homeless men and women compared to men and women in the general population respectively. Homeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.
    Full-text · Article · Oct 2013 · PLoS ONE
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    ABSTRACT: The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.
    No preview · Article · Jan 2013
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