James J. O’Connell

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

BACKGROUND Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death.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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Food insufficiency and health services utilization in a national sample of homeless adults.

BACKGROUNDHomeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization.OBJECTIVEWe tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults.DESIGNWe analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey.PARTICIPANTSParticipants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally.MEASURESWe determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥4 visits).RESULTSOverall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08).CONCLUSIONSOne-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue.

Tobacco-, Alcohol-, and Drug-Attributable Deaths and Their Contribution to Mortality Disparities in a Cohort of Homeless Adults in Boston

OBJECTIVES We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults. METHODS We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences. RESULTS Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults. CONCLUSIONS In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

Health, Housing, and the Heart Cardiovascular Disparities in Homeless People

The interaction between housing and health is intimate and complex, yet little evidence exists with regard to the healthcare outcomes for people struggling to survive without housing. The study in this issue by Lee and colleagues1 not only exposes a resounding need for community-wide interventions to improve the cardiovascular health of homeless adults but also underscores the vexing challenges confronting researchers investigating the health disparities attendant to homelessness. See p 2629 Mortality rates of homeless adults in the United States and Canada have been shown to be 3 to 5 times higher than those of the general population.2,3 Homeless women in Toronto have a 10-fold risk of death when compared with housed women in that city.4 In our ongoing observational study of a cohort of 119 chronically homeless people living on the streets of Boston, almost one third died during a 5-year period from 2000 through 2004. Heart disease is a leading cause of death in older homeless people 45 to 64 years old, and despite other common causes of death in younger homeless people 25 to 44 years old, heart disease is 3 times more common in this group than in the age-matched general population.5 Risk factors for cardiovascular (CV) disease are potentially treatable targets in the prevention of morbidity and premature death in this high-risk subpopulation. The study by Lee et al shows, however, that …

The Need for Homelessness Prevention: A Doctor’s View of Life and Death on the Streets

This issue of The Journal of Primary Prevention sounds an urgent and compelling clarion call to policy makers, politicians, advocates, clinicians, and to all committed to ending the social tragedy of homelessness in modern America. Over the past three decades, homelessness has emerged as a complex social phenomenon that thwarts simple definitions and is perhaps best viewed as a prism that refracts the failures of key sectors of our society, including housing, welfare, labor, education, health care, and corrections. Efforts to prevent homelessness have failed in the face of the compelling urgency of the daily crisis posed by thousands of individuals and families already on our streets and in our shelters. The papers in this timely edition of JPP begin the arduous task of stemming the relentless tide of Americans swept from housing and institutions into homelessness each year. Prevention remains poorly understood and yet is the sine qua non for ending homelessness. Homelessness in urban and rural America includes an eclectic population spanning a continuum from families with children, to adolescents and youths, to

Experience and Outcomes of Hepatitis C Treatment in a Cohort of Homeless and Marginally Housed Adults

Joshua A. Barocas, MD, Marguerite Beiser, NP, Casey León, MPH, Jessie M. Gaeta, MD, James J. O’Connell, MD, and Benjamin P. Linas, MD, MPH Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts (Barocas); Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts (Barocas); Boston Health Care for the Homeless Program, Boston, Massachusetts (Beiser, León, Gaeta, O’Connell); Division of Infectious Diseases, Boston Medical Center, Boston, Massachusetts (Linas); Boston University School of Medicine, Boston, Massachusetts (Linas)

Improving Health Care for Homeless People

Addressing the medical issues of homeless people is the health equity challenge of our time. The most recent US Department of Housing and Urban Development (HUD) report on homelessness, published in 2015, estimated that about 564 000 homeless people in the United States live in shelters and on the streets. This figure, based on a pointin-time snapshot on a single night each January, may well be an underestimate, given varying definitions of homelessness, peripatetic populations, and the lack of robust surveillance systems. Despite official figures documented in the HUD report noting an overall recent population decline of about 11% from 2007 to 2015, numbers of homeless individuals have increased in cities with rising housing costs, such as New York and Los Angeles. Some estimate as many as 2.3 million to 3.5 million individuals experience homelessness each year; persons of color are disproportionately affected, with one-third unsheltered. This vulnerable population comprises a human kaleidoscope of people often excluded from mainstream society: runaways, LGBT (lesbian, gay, bisexual, and transgender) youth, those targeted by domestic violence, struggling veterans, displaced factory workers, migrant laborers, refugees, illiterate individuals, fragile elderly persons, and those discharged from mental hospitals or overcrowded prisons. For many, the daily struggle for food, shelter, clothing, and safety relegates health to a distant priority which, in turn, exacerbates disease, complicates treatment, and drives excess mortality. One recent analysis shows death rates for homeless youth are more than 10 times greater than for the general population. Health disparities are heightened by a complex burden of simultaneous medical, mental health, and substance use problems. A recent study attributes 52% of homeless deaths in Boston to tobacco, alcohol, or other drugs. Chronic conditions such as cancer and heart disease, fueled by tobacco use in approximately threequarters of the population, represent major causes of death. Infections, injuries, and other acute conditions fester, and communicable diseases such as tuberculosis, AIDS, and viral hepatitis readily spread. Violence complicates all aspects of life in crowded shelters. Tackling all these special needs requires not only better ways to care for individuals but also broad policies to address homelessness itself.

Falling Off the Edge

Falling Off the Edge ONE EVENING AS I (S.K.I.) WAS CLEARING THE TABLES in the soup kitchen where I was volunteering, I struck up a conversation with a homeless man. With his long white beard, stooped posture, and limping gait, I was sure he was older than 70 years. I was surprised to learn he was only 48. As a geriatrician with more than 25 years of clinical experience, I am usually pretty good at telling how old someone is. But after this scenario repeated itself several times, I began to wonder whether chronic homelessness might be associated with accelerated aging. Could exposure to the elements and the constant stress of the relentless daily struggle to survive lead to more rapid aging, along with its attendant functional and cognitive decline? With this question in mind, I approached a colleague (J.J.O.) at the Boston Health Care for the Homeless Program (BHCHP), someone who had long inspired me with his work establishing an extensive health care network serving the Boston homeless population. I inquired whether he thought the idea of accelerated aging in the chronically homeless population was a real phenomenon, and without hesitation, he agreed. I asked if I could volunteer as a physician in his program to provide functional and cognitive assessments—the special skills of the geriatrician—to explore this area further. Thus began a great adventure of exploration. I saw patients with frequent falls, severe depression, violent behavior, and unspecified memory problems. For some patients, homelessness was the result of well-recognized and oftcited contributors, including poverty, loss of employment, use of alcohol and other drugs, mental illness, and undertreated chronic illnesses. The phenomenon of accelerated aging was pervasive. However, I was caught unaware by an even more important aspect of aging: that cognitive decline often plays a prominent yet unappreciated role in contributing to homelessness. For me, three cases in particular served to bring this reality to the fore. The first case was a former teacher in her 70s with mild diabetes mellitus and a remote history of head trauma, who had been living on her own until 18 months ago. She found that she could no longer stretch her

Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009

1000/month fixed income to cover her expenses and rent. She took to traveling from town to town, living at bus stations, occasionally finding cleaning jobs, chores, or kind people who would take her in. She had significant deficits in executive functioning (clock-drawing, Trails B), naming, and delayed recall, and she was diagnosed with probable Alzheimer-type dementia. She had been able to subsist at poverty level until her cognitive deficits progressed to the point where she could no longer live independently. She will now require nursing home placement. Thesecondcasewasahighschoolgraduateandformer truck driver in his 70s with multiple chronic conditions, including severe asthma, hypertension, diabetes mellitus, heart failure with a pacemaker for heart block, alcohol abuse, and chronic anxiety. He had been living with family out of state but moved to escape an abusive situation over a year ago. He has recently been placed in a program for the chronically homeless, but experiencing difficulty managing his medications, special diet, and doctors’ appointments. He had become a “frequent flier,” with numerous emergency department and hospital admissions for exacerbations of his medical conditions. His examination reveals evidence of severe wheezing and bibasilar rales, with mild to moderate impairment of executive dysfunction defined below (eg, verbal fluency, abstraction, and Trails B) and marked short-term memory deficits. His diagnosis is mild cognitive impairmentduetomultifactorialcontributors, including alcohol, head trauma, and microvascular disease. He is failing inhiscurrentunsupervised livingsituationandisnowbeing referred for nursing home placement. The third case is a married woman in her late 40s with a grammar school education who suffers from hypertension, hyperlipidemia, diabetes mellitus, depression, alcohol abuse, and frequent falls. She reports life-long learning and functional limitations that have progressively worsened over the past 2 years. She was living independently and providing care for her husband, with a heart condition, until they lost their health insurancewhentheywere livingoutofstate.Theymoved to Boston about a year ago and have been living in separate shelters, sincetheBostonshelterscannotaccommodatecouples. Her physical examination reveals facial features and habitus consistentwithfetalalcoholsyndrome.Cognitivetestingreveals severeglobal cognitive impairments inalldomains tested,with the most severe impairments in executive function. Thus, she demonstrates lifelongpoor intellectualperformanceduetomild mental retardation, now exacerbated by progressive impairment likely due to microvascular disease. She and her husband have now entered the world of chronic homelessness. As these cases highlight, cognitive decline may contribute to chronic homelessness, defined by the US Department of Housing and Urban Development as either being continuously homeless for a year or more or having had at least four episodes of homelessness in the past three years, by precipitating homelessness and by influencing the level of supportive housing that may be required. Cognitive decline is on the rise for several reasons. First, the homeless population is aging even more rapidly than the rest of the US population; fully one-third of the current homeless population is older than 50 years, compared with 11% in the 1990s. Associated with this aging are rising rates of cognitive impairment and dementia. Based on cognitive screening tests, global cognitive impairment has been identified in about 4% to 7% of all homeless adults with rates increas-

The hunger-obesity paradox: obesity in the homeless.

Importance Previous studies have shown high mortality rates among homeless people in general, but little is known about the patterns of mortality among “rough sleepers,” the subgroup of unsheltered urban homeless people who avoid emergency shelters and primarily sleep outside. Objectives To assess the mortality rates and causes of death for a cohort of unsheltered homeless adults from Boston, Massachusetts. Design, Setting, and Participants A 10-year prospective cohort study (2000-2009) of 445 unsheltered homeless adults in Boston, Massachusetts, who were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program’s Street Team during 2000. Data used to describe the unsheltered homeless cohort and to document causes of death were gathered from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The study data set was linked to the death occurrence files by using a probabilistic record linkage program to confirm the deaths. Data analysis was performed from May 1, 2015, to September 6, 2016. Exposure Being unsheltered in an urban setting. Main Outcomes and Measures Age-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios that were calculated for the unsheltered adult cohort using 2 comparison groups: the nonhomeless Massachusetts adult population and an adult homeless cohort from Boston who slept primarily in shelters. Results Of 445 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 299 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). The most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease. Conclusions and Relevance Mortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation of homeless people merits special attention to meet their unique clinical and psychosocial needs.