Stephen W. Hwang

Causes of Death in Homeless Adults in Boston

Homelessness affects an estimated 0.5 to 3 million persons in the United States [1, 2] and has serious health implications. Homeless persons have a high prevalence of substance abuse [3, 4], human immunodeficiency virus (HIV) infection [5, 6], tuberculosis [6, 7], and other medical illnesses [8-10]. Not surprisingly, homeless persons often die prematurely of various preventable causes. In one study, homeless adults in Atlanta died at a median age of 44 years; 48% of the deaths were accidental [11]. In another study, homeless persons in San Francisco died at an average age of 41 years; 34% of the deaths resulted from accidents and 13% from homicides [12]. Compared with that of the general population, the mortality rate of homeless men in Sweden is elevated fourfold [13]. Among homeless adults in Philadelphia, the age-adjusted mortality rate is 3.5 times higher than that of the general population [14]. Our goal was to ascertain cause-specific mortality rates in a cohort of homeless adults. Methods We examined deaths among adults who had contact with the Boston Health Care for the Homeless Program between 1 July 1988 and 31 December 1993. Patients were homeless when first seen by primary care providers at shelters and clinics. The amount of time each patient was homeless during the subsequent observation period was unknown. Thus, persons in the cohort can be described as persons who had been homeless at any time and who had contact with a clinician while they were homeless. Deaths were ascertained by comparing the programs patient database with the Massachusetts death registry for 1988 to 1993. Matching criteria adapted from the National Death Index [15] required agreement on 1) first name or first initial, 2) last name, 3) month of birth, and 4) day of birth or year of birth 1 year. Names were compared by the Soundex algorithm to allow for errors in spelling. Matches were reviewed manually and were confirmed if records agreed on social security number or full name and date of birth. The International Classification of Diseases, Ninth Revision (ICD-9) codes that indicated cause of death were obtained from death certificates. The observation period for each person lasted from the time of first contact until 31 December 1993 or the date of death. Person-years of observation and cause-specific mortality rates were calculated by age group, sex, and race. Mortality rates were adjusted for race by direct standardization using Boston residents as the standard population. Rate ratios were calculated by dividing the race-adjusted mortality rate in the homeless cohort by the corresponding mortality rate in the general population of Boston. Because available sources of data were limited, homeless persons aged 18 to 24 years were compared with Boston residents aged 15 to 24 years. Deaths were categorized by the season of the year and the week of the month in which they occurred. The chi-square goodness-of-fit test was used to compare the number of deaths seen during each period with the expected number of deaths if a constant mortality rate was assumed. Results The study cohort included 17 292 adults, of whom 2365, 3577, 3026, 2687, 2688, and 2949 persons were seen for the first time in 1988, 1989, 1990, 1991, 1992, and 1993, respectively. The cohort was observed for 50 348 person-years (average, 2.9 years per person). Characteristics of the cohort and the 606 decedents in the cohort are shown in Table 1. More deaths were seen in later years of the study because homeless persons joined the cohort over time; therefore, the total number of persons in the study increased with each passing year. Table 1. Characteristics of the Homeless Cohort and the Subset of Decedents within the Cohort* For persons aged 18 to 64 years, the crude mortality rate was 1114 per 100 000 person-years. The average age at death was 47 years (median, 44 years [range, 18 to 86 years]). Death most commonly occurred in a hospital or residential dwelling. Cause-specific mortality rates and rate ratios are shown in Table 2 and Table 3. Because few adults in the homeless cohort were elderly, mortality rates for persons older than 64 years of age were omitted. Table 2. Cause-Specific Mortality Rates (Deaths per 100 000 Person-Years) in the Homeless Cohort, Adjusted for Race* Table 3. Table 2 continued The acquired immunodeficiency syndrome (AIDS) was the leading cause of death among persons who were 25 to 44 years of age. In this age group, AIDS-related mortality rates per 100 000 person-years were 481.9 in black men, 331.4 in white men, 232.4 in black women, and 65.6 in white women. In 18% of the cohort, AIDS was the cause of death; HIV infection was documented on the death certificate in an additional 7% of the cohort. Homicide was a leading cause of death in persons who were 18 to 24 years of age and in women who were 25 to 44 years of age. Traumatic injury and poisoning were the second most common causes of death in men 18 to 24 years of age and 25 to 44 years of age. Poisoning caused by an overdose of drugs, most often opiates, accounted for 6% of the deaths in the cohort. Heart disease was a major cause of death in homeless persons 45 to 64 years of age. For men 25 to 44 years of age, the rate of death from heart disease was more than threefold higher than in the general population. About 50% of deaths caused by heart disease were attributed to coronary artery disease or myocardial infarction; the remainder were caused by various other cardiac illnesses. Certain conditions that are generally associated with homelessness were not common causes of death; exposure to cold caused four deaths, and tuberculosis caused only one death. Death was most likely to occur during the first week of each month. In the first, second, third, fourth, and fifth weeks, 162, 154, 131, 120, and 39 deaths were seen, respectively (chi-square goodness-of-fit test, P = 0.05). Because the fifth week of each month is truncated, 39 deaths during that week is equivalent to 113 deaths during a full week. The number of deaths caused by injuries was highest during the first week of the month. The number of deaths did not vary significantly with the seasons. Discussion Death occurred at an average age of 47 years in this cohort of homeless adults in Boston. Homicide was a leading cause of death in persons who were 18 to 24 years of age, and AIDS caused the most deaths in persons who were 25 to 44 years of age. Heart disease and cancer were the major causes of death in persons who were 45 to 64 years of age. The crude mortality rate was similar to the rate of 1035 per 100 000 person-years noted in a study of homeless persons aged 15 to 74 years in Philadelphia [14]. In contrast with earlier studies [11-14], however, our study shows the enormous effect of the AIDS epidemic on the homeless population. Our study has some limitations. Only homeless persons who had contact with a health care program were included; mortality rates in the general homeless population may be higher or lower than our estimate because homeless adults who avoid contact with clinicians may have long-neglected medical conditions or may be healthier than average. In addition, although persons in our cohort were homeless when first seen, they may have ceased to be homeless during the observation period. The fact that 19% of deaths occurred in a residential dwelling suggests that this did occur. Thus, our findings apply to persons who died and were homeless at any time and may not be generalizable to persons who are continuously homeless. Deaths outside of Massachusetts were not identified. To the extent that such deaths were overlooked, our results underestimate the true mortality rate in the cohort. Causes of death were obtained from death certificates. The accuracy of the data acquired from death certificates has been questioned because major discrepancies have been found between the information on death certificates and that in autopsy reports [16]. However, death certificates have been shown to reliably document deaths caused by coronary heart disease, AIDS, and traumatic injury [17-19]. Although data from death certificates should be interpreted with caution, they remain a valuable epidemiologic tool. Our findings have serious implications for clinicians and policy makers. Deaths caused by AIDS are a major concern. Because a previous study [20] found that homeless and nonhomeless persons in Boston have similar survival rates after the diagnosis of AIDS, efforts to reduce the rate of AIDS-related deaths in homeless persons should probably focus on encouraging early treatment and preventing HIV infection. The high risk for death from homicide and accidental injury is a predictable result of poverty, substance abuse, and living on the streets. Increasing the availability of adequate low-income housing could conceivably reduce this risk. Improving alcohol and drug treatment programs, however, may be a more important way to reduce injuries in the homeless population and might also help to decrease the high mortality rates that are attributed to cirrhosis and drug overdose. The increased number of deaths during the first week of each month may indicate that the arrival of disability checks at the beginning of the month leads to a flurry of substance abuse, injury, and death. If so, mortality in homeless persons might be reduced by carefully monitored payee programs that administer funds on behalf of disabled persons. Pneumonia and influenza were frequent causes of death, even in younger age groups. Homeless persons may be at increased risk for these infections because of a high prevalence of alcoholism, smoking, HIV infection, and chronic disease. Efforts to vaccinate all homeless persons against pneumonia and influenza should be considered. In conclusion, high mortality rates caused by treatable or preventable conditions were seen among homeless adults in Boston. Efforts to reduce mortality rates among homeless persons s

Risk of death among homeless women: a cohort study and review of the literature

Background: Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women. We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population. Methods: A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK). Results: In Toronto, mortality rates were 515 per 100 000 person-years among homeless women 18–44 years of age and 438 per 100 000 person-years among those 45–64 years of age. Homeless women 18–44 years of age were 10 times more likely to die than women in the general population of Toronto. In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different. In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men. Interpretation: Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.

Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. Design Follow-up study. Setting Canada 1991-2001. Participants 15 100 homeless and marginally housed people enumerated in 1991 census. Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city,

Interventions to Improve the Health of the Homeless A Systematic Review

110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

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

BACKGROUND Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. METHODS MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. RESULTS Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. CONCLUSIONS Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

Bed bug infestations in an urban environment.

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.

Interventions to Improve the Health of the Homeless

Bed bug infestations adversely affect health and quality of life, particularly among persons living in homeless shelters.

Universal Health Insurance and Health Care Access for Homeless Persons

BACKGROUND Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. METHODS MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. RESULTS Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. CONCLUSIONS Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

The effect of traumatic brain injury on the health of homeless people

OBJECTIVES We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system. METHODS We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs. RESULTS Unmet health care needs were reported by 17% of participants. Compared with Torontos general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey. CONCLUSIONS Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.