Risk factors for death in homeless adults in Boston.

BACKGROUND: Homeless individuals experience high mortality rates. Males, whites, and substance abusers are more likely to die, but other high-risk characteristics are unknown. OBJECTIVE: To identify demographic and clinical factors associated with an increased risk of death in homeless individuals. METHODS: We conducted a case-control study of 558 adults who were seen by a health care program for the homeless in Boston, Mass, and who died in 1988 to 1993. Age-matched paired controls were selected from among individuals seen by the program who were alive at the end of 1993. Predictive data were obtained by blinded review of medical records. Odds ratios (ORs) for death were calculated using logistic regression analysis models. RESULTS: In a multivariate analysis, the strongest risk factors for death were acquired immunodeficiency syndrome (OR, 55.8), symptomatic human immunodeficiency virus infection (OR, 17.7), asymptomatic human immunodeficiency virus infection (OR, 4.1), renal disease (OR, 18.4), a history of cold-related injury (OR, 8.0), liver disease (OR, 3.8), and arrhythmia (OR, 3.3). A history of substance abuse involving injection drugs (OR, 1.6) or alcohol (OR, 1.5) also increased the risk of mortality. Nonfluency in English was associated with a decreased risk of death (OR, 0.4). CONCLUSIONS: In a group of adults seen by a health care program for the homeless, specific medical illnesses were associated with the greatest risk of death. Substance abuse alone was less strongly associated with death. Interventions to reduce mortality among the homeless should focus on individuals with high-risk characteristics.

Health care utilization among homeless adults prior to death.

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.

AIDS among the homeless of Boston: a cohort study.

We wanted to compare demographics, risk behaviors, AIDS-defining diagnoses, and survival between homeless and housed persons with AIDS in Boston from 1983 to 1991. Our retrospective cohort study used chart review to identify homeless AIDS cases and data from the Massachusetts AIDS Surveillance Program for comparison of homeless and nonhomeless cases. Seventy-two homeless and 1,536 nonhomeless Boston residents were reported to have AIDS between Jan. 1, 1983, and July 1, 1991. Homeless persons with AIDS were more likely to be African American or Latino (81 vs. 39%, p < 0.0001) and have i.v. drug use as a risk behavior (75 vs. 19%, p < 0.0001). The AIDS-defining diagnoses among the homeless were more commonly disseminated Mycobacterium tuberculosis (9 vs. 2%, p < 0.0001) and esophageal candidiasis (17 vs. 9%, p < 0.01). These differences were not seen when the populations were stratified by i.v. drug use. No significant difference in survival between the homeless and nonhomeless cohorts was found. Homeless individuals with human immunodeficiency virus are significantly different than housed persons, and at greater risk of invasive opportunistic infections. Appropriate clinical strategies can be developed to provide needed care to homeless persons with HIV.

Causes of death in homeless adults in Boston.

BACKGROUND: Homeless persons have high mortality rates. OBJECTIVE: To ascertain causes of death in a group of homeless persons. DESIGN: Cohort study. PATIENTS: 17,292 adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993. MEASUREMENTS: Cause-specific mortality rates adjusted for race and rate ratios that compare mortality rates in homeless persons with those in the general population of Boston. RESULTS: Homicide was the leading cause of death among men who were 18 to 24 years of age (mortality rate, 242.7 per 100000 person-years; rate ratio, 4.1). The acquired immunodeficiency syndrome was the major cause of death in men (mortality rate, 336.5 per 100000 person-years; rate ratio, 2.0) and women (mortality rate, 116.0 per 100000 person-years; rate ratio, 5.0) who were 25 to 44 years of age. Heart disease and cancer were the leading causes of death in persons who were 45 to 64 years of age. CONCLUSIONS: The most common causes of death among homeless adults who have contact with clinicians vary by age group. Efforts to reduce the rate of death among homeless persons should focus on these causes.