Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period
Open accessAbstract
BACKGROUND: Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death.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.
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Mortality is substantially increased in homeless people, with the excess risk most evident in younger people and, in some studies, women.
“Findings from several studies have shown that mortality is substantially increased in homeless people,35-45 with the excess risk most evident in younger people39,46 and, in some studies, women.”
From The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations (2014) · cites this paper as [43]
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.
“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].”
From Mortality and life expectancy in homeless men and women in Rotterdam: 2001-2010 (2013) · cites this paper as [15]
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Homelessness as a predictor of mortality: an 11-year register-based cohort study
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Access to palliative care for homeless people: complex lives, complex care
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Estimating the number of homeless deaths in France, 2008–2010
Vuillermoz, C., Aouba, A., Grout, L., Vandentorren, S., Tassin, F., Vazifeh, L., Ghosn, W., Jougla, É., & Rey, G. (2014) · BMC Public Health · doi:10.1186/1471-2458-14-690 · Cited by 57 · see citing works
Older homeless people: increasing numbers and changing needs
Crane, M., & Joly, L. (2014) · Reviews in Clinical Gerontology · doi:10.1017/s095925981400015x · Cited by 58 · see citing works
Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus
Axon, R. N., Gebregziabher, M., Dismuke, C. E., Hunt, K. J., Yeager, D. E., Ana, E. J. S., & Egede, L. E. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3786-z · Cited by 57 · see citing works
Walley, A. Y., Lodi, S., Li, Y., Bernson, D., Babakhanlou‐Chase, H., Land, T. G., & Larochelle, M. R. (2020) · Addiction · doi:10.1111/add.14964 · Cited by 56 · see citing works
Tsai, J., Gelberg, L., & Rosenheck, R. A. (2019) · Journal of General Internal Medicine · doi:10.1007/s11606-019-05070-y · Cited by 55 · see citing works
Five-year standardised mortality ratios in a cohort of homeless people in Dublin
Ivers, J., Zgaga, L., Hynes, B. O., Heary, A., Gallwey, B., & Barry, J. M. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-023010 · Cited by 55 · see citing works
Associations of housing stress with later substance use outcomes: A systematic review
Austin, A. E., Shiue, K. Y., Naumann, R. B., Figgatt, M. C., Gest, C., & Shanahan, M. E. (2021) · Addictive Behaviors · doi:10.1016/j.addbeh.2021.107076 · Cited by 54 · see citing works
Interventions to reduce tobacco use in people experiencing homelessness
Vijayaraghavan, M., Elser, H. C., Frazer, K., Lindson, N., & Apollonio, D. E. (2020) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013413.pub2 · Cited by 51 · see citing works
Communicable disease among people experiencing homelessness in California
Liu, C. Y., Chai, S. J., & Watt, J. (2020) · Epidemiology and Infection · doi:10.1017/s0950268820000722 · Cited by 50 · see citing works
Homelessness and other social determinants of health among emergency department patients
Doran, K. M., Kunzler, N. M., Mijanovich, T., Lang, S. W., Rubin, A. L., Testa, P. A., & Shelley, D. (2016) · Journal of Social Distress and the Homeless · doi:10.1080/10530789.2016.1237699 · Cited by 50 · see citing works
Paudyal, V., MacLure, K., Forbes‐McKay, K., McKenzie, M., MacLeod, J., Smith, A., & Stewart, D. C. (2019) · Health & Social Care in the Community · doi:10.1111/hsc.12850 · Cited by 50 · see citing works
Regis, C., Gaeta, J. M., Mackin, S., Baggett, T. P., Quinlan, J., & Taveras, E. M. (2020) · Frontiers in Public Health · doi:10.3389/fpubh.2020.00501 · Cited by 49 · see citing works
Self-citationTrends in Trimorbidity Among Adults Experiencing Homelessness in Minnesota, 2000–2018
Vickery, K. D., Winkelman, T. N. A., Ford, B. R., Busch, A. M., Robertshaw, D., Pittman, B. P., & Gelberg, L. (2021) · Medical Care · doi:10.1097/mlr.0000000000001435 · Cited by 49 · see citing works
New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model
O'Toole, T. P., Bourgault, C., Johnson, E. E., Redihan, S. G., Borgia, M. L., Aiello, R., & Kane, V. R. (2013) · American Journal of Public Health · doi:10.2105/ajph.2013.301632 · Cited by 49 · see citing works
Bennett, A. S., Guarino, H., Britton, P. C., O'Brien-Mazza, D., Cook, S., Taveras, F., Cortez, J., & Elliott, L. C. (2022) · Annals of Medicine · doi:10.1080/07853890.2022.2092896 · Cited by 52 · see citing works
Kim, J., Fine, D. R., Li, L., Kimmel, S. D., Ngo, L. H., Suzuki, J., Price, C. N., Ronan, M. V., & Herzig, S. J. (2020) · PLoS Medicine · doi:10.1371/journal.pmed.1003247 · Cited by 48 · see citing works
Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review
Kerman, N., Polillo, A., Bardwell, G., Gran-Ruaz, S., Savage, C., Felteau, C., & Tsemberis, S. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.109052 · Cited by 42 · see citing works
Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness
Fine, D. R., Lewis, E., Weinstock, K., Wright, J. D., Gaeta, J. M., & Baggett, T. P. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.0477 · Cited by 46 · see citing works
Self-citationPredictors of Frequent Emergency Room Visits among a Homeless Population
Thakarar, K., Morgan, J. R., Gaeta, J. M., Hohl, C., & Drainoni, M. (2015) · PLoS ONE · doi:10.1371/journal.pone.0124552 · Cited by 46 · see citing works
Oppenheimer, S. C., Nurius, P. S., & Green, S. (2016) · Families in Society The Journal of Contemporary Social Services · doi:10.1606/1044-3894.2016.97.21 · Cited by 46 · see citing works
Landefeld, J. C., Miaskowski, C. A., Tieu, L., Ponath, C., Lee, C. T., Guzman, D., & Kushel, M. (2017) · Journal of Pain · doi:10.1016/j.jpain.2017.03.011 · Cited by 47 · see citing works
Ghinai, I., Davis, E. S., Mayer, S., Toews, K.-A. E., Huggett, T. D., Snow‐Hill, N. L., Perez, O., Hayden, M. K., Tehrani, S., Landi, A. J., et al. (2020) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofaa477 · Cited by 45 · see citing works
Manhapra, A., Stefanovics, E. A., & Rosenheck, R. A. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.108714 · Cited by 45 · see citing works
COVID pandemic as an opportunity for improving mental health treatments of the homeless people
Martin, C., Andrés, P., Bullón, A., Villegas, J. L. V., de la Iglesia-Larrad, J. I., Bonaechea, B. B., Prieto, N., & Roncero, C. (2020) · International Journal of Social Psychiatry · doi:10.1177/0020764020950770 · Cited by 44 · see citing works
Characteristics of Homeless Adults Who Died of Drug Overdose: A Retrospective Record Review
Bauer, L. K., Brody, J. K., León, C., & Baggett, T. P. (2016) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2016.0075 · Cited by 43 · see citing works
Self-citationOpt-Out Patient Navigation to Improve Breast and Cervical Cancer Screening Among Homeless Women
Asgary, R. G., Naderi, R., & Wisnivesky, J. P. (2017) · Journal of Women s Health · doi:10.1089/jwh.2016.6066 · Cited by 43 · see citing works
Johnsen, S., Cuthill, F. M., & Blenkinsopp, J. (2021) · BMC Health Services Research · doi:10.1186/s12913-020-06013-8 · Cited by 43 · see citing works
Smoking policy change at a homeless shelter: Attitudes and effects
Businelle, M. S., Poonawalla, I. B., Kendzor, D. E., Rios, D. M., Cuate, E. L., Savoy, E. J., Ma, P., Baggett, T. P., Reingle, J. M., & Reitzel, L. R. (2014) · Addictive Behaviors · doi:10.1016/j.addbeh.2014.08.013 · Cited by 42 · see citing works
Self-citationMackelprang, J. L., Qiu, Q., & Rivara, F. P. (2015) · Medical Care · doi:10.1097/mlr.0000000000000436 · Cited by 41 · see citing works
Housing First: Lessons from the United States and Challenges for Australia
Kertesz, S. G., & Johnson, G. (2017) · Australian Economic Review · doi:10.1111/1467-8462.12217 · Cited by 41 · see citing works
O'Toole, T. P., Johnson, E. E., Borgia, M. L., Noack, A., Yoon, J., Gehlert, E., & Lo, J. (2018) · Preventing Chronic Disease · doi:10.5888/pcd15.170311 · Cited by 41 · see citing works
Towe, V. L., Wiewel, E. W., Zhong, Y., Linnemayr, S., Johnson, R. E., & Rojas, J. (2019) · AIDS and Behavior · doi:10.1007/s10461-019-02461-4 · Cited by 41 · see citing works
Tsai, J., Havlik, J., Howell, B. A., Johnson, E. E., & Rosenthal, D. (2022) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07970-y · Cited by 39 · see citing works
Coping Styles and Alcohol Dependence among Homeless People
Opalach, C. W., Romaszko, J., Jaracz, M., Kuchta, R., Borkowska, A., & Buciński, A. (2016) · PLoS ONE · doi:10.1371/journal.pone.0162381 · Cited by 39 · see citing works
Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes
Jones, A. L., Hausmann, L. R. M., Kertesz, S. G., Suo, Y., Cashy, J., Mor, M. K., Pettey, W. B. P., Schaefer, J. H., Gordon, A. J., & Gundlapalli, A. V. (2019) · Medical Care · doi:10.1097/mlr.0000000000001070 · Cited by 39 · see citing works
Han, B. H., Doran, K. M., & Krawczyk, N. (2021) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2021.108504 · Cited by 41 · see citing works
Bigé, N., Hejblum, G., Baudel, J.-L., Carron, A., Chevalier, S., Pichereau, C., Maury, É., & Guidet, B. (2015) · Critical Care Medicine · doi:10.1097/ccm.0000000000000944 · Cited by 37 · see citing works
Cardiovascular risk factors and 30-year cardiovascular risk in homeless adults with mental illness
Gozdzik, A., Salehi, R., O'Campo, P. J., Stergiopoulos, V., & Hwang, S. W. (2015) · BMC Public Health · doi:10.1186/s12889-015-1472-4 · Cited by 39 · see citing works
Self-citation
- Authors
- Baggett, T. P., Hwang, S. W., O’Connell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., Singer, D. E., & Rigotti, N. A.
- Affiliations
- Massachusetts General Hospital (US)
- St. Michael's Hospital (CA)
- Washington University in St. Louis (US)
- Brigham and Women's Hospital (US)
- Harvard University (US)
- ORCID
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2013-02-11
- Volume
- 173
- Issue
- 3
- Pages
- 189
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC3713619
- OpenAlex
- W2133962053
- Cited by
- 566
- References
- 38
- Citations by year
- 2026: 24 · 2025: 45 · 2024: 52 · 2023: 49 · 2022: 60 · 2021: 64 · 2020: 57 · 2019: 46 · 2018: 37 · 2017: 28 · 2016: 36 · 2015: 31 · 2014: 22 · 2013: 13
- FWCI
- 61.26
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (T32MH019960)
- National Institute on Drug Abuse (K23DA034008)
- Topics
- Health Sciences › Health Professions › General Health Professions › Homelessness and Social Issues
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Keywords
- homelessness, mortality, causes of death, drug overdose, opioid overdose, HIV, cancer, heart disease, substance use disorders, racial disparities, temporal trends, behavioral health integration
- MeSH terms
- Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Boston, Cause of Death, Female, Ill-Housed Persons, Humans, Male, Middle Aged, Mortality, Retrospective Studies, Sex Factors, Young Adult, Drug Overdose
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