The association of homelessness with rates of diabetes complications: a population-based cohort study
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Abstract
OBJECTIVE: To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects. RESEARCH DESIGN AND METHODS: A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs. RESULTS: Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94). CONCLUSIONS: These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.
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Individuals with low annual household incomes, individuals who live in socioeconomically deprived areas, and individuals who are underinsured or experiencing housing instability experience higher rates of emergency department visits and hospitalizations for hypoglycemia.
“In general, individuals with low annual household incomes (95), individuals who live in socioeconomically deprived areas (98), and individuals who are underinsured (99) or experiencing housing instability (122) experience higher rates of emergency department visits and hospitalizations for hypoglycemia.”
From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [122]
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Cites
Austin, P. C. (2009) · Statistics in Medicine · doi:10.1002/sim.3697 · Cited by 6,758 · see citing works
Self-citation2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary
O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., de Lemos, J. A., Ettinger, S. M., Fang, J. C.-T., Fesmire, F. M., Franklin, B. A., et al. (2012) · Circulation · doi:10.1161/cir.0b013e3182742c84 · Cited by 2,251 · see citing works
Consensus development conference on antipsychotic drugs and obesity and diabetes
American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, & North American Association for the Study of Obesity (2004) · Diabetes Care · doi:10.2337/diacare.27.2.596 · Cited by 1,554 · see citing works
Hux, J. E., Ivis, F. J., Flintoft, V. F., & Bica, A. (2002) · Diabetes Care · doi:10.2337/diacare.25.3.512 · Cited by 1,290 · see citing works
The unmet health care needs of homeless adults: a national study
Baggett, T. P., O'Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010) · American Journal of Public Health · doi:10.2105/ajph.2009.180109 · Cited by 552 · see citing works
The Mental and Physical Health of Homeless Youth: A Literature Review
Edidin, J. P., Ganim, Z., Hunter, S. J., & Karnik, N. S. (2011) · Child Psychiatry & Human Development · doi:10.1007/s10578-011-0270-1 · Cited by 449 · see citing works
Risk of death among homeless women: a cohort study and review of the literature
Cheung, A. M. (2004) · Canadian Medical Association Journal · doi:10.1503/cmaj.1031167 · Cited by 292 · see citing works
Homeless persons' experiences of health‐ and social care: A systematic integrative review
Omérov, P., Craftman, Å. G., Mattsson, E., & Klarare, A. (2019) · Health & Social Care in the Community · doi:10.1111/hsc.12857 · Cited by 285 · see citing works
Relationship Between Avoidable Hospitalizations for Diabetes Mellitus and Income Level
Booth, G. L., & Hux, J. E. (2003) · Archives of Internal Medicine · doi:10.1001/archinte.163.1.101 · Cited by 223 · see citing works
Self-citationUniversal Health Insurance and Health Care Access for Homeless Persons
Hwang, S. W., Ueng, J. J. M., Chiu, S., Kiss, A., Tolomiczenko, G. S., Cowan, L., Levinson, W. S., & Redelmeier, D. A. (2010) · American Journal of Public Health · doi:10.2105/ajph.2009.182022 · Cited by 204 · see citing works
Self-citationCardiovascular Disease and Homelessness
Baggett, T. P., Liauw, S. S. L., & Hwang, S. W. (2018) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2018.02.077 · Cited by 203 · see citing works
Self-citationRisk factors for cardiovascular disease in homeless adults
Lee, T. C., Hanlon, J. G., Ben-David, J., Booth, G. L., Cantor, W. J., Connelly, P. W., & Hwang, S. W. (2005) · Circulation · doi:10.1161/circulationaha.104.510826 · Cited by 191 · see citing works
Self-citationBachmann, M. O., Eachus, J., Hopper, C. D., Smith, G. D., Propper, C., Pearson, N., Williams, S. J., Tallon, D., & Frankel, S. (2003) · Diabetic Medicine · doi:10.1046/j.1464-5491.2003.01050.x · Cited by 183 · see citing works
Primary healthcare needs and barriers to care among Calgary’s homeless populations
Campbell, D. J. T., O’Neill, B. G., Gibson, K., & Thurston, W. E. (2015) · BMC Family Practice · doi:10.1186/s12875-015-0361-3 · Cited by 171 · see citing works
Self-citationSelf-management interventions for type 2 diabetes: a systematic review
Heinrich, E., Schaper, N. C., & de Vries, N. K. (2010) · European Diabetes Nursing · doi:10.1002/edn.160 · Cited by 137 · see citing works
Lin, W.-C., Bharel, M., Zhang, J., O’Connell, E., & Clark, R. E. (2015) · American Journal of Public Health · doi:10.2105/ajph.2015.302693 · Cited by 115 · see citing works
Keene, D. E., Guo, M., & Murillo, S. N. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.11.051 · Cited by 115 · see citing works
Analyzing hospitalization data: potential limitations of Poisson regression
Weaver, C., Ravani, P., Oliver, M. J., Austin, P. C., & Quinn, R. R. (2015) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfv071 · Cited by 87 · see citing works
Self-citationCLEMENT, M. A., Harvey, B., Rabi, D. M., Roscoe, R. S., & Sherifali, D. (2013) · Canadian Journal of Diabetes · doi:10.1016/j.jcjd.2013.01.014 · Cited by 76 · see citing works
Foot Conditions among Homeless Persons: A Systematic Review
To, M. J., Brothers, T. D., & Zoost, C. V. (2016) · PLoS ONE · doi:10.1371/journal.pone.0167463 · Cited by 75 · see citing works
Corrigan, P. W., Pickett, S. A., Kraus, D. J., Burks, R., & Schmidt, A. (2015) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2015.0018 · Cited by 67 · see citing works
Richard, L., Hwang, S. W., Forchuk, C., Nisenbaum, R. A., Clemens, K. K., Wiens, K., Booth, R. G., Azimaee, M., & Shariff, S. Z. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-030221 · Cited by 65 · see citing works
Self-citationHomelessness: Care, Prevention, and Public Policy
Plumb, J. D. (1997) · Annals of Internal Medicine · doi:10.7326/0003-4819-126-12-199706150-00007 · Cited by 63 · see citing works
Risk Factors for Recurrent Lower Extremity Cellulitis in a U.S. Veterans Medical Center Population
Doblecki‐Lewis, S., Peter, G. S., Gómez-Marı́n, O., & Bisno, A. L. (2006) · The American Journal of the Medical Sciences · doi:10.1097/00000441-200612000-00002 · Cited by 58 · see citing works
Nanjo, A., Evans, H. E. R., Direk, K., Hayward, A. C., Story, A., & Banerjee, A. (2020) · European Heart Journal · doi:10.1093/eurheartj/ehaa795 · 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
The challenges of managing diabetes while homeless: a qualitative study using photovoice methodology
Campbell, R. B., Larsen, M., DiGiandomenico, A., Davidson, M. A., Booth, G. L., Hwang, S. W., McBrien, K., & Campbell, D. J. T. (2021) · Canadian Medical Association Journal · doi:10.1503/cmaj.202537 · Cited by 56 · see citing works
Self-citationGrewal, E., Campbell, R. B., Booth, G. L., McBrien, K., Hwang, S. W., O'Campo, P. J., & Campbell, D. J. T. (2021) · International Journal for Equity in Health · doi:10.1186/s12939-021-01494-3 · Cited by 36 · see citing works
Self-citationMcBrien, K., Manns, B., Hemmelgarn, B. R., Weaver, R. G., Edwards, A. L., Ivers, N. M., Rabi, D. M., Lewanczuk, R. Z., Braun, T., Naugler, C. T., et al. (2015) · Diabetic Medicine · doi:10.1111/dme.13023 · Cited by 26 · see citing works
Self-citationMosley-Johnson, E., Walker, R. J., Nagavally, S., Hawks, L. C., Bhandari, S., Trasser, H., Campbell, J. A., & Egede, L. E. (2022) · PLoS ONE · doi:10.1371/journal.pone.0278650 · Cited by 17 · see citing works
Long-term association between homelessness and mortality among people with diabetes
Wiens, K., Bai, L., Austin, P. C., Ronksley, P. E., Hwang, S. W., Spackman, E., Booth, G. L., & Campbell, D. J. T. (2023) · The Lancet Diabetes & Endocrinology · doi:10.1016/s2213-8587(22)00358-8 · Cited by 17 · see citing works
Self-citationHealth Care Utilization of Homeless Minors With Diabetes in New York State From 2009 to 2014
Bizmark, R. S., Mena, L. A., Estevez, D., Webber, E. J., Marr, E. H., Bedel, L. E. M., & Yee, J. K. (2020) · Diabetes Care · doi:10.2337/dc19-2219 · Cited by 13 · see citing works
Liauw, S. S. L., Luong, L., Liu, S., Atcha, M., Kwok, Y., Nisenbaum, R. A., Fam, N., Hwang, S. W., & Cheema, A. N. (2021) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2021.05.003 · Cited by 13 · see citing works
Self-citationIdentifying Challenges and Solutions to Providing Diabetes Care for Those Experiencing Homelessness
Mancini, N. L., Campbell, R. B., Yaphe, H. M., Tibebu, T., Grewal, E., Saunders‐Smith, T., McBrien, K., & Campbell, D. J. T. (2021) · International Journal on Homelessness · doi:10.5206/ijoh.2022.1.13643 · Cited by 10 · see citing works
Self-citationWiens, K., Bai, L., Austin, P. C., Ronksley, P. E., Hwang, S. W., Spackman, E., Booth, G. L., & Campbell, D. J. T. (2022) · medRxiv · doi:10.1101/2022.08.11.22278127 · Cited by 10 · see citing works
Self-citationScott, S., Grewal, E., Tariq, H., & Campbell, D. J. T. (2022) · Pilot and Feasibility Studies · doi:10.1186/s40814-022-01165-2 · Cited by 4 · see citing works
Self-citationThe promises and pitfalls of administrative data linkage for tackling homelessness
Thomas, I., & Tweed, E. (2021) · ORCA Online Research @Cardiff (Cardiff University) · Cited by 2 · see citing works
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Self-citation
- Authors
- Sharan, R., Wiens, K., Ronksley, P. E., Hwang, S. W., Booth, G. L., Austin, P. C., Spackman, E., Bai, L., & Campbell, D. J. T.
- Affiliations
- University of Calgary (CA)
- University of Toronto (CA)
- St. Michael's Hospital (CA)
- Institute for Clinical Evaluative Sciences (CA)
- Corresponding author
- Campbell, David J.T.
- ORCID
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2023-06-05
- Volume
- 46
- Issue
- 8
- Pages
- 1469-1476
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- OpenAlex
- W4379378583
- Cited by
- 30
- References
- 37
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 7 · 2023: 1
- FWCI
- 10.68
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Diabetes Action Canada
- MSI Foundation
- Topics
- Health Sciences › Health Professions › General Health Professions › Homelessness and Social Issues
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- homelessness, diabetes complications, macrovascular complications, revascularization, skin and soft tissue infections, amputation, health disparities, diabetes outcomes
- MeSH terms
- Diabetes Mellitus, Ill-Housed Persons, Humans, Ontario, Cohort Studies, Soft Tissue Infections
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