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Risk Factors for Death in Homeless Adults in Boston
Stephen W. Hwang, MD, MPH;
Joan M. Lebow, MD;
Michael F. Bierer, MD, MPH;
James J. O'Connell, MD;
E. John Orav, PhD;
Troyen A. Brennan, MD, JD, MPH
Arch Intern Med. 1998;158:1454-1460.
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.
From the Inner City Health Program, St Michael's Hospital, Toronto, Ontario (Dr Hwang); Boston Health Care for the Homeless Program (Drs Lebow, Bierer, and O'Connell); the Division of General Medicine, Clinical Initiatives Development Program, Brigham and Women's Hospital (Drs Orav and Brennan), and the Department of Health Policy and Management, Harvard School of Public Health (Dr Brennan), Boston, Mass.
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