Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period

Abstract

Background: Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death.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.

Figure 1

Mortality rate ratios comparing cause-specific and overall mortality rates for the 2003–08 and 1988–93 homeless cohorts. Note: Boxes are weighted in proportion to the total number of deaths due to the specified cause. Prior to computing rate ratios, mortality rates from the 2003–08 cohort were directly standardized to the age, sex, and race distribution of the 1988–93 cohort. Differences between ICD-9 (1988–93) and ICD-10 (2003–08) underlying cause of death codes were accounted for using comparability ratios from the National Center for Health Statistics. See eTable for ICD-9 and ICD-10 codes and comparability ratios. Abbreviations: RR, rate ratio

Figure 2

Race-specific age-standardized mortality rates for homeless adults and adults in the general population of Massachusetts (2003–08), stratified by sex.^{b a}Mortality rate expressed as the number of deaths per 100,000 person-years of observation for the homeless cohort, and deaths per 100,000 for the Massachusetts general population. ^bAll mortality rates are directly standardized to match the age distribution of the homeless cohort using the following categories: 18–24, 25–34, 35–44, 45–54, 55–64, and ≥65 years. Due to limitations in state data, the age-specific mortality rate for 20–24 year old Massachusetts adults was used to estimate the rate for 18–24 year old adults.