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Examining the Mortality of an Unsheltered Homeless Cohort From Boston, MA, 2000 Through 2009
Purpose: This dissertation addressed a gap in homelessness literature by examining mortality outcomes of an unsheltered cohort and by applying criteria developed at the Boston Health Care for the Homeless Program (BHCHP) to predict mortality.
Methods: A 10-year prospective study was conducted with 445 unique unsheltered individuals. Data were collected during encounters with BHCHP’s Street Team clinicians, an integrated program providing care to homeless adults living outside. Decedent data were matched to the Massachusetts Department of Public Health death occurrence files. Analyses included describing the cohort and the high-risk criteria, calculating age-standardized all-cause and cause-specific mortality rates and age-stratified rate ratios using two comparison groups: the Massachusetts population and a general homeless cohort, and conducting survival analysis. The same methods were used when the high-risk for mortality was applied and the cohort was divided into a high-risk group and non-high-risk group.
Results: During the study, 134 deaths occurred. The average age of death was 53 years old. The cohort was largely white and men. Blacks had a lower rate of death compared to whites. The all-cause mortality rate that was almost 10 times higher than the Massachusetts population and nearly three times higher than the general homeless cohort. The most common causes of death were noncommunicable diseases and causes attributable to substance use. Survival analysis showed low probabilities of survival and high rates of mortality for older age groups, men, and whites. Similar patterns of mortality outcomes were seen when the high-risk for mortality criteria were applied. The high-risk group had higher mortality rates than the non-high-risk group; both groups had higher mortality rates for comparisons to Massachusetts and for most comparisons to the general homeless cohort. Survival analysis showed lower probabilities of survival and higher rate of death for the high-risk group.
Conclusions: Deaths occurred prematurely and the leading causes of death were common causes see in the general population. The high-risk for mortality criteria predicted an increased mortality rate. The results were seen despite near-universal access to insurance and care. Future studies are warranted to further understand these health disparities and the social determinants for the unsheltered population