Community News

Kind World #17: The Goodness Deep Within Listen to his story

Max Evans lived on the streets of Boston near the New England Aquarium, making his bed between two jersey barriers each night. He was known for being gruff, feisty, and unkempt, but these traits belied an inner graciousness and sincerity that touched many of those around him.

Good Design

Mortality Among Homeless Adults in Boston

Shifts in Causes of Death Over a 15-Year Period

Travis P. Baggett, MD, MPH; Stephen W. Hwang, MD, MPH; James J. O'Connell, MD; Bianca C. Porneala, MS; Erin J. Stringfellow, MSW; E. John Orav, PhD; Daniel E. Singer, MD; Nancy A. Rigotti, MD

Homeless persons experience excess mor-tality, but US-based studies on this topic are outdated or lack information about causes of death. To our knowl-edge, no studies have examined shifts in causes of death for this population over time.We assessed all-cause and cause-specific mor-tality 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 link-age to the Massachusetts death occurrence files. We com-pared 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 ra-tios with 95% confidence intervals.person-years of observation. Drug overdose (n=219), can-cer (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 immunodefi-ciency virus (HIV) were offset by 3- and 2-fold in-creases in deaths owing to drug overdose and psychoac-tive substance use disorders, resulting in no significant difference in overall mortality. Conclusions:

The all-cause mortality rate among home-less adults in Boston remains high and unchanged since 1988 to 1993 despite a major interim expansion in clini-cal services. Drug overdose has replaced HIV as the emerg-ing epidemic. Interventions to reduce mortality in this population should include behavioral health integra-tion into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness. con-tributing to very high mortality rates in comparison with nonhomeless people Despite the persistence of homeless-ness in the United States, the past decade has yielded few studies on mortality among homeless Americans, and information on causes of death in this population is sparse. In the most recent study that examined causes of death in a US-based homeless population, Hwang et al analyzed data on 17 292 adults seen at Boston Health Care fortheHomelessProgram(BHCHP)in1988 to 1993. This study documented the sub-stantial toll of human immunodeficiency
 (HIV) infection, which was the leading cause of death among 25- to 44-year-olds and accounted for 18% of all deaths in the study cohort. Homicide was the principal cause of death for 18- to 24-year-olds, while heart disease and cancer were the leading causes among 45- to 64-year-olds. For editorial comment see page 178 CME available online at www.jamanetworkcme.com and questions on page 177In view of interim advances in HIV treatment and expansion of federally funded Health Care for the Homeless clini-cal services, the mortality profile of home-less adults in the United States may have changed since 1988 to 1993; however, data to confirm this are lacking. A comprehen-
 Author Affi Medicine Diof Medicine General HosBaggett, ORigotti andDepartmentHarvard Me(Drs BaggetSinger, andHealth Care General InteDepartment Michael�s Hof Toronto,Canada (DrWarren Bro Work, Wash St Louis, Mi Stringfellow General InteDepartmentBrigham anBoston (Dr

 JAMA INTERN MED/ VOL 173 (NO. 3),FEB 11, 2013����� WWW.JAMAINTERNALMED.COM189 �2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Howard Kramer on 02/13/2013

 sive reassessment of mortality and causes of death among homeless adults would provide a needed update on the health status of this vulnerable population and inform policy decisions and clinical practice priorities regard-ing the provision of health care and other services for this group of people. Using methods similar to the 1988-1993 Boston mor-tality study,7 we assessed overall and cause-specific mor-tality rates in a large cohort of adults who used services provided by BHCHP from 2003 to 2008. We compared these mortality rates with those of the general population of Massachusetts residents from 2003 to 2008 and to the cohort of homeless adults seen by BHCHP in 1988 to 1993. We also examined racial variations in mortality since prior studies of homeless individuals have found paradoxically higher death rates among whites than nonwhites.6,12,18METHODSPARTICIPANTS AND SETTING We retrospectively assembled a cohort of all adults at least 18 years old who had an in-person encounter at BHCHP between January 1, 2003, and December 31, 2008. BHCHP serves more than 11 000 individuals annually in over 90 000 outpatient medi-cal, oral health, and behavioral health encounters through a net-work of over 80 service sites based in emergency shelters, tran-sitional housing facilities, hospitals, and other social service settings in greater Boston.19,20 Patients must be homeless to en-roll in services at BHCHP; no other eligibility requirements are imposed. Some patients elect to continue receiving care at BHCHP after they are no longer homeless. Owing to limita-tions in the data, we were unable to distinguish currently vs formerly homeless participants, so this study represents an analy-sis of adults who have ever experienced homelessness. We re-fer to this group as �homeless� for simplicity. Individuals were observed from the date of first contact within the study period until the date of death or December 31, 2008. We measured observation time in person-years. The Partners Human Re-search Committee approved this study. ASCERTAINMENT OF VITAL STATUS We used LinkPlus software (version 2.0; Centers for Disease Control and Prevention [CDC]) to cross-link the BHCHP co-hort with the Massachusetts Department of Public Health (MDPH) death occurrence files for 2003 to 2008. LinkPlus is a probabilistic record linkage software program that uses ex-pectation maximization algorithms and an array of linkage tools to compute linkage probability scores for possible record pairs based on the level of agreement and relative importance of vari-ous personal identifiers.21 Our primary linkage procedure used first and last name, date of birth, and social security number (SSN); sensitivity analyses used sex and race with no addi-tional linkages identified. There were minimal missing data for the core identifiers in the BHCHP cohort (0% for name and birth date, 9% for SSN). We manually reviewed record pairs achiev-ing a probability score of 7 or higher21 and generally accepted a record pair as a true linkage if it matched on one of the fol-lowing National Death Index criteria22 that were also used in the 1988-1993 BHCHP mortality study7: (1) SSN, (2) first and last name, month and year of birth (1 year), or (3) first and last name, month, and day of birth. Two investigators (T.P.B. and B.C.P.) independently conducted the manual review with very high concordance and interrater reliability (=0.99). A third investigator (J.J.O.) adjudicated discrepancies.
CAUSES OF DEATH We based causes of death on the International Statistical Clas-sification of Diseases, 10th Revision (ICD-10) underlying cause of death codes in the MDPH mortality file (eTable; http://www .jamainternalmed.com). The MDPH translates death certifi-cate entries into ICD-10 cause of death codes using software developed by the National Center for Health Statistics (NCHS).23 We defined �drug overdose� as drug poisoning deaths that were unintentional (codes X40-X44) or of undetermined intent (codes Y10-Y14).24 We included undetermined intent drug poison-ings in this definition because Massachusetts medical examin-ers made relatively frequent use of this category prior to a 2005 policy change at the Office of the Chief Medical Examiner re-quiring that most of these deaths be categorized as uninten-tional.23,25 In addition, evidence suggests that poisonings of un-determined intent more closely resemble unintentional poisonings than suicidal poisonings.26 For drug overdose deaths, we exam-ined the multiple cause of death fields to ascertain which sub-stances were implicated in each overdose. We classified deaths due to alcohol poisoning (codes X45, Y15) separately from drug overdose. Drug- and alcohol-related deaths could also be cap-tured under the ICD-10 underlying cause of death codes for men-tal and behavioral disorders due to psychoactive substance use (codes F10-F19), which we analyzed collectively as �psychoac-tive substance use disorders.� These codes are generally in-tended for deaths related to a chronic pattern or sequel of sub-stance abuse rather than acute poisoning.27 Such deaths include those attributed to substance dependence (eg, chronic alcohol-ism), harmful substance use resulting in medical complications (eg, dilated cardiomyopathy, gastrointestinal hemorrhage, aspi-ration pneumonia), and substance withdrawal syndromes (eg, delirium tremens) (Robert N. Anderson, PhD, Chief, Mortality Statistics Branch, NCHS, written communication, June 22, 2012). STATISTICAL ANALYSIS We tabulated the leading causes of death overall and stratified by age and sex. We calculated mortality rates by dividing the number of deaths by the person-years of observation and ex-pressed these rates as deaths per 100 000 person-years. Since the accuracy of the underlying cause of death may depend on whether a decedent underwent autopsy, we assessed the per-centage of homeless decedents who underwent autopsy and used the 2 test to compare this with the percentage who under-went autopsy in the Massachusetts general population. To compare our age- and sex-stratified findings with the 2003-2008 Massachusetts general population, we adjusted for race using direct standardization with weights chosen accord-ing to the racial breakdown in the general population. We then calculated overall and cause-specific mortality rate ratios by di-viding the race-standardized mortality rates in the homeless co-hort by the rates in the general population. We fitted 95% con-fidence intervals using conventional methods for standardized rate ratios.28,29 We obtained mortality data for the 2003-2008 Mas-sachusetts general population from the CDC Wide-ranging On-line Data for Epidemiologic Research (WONDER) underlying cause of death compressed mortality files.30 To compare our findings with the 1988-1993 BHCHP cohort, we directly standardized the overall and cause-specific mortality rates in the 2003-2008 cohort to match the age, sex, and race dis-tribution of the 1988-1993 cohort. We limited this portion of the analysis to 18- to 64-year-olds to correspond to the age range ana-lyzed in 1988 to 1993. From 1988 to 2008, BHCHP experienced substantial growth in the density and intensity of its clinical op-erations but did not change its core mission, geographical ser-vice area, target population, or eligibility requirements for pa-

 JAMA INTERN MED/ VOL 173 (NO. 3),FEB 11, 2013����� WWW.JAMAINTERNALMED.COM190 �2013 American Medical Association. All rights reserved. Downloaded From: http://archinte.jamanetwork.com/ by Howard Kramer on 02/13/2013

Table 1. Characteristics of the Entire Study Cohort and the Decedents
  Characteristic No. (%)
  Entire Cohort (n = 28 033)      
  Age at index observation, mean (SD), y 41.0 (12.4)  
18-24 3493 (12.5)  
25-44 13 805 (49.3)  
45-64 9924 (35.4)  
65-84 793 (2.8)  
  �85 18 (0.1)  
  Sex      
  Male 18 612 (66.4)  
  Female 9421 (33.6)  
  Race/ethnicity      
  White, non-Hispanic 11 912 (42.5)  
  Black, non-Hispanic 8066 (28.8)  
  Hispanic 5301 (18.9)  
  Other/unknown 2754 (9.8)  
         
  Decedents (n = 1302)      
  Age at death, mean (range), y 51.2 (19.3-93.5)  
  Sex      
  Male 1055 (81.0)  
  Female 247 (19.0)  
  Race      
  White, non-Hispanic 784 (60.2)  
  Black, non-Hispanic 301 (23.1)  
  Hispanic 131 (10.1)  
  Other/unknown 86 (6.6)  
  Veteran 164 (12.6)  
  Place of death      
  Hospital 683 (52.5)  
  Residence 352 (27.0)  
  Nursing home 129 (9.9)  
  Other 138 (10.6)  
  Autopsy performed      
  Yes 495 (38.0)  
  No 807 (62.0)  
         
 tient enrollment.20 To gauge the potential impact of this clinical expansion, we distinguished between natural and external causes of death (eTable)27 because the former may be more responsive to traditional medical interventions. Since causes of death were classified according to ICD-9 codes in the 1988-1993 cohort and ICD-10 codes in the 2003-2008 cohort, we applied comparabil-ity ratios (CRs) (eTable) using methods outlined by the NCHS.31-33 We used the CR for drug-induced deaths to analyze drug over-dose mortality. We used the CR for alcohol-induced deaths to ana-lyze mortality due to psychoactive substance use disorders since most of these deaths were alcohol-related. To assess for racial differences in mortality, we compared the age-standardized all-cause mortality rates for white, black, and Hispanic adults, stratified by sex. We used SAS statistical software (version 9.3; SAS Institute Inc) and Microsoft Excel 2003 (Microsoft Corp) to conduct our analyses.RESULTS
Table 2. Causes of Death and Crude Mortality Rates
      Crude Rate  
  Deaths, No. per 100 000  
Underlying Cause of Deatha Person-years  
(% of Total)   (95% CI)  
All causes 1302 (100) 1439.5 (1361.3-1517.7)  
Drug overdose 219 (16.8) 242.1 (210.1-274.2)  
Cancer 206 (15.8) 227.8 (196.6-258.9)  
Trachea, bronchus, and lung 74 (5.7) 81.8 (63.2-100.5)  
Liver and intrahepatic bile ducts 24 (1.8) 26.5 (15.9-37.1)  
Colon, rectum, and anus 18 (1.4) 19.9 (10.7-29.1)  
Esophagus 11 (0.8) 12.2 (5.0-19.3)  
Pancreas 8 (0.6) 8.8 (2.7-15.0)  
Heart disease 203 (15.6) 224.4 (193.6-255.3)  
Psychoactive substance 99 (7.6) 109.5 (87.9-131.0)  
use disorder          
Alcohol use disorder 71 (5.5) 78.5 (60.2-96.8)  
Other substance use disorders 28 (2.2) 31.0 (19.5-42.4)  
Liver disease 89 (6.8) 98.4 (78.0-118.8)  
Chronic liver disease 58 (4.5) 64.1 (47.6-80.6)  
and cirrhosis          
Other liver diseases 31 (2.4) 34.3 (22.2-46.3)  
HIV 76 (5.8) 84.0 (65.1-102.9)  
Ill-defined conditions 41 (3.1) 45.3 (31.5-59.2)  
Suicide 36 (2.8) 39.8 (26.8-52.8)  
Transport accident 26 (2.0) 28.7 (17.7-39.8)  
Pedestrian injured 15 (1.2) 16.6 (8.2-25.0)  
in transport accident          
Cerebrovascular disease 25 (1.9) 27.6 (16.8-38.5)  
Diabetes mellitus 24 (1.8) 26.5 (15.9-37.1)  
Other accidents 23 (1.8) 25.4 (15.0-35.8)  
Sepsis 22 (1.7) 24.3 (14.2-34.5)  
Homicide 21 (1.6) 23.2 (13.3-33.1)  
Nephritis, nephrotic 21 (1.6) 23.2 (13.3-33.1)  
syndrome, and nephrosis          
Events of undetermined intent 21 (1.6) 23.2 (13.3-33.1)  
Chronic lower respiratory diseases 20 (1.5) 22.1 (12.4-31.8)