title: 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  Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death.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.
authors: General Medicine Division, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA. tbaggett@partners.org
authors: Travis P
authors: TP
authors: Baggett
authors: Stephen W
authors: SW
authors: Hwang
authors: James J
authors: JJ
authors: O'Connell
authors: Bianca C
authors: BC
authors: Porneala
authors: Erin J
authors: EJ
authors: Stringfellow
authors: E John
authors: EJ
authors: Orav
authors: Daniel E
authors: DE
authors: Singer
authors: Nancy A
authors: NA
authors: Rigotti
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston / Q000453:epidemiology; D002423:Cause of Death / Q000639:trends*; D062787:Drug Overdose / Q000401:mortality; D005260:Female; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000208:ethnology; D012189:Retrospective Studies; D012737:Sex Factors; D055815:Young Adult