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      Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England.

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          Abstract

          Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes. 

          Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group).

          Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0).  The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600).  The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512).

          Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.

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          The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement

          Routinely collected health data, obtained for administrative and clinical purposes without specific a priori research goals, are increasingly used for research. The rapid evolution and availability of these data have revealed issues not addressed by existing reporting guidelines, such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement was created to fill these gaps. RECORD was created as an extension to the STROBE statement to address reporting items specific to observational studies using routinely collected health data. RECORD consists of a checklist of 13 items related to the title, abstract, introduction, methods, results, and discussion section of articles, and other information required for inclusion in such research reports. This document contains the checklist and explanatory and elaboration information to enhance the use of the checklist. Examples of good reporting for each RECORD checklist item are also included herein. This document, as well as the accompanying website and message board (http://www.record-statement.org), will enhance the implementation and understanding of RECORD. Through implementation of RECORD, authors, journals editors, and peer reviewers can encourage transparency of research reporting.
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            What works in inclusion health: overview of effective interventions for marginalised and excluded populations

            Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.
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              Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

              Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. Design Follow-up study. Setting Canada 1991-2001. Participants 15 100 homeless and marginally housed people enumerated in 1991 census. Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data CurationRole: Formal AnalysisRole: Funding AcquisitionRole: InvestigationRole: MethodologyRole: Project AdministrationRole: SupervisionRole: VisualizationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Data CurationRole: Formal AnalysisRole: InvestigationRole: MethodologyRole: Project AdministrationRole: SoftwareRole: VisualizationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Data CurationRole: Formal AnalysisRole: InvestigationRole: MethodologyRole: SoftwareRole: VisualizationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Project AdministrationRole: SupervisionRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: Data CurationRole: InvestigationRole: Project AdministrationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Data CurationRole: InvestigationRole: MethodologyRole: Project AdministrationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Project AdministrationRole: Writing – Review & Editing
                Role: ConceptualizationRole: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: Funding AcquisitionRole: MethodologyRole: Project AdministrationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: Funding AcquisitionRole: MethodologyRole: Writing – Review & Editing
                Role: ConceptualizationRole: MethodologyRole: Writing – Review & Editing
                Role: MethodologyRole: Project AdministrationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Project AdministrationRole: SupervisionRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Journal
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Research
                F1000 Research Limited (London, UK )
                2398-502X
                11 March 2019
                2019
                : 4
                : 49
                Affiliations
                [1 ]Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
                [2 ]Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
                [3 ]National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
                [4 ]Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
                [5 ]Community and Primary Care Research Group, University of Plymouth, Plymouth, Devon, PL6 8BX, UK
                [6 ]Personal Social Services Research Unit, London School of Economics, London, WC2A 2AE, UK
                [7 ]Institute of Health Informatics, University College London, London, NW1 2DA, UK
                [8 ]NIHR Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
                [9 ]Pathway Charity, Pathway Charity, London, NW1 2PG, UK
                [10 ]Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
                [11 ]Tropical and Infectious Diseases, University College London Hospitals NHS Trust, London, NW1 2PG, UK
                [12 ]Health Services Research, University of Liverpool, Liverpool, L69 3BX, UK
                [13 ]Public Health England, London, NW9 5EQ, UK
                [1 ]I-SPHERE, Heriot-Watt University, Edinburgh, UK
                [1 ]School of Geography and the Environment, University of Oxford, Oxford, UK
                Author notes

                Competing interests: NH is medical director, and ACH is a trustee of the Pathway: Healthcare for homeless people charity. AS is Clinical Lead and Manager for Find and Treat.

                Competing interests: No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Author information
                https://orcid.org/0000-0003-0542-0816
                https://orcid.org/0000-0002-1628-1228
                https://orcid.org/0000-0003-3698-7196
                https://orcid.org/0000-0001-9612-7791
                https://orcid.org/0000-0002-6260-4606
                https://orcid.org/0000-0002-0121-9683
                https://orcid.org/0000-0003-1502-5983
                Article
                10.12688/wellcomeopenres.15151.1
                6449792
                30984881
                98803452-324f-4a87-b214-083aee67dd60
                Copyright: © 2019 Aldridge RW et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 1 March 2019
                Funding
                Funded by: Health Data Research UK
                Funded by: Medical Research Council
                Award ID: MR/S003797/1
                Funded by: National Institute for Health Research
                Award ID: 13/156/10
                Award ID: DRF-2018-11-ST2-016
                Award ID: ICA-CDRF-2016-02-042
                Funded by: Wellcome Trust
                Award ID: 206602
                This work was supported by the Wellcome Trust through a Clinical Research Career Development Fellowship to RWA [206602]. This study was supported by the National Institute for Health Research (NIHR), [Project number: 13/156/10 to HS & DR]. We also acknowledge the support from the Health Data Research (HDR) UK which receives its funding from HDR UK Ltd funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust. ACH’s salary is provided by Central and North West London NHS Community Trust. AS is funded by UCLH Foundation Trust. DL is funded by the NIHR [DRF-2018-11-ST2-016]. JN is part-funded by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. RBl is supported by a UK Research and Innovation Fellowship funded by a grant from the Medical Research Council [MR/S003797/1]. MW is part funded by Liverpool Clinical Commissioning Group. SL is funded by NIHR [ICA-CDRF-2016-02-042]. This article is based on independent research commissioned and funded by the NIHR Health Service and Delivery Programme. The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Wellcome Trust, the Department of Health and Social Care, Public Health England or its arm’s length bodies or other government departments.
                The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Articles

                homeless health,hospital discharge,homeless healthcare,mortality,amenable mortality,data linkage

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