Background

Homelessness, opioid dependence, justice involvement, and psychosis are each associated with an increased risk of poor health and commonly co-occur in the same individuals. Most existing studies of mortality associated with this co-occurrence rely on active follow-up methods prone to selection and retention bias, and focus on a limited set of specific exposures rather than taking a population-based approach. To address these limitations, we did a retrospective cohort study using linked administrative data.

Methods

In this retrospective cohort study, we linked a population register of adults resident in Glasgow, UK, to administrative datasets from homelessness and criminal justice services; community pharmacies; and a clinical psychosis registry with data from April 1, 2010 to March 31, 2014. Linkage to death registrations from April 1, 2014 to March 31, 2019 provided follow-up data on premature mortality (age <75 years) from all causes, non-communicable diseases, and causes considered potentially avoidable through health-care or public health intervention. We estimated hazard ratios (HR) using Poisson regression, adjusting for age, gender, socioeconomic deprivation, and calendar time.

Findings

Of 536 653 cohort members, 11 484 (2·1%) died during follow-up. All-cause premature mortality was significantly higher among people with multiple exposures than among people with single exposures, and among people with any exposure than among people with none (eg, homelessness plus other exposures vs no exposures: HR 8·4 [95% CI 7·3–9·5]; homelessness alone vs no exposures: HR 2·2 [1·9–2·5]). Avoidable premature mortality was highest among those with multiple exposures (eg, imprisonment plus other exposures vs no exposures: HR 10·5 [9·1–12·3]; imprisonment alone vs no exposures: HR 3·8 [3·0–4·8]). Premature mortality from non-communicable disease was higher among those with any exposures than among those with none, despite accounting for a lower proportion of deaths in the exposed group; although in some cases there was little difference between estimates for single versus multiple exposures.

Interpretation

The co-occurrence of at least two of homelessness, opioid dependence, justice involvement, or psychosis is associated with very high rates of premature mortality, particularly from avoidable causes of death, including non-communicable disease. Responding to these findings demands wide-ranging efforts across health-care provision, public health, and social policy. Future work should examine the timing and sequencing of exposures to better understand the causal pathways underlying excess mortality.

Funding

Chief Scientist Office, Medical Research Council, NHS Research Scotland.

中文翻译：

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受同时发生的无家可归、司法介入、阿片类药物依赖和精神病影响的人的过早死亡：一项使用关联管理数据的回顾性队列研究

背景

无家可归、阿片类药物依赖、司法介入和精神病都与健康状况不佳的风险增加有关，并且通常同时发生在同一个人身上。大多数与这种共同发生相关的死亡率的现有研究依赖于容易出现选择和保留偏倚的积极随访方法，并且侧重于一组有限的特定暴露，而不是采用基于人群的方法。为了解决这些局限性，我们使用关联的管理数据进行了一项回顾性队列研究。

方法

在这项回顾性队列研究中，我们将居住在英国格拉斯哥的成年人人口登记册与来自无家可归者和刑事司法服务的行政数据集联系起来；社区药房；和一个临床精神病登记处，其中包含 2010 年 4 月 1 日至 2014 年 3 月 31 日的数据。与 2014 年 4 月 1 日至 2019 年 3 月 31 日的死亡登记的联系提供了所有原因导致的过早死亡（年龄 <75 岁）的后续数据，非传染性疾病，以及被认为可能通过医疗保健或公共卫生干预可以避免的原因。我们使用泊松回归估算了风险比 (HR)，并针对年龄、性别、社会经济剥夺和日历时间进行了调整。

发现

在 536 653 名队列成员中，11 484 人（2·1%）在随访期间死亡。多次暴露人群的全因过早死亡率显着高于单次暴露人群，任何暴露人群均高于无暴露人群（例如，无家可归加上其他暴露与无暴露：HR 8·4 [95% CI 7·3–9·5]；单独无家可归vs无暴露：HR 2·2 [1·9–2·5])。可避免的过早死亡率在多次暴露者中最高（例如，监禁加其他暴露与无暴露：HR 10·5 [9·1–12·3]；单独监禁与无曝光：HR 3·8 [3·0–4·8])。非传染性疾病过早死亡率在有任何暴露的人群中高于没有暴露的人群，尽管在暴露组中死亡的比例较低；尽管在某些情况下，单次接触与多次接触的估计值之间几乎没有差异。

解释

无家可归、阿片类药物依赖、司法介入或精神病中至少两种情况的同时发生与非常高的过早死亡率有关，特别是死于可避免的死因，包括非传染性疾病。应对这些发现需要在医疗保健提供、公共卫生和社会政策方面做出广泛的努力。未来的工作应该检查暴露的时间和顺序，以更好地了解超额死亡率的因果途径。

资金

苏格兰 NHS 研究中心医学研究委员会首席科学家办公室。