Mortality and causes of death among homeless in Finland: a 10-year follow-up study.

BACKGROUND Homelessness is associated with increased mortality, and some predictors of mortality have been previously identified. We examined the overall and cause-specific mortality among homeless men in Helsinki and the associations of social background and health service use with mortality. METHODS To assess cause-specific mortality in a competing risks framework, we performed a register-based, case-control study of 617 homeless men and an age-matched control group of 1240 men from the general population that were followed for 10 years between 2004 and 2014. Cox proportional hazards model was used to calculate HR for death and a competing risks model to calculate sub-HRs (sHR) for cause-specific death. RESULTS During the follow-up, 45.0% of the homeless died compared with 10.5% of controls (HR 5.38, 95% CI 4.39 to 6.59). The risk of death was particularly elevated for the homeless aged≤50 years (HR 10.3, 95% CI 7.0 to 15.2). External causes caused 34% of the deaths (sHR 11.2, 95% CI 6.8 to 18.2), but also deaths from medical causes were common (sHR 3.6, 95% CI 2.9 to 4.6). Age and somatic hospitalisation were significant predictors of death both among homeless and controls. Educational attainment, marital status, employment and psychiatric hospitalisation were significant predictors of mortality among the controls, but not among the homeless. CONCLUSIONS Homelessness is associated with a fivefold mortality compared with the controls, and especially homeless aged ≤50 years have an increased risk of death. Being homeless eliminates the protective effects of marriage, employment and education on mortality risk.