American Diabetes Association
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The association of homelessness with rates of diabetes complications: A population-based cohort study

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posted on 2023-06-05, 20:19 authored by Ruchi Sharan, Kathryn Wiens, Paul Ronksley, Stephen Hwang, Gillian Booth, Peter Austin, Eldon Spackman, David JT Campbell

Objective: To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of non-homeless controls.

Research Design and Methods: A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to non-homeless controls with similar sociodemographic and clinical characteristics. Rate ratios for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with Negative Binomial distribution and robust standard errors. 

Results: 1,076,437 people were eligible for inclusion in the study, and of these, 6944 were identified as homeless. A suitable non-homeless match was found for 5219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared to non-homeless controls (RR=1.85; 95%CI:1.64-2.07), as were rates of hospitalization for glycemia (RR=5.64; 95%CI: 4.07-7.81) and skin/soft tissue infections (RR=3.78; 95%CI: 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR=0.76; 95%CI: 0.62-0.94). 

Conclusions:  These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.


This study was supported by ICES, which is funded by a grant from the Government of Ontario. This work was also supported by the Ontario Health Data Platform (OHDP), a Province of Ontario initiative to support Ontario’s ongoing response to COVID-19 and its related impacts. This study also received funding by a grant from the MSI Foundation to DJTC and an Early Career Mentorship Award from Diabetes Action Canada to DJTC, PER, GLB. Parts of this material are based on data and information compiled and provided by: CIHI. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. No endorsement by the OHDP, its partners, or the Province of Ontario is intended or should be inferred.


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