The association of homelessness with rates of diabetes complications: A population-based cohort study
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.