Homelessness is an independent risk factor for long-term complications in individuals with diabetes, according to study results published in Diabetes Care.
The association between socioeconomic status and poor outcomes in individuals with diabetes is well established. However, little is known about the effect of homelessness on diabetes management.
Researchers sought to evaluate whether homelessness is an independent risk factor for adverse outcomes of diabetes. Administrative health data from the Institute for Clinical Evaluative Sciences in Ontario, Canada and a validated administrative data algorithm was used to confirm whether individuals with diabetes who had at least 1 hospital admission or emergency department visit between April 2006 and March 2019 were experiencing homelessness.
The primary outcomes of interest were macrovascular complications; revascularization procedures; and hospitalization for acute glycemic emergencies, skin/soft tissue infections, or amputation.
From a cohort of 1,076,437 eligible individuals, 6944 were identified as experiencing homelessness and matched against 5219 individuals who were not experiencing homelessness (controls). A group of low-income individuals (n=4670) was also included for comparison.
A higher risk for macrovascular complications was noted among individuals experiencing homelessness compared with those in the control group (137.3 vs 72.4 per 1000 person-years, respectively). Individuals experiencing homelessness also had increased risk for complications related to acute myocardial infarction (risk ratio [RR], 1.26; 95% CI, 1.02-1.54), stroke (RR, 1.41; 95% CI, 1.15-1.73), heart failure (RR, 1.78; 95% CI, 1.51-2.11), and peripheral artery disease (RR, 2.92; 95% CI, 2.38-3.60).
Further analysis showed that rates of coronary artery bypass graft procedures and percutaneous transluminal coronary angioplasty were 37% and 21% lower, respectively, among individuals experiencing homelessness compared with those in the control group.
The rate of vascular complications was higher among individuals experiencing homelessness compared with those in the low-income group, the most significant of which was peripheral artery disease (RR, 3.50; 95% CI, 2.77-4.42).
Hospitalizations for diabetic ketoacidosis were approximately 5-times higher in individuals experiencing homelessness vs those in the control group (40.3 vs 8.2 per 1000 person-years). In addition, hospital visits with documented hypoglycemia or hyperglycemia were approximately 3-times higher among individuals experiencing homelessness vs those in the control group.
Additional comparisons between the groups showed that homelessness was associated with significantly increased risk for skin/soft tissue infections (RR, 3.78; 95% CI, 3.31-4.32) and amputations (RR, 2.32; 95% CI, 1.65-3.27).
Study limitations include that data were captured only from individuals who used acute care services, selection bias, and the inability to control for confounders.
“With increased burden of diabetes complications on people experiencing homelessness, funding for targeted outreach practices to improve health outcomes in this population is essential,” the researchers concluded.
Sharan R, Wiens K, Ronksley PE, Hwang SW, et al. The association of homelessness with rates of diabetes complications: a population-based cohort study. Diabetes Care. Published online June 5, 2023. doi:10.2337/dc23-0211