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Koh KA, Szymkowiak D, Tsai J. Benzodiazepine Prescriptions for Homeless Veterans Affairs Service Users With Mental Illness. Psychiatr Serv 2024; 75:316-325. [PMID: 37904492 DOI: 10.1176/appi.ps.20220472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Despite elevated risk for substance use disorder and overdose death in the homeless population, benzodiazepine prescribing for this population has not been examined. In this study, the authors used data from the U.S. Department of Veterans Affairs (VA) health care system to examine benzodiazepine prescribing and risky and potentially inappropriate benzodiazepine prescribing practices for homeless VA service users. METHODS Using national VA administrative data (2018-2019), the authors conducted logistic regression to compare likelihood of benzodiazepine prescribing and t tests to compare indicators of risky and potentially inappropriate benzodiazepine prescribing patterns for homeless service users with mental illness (N=244,113) and their housed peers (N=2,763,513). RESULTS Unadjusted analyses showed that benzodiazepines were prescribed for 7.5% of homeless VA service users with mental illness, versus 9.4% of their housed peers (p<0.001). Analyses adjusted for sociodemographic and clinical characteristics and health care utilization showed that homeless service users were less likely than their housed peers to receive a benzodiazepine prescription (AOR=0.70, 99% CI=0.68-0.72). However, compared with their housed peers, homeless service users received higher rates of risky and potentially inappropriate benzodiazepine prescriptions, including multiple concurrent benzodiazepine prescriptions (9.4% vs. 7.0%, p<0.001) and concurrent prescriptions for benzodiazepines and opioids (36.9% vs. 31.2%, p<0.001) or sedatives (61.9% vs. 45.9%, p<0.001). CONCLUSIONS Although homeless VA service users with mental illness were less likely than their housed peers to receive a benzodiazepine prescription, benzodiazepine prescriptions for these service users had more characteristics of risky and potentially inappropriate prescribing.
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Affiliation(s)
- Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Dorota Szymkowiak
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Jack Tsai
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
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Tsai J, Szymkowiak D, Hooshyar D, Gildea SM, Hwang I, Kennedy CJ, King AJ, Koh KA, Luedtke A, Marx BP, Montgomery AE, O'Brien RW, Petukhova MV, Sampson NA, Stein MB, Ursano RJ, Kessler RC. Predicting Homelessness Among Transitioning U.S. Army Soldiers. Am J Prev Med 2024:S0749-3797(24)00034-5. [PMID: 38311192 DOI: 10.1016/j.amepre.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION This study develops a practical method to triage Army transitioning service members (TSMs) at highest risk of homelessness to target a preventive intervention. METHODS The sample included 4,790 soldiers from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in 1 of 3 Army STARRS 2011-2014 baseline surveys followed by the third wave of the STARRS-LS online panel surveys (2020-2022). Two machine learning models were trained: a Stage-1 model that used administrative predictors and geospatial data available for all TSMs at discharge to identify high-risk TSMs for initial outreach; and a Stage-2 model estimated in the high-risk subsample that used self-reported survey data to help determine highest risk based on additional information collected from high-risk TSMs once they are contacted. The outcome in both models was homelessness within 12 months after leaving active service. RESULTS Twelve-month prevalence of post-transition homelessness was 5.0% (SE=0.5). The Stage-1 model identified 30% of high-risk TSMs who accounted for 52% of homelessness. The Stage-2 model identified 10% of all TSMs (i.e., 33% of high-risk TSMs) who accounted for 35% of all homelessness (i.e., 63% of the homeless among high-risk TSMs). CONCLUSIONS Machine learning can help target outreach and assessment of TSMs for homeless prevention interventions.
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Affiliation(s)
- Jack Tsai
- National Center on Homelessness among Veterans, VA Homeless Programs Office, Washington, District of Columbia; School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Dorota Szymkowiak
- National Center on Homelessness among Veterans, VA Homeless Programs Office, Washington, District of Columbia
| | - Dina Hooshyar
- National Center on Homelessness among Veterans, VA Homeless Programs Office, Washington, District of Columbia; Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah M Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Chris J Kennedy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew J King
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, Massachusetts; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brian P Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts; Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Ann E Montgomery
- National Center on Homelessness among Veterans, VA Homeless Programs Office, Washington, District of Columbia; School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; VA Birmingham Health Care System, Birmingham, Alabama
| | - Robert W O'Brien
- VA Health Services Research and Development Service, Washington, District of Columbia
| | - Maria V Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, California; School of Public Health, University of California San Diego, La Jolla, California; VA San Diego Healthcare System, San Diego, California
| | - Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Velasquez DE, Sandhu S, Koh KA, Ganguli I. Advancing social risk-informed care for people experiencing homelessness. J Hosp Med 2023; 18:1041-1044. [PMID: 37039109 PMCID: PMC10616886 DOI: 10.1002/jhm.13100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/12/2023]
Affiliation(s)
- David E. Velasquez
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
- Harvard Kennedy School of Government, Cambridge, Massachusetts, USA
| | - Sahil Sandhu
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine A. Koh
- Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Song Z, Zubizarreta JR, Giuriato M, Koh KA, Sacks CA. Firearm Injuries In Children And Adolescents: Health And Economic Consequences Among Survivors And Family Members. Health Aff (Millwood) 2023; 42:1541-1550. [PMID: 37931194 DOI: 10.1377/hlthaff.2023.00587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
More US children and adolescents today die from firearms than any other cause, and many more sustain firearm injuries and survive. The clinical and economic impact of these firearm injuries on survivors and family members remains poorly understood. Using 2007-21 commercial health insurance claims data, we studied 2,052 child and adolescent survivors compared to 9,983 matched controls who did not incur firearm injuries, along with 6,209 family members of survivors compared to 29,877 matched controls, and 265 family members of decedents compared to 1,263 matched controls. Through one year after firearm injury, child and adolescent survivors experienced a 117 percent increase in pain disorders, a 68 percent increase in psychiatric disorders, and a 144 percent increase in substance use disorders relative to the controls. Survivors' health care spending increased by an average of $34,884-a 17.1-fold increase-with 95 percent paid by insurers or employers. Parents of survivors experienced a 30-31 percent increase in psychiatric disorders, with 75 percent more mental health visits by mothers, and 5-14 percent reductions in mothers' and siblings' routine medical care. Family members of decedents experienced substantially larger 2.3- to 5.3-fold increases in psychiatric disorders, with at least 15.3-fold more mental health visits among parents. Firearm injuries in youth have notable health implications for the whole family, along with large effects on societal spending.
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Affiliation(s)
- Zirui Song
- Zirui Song , Harvard University and Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Katherine A Koh
- Katherine A. Koh, Boston Health Care for the Homeless Program, Boston, Massachusetts, and Massachusetts General Hospital
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Montgomery AE, Koh KA, King AJ, O’Brien R, Sampson NA, Petriceks A, Stein MB, Ursano RJ, Kessler RC. Stressful Life Events and Risk of Homelessness After Active Duty: An Assessment of Risk and Resilience Among Servicemembers. Public Health Rep 2023; 138:963-970. [PMID: 36726307 PMCID: PMC10576479 DOI: 10.1177/00333549221149092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The transition from military to civilian life may present increased exposure to various stressful life events (SLEs) that can increase the risk of homelessness (eg, loss of employment, dissolution of romantic relationships). We assessed the extent to which exposure to SLEs occurring proximal to US Army soldier transitions out of active duty was associated with risk of homelessness. METHODS A total of 16 589 respondents who were no longer on active duty but participated while on active duty during 2011-2014 baseline surveys completed follow-up surveys during 2016-2018 and 2018-2019. The follow-up surveys assessed SLEs and homelessness occurring in the past 12 months. We used modified Poisson regression models to evaluate how much differential SLE exposure and effects explained the aggregate association of a risk index with homelessness among a sample of 6837 respondents, weighted to represent the full sample. RESULTS More than half (n = 3510, 52.8%) of respondents reported experiencing any SLEs in the past 12 months. Most (60.5%) of the difference in prevalence of homelessness among respondents defined as being at high risk of homelessness (vs lower risk) was explained by differential exposure to, and/or effects of, these SLEs. Personal betrayal by a loved one and economic problems played the largest roles in adjusted risk differences (0.045 and 0.074, respectively). CONCLUSIONS Homelessness might be reduced by gearing interventions toward soldiers at high risk of homelessness who are transitioning out of active duty to reduce exposure to and effects of modifiable SLEs on experiencing homelessness.
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Affiliation(s)
- Ann Elizabeth Montgomery
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham Veterans Affairs Health Care System, Birmingham, AL, USA
| | - Katherine A. Koh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Andrew J. King
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Robert O’Brien
- VA Health Services Research and Development Service, Washington, DC, USA
| | - Nancy A. Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- School of Public Health, University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, La Jolla, CA, USA
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Koh HK, Hrabchak Molinsky J, Koh KA, Roncarati JS, Sullivan MM, Lazowy EE, O’Connell JJ. Establishing Academic Homes for Homelessness: A Call to Action. Public Health Rep 2023; 138:838-844. [PMID: 36062354 PMCID: PMC10467508 DOI: 10.1177/00333549221120453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.
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Affiliation(s)
- Howard K. Koh
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
| | | | - Katherine A. Koh
- Boston Health Care for the Homeless Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Margaret M. Sullivan
- Boston Health Care for the Homeless Program, Boston, MA, USA
- FXB Center for Health and Human Rights at Harvard University, Boston, MA, USA
| | | | - James J. O’Connell
- Boston Health Care for the Homeless Program, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Koh KA, Gorman BL. Reimagining Institutionalization and a Continuum of Care for People Experiencing Homelessness and Mental Illness. JAMA 2023; 329:1449-1450. [PMID: 37036729 DOI: 10.1001/jama.2023.6132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Affiliation(s)
- Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Boston Health Care for the Homeless Program, Boston, Massachusetts
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Naifeh JA, Capaldi VF, Chu C, King AJ, Koh KA, Marx BP, Montgomery AE, O'Brien RW, Sampson NA, Stanley IH, Tsai J, Vogt D, Ursano RJ, Stein MB, Kessler RC. Prospective Associations of Military Discharge Characterization with Post-active Duty Suicide Attempts and Homelessness: Results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). Mil Med 2022; 188:usac232. [PMID: 35943145 PMCID: PMC10363011 DOI: 10.1093/milmed/usac232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Active duty service members transitioning to civilian life can experience significant readjustment stressors. Over the past two decades of the United States' longest sustained conflict, reducing transitioning veterans' suicidal behavior and homelessness became national priorities. However, it remains a significant challenge to identify which service members are at greatest risk of these post-active duty outcomes. Discharge characterization, which indicates the quality of an individual's military service and affects eligibility for benefits and services at the Department of Veterans Affairs, is a potentially important indicator of risk. MATERIALS AND METHODS This study used data from two self-report panel surveys of the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) (LS1: 2016-2018, n = 14,508; and LS2: 2018-2019, n = 12,156), which were administered to respondents who previously participated while on active duty in one of the three Army STARRS baseline self-report surveys (2011-2014): the New Soldier Study (NSS), a survey of soldiers entering basic training; All Army Study, a survey of active duty soldiers around the world; and the Pre-Post Deployment Study, a survey of soldiers before and after combat deployment. Human Subjects Committees of the participating institutions approved all recruitment, informed consent, and data collection protocols. We used modified Poisson regression models to prospectively examine the association of discharge characterization (honorable, general, "bad paper" [other than honorable, bad conduct, dishonorable], and uncharacterized [due to separation within the first 180 days of service]) with suicide attempt (subsample of n = 4334 observations) and homelessness (subsample of n = 6837 observations) among those no longer on active duty (i.e., separated or deactivated). Analyses controlled for other suicide attempt and homelessness risk factors using standardized risk indices that were previously developed using the LS survey data. RESULTS Twelve-month prevalence rates of self-reported suicide attempts and homelessness in the total pooled LS sample were 1.0% and 2.9%, respectively. While not associated with suicide attempt risk, discharge characterization was associated with homelessness after controlling for other risk factors. Compared to soldiers with an honorable discharge, those with a bad paper discharge had an increased risk of homelessness in the total sample (relative risk [RR] = 4.4 [95% CI = 2.3-8.4]), as well as within subsamples defined by which baseline survey respondents completed (NSS vs. All Army Study/Pre-Post Deployment Study), whether respondents had been separated (vs. deactivated), and how much time had elapsed since respondents were last on active duty. CONCLUSIONS There is a robust association between receiving a bad paper discharge and post-separation/deactivation homelessness. Policies that enhance transition assistance and access to mental healthcare for high-risk soldiers may aid in reducing post-separation/deactivation homelessness among those who do not receive an honorable discharge.
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Affiliation(s)
- James A Naifeh
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Vincent F Capaldi
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Carol Chu
- Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - Andrew J King
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
| | - Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Boston Health Care for the Homeless Program, Boston, MA 02118, USA
| | - Brian P Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Ann Elizabeth Montgomery
- Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham, Birmingham, AL 35233, USA
- Birmingham VA Health Care System, Birmingham, AL 35233, USA
| | - Robert W O'Brien
- VA Health Services Research and Development Service, Washington, DC 20571, USA
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
| | - Ian H Stanley
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Jack Tsai
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Tampa, FL 33637, USA
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Dawne Vogt
- National Center for PTSD, VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Robert J Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Murray B Stein
- Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA 92093-0855, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
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Koh KA, Montgomery AE, O'Brien RW, Kennedy CJ, Luedtke A, Sampson NA, Gildea SM, Hwang I, King AJ, Petriceks AH, Petukhova MV, Stein MB, Ursano RJ, Kessler RC. Predicting Homelessness Among U.S. Army Soldiers No Longer on Active Duty. Am J Prev Med 2022; 63:13-23. [PMID: 35725125 PMCID: PMC9219110 DOI: 10.1016/j.amepre.2021.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/24/2021] [Accepted: 12/14/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The ability to predict and prevent homelessness has been an elusive goal. The purpose of this study was to develop a prediction model that identified U.S. Army soldiers at high risk of becoming homeless after transitioning to civilian life based on information available before the time of this transition. METHODS The prospective cohort study consisted of observations from 16,589 soldiers who were separated or deactivated from service and who had previously participated in 1 of 3 baseline surveys of the Army Study to Assess Risk and Resilience in Servicemembers in 2011-2014. A machine learning model was developed in a 70% training sample and evaluated in the remaining 30% test sample to predict self-reported homelessness in 1 of 2 Longitudinal Study surveys administered in 2016-2018 and 2018-2019. Predictors included survey, administrative, and geospatial variables available before separation/deactivation. Analysis was conducted in November 2020-May 2021. RESULTS The 12-month prevalence of homelessness was 2.9% (SE=0.2%) in the total Longitudinal Study sample. The area under the receiver operating characteristic curve in the test sample was 0.78 (SE=0.02) for homelessness. The 4 highest ventiles (top 20%) of predicted risk included 61% of respondents with homelessness. Self-reported lifetime histories of depression, trauma of having a loved one murdered, and post-traumatic stress disorder were the 3 strongest predictors of homelessness. CONCLUSIONS A prediction model for homelessness can accurately target soldiers for preventive intervention before transition to civilian life.
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Affiliation(s)
- Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Boston Health Care for the Homeless Program, Boston, Massachusetts.
| | - Ann Elizabeth Montgomery
- Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama; VA Health Care System, Birmingham, U.S. Department of Veteran Affairs, Birmingham, Alabama
| | - Robert W O'Brien
- VA Health Services Research and Development Service, Washington, District of Columbia
| | - Chris J Kennedy
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, Washington; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sarah M Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Irving Hwang
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Andrew J King
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Maria V Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, San Diego, California; Department of Family Medicine & Public Health, University of California San Diego, San Diego, California
| | - Robert J Ursano
- Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Song Z, Zubizarreta JR, Giuriato M, Paulos E, Koh KA. Changes in Health Care Spending, Use, and Clinical Outcomes After Nonfatal Firearm Injuries Among Survivors and Family Members : A Cohort Study. Ann Intern Med 2022; 175:795-803. [PMID: 35377713 DOI: 10.7326/m21-2812] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite increasing awareness of firearm-related deaths, evidence on the clinical and economic implications of nonfatal firearm injuries is limited. OBJECTIVE To measure changes in clinical and economic outcomes after nonfatal firearm injuries among survivors and their family members. DESIGN Cohort study. SETTING MarketScan Medicare and commercial claims data, 2008 to 2018. PARTICIPANTS 6498 survivors of firearm injuries matched to 32 490 control participants and 12 489 family members of survivors matched to 62 445 control participants. INTERVENTION Exposure to nonfatal firearm injury as a survivor or family member of a survivor. MEASUREMENTS Changes in health care spending, use, and morbidity from preinjury through 1 year postinjury relative to control participants, on average and by type and severity of firearm injury. RESULTS After nonfatal firearm injury, medical spending increased $2495 per person per month (402%) and cost sharing increased $102 per person per month (176%) among survivors relative to control participants (P < 0.001) in the first year after injury, driven by an increase in the first month of $25 554 (4122%) in spending and $1112 (1917%) in cost sharing per survivor (P < 0.001). All categories of health care use increased relative to the control group. Survivors had a 40% increase in pain diagnoses, a 51% increase in psychiatric disorders, and an 85% increase in substance use disorders after firearm injury relative to control participants (P < 0.001), accompanied by increased pain and psychiatric medications. Family members had a 12% increase in psychiatric disorders relative to their control participants (P = 0.003). These overall clinical and economic changes were driven by intentional firearm injuries and more severe firearm injuries. LIMITATION Precision of diagnostic codes and generalizability to other patient populations, including Medicaid and uninsured patients. CONCLUSION In survivors, nonfatal firearm injuries led to increases in psychiatric disorders, substance use disorders, and pain diagnoses, alongside substantial increases in health care spending and use. In addition, mental health worsened among family members. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Zirui Song
- Department of Health Care Policy, Harvard Medical School and Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (Z.S.)
| | - José R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Department of Biostatistics and CAUSALab, Harvard T.H. Chan School of Public Health, and Department of Statistics, Faculty of Arts and Sciences, Harvard University, Boston, Massachusetts (J.R.Z.)
| | - Mia Giuriato
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (M.G.)
| | - Erica Paulos
- University of Michigan, Ann Arbor, Michigan (E.P.)
| | - Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital and Boston Health Care for the Homeless Program, Boston, Massachusetts (K.A.K.)
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Koh KA, Roncarati JS, Racine MW, O'Connell JJ, Gaeta JM. Unsheltered vs. Sheltered Adults Experiencing Homelessness: Health Care Spending and Utilization. J Gen Intern Med 2022; 37:2100-2102. [PMID: 34643873 PMCID: PMC9198173 DOI: 10.1007/s11606-021-07153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Katherine A Koh
- Boston Health Care for the Homeless Program, Boston, MA, USA. .,Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WAC 8, Boston, MA, 02114, USA.
| | - Jill S Roncarati
- Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs, MA, Bedford, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - James J O'Connell
- Boston Health Care for the Homeless Program, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jessie M Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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12
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Abstract
This study uses data from the state-level Youth Risk Behavioral Survey to evaluate mental health and substance use outcomes among homeless and nonhomeless adolescents in 2019.
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Affiliation(s)
- Michael Liu
- Harvard Medical School, Boston, Massachusetts
| | - Katherine A. Koh
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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13
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Koh KA, Montgomery AE. Adverse childhood experiences and homelessness: advances and aspirations. The Lancet Public Health 2021; 6:e787-e788. [DOI: 10.1016/s2468-2667(21)00210-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022] Open
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14
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Koh KA, Roncarati JS, O'Connell JJ. A Clinical Approach to Preventing Death on the Streets. JAMA Intern Med 2021; 181:899-901. [PMID: 34047781 DOI: 10.1001/jamainternmed.2021.2402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Katherine A Koh
- Street Team, Boston Health Care for the Homeless Program, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Jill S Roncarati
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, Massachusetts.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - James J O'Connell
- Street Team, Boston Health Care for the Homeless Program, Boston, Massachusetts.,Department of Medicine, Massachusetts General Hospital, Boston
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15
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Koh KA, Racine M, Gaeta JM, Goldie J, Martin DP, Bock B, Takach M, O'Connell JJ, Song Z. Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations. Health Aff (Millwood) 2021; 39:214-223. [PMID: 32011951 DOI: 10.1377/hlthaff.2019.00687] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.
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Affiliation(s)
- Katherine A Koh
- Katherine A. Koh ( kkoh@partners. org ) is a physician at the Boston Health Care for the Homeless Program and Massachusetts General Hospital, both in Boston, Massachusetts
| | - Melanie Racine
- Melanie Racine is the director of special projects at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care
| | - Jessie M Gaeta
- Jessie M. Gaeta is chief medical officer at the Boston Health Care for the Homeless Program and a member of its Institute for Research, Quality, and Policy in Homeless Health Care. She is also an assistant professor of medicine at Boston University School of Medicine
| | - John Goldie
- John Goldie is executive director of system analytics, Boston Medical Center Health System
| | - Daniel P Martin
- Daniel P. Martin is a data scientist in the Population Health Analytics and Strategy team, Boston Medical Center Health System
| | - Barry Bock
- Barry Bock is chief executive officer of the Boston Health Care for the Homeless Program
| | - Mary Takach
- Mary Takach is a senior health policy adviser at the Boston Health Care for the Homeless Program
| | - James J O'Connell
- James J. O'Connell is president of the Boston Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School, in Boston
| | - Zirui Song
- Zirui Song is an assistant professor of health care policy and medicine at Harvard Medical School and Massachusetts General Hospital, and a faculty member in the Center for Primary Care at Harvard Medical School
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16
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Affiliation(s)
- Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital, Boston (all authors); Boston Health Care for the Homeless Program, Boston (Koh); Partners in Health, Boston (Raviola)
| | - Giuseppe Raviola
- Department of Psychiatry, Massachusetts General Hospital, Boston (all authors); Boston Health Care for the Homeless Program, Boston (Koh); Partners in Health, Boston (Raviola)
| | - Frederick J Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Boston (all authors); Boston Health Care for the Homeless Program, Boston (Koh); Partners in Health, Boston (Raviola)
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17
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Dotson S, Ciarocco S, Koh KA. Disaster psychiatry and homelessness: creating a mental health COVID-19 response. Lancet Psychiatry 2020; 7:1006-1008. [PMID: 32763148 PMCID: PMC7402664 DOI: 10.1016/s2215-0366(20)30343-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/03/2020] [Accepted: 07/17/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Samuel Dotson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA; Boston Health Care for the Homeless Program, Boston, MA, USA.
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18
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Affiliation(s)
- Katherine A Koh
- Boston Health Care for the Homeless Program, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston
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19
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von Keudell A, Koh KA, Shah SB, Harris MB, Smith M, Rodriguez EK, Dyer G. Mental health after the Boston marathon bombing. Lancet Psychiatry 2016; 3:802-4. [PMID: 27568262 DOI: 10.1016/s2215-0366(16)30170-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Arvind von Keudell
- Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA.
| | | | - Sejal B Shah
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B Harris
- Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Malcolm Smith
- Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward K Rodriguez
- Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA, USA
| | - George Dyer
- Harvard Orthopedic Trauma Initiative, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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20
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Thomas JJ, Koh KA, Eddy KT, Hartmann AS, Murray HB, Gorman MJ, Sogg S, Becker AE. Do DSM-5 eating disorder criteria overpathologize normative eating patterns among individuals with obesity? J Obes 2014; 2014:320803. [PMID: 25057413 PMCID: PMC4098982 DOI: 10.1155/2014/320803] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 05/26/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND DSM-5 revisions have been criticized in the popular press for overpathologizing normative eating patterns-particularly among individuals with obesity. To evaluate the evidence for this and other DSM-5 critiques, we compared the point prevalence and interrater reliability of DSM-IV versus DSM-5 eating disorders (EDs) among adults seeking weight-loss treatment. METHOD Clinicians (n = 2) assigned DSM-IV and DSM-5 ED diagnoses to 100 participants via routine clinical interview. Research assessors (n = 3) independently conferred ED diagnoses via Structured Clinical Interview for DSM-IV and a DSM-5 checklist. RESULTS Research assessors diagnosed a similar proportion of participants with EDs under DSM-IV (29%) versus DSM-5 (32%). DSM-5 research diagnoses included binge eating disorder (9%), bulimia nervosa (2%), subthreshold binge eating disorder (5%), subthreshold bulimia nervosa (2%), purging disorder (1%), night eating syndrome (6%), and other (7%). Interrater reliability between clinicians and research assessors was "substantial" for both DSM-IV (κ = 0.64, 84% agreement) and DSM-5 (κ = 0.63, 83% agreement). CONCLUSION DSM-5 ED criteria can be reliably applied in an obesity treatment setting and appear to yield an overall ED point prevalence comparable to DSM-IV.
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Affiliation(s)
- Jennifer J. Thomas
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
- *Jennifer J. Thomas:
| | - Katherine A. Koh
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
| | - Kamryn T. Eddy
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
| | - Andrea S. Hartmann
- Institute for Psychology, University of Osnabrück, 49074 Osnabrück, Germany
| | - Helen B. Murray
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Mark J. Gorman
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
- Massachusetts General Hospital Weight Center, Boston, MA 02114, USA
| | - Stephanie Sogg
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
- Massachusetts General Hospital Weight Center, Boston, MA 02114, USA
| | - Anne E. Becker
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA 02115, USA
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21
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Abstract
Despite stereotypes of the homeless population as underweight, the literature lacks a rigorous analysis of weight status in homeless adults. The purpose of this study is to present the body mass index (BMI) distribution in a large adult homeless population and to compare this distribution to the non-homeless population in the United States. Demographic, BMI, and socioeconomic variables from patients seen in 2007-2008 were collected from the Boston Health Care for the Homeless Program (BHCHP). This population was compared to non-homeless adults from the National Health and Nutrition Examination Survey (NHANES). Among 5,632 homeless adults, the mean BMI was 28.4 kg/m(2) and the prevalence of obesity was 32.3 %. Only 1.6 % of homeless adults were underweight. Compared to mean BMI in NHANES (28.6 kg/m(2)), the difference was not significant in unadjusted analysis (p = 0.14). Adjusted analyses predicting BMI or likelihood of obesity also showed that the homeless had a weight distribution not statistically different from the general population. Although underweight has been traditionally associated with homelessness, this study suggests that obesity may be the new malnutrition of the homeless in the United States.
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22
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Abstract
In a prospective study of 10 011 men with 815 prostate cancer cases, despite plausible biological mechanisms, neither increasing intake levels of dairy products nor calcium from dairy products (P trend; 0.23 and 0.64, respectively), or calcium supplements was associated with prostate cancer risk (relative risk, 1.05; 95% confidence interval, 0.84–1.31).
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Affiliation(s)
- K A Koh
- Harvard University, 8 Garden Street, Cambridge, MA 02138, USA
| | - H D Sesso
- Department of Medicine, Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, 900 Commonwealth, Avenue East, Boston, MA 02215, USA
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
| | - R S Paffenbarger
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Division of Epidemiology, Department of Health Research Policy, HRP Redwood Building, T213B, Stanford, CA 94305, USA
| | - I-M Lee
- Department of Medicine, Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, 900 Commonwealth, Avenue East, Boston, MA 02215, USA
- Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Medicine, Brigham Women's Hospital, Harvard Medical School, 900 Commonwealth, Avenue East, Boston, MA 02215, USA. E-mail:
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