# The Impact of Homelessness on Lung Cancer Survival and Healthcare Utilization in the Hungarian Universal Healthcare System

## TL;DR

Homeless people in Hungary with lung cancer face worse survival and lower healthcare costs compared to non-homeless individuals, with longer homelessness worsening outcomes.

## Contribution

This study provides the first national-level evidence on how homelessness affects lung cancer outcomes within a universal healthcare system.

## Key findings

- Homeless individuals had three times higher lung cancer prevalence than non-homeless controls.
- Homeless patients had 47% lower annual lung cancer-related healthcare costs and lower survival rates.
- Longer homelessness duration significantly increased mortality risk, with hazard ratios of 1.47 for HLI 2 and 3.

## Abstract

This study looks at the health effects of homelessness in subjects diagnosed with lung cancer in a nationwide dataset in Hungary. Healthcare costs and survival analysis showed worse outcomes, with the length of experienced homelessness playing a key role.

Differences in the lifestyle and health-service-seeking behavior of persons experiencing homelessness (PEH) are well known. However, a comprehensive estimation of the resulting healthcare utilization differences and health outcome impacts are so far under-researched, especially at the national level. We aim to close this gap of evidence for lung cancer within the Hungarian universal healthcare system. We analyzed lung cancer-related information for the PEH population in the Hungarian national central health insurance register dataset and a matched control population between 2015 and 2021. In this period, 11,857 people were registered as homeless for the majority of at least one year. To capture the effect of homelessness, we created a categorical “homelessness length index” (HLI) according to the proportion of time an individual experienced homelessness during the investigation period (HLI 0: 0; HLI 1: >0–1/3; HLI 2: >1/3–2/3; HLI 3: >2/3). PEH individuals were matched 1:5 with a non-PEH control sample adjusted for age, sex and region. We conducted Kaplan–Meier survival analysis and Cox proportional hazards (CPH) regression adjusted for age, sex, HLI and average lung cancer-related healthcare costs. Our final analysis sample consisted of 641 patients (233 PEH, 408 control) who were newly diagnosed with lung cancer during the observation period. The lung cancer prevalence in the PEH group was 1.97% as opposed to 0.69% in the control group. The Kaplan–Meier curve showed lower average survival times for the PEH group, compared to the control group. Lung cancer associated costs between diagnosis and death/censoring were substantially different with average per patient cumulative costs of EUR 3668 in the PEH group compared to EUR 6827 in the control group (2018 prices). This translated to an average 47% lower annual lung cancer-related healthcare cost per PEH patient. CPH analysis showed that after disease severity, the degree of time spent in homelessness had the most significant effect on mortality, with a HR of 1.47 associated with both HLI 2 and 3 (95% CI: 1.08–2.00 and 1.01–2.14, respectively). We find that in Hungary, homelessness is associated with a much higher lung cancer burden linked to a three-times-higher prevalence, lower overall survival and almost 50% lower annualized disease-specific healthcare costs. Worse outcomes are mainly driven by long-term homelessness. Results could not be further refined according to lifestyle-related factors due to data availability limitations.