{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T06:03:16Z","timestamp":1780984996644,"version":"3.54.1"},"reference-count":34,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,3,29]],"date-time":"2025-03-29T00:00:00Z","timestamp":1743206400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>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 \u201chomelessness length index\u201d (HLI) according to the proportion of time an individual experienced homelessness during the investigation period (HLI 0: 0; HLI 1: &gt;0\u20131\/3; HLI 2: &gt;1\/3\u20132\/3; HLI 3: &gt;2\/3). PEH individuals were matched 1:5 with a non-PEH control sample adjusted for age, sex and region. We conducted Kaplan\u2013Meier 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\u2013Meier 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\u20132.00 and 1.01\u20132.14, 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.<\/jats:p>","DOI":"10.3390\/cancers17071158","type":"journal-article","created":{"date-parts":[[2025,3,31]],"date-time":"2025-03-31T01:59:36Z","timestamp":1743386376000},"page":"1158","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["The Impact of Homelessness on Lung Cancer Survival and Healthcare Utilization in the Hungarian Universal Healthcare System"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8370-8236","authenticated-orcid":false,"given":"Daniel","family":"Heilig","sequence":"first","affiliation":[{"name":"Department of Health Economics, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2386-4525","authenticated-orcid":false,"given":"\u00c1kos","family":"Szab\u00f3","sequence":"additional","affiliation":[{"name":"Department of Financial Accounting, Corvinus University of Budapest, 1093 Budapest, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0858-8924","authenticated-orcid":false,"given":"Petra","family":"Fadgyas-Freyler","sequence":"additional","affiliation":[{"name":"Department of Health Policy, Corvinus University of Budapest, 1093 Budapest, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9279-8627","authenticated-orcid":false,"given":"Judit","family":"Simon","sequence":"additional","affiliation":[{"name":"Department of Health Economics, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria"},{"name":"Department of Health Policy, Corvinus University of Budapest, 1093 Budapest, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,3,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Fornaro, M., Dragioti, E., De Prisco, M., Billeci, M., Mondin, A.M., Calati, R., Smith, L., Hatcher, S., Kaluzienski, M., and Fiedorowicz, J.G. (2021). Homelessness and health-related outcomes: An umbrella review of observational studies and randomized controlled trials. BMC Med., 20.","DOI":"10.1186\/s12916-022-02423-z"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1016\/j.habitatint.2003.11.002","article-title":"Definitions of homelessness in developing countries","volume":"29","author":"Tipple","year":"2005","journal-title":"Habitat Int."},{"key":"ref_3","unstructured":"Lung cancer n.d. (2024, August 29). Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/lung-cancer."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Redondo-S\u00e1nchez, D., Petrova, D., Rodr\u00edguez-Barranco, M., Fern\u00e1ndez-Navarro, P., Jim\u00e9nez-Mole\u00f3n, J.J., and S\u00e1nchez, M.-J. (2022). Socio-Economic Inequalities in Lung Cancer Outcomes: An Overview of Systematic Reviews. Cancers, 14.","DOI":"10.3390\/cancers14020398"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"pkz006","DOI":"10.1093\/jncics\/pkz006","article-title":"The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit","volume":"3","author":"Holowatyj","year":"2019","journal-title":"JNCI Cancer Spectr."},{"key":"ref_6","unstructured":"OECD Data Explorer Healthcare coverage n.d. (2024, June 12). Available online: https:\/\/data-explorer.oecd.org\/vis?fs[0]=Topic%2C1%7CHealth%23HEA%23%7CHealthcare%20coverage%23HEA_COV%23&pg=0&fc=Topic&bp=true&snb=1&vw=tl&df[ds]=dsDisseminateFinalDMZ&df[id]=DSD_HEALTH_PROT%40DF_HEALTH_PROT&df[ag]=OECD.ELS.HD&df[vs]=1.0&pd=2010%2C&dq=HUN.A..PT_POP.&ly[cl]=TIME_PERIOD&to[TIME_PERIOD]=false."},{"key":"ref_7","unstructured":"(2025, March 07). Tasks of the National Health Insurance Fund of Hungary (Hungarian acronym: NEAK)\u2014NEAK n.d, Available online: https:\/\/www.neak.gov.hu\/oldalak\/nyelvi-oldalak\/english."},{"key":"ref_8","unstructured":"World Health Organization (2025, March 24). International Statistical Classification of Diseases and Related Health Problems (10th ed.) 2019. Available online: https:\/\/icd.who.int\/browse10\/2019\/en."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.2147\/CLEP.S155063","article-title":"Demographic shift disproportionately increases cancer burden in an aging nation: Current and expected incidence and mortality in Hungary up to 2030","volume":"10","author":"Fekete","year":"2018","journal-title":"Clin. Epidemiol."},{"key":"ref_10","first-page":"223","article-title":"Prognostic\/Clinical Prediction Models: Multivariable Prognostic Models: Issues in Developing Models, Evaluating Assumptions and Adequacy, and Measuring and Reducing Errors. Tutorials in Biostatistics","volume":"1","author":"Harrell","year":"2005","journal-title":"Stat. Methods Clin. Stud."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2179","DOI":"10.1002\/sim.9717","article-title":"Pitfalls of the concordance index for survival outcomes","volume":"42","author":"Hartman","year":"2023","journal-title":"Stat. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1023\/A:1022176402357","article-title":"Applying Cluster Analysis to Test a Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data","volume":"26","author":"Kuhn","year":"1998","journal-title":"Am. J. Community Psychol."},{"key":"ref_13","unstructured":"(2024, September 01). Exchange Rates and PPPs by Indicator, Country and Year. UNECE Statistical Database n.d.. Available online: https:\/\/w3.unece.org\/PXWeb2015\/pxweb\/en\/STAT\/STAT__20-ME__6-MEER\/30_en_MECCExchPPPsNEWY_r.px\/."},{"key":"ref_14","unstructured":"Statistics\u2014Eurostat n.d. (2025, February 24). Available online: https:\/\/ec.europa.eu\/eurostat\/databrowser\/view\/ERT_BIL_EUR_A\/default\/table?lang=en."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1080\/01621459.1958.10501452","article-title":"Nonparametric Estimation from Incomplete Observations","volume":"53","author":"Kaplan","year":"1958","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1111\/j.2517-6161.1972.tb00899.x","article-title":"Regression Models and Life-Tables","volume":"34","author":"Cox","year":"1972","journal-title":"J. R. Stat. Soc. Ser. B"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e1210","DOI":"10.1002\/cnr2.1210","article-title":"Parametric survival analysis using R: Illustration with lung cancer data","volume":"3","author":"Kumar","year":"2020","journal-title":"Cancer Rep."},{"key":"ref_18","unstructured":"(2025, February 20). T\u00e1j\u00e9koztat\u00f3 a K\u00f6zadatok \u00dajrahasznos\u00edt\u00e1s\u00e1r\u00f3l\u2014NEAK n.d, Available online: http:\/\/www.neak.gov.hu\/felso_menu\/rolunk\/kozerdeku_adatok\/kozadatok_igenylese\/kozadat_ujrahasznositas."},{"key":"ref_19","unstructured":"(2025, February 24). OECD Data Explorer\u2014Annual Purchasing Power Parities and exchange rates n.d. Available online: https:\/\/data-explorer.oecd.org\/vis?tm=purchasing%20power&pg=0&snb=44&vw=tb&df[ds]=dsDisseminateFinalDMZ&df[id]=DSD_NAMAIN10%40DF_TABLE4&df[ag]=OECD.SDD.NAD&df[vs]=2.0&dq=A.EU27_2020%2BEA20%2BHUN...PPP_B1GQ.......&lom=LASTNPERIODS&lo=10&to[TIME_PERIOD]=false."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"May, L., Shows, K., Nana-Sinkam, P., Li, H., and Landry, J.W. (2023). Sex Differences in Lung Cancer. Cancers, 15.","DOI":"10.3390\/cancers15123111"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"688","DOI":"10.1016\/j.jtho.2022.01.016","article-title":"Evaluating Prognostic Factors for Sex Differences in Lung Cancer Survival: Findings from a Large Australian Cohort","volume":"17","author":"Yu","year":"2022","journal-title":"J. Thorac. Oncol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1001\/jamapsychiatry.2024.0426","article-title":"Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness: A Systematic Review and Meta-Analysis","volume":"81","author":"Barry","year":"2024","journal-title":"JAMA Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1017\/jsc.2020.11","article-title":"Smoking amongst adults experiencing homelessness: A systematic review of prevalence rates, interventions and the barriers and facilitators to quitting and staying quit","volume":"15","author":"Soar","year":"2020","journal-title":"J. Smok. Cessat."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1016\/j.amepre.2015.03.038","article-title":"Disparities in Cancer Incidence, Stage, and Mortality at Boston Health Care for the Homeless Program","volume":"49","author":"Baggett","year":"2015","journal-title":"Am. J. Prev. Med."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Preda, M., T\u0103nase, B.C., Zob, D.L., Gheorghe, A.S., Lungulescu, C.V., Dumitrescu, E.A., St\u0103nculeanu, D.L., Manolescu, L.S.C., Popescu, O., and Ibraim, E. (2023). The Bidirectional Relationship between Pulmonary Tuberculosis and Lung Cancer. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20021282"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"327","DOI":"10.5588\/ijtld.16.0597","article-title":"Tuberculosis among the homeless: Should we change the strategy?","volume":"21","author":"Dias","year":"2017","journal-title":"Int. J. Tuberc. Lung Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.vhri.2015.03.020","article-title":"Prognosis, Cost, and Occurrence of Colorectal, Lung, Breast, and Prostate Cancer in Hungary","volume":"7","author":"Inotai","year":"2015","journal-title":"Value Heal. Reg. Issues"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"525","DOI":"10.3111\/13696998.2015.1032974","article-title":"Treatment cost of non-small cell lung cancer in three European countries: Comparisons across France, Germany, and England using administrative databases","volume":"18","author":"McGuire","year":"2015","journal-title":"J. Med. Econ."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1498","DOI":"10.1200\/JCO.2010.33.4631","article-title":"Relationship Between Deficits in Overall Quality of Life and Non\u2013Small-Cell Lung Cancer Survival","volume":"30","author":"Sloan","year":"2012","journal-title":"J. Clin. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1177\/1078390320985286","article-title":"Factors That Influence Quality of Life in People Experiencing Homelessness: A Systematic Mixed Studies Review","volume":"28","author":"Flike","year":"2022","journal-title":"J. Am. Psychiatr. Nurses Assoc."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e1004","DOI":"10.1200\/JOP.19.00694","article-title":"Outcomes Among Homeless Patients with Non\u2013Small-Cell Lung Cancer: A County Hospital Experience","volume":"16","author":"Concannon","year":"2020","journal-title":"JCO Oncol. Pr."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13561-023-00465-4","article-title":"Upcoding in medicare: Where does it matter most?","volume":"14","author":"Joiner","year":"2024","journal-title":"Health Econ. Rev."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1002\/hec.2959","article-title":"Medicare Skilled Nursing Facility Reimbursement and Upcoding","volume":"23","author":"Bowblis","year":"2014","journal-title":"Health Econ."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1097\/00000478-199808000-00003","article-title":"Survival Analysis of 200 Pulmonary Neuroendocrine Tumors with Clarification of Criteria for Atypical Carcinoid and Its Separation from Typical Carcinoid","volume":"22","author":"Travis","year":"1998","journal-title":"Am. J. Surg. Pathol."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/17\/7\/1158\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:05:40Z","timestamp":1760029540000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/17\/7\/1158"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,29]]},"references-count":34,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,4]]}},"alternative-id":["cancers17071158"],"URL":"https:\/\/doi.org\/10.3390\/cancers17071158","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,29]]}}}