Fundamentals Of Correctional Health Care
Incarceration Is Common And Costly
The prison population has tripled in the past 20 years, and the USA now incarcerates more people per capita than any other nation. Worldwide, imprisonment ranges from 30 people per 100,000/year in India, 119 in China, 148 in the United Kingdom, 628 in Russia, to 750 in the USA (Wamsley 2006). Currently, 2.3 million individuals are incarcerated with an additional 4.6 million on parole or probation, such that one out of every 31 Americans is under the supervision of the criminal justice system (The Pew Center on the States 2009). An additional five million Americans are estimated to have a history of incarceration but are no longer under the criminal justice system jurisdiction (Wilper et al. 2009). In 2008, corrections was the fastest expanding segment of state budgets, with expenditures totaling $44 billion annually. Medical care is one of the principal drivers of cost, totaling $9.9 billion per year (Spaulding et al. 2011). By conservative estimates incarcerating individuals with chronic medical conditions like cardiovascular risk factors and disease by conservative estimates costs two times more than the average inmate.
Definition Of Prison And Jail
Having a history of incarceration can range from a brief stay in jail (facilities that typically house those who are awaiting adjudication or serving sentences of less than 1 year) to longer sentences in prison (which house those who have been sentenced to more than 1 year). The median length of stay in jail is less than 7 days and in prison, 2 years. Despite the range of exposure to the correctional system, there are shared experiences that uniquely define the incarcerated population’s health. To start, prisons and jails are one of the only places in the USA where health care is guaranteed by law. In 1976, the Supreme Court ruled in Estelle v. Gamble that it was “cruel and unusual punishment” not to provide basic health care in correctional facilities. Following the ruling, prisons and jails were mandated to provide acute care services. But as the prison population demographics have changed, health care services have adapted to provide chronic medical care. Between 1995 and 2010, the number of state and federal prisoners aged 55 or older nearly quadrupled (increasing 282 %), while the number of all prisoners grew by less than half (increasing 42 %). There are now 124,400 prisoners aged 55 or older. Many correctional facilities provide individuals their first access as adults to preventive and chronic medical care. An estimated 40 % of inmates are diagnosed with a chronic disease while incarcerated, and 80 % report seeing a medical provider while incarcerated. The correctional health care setting likely influences how ever-incarcerated patients understand their chronic medical condition and how to manage their disease condition.
Quality Of Correctional Health Care
The quality of chronic medical care in correctional health care settings is variable, given limited state budgets or profit motives in privatized prisons. Unlike most free world health systems, which undergo annual quality measurement and public reporting of results, the quality of care within prisons and jails is not subject to government oversight or standardization. Standards of correctional health care are evolving for chronic conditions like hypertension, diabetes, and cardiovascular disease. National organizations such as the National Commission on Correctional Health Care (NCCHC) have established guidelines for accrediting prisons and jails, but it is voluntary whether prisons and jails agree to participate. Further, while the NCCHC and organizations like the American Diabetes Association have established screening, diagnosis, and treatment recommendations in prisons and jails, these have not been standardized in jails or prisons. Some prison systems, including Texas, Missouri, and California, have adapted free world measures of quality and have implemented quality improvement projects in the state prison systems (Damberg et al. 2011). For instance, California adopted 79 measures for quality of care, seven of which focus on cardiovascular risk factors and disease. Data on the performance of these prison systems are not publically available. Acute care for chronic medical conditions is typically contracted to outside community hospitals. Only one study has evaluated the quality of care for patients hospitalized with chest pain and found that on average inmate patients with heart disease stay in the hospital longer and receive treatment sooner compared to noninmate patients, indicating that inmates do not receive worse quality hospital care compared to noninmates (Winter 2011).
Transitions Between Correctional And Community Health Systems
Discharge planning does not fall under the constitutional guarantee for health care and nor does health care post-release. Among 33 states surveyed in 2004, all prisons offered some form of discharge planning to a limited number of patients and in most cases only those with HIV disease (Flanagan 2004). Patients with diabetes, hypertension, or cardiovascular disease are often released without medications or a follow-up appointment in the community (Mallik-Kane and Visher 2008). Even when provided medications upon release, many do not obtain them. Recently released inmates are less likely to have a primary care physician and disproportionately use the emergency department for health care compared to the general population. In one study, 90 % of individuals released from jail were uninsured or lacked financial resources to pay for their medical care (Conklin et al. 2000). Inmates with health problems may have a harder time returning to the community, as they are additionally confronted with the task of managing their health problems, obtaining health care, and keeping up with medications or appointments, while meeting their basic needs. Many return to the community without financial resources, housing, employment, or family support. And many individuals convicted of drug felonies are released from prison and prohibited from accessing safety net services, including food stamps, public housing, or federal grants for education.
Epidemiology Of Cardiovascular Risk Factors And Disease
Cardiovascular Disease Mortality Cardiovascular disease is one of the top causes of death of inmates in the incarcerated population. According to the Bureau of Justice Statistics, during the period of 2001–2004, 12,129 state inmates deaths were reported and 27 % of these deaths were attributed to heart disease (Mumola 2007). However, in spite of being a leading cause of death, the risk for death from cardiovascular disease is not higher than what would be expected if they were living in the free world (Spaulding et al. 2011). In contrast, recently released inmates have an increased risk for mortality compared to the general population (Binswanger et al. 2007; Rosen et al. 2008; Spaulding et al. 2011). In a retrospective study of 30,000 individuals released from Washington state prison, recently released inmates had a greater risk of all cause and cardiovascular disease mortality than the general population in the year following release (adjusted HRs 2.1, 95 % CI 1.7–2.6) (Binswanger et al. 2007). Evidence to date suggests that white inmates have an increased risk of dying compared to the general population, whereas blacks do not. A retrospective study of individuals released from North Carolina prison between 1985 and 2000 found that white ex-prisoners had 30 % greater than expected rate of death from diabetes and cardiovascular disease compared to the general population, although no difference was detected among black former inmates (Rosen et al. 2008). A study from Georgia, in which two-thirds of the prison population was black, also found no increased risk of cardiovascular death upon release (Spaulding et al. 2011). Importantly, there have been no national or prospective studies looking at the association between incarceration and cardiovascular disease mortality.