Prison health services: a utilization study

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Background

Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population.

Methods

We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method.

Results

Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care.

Conclusions

Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3660-2) contains supplementary material, which is available to authorized users.

The health care utilization of people in prison and after prison release: A population-based cohort study in Ontario, Canada

BACKGROUND

Many people experience imprisonment each year, and this population bears a disproportionate burden of morbidity and mortality. States have an obligation to provide equitable health care in prison and to attend to care on release. Our objective was to describe health care utilization in prison and post-release for persons released from provincial prison in Ontario, Canada in 2010, and to compare health care utilization with the general population.

METHODS

We conducted a population-based retrospective cohort study. We included all persons released from provincial prison to the community in 2010, and age- and sex-matched general population controls. We linked identities for persons released from prison to administrative health data. We matched each person by age and sex with four general population controls. We examined ambulatory care and emergency department utilization and medical-surgical and psychiatric hospitalization, both in prison and in the three months after release to the community. We compared rates with those of the general population.

RESULTS

The rates of all types of health care utilization were significantly higher in prison and on release for people released from prison (N = 48,861) compared to general population controls (N = 195,444). Comparing those released from prison to general population controls in prison and in the 3 months after release, respectively, utilization rates were 5.3 (95% CI 5.2, 5.4) and 2.4 (95% CI 2.4, 2.5) for ambulatory care, 3.5 (95% CI 3.3, 3.7) and 5.0 (95% CI 4.9, 5.3) for emergency department utilization, 2.3 (95% CI 2.0, 2.7) and 3.2 (95% CI 2.9, 3.5) for medical-surgical hospitalization, and 21.5 (95% CI 16.7, 27.7) and 17.5 (14.4, 21.2) for psychiatric hospitalization. Comparing the time in prison to the week after release, ambulatory care use decreased from 16.0 (95% CI 15.9,16.1) to 10.7 (95% CI 10.5, 10.9) visits/person-year, emergency department use increased from 0.7 (95% CI 0.6, 0.7) to 2.6 (95% CI 2.5, 2.7) visits/person-year, and hospitalization increased from 5.4 (95% CI 4.8, 5.9) to 12.3 (95% CI 10.1, 14.6) admissions/100 person-years for medical-surgical reasons and from 8.6 (95% CI 7.9, 9.3) to 17.3 (95% CI 14.6, 20.0) admissions/100 person-years for psychiatric reasons.

CONCLUSIONS

Across care types, health care utilization in prison and on release is elevated for people who experience imprisonment in Ontario, Canada. This may reflect high morbidity and suboptimal access to quality health care. Future research should identify reasons for increased use and interventions to improve care.

Exploring differences in healthcare utilization of prisoners in the Canton of Vaud, Switzerland

Prison healthcare is an important public health concern given the increasing healthcare needs of a growing and aging prison population, which accumulates vulnerability factors and suffers from higher disease prevalence than the general population. This study identifies the key factors associated with outpatient general practitioner (GP), nursing or psychiatric healthcare utilization (HCU) within prisons. Cross-sectional data systematically collected by the prison medical staff were obtained for a sample of 1664 adult prisoners of the Canton of Vaud, Switzerland, for the year 2011. They contain detailed information on demographics (predisposing factors), diagnosed chronic somatic and psychiatric disorders (needs factors), as well as prison stay characteristics (contextual factors). For GP, nurse and psychiatric care, two-part regressions are used to model separately the probability and the volume of HCU. Predisposing factors are generally not associated with the probability to use healthcare services after controlling for needs factors. However, female inmates use higher volumes of care, and the volume of GP consultations increases with age. Chronic somatic and psychiatric conditions are the most important predictors of the probability of HCU, but associations with volumes differ in their magnitude and significance across disease groups. Infectious, musculoskeletal, nervous and circulatory diseases actively mobilize GP and nursing staff. Schizophrenia, illicit drug and pharmaceuticals abuse are strongly positively associated with psychiatric and nurse HCU. The occupancy rate displays positive associations among contextual factors. Prison healthcare systems face increasingly complex organizational, budgetary and ethical challenges. This study provides relevant insights into the HCU patterns of a marginalized and understudied population.

Impact of a prison triage system on injuries seen in emergency departments

OBJECTIVES

1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system.

DESIGN

A chart review.

SETTING

The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males.

OBSERVATIONS

Injuries to male prisoners (ages 18-75 years) who were treated in the ED during 1996-98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996-98 were compared with those seen during a similar period prior to the introduction of the triage system (1981-84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay.

RESULTS

148 prisoner injuries were identified for 1996-98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p < 0.001), blunt head injuries (10.1% vs. 2.2%, p < 0.001), hospital admissions (42.6% vs. 4.1%, p < 0.001) and deaths (2.7% vs. 0.6%, p < 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after], p < 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p < 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p < 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p < 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99).

CONCLUSIONS

The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.

Effects of disclosure of traumatic events on illness behavior among psychiatric prison inmates

To assess the health effects of writing about traumatic events in a clinical population, 98 psychiatric prison inmates were randomly assigned to 1 of 3 conditions in which they were asked to write about their deepest thoughts and feelings surrounding upsetting experiences (trauma writing condition), write about trivial topics (trivial writing control), or go about their daily routine without writing (no-writing control). Both writing groups wrote for 20 min per day for 3 consecutive days. Participants in the trauma condition reported experiencing more physical symptoms subsequent to the intervention relative to those in the other conditions. Despite this, controlling for prewriting infirmary visits, sex offenders in the trauma writing condition decreased their postwriting infirmary visits. These results are congruent with predictions based on stigmatization and inhibition.

The disease profile of Texas prison inmates

PURPOSE

Whereas prison inmates are reported to exhibit poorer overall health status and higher rates of health care utilization than the general population, no current information exists on the overall disease profile of the U.S. prison population. The present study examined the prevalence of major acute and chronic conditions in one of the nation's largest prison populations.

METHODS

The study population consisted of 170,215 Texas Department of Criminal Justice (TDCJ) inmates who were incarcerated between August 1997 and July 1998. Information on medical conditions and sociodemographic factors was obtained from an institution-wide medical information system.

RESULTS

Infectious diseases (29.6%) constituted the most prevalent major disease category among inmates. This was followed by diseases of the musculoskeletal system and connective tissue (15.3%), diseases of the circulatory system (14.0%), mental disorders (10.8%), and diseases of the respiratory system (6.3%). Among the specific conditions examined, evidence of tuberculosis infection without active pulmonary disease (20.1%) was found to be the most prevalent condition, followed by hypertension (9.8%), asthma (5.2%), low back pain (5.1%), and viral hepatitis (5.0%).

CONCLUSIONS

The present study shows that for a number of conditions, the prison population exhibited prevalence rates that were substantially higher than those reported for the general population. Moreover, estimates for a number of diseases varied substantially according to age, race, and gender. Understanding the disease profile in U.S. incarcerated populations will permit correctional administrators to develop more efficient health care delivery systems for prison inmates.

Health behind bars: utilization and evaluation of medical care among jail inmates

Jail and prison inmates experience disproportionately high levels of chronic and acute physical health problems, resulting in increased utilization of health services in correctional institutions. Variations in both health status and health care utilization are likely, although several important factors have been under-researched. Gender, in particular, is presumed to influence health outcomes and use of medical care in correctional facilities. The current study explores the physical health status of a systematic sample of 198 male and female inmates incarcerated in a large county jail located in a medium-sized Southern city. Using multiple regression analysis, predictors of physical health status, utilization of medical care, and inmates' evaluations of the accessibility and quality of health care are identified. The results indicate that gender and age are the most consistent demographic predictors of health status and medical care utilization, with females and older inmates reporting higher morbidity and concomitantly higher numbers of medical encounters. The experience of incarceration also appears to influence the physical health of inmates, as self-reported health problems increase with inmates' duration of incarceration. Evaluations of jail medical care differ significantly by gender, with female inmates reporting more difficulty accessing health services, yet higher satisfaction with the quality of services received. The results suggest a need for medical care in correctional settings to adapt to the medical needs of older inmates and women, in addition to improving treatment for chronic conditions and preventive services.