All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-Analysis

Objectives. We systematically reviewed studies of mortality following release from prison and examined possible demographic and methodological factors associated with variation in mortality rates.Methods. We searched 5 computer-based literature indexes to conduct a systematic review of studies that reported all-cause, drug-related, suicide, and homicide deaths of released prisoners. We extracted and meta-analyzed crude death rates and standardized mortality ratios by age, gender, and race/ethnicity, where reported.Results. Eighteen cohorts met review criteria reporting 26 163 deaths with substantial heterogeneity in rates. The all-cause crude death rates ranged from 720 to 2054 per 100 000 person-years. Male all-cause standardized mortality ratios ranged from 1.0 to 9.4 and female standardized mortality ratios from 2.6 to 41.3. There were higher standardized mortality ratios in White, female, and younger prisoners.Conclusions. Released prisoners are at increased risk for death following release from prison, particularly in the early period. Aftercare planning for released prisoners could potentially have a large public health impact, and further work is needed to determine whether certain groups should be targeted as part of strategies to reduce mortality.The global prison population in 2008 was estimated at 9.8 million with a median rate of imprisonment of 145 prisoners per 100 000 persons, most of whom are aged between 18 and 44 years.1 More than 2.3 million of these prisoners reside in the United States, which has the highest rate of imprisonment of 756 per 100 000 population. Natural cause mortality inside prison has been reported to be lower than that of the general population in France,2 Russia,3 England and Wales,4 and the United States.5 However, it is well-established that prisoner suicide rates are elevated compared with age-matched general populations.6 For example, the suicide rate of male prisoners in England and Wales between 1973 and 2003 was found to be 5 times higher than that of the general population,7 and in US jails, it has been reported to be 8 times higher.8 The odds of chronic medical conditions are increased by up to 4 times in US prisons.9 As prison populations are drawn from socioeconomically deprived backgrounds with reduced access to health care and health-seeking behavior when living in the community,10 prison provides an opportunity to provide public health interventions including health education and improving engagement with health services following release.11 For example, targeted health interventions such as medication review12 and HIV health education13,14 have been proposed.The health of prisoners following release from prison is less understood. At the end of 2009 in the United States, 819 308 prisoners were on parole or release following a prison term,15 and in England and Wales 20 895 offenders were released from prison in the first quarter of 2011.16 Despite these high absolute numbers, research has demonstrated that most sampled US jails did not plan for release of prisoners with mental illness, cardiovascular disease, or HIV/AIDS even though they considered it important.17 Mortality from suicide and drug-related causes has been reported to be particularly high in the immediate postrelease period,18,19 and, thus, public health interventions to target this period for those with a history of substance misuse have been outlined.20 The current review aims to synthesize evidence on mortality rates following release from prison and examine possible demographic and methodological factors associated with variation in these rates.     

Aging in Correctional Custody: Setting a Policy Agenda for Older Prisoner Health Care

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.Among Western nations, mass incarceration is a uniquely American experience.1 At the US prison population''s zenith in 2008, 1 in every 100 American adults was incarcerated, with an incarceration rate of 756 per 100 000 persons.2,3 This rate surpasses that of Russia, which has the next-highest rate at 629 per 100 000 persons.3 Perhaps more surprising than the sheer number of Americans who are incarcerated are the changing demographics of the prison population; the most rapidly growing prisoner age groups are middle aged (45–54 years) and older (≥ 55 years).4 Between 2000 and 2009, the overall US prison population increased 16.3%, and the number of older prisoners increased 79.0%.5,6Through the Eighth Amendment to the US Constitution (which protects against cruel and unusual punishment), prisoners have a right to timely access to an appropriate level of care for serious medical needs.7 Yet many health care and service providers in the criminal justice system are underprepared to provide cost-effective quality care for older adults. Older prisoners disproportionately account for escalating correctional health care costs and create new and costly challenges for the criminal justice system. Prison-based health care systems increasingly must provide care to older persons with multiple, costly chronic medical conditions, such as diabetes, heart failure, cognitive impairment, and end-stage liver disease.8–10 Older prisoners also have higher rates of disability than do younger prisoners, and their overall costs are approximately 3 times as high.9,11 In addition, older prisoners may generate high hidden costs. For example, prisons built to house younger persons may need to be renovated or rebuilt to accommodate an increasing number of older prisoners with disabilities.Beyond legal and moral arguments for attention to the health care needs of older prisoners, we should consider other benefits to society. More than 95% of prisoners are eventually released to the community.12 Many have chronic medical conditions and rely on expensive emergency services or are hospitalized after release.13 Earlier identification of and attention to age-related disabilities and chronic disease could foster independent function in the community through the use of community health care resources. Furthermore, prison programs that improve health and cognitive skills or that target substance abuse have been associated with decreased recidivism (and rearrest).14 Jails and prisons are also important sites for delivery of needed medical care to vulnerable populations with infectious diseases such as HIV, tuberculosis, and hepatitis C. In light of the increasing number and associated costs of older prisoners, our constitutional obligation to provide medical care to prisoners, and the potential benefits to society, it is critical that a policy agenda be set to improve older prisoner health care. This policy agenda can be advanced through the efforts of policymakers, correctional administrators, health professions organizations, and correctional health care organizations.We convened a roundtable meeting in 2011 at John Jay College of Criminal Justice in New York City to identify special considerations for the care of older prisoners and to propose a set of priority areas that need to be addressed in a new policy agenda. We also, when appropriate, identified important gaps in knowledge that should be addressed to better inform a policy agenda. This meeting was the third in a series of roundtable discussions that brought US private- and public-sector correctional health care leaders together with leaders in academic medicine, nursing, and civil rights to discuss topical issues in prison health care, where there are no existing standards. Discussion focused on the development of action items and standards through group consensus. The Jacob and Valeria Langeloth Foundation funded the public–private roundtables, with additional funding from private correctional health care vendors and in-kind contributions from John Jay College of Criminal Justice. The first15 and second16 roundtables addressed patient safety and challenges in contracting for correctional health care services, respectively.     

Medication Prescribing Practices for Older Prisoners in the Texas Prison System

Objectives. We sought to assess appropriateness of medication prescribing for older Texas prisoners.Methods. In this 12-month cross-sectional study of 13 117 prisoners (aged ≥ 55 years), we assessed medication use with Zhan criteria and compared our results to prior studies of community prescribing. We assessed use of indicated medications with 6 Assessing Care of Vulnerable Elders indicators.Results. Inappropriate medications were prescribed to a third of older prisoners; half of inappropriate use was attributable to over-the-counter antihistamines. When these antihistamines were excluded, inappropriate use dropped to 14% (≥ 55 years) and 17% (≥ 65 years), equivalent to rates in a Department of Veterans Affairs study (17%) and lower than rates in a health maintenance organization study (26%). Median rate of indicated medication use for the 6 indicators was 80% (range = 12%–95%); gastrointestinal prophylaxis for patients on nonsteroidal anti-inflammatories at high risk for gastrointestinal bleed constituted the lowest rate.Conclusions. Medication prescribing for older prisoners in Texas was similar to that for older community adults. However, overuse of antihistamines and underuse of gastrointestinal prophylaxis suggests a need for education of prison health care providers in appropriate prescribing practices for older adults.More than 1 in 100 Americans are incarcerated in a US prison or jail¹ and older prisoners are among the most rapidly growing correctional populations.^1–4 With high rates of chronic disease,^5–7 older prisoners cost on average 2 to 3 times more than younger prisoners to incarcerate.^1,8 Yet prisons are often ill-equipped to care for older prisoners with complex medical problems, such as functional or cognitive impairments.^9–12 This is largely because older adults have substantively different health care needs than younger adults who have traditionally been the focus of prison health care.¹² Despite the increasing numbers and cost of older prisoners, research about the quality of geriatric care in prisons is sparse.One important difference in the care of younger and older adults is medication prescribing.^13,14 Older adults often require medications for multiple chronic diseases, whereas younger adults typically require short-term medications for acute injuries or infection. Although older patients are at increased risk for medication-related adverse events leading to morbidity, mortality, and high costs,^15,16 underuse of indicated medications can deny older adults improved quality and length of life.¹⁵ Despite the safety concerns and high cost associated with inappropriate medication use in older adults, little is known about medication prescribing practices for older prisoners.We assessed medication prescribing practices among older prisoners in the Texas Department of Criminal Justice (TDCJ)—one of the nation''s largest state prison systems. Since 1994, when the TDCJ implemented an academic-based managed care system run by the University of Texas Medical Branch, it has reported substantial improvements in health care and has been proposed as a nationwide model.^17,18 It is unknown if this improved quality has extended to elements of care of the older prisoners, such as medication prescribing quality.     

Mental Health of Prisoners: Identifying Barriers to Mental Health Treatment and Medication Continuity

Objectives. We assessed mental health screening and medication continuity in a nationally representative sample of US prisoners.Methods. We obtained data from 18 185 prisoners interviewed in the 2004 Survey of Inmates in State and Federal Correctional Facilities. We conducted survey logistic regressions with Stata version 13.Results. About 26% of the inmates were diagnosed with a mental health condition at some point during their lifetime, and a very small proportion (18%) were taking medication for their condition(s) on admission to prison. In prison, more than 50% of those who were medicated for mental health conditions at admission did not receive pharmacotherapy in prison. Inmates with schizophrenia were most likely to receive pharmacotherapy compared with those presenting with less overt conditions (e.g., depression). This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison.Conclusions. A substantial portion of the prison population is not receiving treatment for mental health conditions. This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.Mental health disorders among prisoners have consistently exceeded rates of such disorders in the general population, and correctional facilities in the United States are often considered to be the largest provider of mental health services.1–3 Despite court mandates for access to adequate health care in prisons (these mandates are even further limited to “severe” and “serious” mental illness treatment requirements in prison settings), inmate access to health and mental health care has been sporadic.4,5 Treatment decisions often depend on the limited available resources, public support of correctional treatment, and correctional management decision-making.4,5 Some studies report that at least half of male inmates and up to three quarters of female inmates reported symptoms of mental health conditions in the prior year (compared with 9% or fewer in the general population).3,6–8 These rates underscore the importance of access to mental health treatment for inmates, because lack of access to treatment can have important policy implications, particularly when financial resources are limited for correctional intervention and treatment.Individuals with untreated mental health conditions may be at higher risk for correctional rehabilitation treatment failure and future recidivism on release from prison.2,9,10 In fact, Baillargeon et al.10 found that after release from prison, former inmates who received a professional diagnosis of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental health disorder were 70% more likely to return to prison at least once than were those who were not given a diagnosis. Furthermore, among those who have been previously incarcerated, the rates of recidivism are between 50% and 230% higher for persons with mental health conditions than for those without any mental health conditions, regardless of the diagnosis.The limited treatment options in many prison settings are directly reflected in the greater number of disciplinary problems, rule violations, and physical assaults among those who have mental health disorders,11 often compounded by the resulting solitary confinement as punishment for these behaviors.1 Although all prisons are required to provide some level of health care, we know very little about whether mental health treatment is actually available to inmates on a case-by-case basis.3,9 In fact, Wilper et al. found that most prisoners, even those who have chronic medical conditions (such as diabetes or hypertension), had limited access to health care in prison.3 Therefore, we used a nationally representative sample of US prisoners to assess whether all persons with a history of mental health conditions were screened and evaluated by a medical professional for these conditions and whether medication use was continuous from the community setting to the prison setting.Mental health conditions represent a different level of need when compared with physical health needs among prisoners. For instance, tuberculosis transmission is a physical health hazard to all inmates and staff. Therefore, correctional administrators ensure that individuals suspected of having tuberculosis obtain proper assessment and subsequent access to health care. Symptoms inherent to many mental health disorders, however, may be less obvious to prison staff, especially without assessment by trained mental health professionals. In addition, a report on mental health care in prison emphasized the need for screening and treatment of mental health conditions among inmates from both a legal and a humanitarian perspective.12 Specifically, several US Supreme Court decisions have supported the rights of prisoners to receive health care, including mental health care (see Bowring v Godiva, 551 F2d 44 [4th Cir 1977]; Laamon v. Helgemoe, 437 F Supp 269 [DNH 1977]; and Ruiz v Estelle, 503 F Supp 1265 [SD Tex 1980]). To date, however, a great deal of variation remains in screening for and treatment of mental health disorders in prison settings.13,14 The use of pharmacotherapy, in conjunction with counseling and self-help groups, to treat mental health conditions in correctional settings has been largely accepted in the correctional community; however, many medications are expensive and, therefore, not offered widely within institutions.4,12,13,15Several practical issues might explain why an individual in the correctional system would have difficulty receiving (or continuing to receive) pharmacotherapy for mental health conditions. First, psychologists and psychiatrists who may properly diagnose disorders are in short supply,12 and the screening tools that are typically used in prison settings are not diagnostic tests. Instead, the purpose of these tools is to gauge the security risk of a new inmate at the institution.4 Second, the continuously declining correctional budget may limit treatment access to those with only the most serious mental health conditions.5 In an ideal situation in which a licensed professional properly diagnoses inmates, specialized treatment programs (rarely located inside of prison facilities) are available. Unfortunately, the use of these outside treatment programs is limited, because correctional budgets do not have the extensive resources necessary to manage inmates enrolled in off-site treatment or to handle the logistics (such as secure transport) involved.15The incarceration experience itself poses a challenge to mental health treatment. Untreated mental health (and physical health) conditions are known to result in poor adjustment to life in prison.12 Furthermore, crowded living quarters, lack of privacy, increased risk of victimization, and solitary confinement within the institution have been identified as strong correlates for self-harm and adaptation challenges for those with mental health conditions in prison settings.16,17Given the strong relation between mental health and criminal behavior,18 the public health system has a great deal to gain from better mental health treatment among inmates, particularly in reducing the costs associated with high recidivism rates.5,10,19 Therefore, this study extends previous research on prisoner health conducted by Wilper et al.3 by assessing the continuity of pharmacotherapy (e.g., medication used to treat a mental health condition in prison), beyond the prevalence rates of pharmacotherapy in prison. Furthermore, we examined potential explanations for both continuity and discontinuity of treatment in the inmate population. Specifically, this study will contribute to the literature by evaluating 3 specific aims: (1) to assess medication continuity for a mental health condition since admission to prison; (2) to assess the correlates of medication continuity, medical screening, and receipt of examinations by medical personnel; and (3) to assess the degree to which medication continuity is predicted by screening prisoners for mental health conditions at intake to prison.     

The Collateral Damage of Mass Incarceration: Risk of Psychiatric Morbidity Among Nonincarcerated Residents of High-Incarceration Neighborhoods

Objectives. We examined whether residence in neighborhoods with high levels of incarceration is associated with psychiatric morbidity among nonincarcerated community members.Methods. We linked zip code–linked information on neighborhood prison admissions rates to individual-level data on mental health from the Detroit Neighborhood Health Study (2008–2012), a prospective probability sample of predominantly Black individuals.Results. Controlling for individual- and neighborhood-level risk factors, individuals living in neighborhoods with high prison admission rates were more likely to meet criteria for a current (odds ratio [OR] = 2.9; 95% confidence interval [CI] = 1.7, 5.5) and lifetime (OR = 2.5; 95% CI = 1.4, 4.6) major depressive disorder across the 3 waves of follow-up as well as current (OR = 2.1; 95% CI = 1.0, 4.2) and lifetime (OR = 2.3; 95% CI = 1.2, 4.5) generalized anxiety disorder than were individuals living in neighborhoods with low prison admission rates. These relationships between neighborhood-level incarceration and mental health were comparable for individuals with and without a personal history of incarceration.Conclusions. Incarceration may exert collateral damage on the mental health of individuals living in high-incarceration neighborhoods, suggesting that the public mental health impact of mass incarceration extends beyond those who are incarcerated.The United States leads the world in the percentage of its population that serves time in prison or jail.1,2 As of 2012, nearly 7 million men and women are on probation, parole, or under some other form of community supervision, which means that nearly 3% of the American adult population is currently involved in correctional supervision.3 The burden of incarceration in the United States is not equally distributed in the population. Current estimates from the Bureau of Justice Statistics indicate that 1 of every 3 Black men will serve time in prison in their lifetimes.4 In some communities, these figures are even starker. In Washington, DC, for example, more than 95% of Black men have been in prison in their lifetimes.1 Because of the scope of incarceration within particular subgroups, the current state of the US criminal justice system has been described in such terms as mass imprisonment5 and hyperincarceration.6Research on the health consequences of incarceration falls largely into 2 broad categories. The first, which has received the most empirical attention, has focused on individuals directly involved in the criminal justice system. Individual incarceration exposure is associated with adverse mental7–9 and physical10 health outcomes. A second line of inquiry has evaluated the broader health consequences of incarceration—what has been variously called the “long arm” of corrections,11 the collateral consequences of mass incarceration,5 and “spillover” effects related to incarceration.12 For example, female partners of recently released male prisoners experience depression and anxiety symptoms,13,14 and the children of incarcerated parents are at increased risk for behavioral and mental health problems.15,16 The deleterious health effects of incarceration are not merely confined to the family members of incarcerated individuals, however. Nonincarcerated individuals living in the communities from which inmates are drawn also appear to be at heightened risk for a variety of adverse outcomes, including increased crime rates17 and infectious diseases.18Although this research provides important initial insights into some of the negative consequences of incarceration at the community level, it remains largely unknown whether incarceration influences the mental health of community members who reside in neighborhoods with high-incarceration rates. How might incarceration affect community mental health? High levels of incarceration in neighborhoods can alter the social ecology of communities by eroding social capital and disrupting the kinds of social and family networks and relationships that are necessary for sustaining individuals’ mental health as well as the well-being of communities.1,19–22We examined whether high levels of incarceration in neighborhoods affect the mental health of individuals living in these neighborhoods. We treated incarceration as an ecological or contextual effect, rather than as an individual-level risk factor, which has characterized the majority of research on incarceration and mental health.7,23 That is, rather than examining the mental health consequences of incarceration among those who have themselves been incarcerated or among their family members, we examined the mental health of individuals living in communities that have been exposed to elevated levels of incarceration.     

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003).Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.The average age of the US homeless population is increasing. Whereas 11% of the homeless population was aged 50 years or older in 1990, this percentage had increased to 32% by 20031 and has continued to rise since then.2 The median age of single homeless adults has increased from 37 years in 19901 to between 49 and 50 years today.2,3 This trend is thought to be because of the aging of individuals born in the second half of the baby boom generation (those born 1954–1965), who have a higher risk of homelessness than do other age cohorts.3 Most homeless adults aged 50 years and older are aged between 50 and 64 years, with adults aged 65 years and older making up less than 5% of the total homeless population.1,3In the general population, adults aged 50 to 64 years are considered middle aged and have lower rates of chronic conditions than do those considered elderly, adults aged 65 years and older.4,5 However, homeless adults aged 50 years and older have rates of chronic illnesses and geriatric conditions similar to or higher than those of housed adults 15 to 20 years older, including conditions often thought to be limited to the elderly, such as falls and memory loss.6,7 Because middle-aged homeless adults face the same geriatric problems as do elderly housed adults, experts consider them to be elderly when aged 50 years, despite their relatively younger age.6,8 Similar patterns of premature aging have been found in other vulnerable populations, including prisoners9 and patients with developmental disabilities.10Despite the growth of the older homeless population, relatively little is known about use of health services among older homeless adults. Homeless health services and research have focused on problems that are common among younger homeless adults, including infectious disease,11 substance use,12 and mental illness.13 The few studies that have focused on older homeless adults found that they have medical problems that differ from those of younger homeless adults, including higher rates of chronic illnesses6,14 and geriatric syndromes6 and lower rates of substance use.15 New frameworks for providing care to the vulnerable and growing older population are needed but cannot be developed until more is known about their use of health services.Homeless adults aged 50 years and older use the emergency department (ED) frequently and at rates nearly 4 times those of the general population.16–18 Knowledge about ED care that older homeless adults receive may allow researchers and clinicians to design interventions to reduce use of the ED and improve ED care for this vulnerable older population. Therefore, we have identified the demographic, clinical, and health services characteristics of ED visits in older versus younger homeless adults, using a nationally representative survey of US ED visits.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

The Case for Improving the Health of Ex-Prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill.There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings.There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.The world prison population is more than 10.75 million and is growing at a rate in excess of population growth.1 Although in the United States there is a distinction between prisoners (felony offenders incarcerated in state and federal prisons) and jail detainees (mostly misdemeanor offenders), this distinction is not made in most countries. Here we use the term prisoner to refer to both prisoners and jail detainees. Because of the rapid turnover of custodial populations, it has been estimated that globally, more than 30 million people move through prisons each year.2 Incarceration rates vary markedly within and between countries, and are heavily influenced by public policy decisions, such as the criminalization of drug users3 and the de-institutionalization of the mentally ill.4 The United States has the highest incarceration rate in the world (743 per 100 000 population) and accounts for more than one fifth of the world’s prisoners, with approximately 2.2 million people in custody on any one day.1 Of these, 1.5 million are held in state and federal prisons, and spend on average three years in custody before returning to the community; more than 700 000 are held in local jails, where the average stay is less than seven days. Given the large incarcerated population and rapid turnover of jail detainees, in excess of 11 million persons pass through US correctional facilities each year—more than in any other country.5–7Prisoners globally are characterized by complex and multifaceted health problems.8 Although imprisonment confers its own unique health risks,9,10 health usually improves in custody, where stable accommodation and regular meals are provided at little or no cost, illicit drugs are less readily available, and high-intensity health services are routinely provided.11,12 Unfortunately, these health gains are often rapidly lost after return to the community, where many ex-prisoners experience poor health-related outcomes, including poorly controlled disease,13 elevated rates of life-threatening drug overdose,14,15 preventable hospitalization,16,17 and mortality.18,19 Key to improving these outcomes is increased access to health care for ex-prisoners,20 but this has proven difficult to achieve. Despite recent encouraging research findings,21 the greater challenge has been translating promising pilot programs into policy, at scale and in a sustainable way. Here we make the case for improving the health of ex-prisoners, in the hope that this will provide a platform for evidence-based advocacy to improve the health of this profoundly marginalized, challenging, and underserved population.     

Determining What We Stand for Will Guide What We Do: Community Priorities,Ethical Research Paradigms,and Research With Vulnerable Populations

Prisoners, ex-offenders, and the communities they belong to constitute a distinct and highly vulnerable population, and research must be sensitive to their priorities. In light of recent suggestions that scientific experimentation involving prisoners be reconsidered, community-based participatory research can be a valuable tool for determining the immediate concerns of prisoners, such as the receipt of high-quality and dignified health care inside and outside prisons. In building research agendas, more must be done to ensure the participation of communities affected by the resulting policies.GIVEN RECENT PROPOSALS to reexamine federal regulations pertaining to human experimentation in prisons,^1–4 it is important that more be done to ensure that the viewpoints and life experiences of prisoners, ex-offenders, and their communities be considered. There has been recent debate about what constitutes ethical research in prisons and about the possible expansion of the scope of what is allowable. These questions arise because biomedical researchers are having difficulty in recruiting volunteers for clinical trials⁵ in the United States and because a number of private companies are increasingly seeking volunteers in other countries in which the costs of these experiments are less expensive, protocols are less complex, and compliance standards are less onerous.^6–9Some US researchers suggest that current regulations guiding prison research may be too strict and outdated,^1,4 and arguments have been made in favor of reassessing the current norms.^3,4 It has been noted, for example, that with the existence of institutional research boards, prisoners may actually benefit from this research if protocols are strengthened.^1,3,4 At least one researcher has argued that prisoners have a constitutional right to choose to participate in a study, clinical or otherwise.² Other work has suggested that prisoners ought to have the same access to experimental drugs as people who are not in prison and that there are ways to erect safeguards to ensure that the abuses committed in the past are not repeated.^2–4We argue that until the question of adequate health care for prisoners is resolved, human experimentation should not be allowed. Why are so many people from low-income, minority communities incarcerated? Why do these populations appear to be a convenient and natural source for social research? And, given that prisons do exist, why is it that that a stronger focus is not placed on appropriate and dignified care for confined populations, such as those inside prisons as well as for ex-offenders and their communities? Why is not greater precedence being given to finding the best methods for ensuring one single standard for all?We know, for example, that prisoners tend to be sicker than the rest of the population, bearing significantly higher rates of infectious diseases such as hepatitis C, tuberculosis, and HIV as well as chronic conditions including asthma, hypertension, diabetes, and oral illnesses. High rates of mental illness are also prevalent,^10–12 as well as the co-occurrence of substance abuse and mental illness. How these illnesses are treated in prison, and how much care is provided to ex-offenders after they leave prison, have direct implications for whether an ex-offender will reintegrate into society successfully.¹³For research in prisons to be ethical, it must be interested in upholding prisoners’ constitutional right to appropriate quality care while in prison and ensuring a stronger and more effective safety net for them when they return home. It must focus first on ensuring that the health of all is protected. It must ask what safeguards are in place for those who have engaged in clinical trials while in prison should they later become ill or infected.     

All-cause and cause-specific mortality among men released from state prison, 1980-2005

Objectives. We compared mortality of ex-prisoners and other state residents to identify unmet health care needs among former prisoners.Methods. We linked North Carolina prison records with state death records for 1980 to 2005 to estimate the number of overall and cause-specific deaths among male ex-prisoners aged 20 to 69 years and used standardized mortality ratios (SMRs) to compare these observed deaths with the number of expected deaths had they experienced the same age-, race-, and cause-specific death rates as other state residents.Results. All-cause mortality among White (SMR = 2.08; 95% confidence interval [CI] = 2.04, 2.13) and Black (SMR = 1.03; 95% CI = 1.01, 1.05) ex-prisoners was greater than for other male NC residents. Ex-prisoners'' deaths from homicide, accidents, substance use, HIV, liver disease, and liver cancer were greater than the expected number of deaths estimated using death rates among other NC residents. Deaths from cardiovascular disease, lung cancer, respiratory diseases, and diabetes were at least 30% greater than expected for White ex-prisoners, but less than expected for Black ex-prisoners.Conclusions. Ex-prisoners experienced more deaths than would have been expected among other NC residents. Excess deaths from injuries and medical conditions common to prison populations highlight ex-prisoners'' medical vulnerability and the need to improve correctional and community preventive health services.The United States has the highest incarceration rate in the world,¹ but 95% of prisoners are eventually released,² with most reentering society after less than 2 years of imprisonment.³ The result is a large and ever-increasing population of former inmates.⁴This growing population shoulders a heavy burden of disease, particularly infectious diseases such as hepatitis C virus, HIV, and other sexually transmitted infections.⁵ This burden is a reflection of high disease rates in the impoverished communities from which prisoners come and prisoners'' engagement in behaviors that are both illegal and harmful to health.⁶ Mental health conditions, including substance use disorders, are also common among prisoners.^7,8 These conditions are not only directly harmful, they also may exacerbate other comorbidities (e.g., cardiovascular disease and diabetes)^9,10 and are associated with diminished access to routine medical care.^11,12The transition from prison back into the community is typically difficult. Ex-prisoners often need to seek out housing and employment, reestablish personal relationships, navigate access to supportive services, and abide by the restrictions of parole and other legal sanctions.¹³ These needs frequently supersede routine health care.¹⁴For some, the transition is also dangerous. For ex-prisoners, risk of death in the first year—and especially in the first few weeks—after release is high compared with the risk of death among the general population.^15–18 The vast majority of these deaths are the result of nonnatural causes, particularly homicide, suicide, and drug overdose.^15–18 In one of the few US studies of its kind, risk of death among former Washington state prisoners during the first 2 weeks after release was 12.7 times the risk of death among other state residents, and risk of death from drug overdose during the first 2 weeks after release was 129 times that of other state residents.¹⁸Even less well-studied in the United States are the long-term health outcomes of former prisoners. A large retrospective study conducted in Australia reported that mortality among prisoners exceeded that of the general population across all major causes of death.¹⁹ The public health implication of these findings for the United States is troubling given the large size of the US ex-prisoner population, the heavy burden of disease among prisoners, and the legal sanctions and social stigma that diminish access to resources after release from prison.The purpose of our study was to examine the mortality of prisoners after their release. Specifically, we used age-standardized mortality ratios stratified by race to examine overall and cause-specific mortality among male former inmates. In addition, we examined the relative risk of mortality among former prisoners after we controlled for a measure of socioeconomic status (SES) and assessed time between prison release and death from injuries common to former prisoners. Enumeration of mortality disparities among former inmates could help detect lapses in the continuity between correctional and community health care resources.     

Emergency Care for Homeless Patients: A French Multicenter Cohort Study

Objectives. To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources.Methods. We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition.Results. A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints.Conclusions. We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.On any given night in the European Union, 400 000 people are homeless.1,2 In France, the total number of homeless people increased by 44% between 2001 and 2012.2 These patients experience a high disease burden: it has been reported that there is a higher prevalence in the homeless population of various diseases such as mental illness, substance abuse, injuries, infectious diseases, and cardiovascular diseases than in the general population.1,3–7 Homeless patients seem to be admitted to hospital 10 to 15 years earlier than nonhomeless inpatients for the same diseases, and functional impairment occurs 20 years earlier than in nonhomeless patients.8–10 The all-cause mortality rate among homeless patients at any age is higher than in the general population, which in part is attributable to suicide and unintentional injuries.1,6,11,12Homeless patients often delay seeking medical care. Because they have difficulties in accessing health care, they have a lower rate of access to primary care than the general population.13,14 Their delayed health care can be attributed to a lack of medical insurance coverage, transportation barriers, or competing priorities (such as looking for food or shelter).15 However, homelessness is reported to be an independent risk factor for emergency department (ED) attendance and those patients are more likely to return to the ED after hospitalization.14,16–20 These ED frequent users are seen as prone to difficult behavior and little compliance to treatment.15,21 Some studies have shown that care providers may feel that homeless patients do not receive standard ED care.22–24Even though homeless patients are often frequent ED users, there is scarce literature on health care resource consumption from homeless people in the ED, especially in Europe. As it has been described in other frail populations (such as older patients25,26), we tested the hypothesis that homeless patients experience suboptimal care, by the provision of fewer health care resources.     

The Cost-Effectiveness of School-Based Eating Disorder Screening

Objectives. We aimed to assess the value of school-based eating disorder (ED) screening for a hypothetical cohort of US public school students.Methods. We used a decision-analytic microsimulation model to model the effectiveness (life-years with ED and quality-adjusted life-years [QALYs]), total direct costs, and cost-effectiveness (cost per QALY gained) of screening relative to current practice.Results. The screening strategy cost $2260 (95% confidence interval [CI] = $1892, $2668) per student and resulted in a per capita gain of 0.25 fewer life-years with ED (95% CI = 0.21, 0.30) and 0.04 QALYs (95% CI = 0.03, 0.05) relative to current practice. The base case cost-effectiveness of the intervention was $9041 per life-year with ED avoided (95% CI = $6617, $12 344) and $56 500 per QALY gained (95% CI = $38 805, $71 250).Conclusions. At willingness-to-pay thresholds of $50 000 and $100 000 per QALY gained, school-based ED screening is 41% and 100% likely to be cost-effective, respectively. The cost-effectiveness of ED screening is comparable to many other accepted pediatric health interventions, including hypertension screening.Eating disorders (EDs), including anorexia nervosa, bulimia nervosa, and binge-eating disorder, are prevalent among adolescents.1 Approximately 3.8% of females and 1.5% of males aged 13 to 18 years have an ED,2 and 16.3% of US 9th to 12th graders report engaging in disordered eating behaviors such as fasting or vomiting to lose weight.3 Although efficacious treatments for EDs exist,4 services for these conditions are underused.5 Seventy-eight percent to 88% of adolescents with EDs have contact with a health provider; of these youths, however, only 3% to 28% received treatment specifically for eating problems.1 Left untreated, EDs can significantly affect the length and quality of adolescent lives.6,7 ED medical complication, hospitalization, and mortality rates are the highest of any psychiatric disorder.8–11 Like many other chronic mental heath disorders, EDs can be costly to treat and place a considerable burden on patients and their caregivers. Estimates of the annual impact of EDs on health care costs and economic productivity in Australia and England range from US $1.8 billion to $19.2 billion.12–14 With early diagnosis and timely treatment, we may be able to decrease the economic and health burden of EDs.The American Academy of Pediatrics suggests that schools are a viable setting for health screening.15 Scoliosis, hearing, body mass index, and other health screenings are currently conducted in US public schools or required for enrollment.16 Policies designed to identify secondary school students with ED have been introduced in several states (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). As of September 2013, only 1 state passed legislation aimed at improving detection of EDs, requiring schools to educate parents on how to recognize symptoms of an ED. Three states are currently considering ED-related legislation and ED screening legislation has failed in 2 states (Taryn O’Brien, written communication, September 2013).The impact of school-based screening on ED diagnosis and treatment duration is unknown. No studies have evaluated the health or economic impact of screening for EDs in school-based settings. Given the high proportion of EDs that remain undetected and the fact that no states currently mandate ED screening, experimentally evaluating the benefits of such screening programs in the real world would be resource intensive and may underestimate the potential benefits of screening. However, simulation models can be used to estimate the cost-effectiveness of screening with few constraints.17 We used a decision-analytic simulation model to evaluate the cost-effectiveness of a theoretical school-based ED screening program.     

Visiting the Emergency Department for Dental Problems: Trends in Utilization, 2001 to 2008

Objectives. We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care.Methods. Data from 2001 through 2008 were collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Population-based visit rates for dental problems, and, for comparison, asthma, were calculated using annual US Census Bureau estimates. As part of the analysis, we described patient characteristics associated with large increases in ED dental utilization.Results. Dental visit rates increased most dramatically for the following subpopulations: those aged 18 to 44 years (7.2–12.2 per 1000, P < .01); Blacks (6.0–10.4 per 1000, P < .01); and the uninsured (9.5–13.2 per 1000, P < .01). Asthma visit rates did not change although dental visit rates increased 59% from 2001 to 2008.Conclusions. There is an increasing trend in ED visits for dental issues, which was most pronounced among those aged 18 to 44 years, the uninsured, and Blacks. Dental visit rates increased significantly although there was no overall change in asthma visit rates. This suggests that community access to dental care compared with medical care is worsening over time.Medically underserved patients are increasing their reliance upon emergency departments (EDs) as a safety net provider because of absent or inadequate access to other sources of medical care.1 Many Americans turn to the ED for a variety of health care needs, including dental care, when access to professional dental care is limited.2 Visits to the ED for dental issues have been shown to increase as Medicaid reimbursement declines or is eliminated.3,4 Recent literature has linked the loss of state Medicaid dental benefits along with increases in dental ED use and expenditures to the decrease in utilization of preventive services.5,6 Age-related trends in dental disease may contribute to an overall increased need for dental services over time. Specifically, middle-aged and older adults are experiencing greater rates of tooth retention, thus increasing the demand for care in this cohort.To date, there are no published reports that quantify temporal trends in national ED utilization patterns for dental issues, although there are several reasons to believe dental care is more difficult to access than medical care. Dental insurance coverage, in addition to provider workforce, health beliefs, and social determinants of health, is one of many important factors in promoting dental care utilization, particularly for vulnerable populations.7–10 First, a greater number of Americans have medical insurance compared with dental insurance, with estimates of as many as 130 million Americans without dental coverage.11 Second, public and private insurance programs tend to cover medical care more extensively than dental care for adults, resulting in higher out-of-pocket cost for dental care.12–14 Medicaid-covered adult dental benefits vary between states but generally are limited to individuals with incomes well below the poverty line and to emergency dental care. Recent state budget cuts have further limited adult dental care options. The majority of low-income adults do not receive basic dental care and experience limited coverage, access, and use of dental care.15 As a result, access to dental care is dependent on both insurance coverage and sufficient discretionary income. Third, although medical care for the uninsured and underinsured is supported by an extensive public health safety net, the dental public health infrastructure is quite limited.16 Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes (community health centers that resemble FQHCs but do not receive grant funding) serve an increasing role in providing primary care to underserved areas. From 2007 to 2010 the number of FQHCs increased from 1067 (16 050 835 patients) to 1124 (19 469 467 patients).17 The FQHC patient demographic comprises mostly low-income, underinsured patients or those on public insurance programs. FQHCs and Look-Alikes that receive federal grant funding must provide access to dental services for their patients. However, FQHCs face difficulties in recruitment and retention of dental providers.18In the absence of adequate community-based dental care, another source of dental care for vulnerable populations are EDs, which are staffed by medical providers and rarely employ dentists. Seeking care in the ED for a dental issue often results in temporizing treatment through symptomatic relief (antibiotics and narcotics), which does not definitively treat the underlying disease process.19a Therefore, use of the ED for dental problems is a marker for disparities in dental care quality and access.We hypothesized that with secular changes over time (e.g., economic downturn, increased unemployment, budget deficits, public program reductions), access to appropriate sources of dental care would decrease, resulting in increased ED utilization for dental problems. The unemployment rate, according to the Bureau of Labor Statistics, was 4.6% before the most recent recession (2006) and peaked at 10.3% (2009).19b We hypothesized that there is a positive relationship between the recent economic recession and higher utilization of EDs for untreated dental problems, which serves as a marker for reduced access to preventive dental care. We also hypothesized that, although similar factors would also impact access to medical care, there would be a more substantial rise in ED dental visits for the reasons discussed above. Therefore, we expected a greater increase in ED dental utilization compared with ED use for ambulatory-care sensitive conditions.     

Older Jail Inmates and Community Acute Care Use

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release.Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use.Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89).Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.Jail has become a critical site for linking medically vulnerable older adults to community health care. Approximately 12 million Americans pass through jails each year and nearly all return to the community within 6 months where many struggle to access nonemergency medical care. Between 1996 and 2008 the number of “older” or “geriatric” inmates (aged 55 years or older) increased 278% compared with a 53% growth in the overall jail population.1,2 Now, approximately 550 000 older adults spend time in jail each year, comprising 10% of all inmates. Yet little is known about their health care and social service needs.Reducing acute care use (hospitalizations and emergency department [ED] use) and improving insurance access for former inmates is a priority in the Affordable Care Act (ACA).3 Although most inmates are without health insurance,4 those with insurance demonstrate reduced recidivism and better access to mental health and substance abuse treatment when released.5–7 The ACA expands Medicaid eligibility for low-income adults and allows eligible inmates to apply for coverage while in jail.3,8 As most persons passing through jails will be eligible for Medicaid in states participating in the expansion, an estimated 4 to 6 million jail inmates will gain new coverage by the end of 2014 through outreach and patient navigator assistance.9For community-dwelling older adults, health and social factors beyond insurance drive community acute care use, such as functional impairment, uncontrolled symptoms, and housing instability.10–12 This may also be true for older former inmates, many of whom experience “accelerated aging” because of high rates of disability and chronic disease at relatively young ages.13 Therefore, we conducted a study of older jail inmates to describe predetainment acute care use and anticipated plans for using acute care after release, and to assess the factors associated with use.     

Colorectal Cancer Screening Among the Homeless Population of New York City Shelter-Based Clinics

Objectives. We determined colorectal cancer (CRC) screening rates, predictors, and barriers in 2 major New York City shelter-based clinics.Methods. We extracted screening rates, sociodemographic characteristics, and factors associated with homelessness from medical records of domiciled and homeless patients aged 50 years and older (n = 443) with at least 3 clinic visits between 2010 and 2012.Results. The majority of patients were African American or Hispanic, 76% were male, and 60.7% were homeless (mean = 2.4 years; SD = 2.8 years). Domiciled patients were more likely than homeless patients to be screened (41.3% vs 19.7%; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening (P < .001). In logistic regression, gender, race, duration of homelessness, insurance status, substance and alcohol abuse, chronic diseases, and mental health were not associated with screening, but housing, provider counseling, and older age were.Conclusions. Proposed interventions to improve CRC screening include respite shelter rooms for colonoscopy prepping, patient navigators to help navigate the health system and accompany patients to and from the procedure, counseling at all clinical encounters, and tailored patient education to address misconceptions.Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death in the Unites States, with 53 000 largely preventable deaths annually.1,2 CRC screening reduces morbidity and mortality by 60% and is considered the standard of care.3 The US Preventive Services Task Force (USPSTF) recommends CRC screening for all adults aged 50 to 75 years and for high-risk adults until age 85 years: a fecal occult blood test (FOBT) once per year, flexible sigmoidoscopy every 5 years with an FOBT every 3 years, or screening colonoscopy every 10 years.2 Despite recommendations, screening rates for CRC remain lower than for other types of cancer.1Little is known about CRC screening practices in the homeless population,4 but this population is expanding. An estimated 3.5 million Americans experience homelessness each year, and an estimated 633 782 people experience homelessness each night in the United States.5,6 More than 15% of these individuals are chronically homeless, and more than 18% of the homeless are older than 50 years.5,7 This population is aging and has a large component of persons born during the latter part of the baby boom era. Men aged 45 to 54 years are at the highest risk for homelessness, and many of them are veterans.8 These individual are entering their 50s and are due for CRC screening.2,9,10 New York State''s homeless population surpasses the national average, and the rate of chronic homelessness is rising.5 New York City is experiencing an all-time high of homelessness, with more than 28 000 adults sleeping each night in the municipal shelter system11 and approximately 3000 living on the streets.12Barriers to CRC screening include low rates of provider recommendation and patients’ lack of CRC knowledge,13–15 invasiveness, extensive preparation, discomfort, inability to pay for screening or follow-up care or lack of medical insurance,13 lack of trust in physicians, embarrassment, absence of symptoms, and fatalistic views about cancer.16 Screening rates are particularly low in minority and low-income populations, and these groups suffer higher rates of CRC mortality, in part because cancers are detected at a later stage.1,4 Other risk factors for never having or not being up-to-date with screening recommendations are Hispanic ethnicity, low education level, low income, recent immigration status, lack of a primary care physician, and no visit to a physician in the past year.17 Interventions implemented in primary care settings to improve CRC screening rates among racial and ethnic minorities have helped improve rates significantly.18Homeless persons are especially vulnerable and suffer worse health than domiciled ethnic and minority populations. The homeless have high rates of physical illness, mental illness, and substance abuse and are at increased risk for premature death.10,19 They are less likely to have a primary care provider and to adhere to medication regimens.10 Subsistence needs often take priority over health care that is not seen as urgent, such as preventive care. Furthermore, past experiences of discrimination in the health care setting decrease their likelihood of seeking health care again.16,19A considerable portion of nondomiciled Americans would likely benefit from CRC screening. We compared CRC screening rates among a New York City homeless population and an underserved population that used the same health facilities for adherence to USPSTF recommendations and identified predictors of and barriers to screening among the homeless population.     

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.Approximately 400 000 to 500 000 US emergency department (ED) visits occur annually for suicide attempts.1,2 The ED is a primary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and discharged directly to outpatient care.1,2 Unfortunately, only 50% of these patients follow up on their referrals and attend 1 or more outpatient behavioral health sessions.3 Consequently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for a suicide-related concern return to the ED for another suicide-related concern within 1 year,4 and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6–8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an important intervention site to increase outpatient treatment engagement and reduce repeat suicidal behavior, ED visits, and hospitalizations.11     

Medicaid Policies and Practices in US State Prison Systems

Medicaid is an important source of health care coverage for prison-involved populations. From 2011 to 2012, we surveyed state prison system (SPS) policies affecting Medicaid enrollment during incarceration and upon release; 42 of 50 SPSs participated.Upon incarceration, Medicaid benefits were suspended in 9 (21.4%) SPSs and terminated in 28 (66.7%); 27 (64.3%) SPSs screened prisoners for potential Medicaid eligibility.Although many states supported Medicaid enrollment upon release, several did not. We have considered implications for Medicaid expansion.Prisoners have a heavy burden of disease.1–5 For qualifying individuals (e.g., disabled, impoverished adults with dependents and—starting in 2014 in states that choose to expand their Medicaid eligibility as part of health care reform—impoverished adults without dependents), Medicaid can provide health care coverage before and after incarceration.6 Although not assessed nationally, a study of former Texas and Ohio prisoners found that only 8% of men and 21% of women enrolled in Medicaid 8 to 10 months after release, whereas 68% and 58%, respectively, were without any health care coverage.7 Medicaid can also provide health care coverage for eligible prisoners during incarceration, when care is delivered in an inpatient setting, separate from the prison system.8Despite the role of Medicaid in financing health care for prisoners and former prisoners, the current landscape of policies and practices affecting state prisoners’ enrollment in Medicaid has not been broadly assessed. To address this gap, we conducted a survey to understand Medicaid policies and practices employed in state prison systems (SPSs).