Andrew P. Wilper

The Health and Health Care of US Prisoners: Results of a Nationwide Survey

OBJECTIVES We analyzed the prevalence of chronic illnesses, including mental illness, and access to health care among US inmates. METHODS We used the 2002 Survey of Inmates in Local Jails and the 2004 Survey of Inmates in State and Federal Correctional Facilities to analyze disease prevalence and clinical measures of access to health care for inmates. RESULTS Among inmates in federal prisons, state prisons, and local jails, 38.5% (SE = 2.2%), 42.8% (SE = 1.1%), and 38.7% (SE = 0.7%), respectively, suffered a chronic medical condition. Among inmates with a mental condition ever treated with a psychiatric medication, only 25.5% (SE = 7.5%) of federal, 29.6% (SE = 2.8%) of state, and 38.5% (SE = 1.5%) of local jail inmates were taking a psychiatric medication at the time of arrest, whereas 69.1% (SE = 4.8%), 68.6% (SE = 1.9%), and 45.5% (SE = 1.6%) were on a psychiatric medication after admission. CONCLUSIONS Many inmates with a serious chronic physical illness fail to receive care while incarcerated. Among inmates with mental illness, most were off their treatments at the time of arrest. Improvements are needed both in correctional health care and in community mental health services that might prevent crime and incarceration.

Health Insurance and Mortality in US Adults

OBJECTIVES A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. METHODS We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. RESULTS Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance. CONCLUSIONS Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

Increasing Length of Stay Among Adult Visits to U.S. Emergency Departments, 2001–2005

BACKGROUND Emergency departments (EDs) are traditionally designed to provide rapid evaluation and stabilization and are neither staffed nor equipped to provide prolonged care. Longer ED length of stay (LOS) may compromise quality of care and contribute to delays in the emergency evaluation of other patients. OBJECTIVES The objective was to determine whether ED LOS increased between 2001 and 2005 and whether trends varied by patient and hospital factors. METHODS This was a retrospective analysis of a nationally representative sample of 138,569 adult ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001 to 2005. ED LOS was measured from registration to discharge. RESULTS Median ED LOS increased 3.5% per year from 132 minutes in 2001 to 154 minutes in 2005 (p-value for trend < 0.001). There was a larger increase among critically ill patients for whom ED LOS increased 7.0% annually from 185 minutes in 2001 to 254 minutes in 2005 (p-value for trend < 0.01). ED LOS was persistently longer for black/African American, non-Hispanic patients (10.6% longer) and Hispanic patients (13.9% longer) than for non-Hispanic white patients, and these differences did not diminish over time. Among factors potentially associated with increasing ED LOS, a large increase was found (60.1%, p-value for trend < 0.001) in the use of advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MR], and ultrasound [US]) and in the proportion of ED visits at which five or more diagnostic or screening tests were ordered (17.6% increase, p-value for trend = 0.001). The proportion of uninsured patients was stable throughout the study period, and EDs with predominately privately insured patients experienced significant increases in ED LOS (4.0% per year from 2001 to 2005, p-value for trend < 0.01). CONCLUSIONS Emergency department LOS in the United States is increasing, especially for critically ill patients for whom time-sensitive interventions are most important. The disparity of longer ED LOS for African Americans and Hispanics is not improving.

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

OBJECTIVES We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care. METHODS Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485). RESULTS Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia. CONCLUSIONS Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

Instituting systems-based practice and practice-based learning and improvement: a curriculum of inquiry

Background The Accreditation Council for Graduate Medical Education (ACGME) requires that training programs integrate system-based practice (SBP) and practice-based learning and improvement (PBLI) into internal medicine residency curricula. Context and setting We instituted a seminar series and year-long-mentored curriculum designed to engage internal medicine residents in these competencies. Methods Residents participate in a seminar series that includes assigned reading and structured discussion with faculty who assist in the development of quality improvement or research projects. Residents pursue projects over the remainder of the year. Monthly works in progress meetings, protected time for inquiry, and continued faculty mentorship guide the residents in their project development. Trainees present their work at hospital-wide grand rounds at the end of the academic year. We performed a survey of residents to assess their self-reported knowledge, attitudes and skills in SBP and PBLI. In addition, blinded faculty scored projects for appropriateness, impact, and feasibility. Outcomes We measured resident self-reported knowledge, attitudes, and skills at the end of the academic year. We found evidence that participants improved their understanding of the context in which they were practicing, and that their ability to engage in quality improvement projects increased. Blinded faculty reviewers favorably ranked the projects’ feasibility, impact, and appropriateness. The ‘Curriculum of Inquiry’ generated 11 quality improvement and research projects during the study period. Barriers to the ongoing work include a limited supply of mentors and delays due to Institutional Review Board approval. Hospital leadership recognizes the importance of the curriculum, and our accreditation manager now cites our ongoing work. Conclusions A structured residency-based curriculum facilitates resident demonstration of SBP and practice-based learning and improvement. Residents gain knowledge and skills though this enterprise and hospitals gain access to trainees who help to solve ongoing problems and meet accreditation requirements.

Changes in Idaho primary care physician clinical work hours, 1996-2009.

increase in related costs, calling attention to the increasingly important role these hospitals play in the US health care system. Drs Votto and Hotes and Dr Muldoon correctly state that our study cannot be used to infer whether care in a longterm acute care hospital is beneficial or harmful compared with an alternative site of care. As we stated in our discussion, there are plausible reasons why long-term acute care hospitals might either improve or worsen outcomes after critical illness. The studies quoted by Votto and Hotes, as well as others, provide important preliminary evidence but do not offer definitive conclusions. Rigorous comparative effectiveness research is needed to determine not only which patients may benefit from the services long-term acute care hospitals provide, but also the optimal site of care for these services. We disagree with the letter writers that MedPAR files lack sufficient “clinical nuances” or are “necessarily dated” and thus are unable to contribute to the policy debate. Despite their well-known limitations, for decades administrative data such as MedPAR have been an essential resource for important questions concerning US health policy. By suggesting an implausible evidentiary standard, the writers create a world in which the structures and processes that comprise the health care system cannot be critically evaluated. Such a scenario is neither practical nor tenable. For matters so consequential to patient welfare and public finances as the care of critically ill individuals, real-world effectiveness research using the best available data are urgently needed.

Primary care collaborative practice in quality improvement: Description of an interprofessional curriculum

Purpose. An innovative quality improvement (QI)–focused interprofessional training curriculum for pharmacy residents and other healthcare trainees is described. Summary. Effective interprofessional collaboration and the ability to carry out QI initiatives are important skills for all healthcare trainees to develop when they are in training. To cultivate those skills, in 2011 a Veterans Affairs medical center in Idaho implemented a unique yearlong interprofessional curriculum for healthcare trainees, including postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residents, physician trainees in internal medicine, nurses, and psychologists. The curriculum has both didactic and experiential components. After attending a series of 1‐hour workshops early in the academic year, trainees are assigned to interprofessional teams and work for the remainder of the year to complete QI projects. Over 100 trainees have participated in the interprofessional QI curriculum, with the majority of trainee projects based in the primary care setting. Pharmacy residents were involved in 62% of the projects completed in the 6 academic years ending with the 2016–17 year. Conclusion. Establishing an interprofessional QI curriculum allowed pharmacy residents in PGY1 and PGY2 programs to collaborate with other members of the healthcare team. Benefits include QI skills development, a greater understanding of QI initiatives at the institution, stronger relationships with other healthcare trainees and mentors, and improvements to patient care and safety and facility performance.

WILPER ET AL. RESPOND

The United States has embraced mass incarceration as social policy. We join the American Public Health Association in opposition to this practice and consider it to be a national disgrace.1 This convention violates the human and constitutional rights of many inmates, and damages communities and children raised with a parent behind bars. Incarceration of the mentally ill is especially egregious, common, and often preventable. We believe that everyone has a right to high-quality health care, whether they are incarcerated or not. As a Bush administration surgeon general put it in a report that was suppressed for fear that it would force increases in government spending, “Often overlooked by the health system in the United States, incarcerated men and women have access to adequate health and mental health care and substance abuse treatment services inside the walls of correctional facilities. For these inmates, incarceration is an opportunity—a ‘reachable, teachable moment’—to learn what support they need for their health and mental health problems and substance abuse issues.”2,3 Our study sheds light on a fact largely known only by inmates and those working in correctional health care: inmates carry a heavy disease burden, and often have limited access to the care that is supposedly guaranteed to them by the Supreme Court. The results of our study deflate the credibility of claims that inmates have access to adequate health care in the United States. We concur with Ebers call for a greater role for public health expertise in improving inmate health through litigation. Limited access to health care in jails and prisons certainly increases morbidity and mortality among inmates, but also increases the burden communities bear where released inmates return. Indeed, with approximately 1% of US adults behind bars, the public health implications of improved treatment of these individuals who have relatively higher rates of chronic conditions such as HIV, asthma, prior myocardial infarction, and diabetes are substantial. Inmates rely entirely on their jailers for health care. Investigations into the health and health care of inmates focus attention on a politically unpopular but extremely vulnerable group. Funders and researchers aiming to improve health care for disadvantaged populations should devote additional resources for investigations into inmate health. The public health community ought to oppose mass incarceration and work to improve health care inside prisons.