Emily A. Wang

Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study

BACKGROUND Incarceration is associated with increased cardiovascular disease mortality, but prospective studies exploring mechanisms of this association are lacking. METHODS We examined the independent association of prior incarceration with incident hypertension, diabetes, and dyslipidemia using the Coronary Artery Risk Development in Young Adults (CARDIA) study-a cohort of young adults aged 18 to 30 years at enrollment in 1985-1986, balanced by sex, race (black and white), and education (high school education or less). We also examined the association of incarceration with left ventricular hypertrophy on echocardiography and with barriers to health care access. RESULTS Of 4350 participants, 288 (7%) reported previous incarceration. Incident hypertension in young adulthood was more common among former inmates than in those without incarceration history (12% vs 7%; odds ratio, 1.7 [95% confidence interval {CI}, 1.2-2.6]), and this association persisted after adjustment for smoking, alcohol and illicit drug use, and family income (adjusted odds ratio [AOR], 1.6 [95% CI, 1.0-2.6]). Incarceration was significantly associated with incident hypertension in those groups with the highest prevalence of prior incarceration, ie, black men (AOR, 1.9 [95% CI, 1.1-3.5]) and less-educated participants (AOR, 4.0 [95% CI, 1.0-17.3]). Former inmates were more likely to have left ventricular hypertrophy (AOR, 2.7, [95% CI, 0.9-7.9]) and to report no regular source for medical care (AOR, 2.5, [95% CI, 1.3-4.8]). Cholesterol levels and diabetes rates did not differ by history of incarceration. CONCLUSIONS Incarceration is associated with future hypertension and left ventricular hypertrophy among young adults. Identification and treatment of hypertension may be important in reducing cardiovascular disease risk among formerly incarcerated individuals.

Engaging Individuals Recently Released From Prison Into Primary Care: A Randomized Trial

OBJECTIVES Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care-based care management program with a community health worker, versus expedited primary care. METHODS We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit). RESULTS Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04). CONCLUSIONS Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care-based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.

Transitions clinic: creating a community-based model of health care for recently released California prisoners.

Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Healths safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.

A Heavy Burden: The Cardiovascular Health Consequences of Having a Family Member Incarcerated

OBJECTIVES We examined the association of family member incarceration with cardiovascular risk factors and disease by gender. METHODS We used a sample of 5470 adults aged 18 years and older in the National Survey of American Life, a 2001-2003 nationally representative cross-sectional survey of Blacks and Whites living in the United States, to examine 5 self-reported health conditions (diabetes, hypertension, heart attack or stroke, obesity, and fair or poor health). RESULTS Family member incarceration was associated with increased likelihood of poor health across all 5 conditions for women but not for men. In adjusted models, women with family members who were currently incarcerated had 1.44 (95% confidence interval [CI] = 1.03, 2.00), 2.53 (95% CI = 1.80, 3.55), and 1.93 (95% CI = 1.45, 2.58) times the odds of being obese, having had a heart attack or stroke, and being in fair or poor health, respectively. CONCLUSIONS Family member incarceration has profound implications for womens cardiovascular health and should be considered a unique risk factor that contributes to racial disparities in health.

Discharge Planning and Continuity of Health Care: Findings From the San Francisco County Jail

Continuity of health care among the formerly incarcerated is an emerging public health challenge. We used data from the San Francisco County Jail to determine whether discharge planning improves access to care on release. Inmates who were HIV positive and received discharge planning were 6 times more likely to have a regular source of care in the community compared with inmates with other chronic medical conditions, and they were as likely to have a regular source of care compared with the general San Francisco population.

Mass incarceration, public health, and widening inequality in the USA

In this Series paper, we examine how mass incarceration shapes inequality in health. The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. However, until recently the public health implications of mass incarceration were unclear. Most research in this area has focused on the health of current and former inmates, with findings suggesting that incarceration could produce some short-term improvements in physical health during imprisonment but has profoundly harmful effects on physical and mental health after release. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries. Research into interventions, policies, and practices that could mitigate the harms of incarceration and the post-incarceration period is urgently needed, particularly studies using rigorous experimental or quasi-experimental designs.

How Health Care Reform Can Transform The Health Of Criminal Justice–Involved Individuals

Provisions of the Affordable Care Act offer new opportunities to apply a public health and medical perspective to the complex relationship between involvement in the criminal justice system and the existence of fundamental health disparities. Incarceration can cause harm to individual and community health, but prisons and jails also hold enormous potential to play an active and beneficial role in the health care system and, ultimately, to improving health. Traditionally, incarcerated populations have been incorrectly viewed as isolated and self-contained communities with only peripheral importance to the public health at large. This misconception has resulted in missed opportunities to positively affect the health of both the individuals and the imprisoned community as a whole and potentially to mitigate risk behaviors that may contribute to incarceration. Both community and correctional health care professionals can capitalize on these opportunities by working together to advocate for the health of the criminal justice-involved population and their communities. We present a set of recommendations for the improvement of both correctional health care, such as improving systems of external oversight and quality management, and access to community-based care, including establishing strategies for postrelease care and medical record transfers.

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.

A High Risk of Hospitalization Following Release From Correctional Facilities in Medicare Beneficiaries: A Retrospective Matched Cohort Study, 2002 to 2010

IMPORTANCE Little is known about the risk of individuals who are released from correctional facilities, a time when there may be discontinuity in care. OBJECTIVE To study the risk for hospitalizations among former inmates soon after their release from correctional facilities. DESIGN Retrospective cohort study. PARTICIPANTS Data from Medicare administrative claims for 110,419 fee-for-service beneficiaries who were released from a correctional facility from 2002 through 2010 and controls matched by age, sex, race, Medicare status, and residential zip code. MAIN OUTCOMES AND MEASURES Hospitalization rates and specifically those for ambulatory care-sensitive conditions 7, 30, and 90 days after release. RESULTS Of 110,419 released inmates, 1559 individuals (1.4%) were hospitalized within 7 days after release; 4285 individuals (3.9%) within 30 days; and 9196 (8.3%) within 90 days. The odds of hospitalization was higher for released inmates compared with those of matched controls (within 7 days: odds ratio [OR], 2.5 [95% CI, 2.3-2.8]; within 30 days: OR, 2.1 [95% CI, 2.0-2.2]; and within 90 days: OR, 1.8 [95% CI, 1.7-1.9]). Compared with matched controls, former inmates were more likely to be hospitalized for ambulatory care-sensitive conditions (within 7 days: OR, 1.7 [95% CI, 1.4-2.1]; within 30 days: OR, 1.6 [95% CI, 1.5-1.8]; and within 90 days: OR, 1.6 [95% CI, 1.5-1.7]). CONCLUSIONS AND RELEVANCE About 1 in 70 former inmates are hospitalized for an acute condition within 7 days of release, and 1 in 12 by 90 days, a rate much higher than in the general population.

Food Insecurity and Health: Data from the Veterans Aging Cohort Study

Objective. Food insecurity may be a modifiable and independent risk factor for worse control of medical conditions, but it has not been explored among veterans. We determined the prevalence of, and factors independently associated with, food insecurity among veterans in the Veterans Aging Cohort Study (VACS). Methods. Using data from VACS from 2002–2008, we determined the prevalence of food insecurity among veterans who have accessed health care in the Veterans Health Administration (VA) as defined by “concern about having enough food for you or your family in the past month.” We used multivariable logistic regression to determine factors independently associated with food insecurity and tests of trend to measure the association between food insecurity and control of hypertension, diabetes, HIV, and depression. Results. Of the 6,709 veterans enrolled in VACS, 1,624 (24%) reported being food insecure. Food insecurity was independently associated with being African American, earning <