Frequent Attendance to the Emergency Department after Release from Prison: a Prospective Data Linkage Study

Sex differences in acute health service contact after release from prison in Australia: a data linkage study

OBJECTIVES

Women released from prison typically experience worse health outcomes than their male counterparts. We examined sex differences in the patterns, characteristics, and predictors of acute health service contact (AHSC) (i.e. ambulance and/or emergency department use) after release from prison.

STUDY DESIGN

Data linkage study.

METHODS

Baseline survey data from 1307 adults (21% women) within six weeks of expected release from prisons in Queensland, Australia (2008-2010) were linked prospectively with state-wide ambulance and emergency department, correctional, mental health, and death records. Crude and adjusted incidence rates and incidence rate ratios of AHSC were calculated overall and by sex. An Andersen-Gill model was fit to examine whether sex predicted AHSC. The interaction effect between sex and each model covariate was tested.

RESULTS

The crude incidence rates of AHSC after release from prison were 1.4 (95% confidence interval [CI]: 1.3-1.5) and 1·1 (95%CI: 1.1-1.2) per person-year for women and men, respectively. The relationship between perceived physical health-related functioning at the baseline and AHSC was modified by sex (P = 0·039). The relationship between perceived health-related functioning and AHSC also differed among women. Compared to women who perceived their physical health as fair or good at the baseline, women who perceived their physical health as poor were at greater risk of AHSC (hazard ratio = 2.4, 95%CI: 1.4-3·9, P = 0.001) after release from prison.

CONCLUSIONS

Among people released from prison, women's and men's AHSC differs depending on how they perceive their own physical health. The specific needs of women and men must be considered in transitional support policy and planning to improve their health outcomes.

Non-communicable disease mortality in young people with a history of contact with the youth justice system in Queensland, Australia: a retrospective, population-based cohort study

BACKGROUND

Young people who have had contact with the criminal justice system are at increased risk of early death, especially from injuries. However, deaths due to non-communicable diseases (NCDs) in this population remain poorly described. We aimed to estimate mortality due to NCDs in people with a history of involvement with the youth justice system, compare NCD mortality rates in this population with those in the general population, and characterise demographic and justice-related factors associated with deaths caused by NCDs in people with a history of contact with the youth justice system.

METHODS

In this retrospective, population-based cohort study (the Youth Justice Mortality [YJ-Mort] study), we included all people aged 10-18 years (at baseline) charged with a criminal offence in Queensland, Australia, between June 30, 1993, and July 1, 2014. We probabilistically linked youth justice records with adult correctional records and national death records up to Jan 31, 2017. Indigenous status was ascertained from youth justice and adult correctional records, with individuals identified as Indigenous in either source classified as Indigenous in the final dataset. We estimated crude mortality rates and standardised mortality ratios (SMRs) for comparisons with data from the Australian general population. We identified risk factors for NCD deaths using competing-risks regression.

FINDINGS

Of 48 670 individuals aged 10-18 years (at baseline) charged with a criminal offence in Queensland, Australia, between June 30, 1993, and July 1, 2014, 11 897 (24·4%) individuals were female, 36 773 (75·6%) were male, and 13 250 (27·2%) were identified as identified as Indigenous. The median age at first contact with the youth justice system was 15 years (IQR 14-16), the median follow-up time was 13·4 years (8·4-18·4), and the median age at the end of the study was 28·6 years (23·6-33·6). Of 1431 deaths, 932 (65·1%) had a known and attributed cause, and 121 (13·0%) of these were caused by an NCD. The crude mortality rate from NCDs was 18·5 (95% CI 15·5-22·1) per 100 000 person-years among individuals with a history of involvement with the youth justice system, which was higher than among the age-matched and sex-matched Australian general population (SMR 1·67 [1·39-1·99]). Two or more admissions to adult custody (compared with none; adjusted sub-distribution hazard ratio 2·09 [1·36-3·22]), and up to 52 weeks in adult custody (compared with none; 1·98 [1·18-3·32]) was associated with NCD death.

INTERPRETATION

Young people with a history of contact with the justice system are at increased risk of death from NCDs compared with age-matched and sex-matched peers in the general Australian population. Reducing youth incarceration and providing young people's rights to access clinical, preventive, and restorative services should be a priority.

FUNDING

National Health and Medical Research Council.

Burden of opioid toxicity death in the fentanyl-dominant era for people who experience incarceration in Ontario, Canada, 2015-2020: a whole population retrospective cohort study

OBJECTIVES

To describe mortality due to opioid toxicity among people who experienced incarceration in Ontario between 2015 and 2020, during the fentanyl-dominant era.

DESIGN

In this retrospective cohort study, we linked Ontario coronial data on opioid toxicity deaths between 2015 and 2020 with correctional data for adults incarcerated in Ontario provincial correctional facilities.

SETTING

Ontario, Canada.

PARTICIPANTS

Whole population data.

MAIN OUTCOMES AND MEASURES

The primary outcome was opioid toxicity death and the exposure was any incarceration in a provincial correctional facility between 2015 and 2020. We calculated crude death rates and age-standardised mortality ratios (SMR).

RESULTS

Between 2015 and 2020, 8460 people died from opioid toxicity in Ontario. Of those, 2207 (26.1%) were exposed to incarceration during the study period. Among those exposed to incarceration during the study period (n=1 29 152), 1.7% died from opioid toxicity during this period. Crude opioid toxicity death rates per 10 000 persons years were 43.6 (95% CI=41.8 to 45.5) for those exposed to incarceration and 0.95 (95% CI=0.93 to 0.97) for those not exposed. Compared with those not exposed, the SMR for people exposed to incarceration was 31.2 (95% CI=29.8 to 32.6), and differed by sex, at 28.1 (95% CI=26.7 to 29.5) for males and 77.7 (95% CI=69.6 to 85.9) for females. For those exposed to incarceration who died from opioid toxicity, 10.6% died within 14 days of release and the risk was highest between days 4 and 7 postrelease, at 288.1 per 10 000 person years (95% CI=227.8 to 348.1).

CONCLUSIONS

The risk of opioid toxicity death is many times higher for people who experience incarceration compared with others in Ontario. Risk is markedly elevated in the week after release, and women who experience incarceration have a substantially higher SMR than men who experience incarceration. Initiatives to prevent deaths should consider programmes and policies in correctional facilities to address high risk on release.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

Prospective study of retention in opioid agonist treatment and contact with emergency healthcare following release from prisons in Victoria, Australia

BACKGROUND

People recently released from prison engage with emergency healthcare at greater rates than the general population. While retention in opioid agonist treatment (OAT) is associated with substantial reductions in the risk of opioid-related mortality postrelease, it is unknown how OAT affects contact with emergency healthcare. In a cohort of men who injected drugs regularly prior to imprisonment, we described rates of contact with ambulance services and EDs, and their associations with use of OAT, in the 3 months after release from prison.

METHODS

Self-report data from a prospective observational cohort of men who regularly injected drugs before a period of sentenced imprisonment, recruited between September 2014 and May 2016, were linked to state-wide ambulance and ED records over a 3-month postrelease period in Victoria, Australia. We used generalised linear models to estimate associations between OAT use (none/interrupted/retained) and contact with ambulance and EDs postrelease, adjusted for other covariates.

RESULTS

Among 265 participants, we observed 77 ambulance contacts and 123 ED contacts over a median of 98 days of observation (IQR 87-125 days). Participants who were retained in OAT between prison release and scheduled 3-month postrelease follow-up interviews had lower rates of contact with ambulance (adjusted incidence rate ratio (AIRR) 0.33, 95% CI 0.14 to 0.76) and ED (AIRR 0.43, 95% CI 0.22 to 0.83), compared with participants with no OAT use postrelease. Participants with interrupted OAT use did not differ from those with no OAT use in rates of contact with ambulance or ED.

CONCLUSION

We found lower rates of contact with emergency healthcare after release among people retained in OAT, but not among people reporting interrupted OAT use, underscoring the benefits of postrelease OAT retention. Strategies to improve accessibility and support OAT retention after leaving prison are important for men who inject drugs.

A prison mental health network in the RANZCP

OBJECTIVE

Consider the unique features and challenges of prison psychiatry.

CONCLUSIONS

A Prison Mental Health Network within the Royal Australian and New Zealand College of Psychiatrists would serve many useful functions including improving the quality of mental health services by promoting high clinical standards and ethical practice by psychiatrists working in prisons.

Women sleeping rough: The health, social and economic costs of homelessness

This study seeks to assess the health, social and economic outcomes associated with rough sleeping among women and compare those outcomes with those of (1) men sleeping rough, and (2) women experiencing other forms of homelessness (such as being housed in temporary supported accommodation due to family and domestic violence). The paper analyses survey data using the Vulnerability Index-Service Prioritization Decision Analysis Tool (VI-SPDAT) collected from 2735 women experiencing homelessness and 3124 men sleeping rough in Australian cities from 2010 to 2017. We find that women sleeping rough report poorer physical and mental health outcomes and greater problematic drug and or alcohol use relative to both men sleeping rough and women experiencing other types of homelessness (all p < 0.5). Women sleeping rough report significantly higher levels of crisis service utilisation (Β = 17.9, SE = 3.9, p < 0.001) and interactions with police in the previous 6 months (Β = 1.9, SE = 0.3, p < 0.001) than women experiencing homelessness not sleeping rough. Women sleeping rough also report greater healthcare utilisation, and, therefore, healthcare costs, than women experiencing homelessness not sleeping rough and men sleeping rough (all p < 0.05). From a policy perspective, the evidence presented in this paper supports a social determinants approach that moves from addressing symptoms of poor health outcomes associated with homelessness to preventing and ending homelessness with a particular focus on the life trajectories of women. Integrated services and homelessness strategies need to be developed through a gender lens, providing women sleeping rough with tailored permanent housing with wrap-around supportive housing to address poor health outcomes.

Prevalence of Mental Health Needs, Substance Use, and Co-occurring Disorders Among People Admitted to Prison

OBJECTIVE

People who are incarcerated experience social exclusion and have higher rates of mental and substance use disorders than the general population. Prisons are not suitable for treating mental illness, and understanding how the profile of prison populations changes provides essential information for correctional service planning. This study examined changes in the prevalence of mental and substance use disorders among people admitted to provincial prisons in British Columbia (BC), Canada.

METHODS

The study included all people admitted to any of the 10 provincial prisons in BC from 2009 through 2017 (N=47,117). Using the Jail Screening Assessment Tool, a validated intake screening tool designed for rapid identification of mental health needs, the authors calculated the period prevalence (by calendar year) of mental health needs, substance use disorders, and drug use.

RESULTS

The proportion of people with co-occurring mental health needs and substance use disorders increased markedly per year, from 15% in 2009 to 32% in 2017. Prevalence of methamphetamine use disorder increased nearly fivefold, from 6% to 29%, and heroin use disorder increased from 11% to 26%. The proportion of people with any mental health need and/or substance use disorder increased from 61% to 75%.

CONCLUSION

The clinical profile of people admitted to BC prisons has changed, with dramatic increases in the proportion of people with co-occurring disorders and reported methamphetamine use. More treatment and efforts to address social and structural inequities for people with complex clinical profiles are required in the community to reduce incarceration among people with multifaceted and complex mental health care needs.

Understanding the association between frequent emergency department use and jail incarceration: A cross-sectional analysis

BACKGROUND

Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration.

METHODS

We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters.

RESULTS

The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest.

CONCLUSIONS

Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.

Continuity of mental health care during the transition from prison to the community following brief periods of imprisonment

PURPOSE

The prison-to-community transition period is one of high risk and need, particularly for those with mental illness. Some individuals cycle in and out of prison for short periods with little opportunity for mental health stabilization or service planning either in prison or the community. This study describes the socio-demographic, clinical and criminal justice characteristics of individuals with mental illness and frequent, brief periods of imprisonment, examines continuity of mental health care between prison and the community for this group, and reports on their post-release mental health and criminal justice outcomes.

DESIGN/METHODOLOGY/APPROACH

This study examined a sample of 275 men who had recently entered prison in New South Wales (NSW), Australia, who had been charged with relatively minor offenses and had been identified on reception screening as having significant mental health needs. Baseline demographic and mental health information was collected via interview and file review and contacts with the prison mental health service were recorded for the period of incarceration. Follow-up interviews were conducted 3 months post-release to determine level of health service contact and mental health symptoms. Information on criminal justice contact during the 3 month period was also collected.

FINDINGS

The majority (85.5%) of the sample had contact with a mental health professional during their period of incarceration. Mental health discharge planning was, however, lacking, with only one in 20 receiving a referral to a community mental health team (CMHT) and one in eight being referred for any kind of mental health follow-up on release. Of those followed up 3 months post-release (n = 113), 14.2% had had contact with a CMHT. Of those released for at least 3 months (n = 255), one in three had received new charges in this period and one in five had been reincarcerated.

CONCLUSION

Continuity of mental health care for those exiting prison is poor, particularly for those with mental health needs experiencing brief periods of imprisonment, and rates of CMHT contact are low in the immediate post-release period. These findings suggest a need for early identification of individuals in this group for timely commencement of intervention and release planning, and opportunities for diversion from prison should be utilized where possible.