Agency for Healthcare Research and Quality.

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.

Background: Drug use-associated infective endocarditis (DUA-IE) is rising during the opioid epidemic. Infective endocarditis (IE) can require valve surgery, but surgical treatment of DUA-IE has invoked controversy and the extent of its use is unknown. Objective: To examine hospitalization trends for DUA-IE, the proportion with surgery, patient characteristics, length of stay and charges. Design: Ten-year analysis of a statewide hospital discharge database. Setting: North Carolina hospitals, 2007–2017. Patients: All patients hospitalized for IE aged ≥ 18 years. Measurements: Annual trends in all IE hospitalizations and those with valve surgery, stratified by patients’ drug use. Characteristics of DUA-IE surgical hospitalizations including demographics, length of stay, disposition and charges. Results: Of 22,825 IE hospitalizations, 2,602 (11%) were for DUA-IE. Valve surgery was performed in 1,655 (7%) IE hospitalizations, including 285 (17%) for DUA-IE. Annual DUA-IE hospitalizations increased from 0.92 to 10.95 per 100,000, and DUA-IE hospitalizations with surgery rose from 0.10 per 100,000 to 1.38 per 100,000. In the final year, surgeries for DUA-IE comprised 42% of IE valve surgeries. Compared to other IE surgical patients, DUA-IE patients were younger (median age 33 vs. 56), more commonly female (47% vs. 33%) and White (89% vs. 63%), and primarily insured by Medicaid (38%) or uninsured (35%). Hospital stays for DUA-IE were longer (median 27 vs. 17 days) with higher median charges ($250,994 vs. $198,764). Charges for 282 DUA-IE hospitalizations exceeded $78,000,000. Limitations: Reliance on administrative data and billing codes. Conclusions: DUA-IE hospitalizations and valve surgeries increased over twelve-fold and DUA-IE approached half of all IE valve surgeries. The swell of DUA-IE patients is reshaping the scope, type, and financing of healthcare resources needed for effective IE treatment.

Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P >0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24–90.7% with BCM and 89.1% with SOC (P >0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P >0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison.

Key PointsQuestionIs restrictive housing, otherwise known as solitary confinement, during incarceration associated with an increased risk of mortality after release into the community?FindingsThis cohort study included 229 274 people who were released from incarceration in North Carolina from 2000 to 2015. Compared with individuals who were incarcerated and not placed in restrictive housing, individuals who spent any time in restrictive housing were 24% more likely to die in the first year after release, especially from suicide (78% more likely) and homicide (54% more likely); they were also 127% more likely to die of an opioid overdose in the first 2 weeks after release.MeaningThe results of this study suggest that exposure to restrictive housing as a condition of confinement is associated with an increased risk of death during community reentry.

BackgroundAlthough prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison.MethodsWe conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures.ResultsMost participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care.ConclusionThese findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

Purpose We compared mortality rates among state prisoners and other state residents to identify prisoners’ healthcare needs Methods We linked North Carolina prison records with state death records for 1995-2005 to estimate all-cause and cause-specific death rates among Black and White male prisoners aged 20-79 years, and used standardized mortality ratios (SMRs) to compare these observed deaths with the expected number based on death rates among state residents Results The all-cause SMR of Black prisoners was 0.52 (95%CI: 0.48 0.57), with fewer deaths than expected from accidents, homicides, cardiovascular disease and cancer. The all-cause SMR of White prisoners was 1.12 (95%CI: 1.01, 1.25) with fewer deaths than expected for accidents, but more deaths than expected from viral hepatitis, liver disease, cancer, chronic lower respiratory disease, and HIV. Conclusions Mortality of Black prisoners was lower than that of Black state residents for both traumatic and chronic causes of death. Mortality of White prisoners was lower than that of White state residents for accidents, but higher for several chronic causes of death. Future studies should investigate the effect of prisoners’ pre-incarceration and in-prison morbidity, the prison environment, and prison healthcare on prisoners’ patterns of mortality.

Directly observed therapy (DOT) for human immunodeficiency virus (HIV) infection is commonly used in correctional settings; however, the efficacy of DOT for treating HIV infection has not been determined. We prospectively assessed adherence to antiretroviral therapy regimens among 31 HIV-infected prison inmates who were receiving >or=1 antiretrovirals via DOT. Adherence was measured by self-report, pill count, electronic monitoring caps, and, for DOT only, medication administration records. Overall, median adherence was 90%, as measured by pill count; 86%, by electronic monitoring caps; and 100%, by self-report. Adherence, as measured by electronic monitoring caps, was >90% in 32% of the subjects. In 91% of cases, adherence, as measured by medication administration records, was greater than that recorded by electronic monitoring caps for the same medications administered by DOT. Objective methods of measurement revealed that adherence to antiretroviral regimens administered wholly or in part by DOT was