Future Directions: Interventions To Reduce Cardiovascular Disease Morbidity And Mortality

 

Previous studies have demonstrated that recently released inmates have an increased risk of death from cardiovascular disease and current and former inmates are likely to have increased rates of cardiovascular risk factors. However, the reasons for this are unclear, making interventions that improve this population’s health difficult to design. As the correctional population continues to age and correctional health care shifts from a focus on acute conditions and infectious diseases to noncommunicable diseases, like cardiovascular disease, important first steps are to understand why current and former inmates have increased rates of cardiovascular risk factors and disease, followed by design of prison and community-based interventions. To achieve this aim, we need more comprehensive studies that include patients with a history of incarceration and the correctional health care system.
Better Studies
Currently incarcerated individuals are not included in national surveys studying cardiovascular risk factors and disease, including the National Health and Nutrition Examination Study and the Behavioral Risk Factor Surveillance System (Wang and Wildeman 2011). Also, longitudinal cohort studies funded by the National Heart, Lung, and Blood Institute designed specifically to examine the epidemiology of cardiovascular risk factors and disease in minority populations do not follow individuals from the community into the correctional system, thus leading to loss of follow-up among minority populations, in particular black men and, thus, biased estimates of risk and disease. Why is this the case? In 1978, following decades of unethical prison research, the federal government instituted a moratorium on research in correctional settings. Recently, the Institute of Medicine revisited the issue at the behest of the Department of Health and Human Services and released a report on the ethics of conducting research on prisoners. It recommended the continuation of current restrictions but suggested updates to improve prisoners’ ability to participate in limited clinical studies, particularly those with minimal risk and only interventions with demonstrated safety and efficacy. Despite these recommendations, the prohibition on prison research has not been lifted. Currently, individuals who enroll in studies while free may not be followed into prisons and jails (unless the researcher seeks OHRP approval under Subpart C) and in certain jurisdictions cannot be followed even upon release. Under the current guidelines, participants are removed from the study at the time of incarceration, unless specifications are delineated in the initial institutional review board application. Given this barrier, national surveillance systems may provide flawed estimates of cardiovascular risk factors and miss opportunities to understand how incarceration and the correctional health care system affect cardiovascular risk factors and disease. National policies should be created that allow incarcerated individuals to enroll in surveillance studies or continue their participation in a study they enrolled in prior to incarceration. Ever-incarcerated individuals, prison officials, researchers, and ethicists should be included in this dialogue so that such policies are patient-centered and acknowledge the unique logistics of conducting research in prison (or jail) without impeding good science or violating research ethics.
Understanding The Patient’s Experience
Self-management is the cornerstone of treatment for patients at risk for or living with cardiovascular disease. Many studies have shown that a patient’s health beliefs and experiences, medication adherence, or self-care behaviors are associated with improved blood pressure, diabetes, and cholesterol control. We know that individuals who are incarcerated are disproportionately comprised of minority racial groups and individuals from low socioeconomic environments. Additionally, given the established association between racial discrimination and hypertension, the incarcerated population has the added stigma of being incarcerated. How discrimination might impact their health and health care access has not been fleshed out. The determinants of ever-incarcerated individuals’ cardiovascular disease outcomes are likely multifactorial, but their knowledge, attitudes, and health beliefs likely play a significant role and are shaped by the correctional health setting. Specific attention should be paid to studying the health knowledge, attitudes, and beliefs of ever-incarcerated individuals and how prison environmental issues, including access to healthy foods and health care in prison and upon release, affect self-efficacy for managing health in prison and upon release.
Include The Prison System
Given that around 60 % of inmates return back to prison within 3 years, understanding how the correctional health care system delivers care for individuals with cardiovascular risk factors and disease and particularly transitions of care are crucial to reducing cardiovascular disease morbidity and mortality in this population. A framework to improve the delivery of chronic care in the correctional system must be applied to study and improve care in the correctional setting. One such model, the Chronic Care Model, has already been applied in California (Wagner et al. 2001). The Chronic Care Model is a patient-centered model of care that identifies the essential elements of a health care system that encourages high-quality chronic disease care. These elements include the community, the health care system, self-management support, delivery system design, decision support, and clinical information systems. Redesigning systems of community primary care to the Chronic Care Model has led to improvements in health care outcomes for individuals with cardiovascular diseases. Adapting this model and appropriate metrics for assessing care delivery in correctional settings are underway and should incorporate corrections-specific needs (including security, transfers, and lock-downs) and the realities of the state of correctional medicine including the lack of robust informational technologies (Ha and Robinson 2011). These efforts will generate hypotheses about how prison health care, particularly self-management support and discharge planning, might impact inmates’ long-term control of cardiovascular risk factors and management of disease. Moreover, current initiatives to improve quality of care in the correctional system should be mandated and overseen by state and local government entities, given that taxpayers pay for care behind bars. These initiatives may lead to lower costs and improved health for inmates with cardiovascular risk factors and disease.
Conclusion
Whether incarceration is independently associated with increased cardiovascular risk factors and disease remains unknown. However, what is clear is that prisons and jails house a disproportionate number of individuals who have or are at risk for cardiovascular disease. Acknowledging this reality and making attempts to both study and improve cardiovascular health in prison may mitigate disease among inmates.

Bibliography:

 	
Baillargeon J, Black SA, Pulvino J, Dunn K (2000) The disease profile of Texas prison inmates. Ann Epidemiol 10:74–80