Asthma, other chronic conditions undertreated among incarcerated individuals

Key takeaways:

• Incarcerated individuals account for 0.85% of the total population with asthma but only 0.15% of asthma prescriptions.
• Asthma had the highest magnitude of difference between disease burden and treatment at 5.45.

Individuals with asthma and other chronic illnesses in jail and prison in the United States may be undertreated compared with the general population, according to a study published in JAMA Health Forum.

These findings indicate an opportunity to improve the health of people who are incarcerated in the U.S., Jill Curran, MS, research program manager, Johns Hopkins Bloomberg School of Public Health, and colleagues wrote in the study.

“We previously conducted research on the utilization of buprenorphine in jails and prisons and found that while use had increased, it was still inadequate, with an estimated 3.6% of incarcerated individuals with opioid use disorder in the U.S. receiving buprenorphine,” Curran told Healio.

“We sought to determine whether findings from our prior research demonstrating inadequate use to buprenorphine in correctional settings would be the same for other chronic conditions given the high rates of these conditions among the incarcerated population,” she continued.

Study results

The researchers examined 2018 to 2020 data from the National Survey on Drug Use and Health and from IQVIA’s National Sales Perspective, which measured the distribution of prescription medications to incarcerated and nonincarcerated populations.

The incarcerated populations included individuals in local jails and state prisons aged 18 years and older, but not federal institutions..

“We were very surprised by the extent of potential undertreatment of these common chronic conditions we identified among the incarcerated population,” Curran said.

“We were particularly surprised by the results for asthma, depression and severe mental illness, for which we observed over fourfold relative disparities in treatment after adjusting for disease prevalence,” she said.

Incarcerated individuals accounted for 0.85% (95% CI, 0.67% to 1.06%) of the population of patients with asthma in the U.S., but only 0.15% of asthma treatment volume was distributed to jails and state prisons, indicating a 5.45-fold (95% CI, 4.32-6.83) relative difference between diagnosis and care.

Asthma had the highest relative difference between diagnosis and treatment among the seven conditions the researchers measured. These disparities also included a 1.87-fold difference for hepatitis B or C, 2.4-fold difference for hypertension, 2.86-fold difference for diabetes, 3.01-fold difference for HIV, 4.08-fold difference for depression and 4.11-fold difference for severe mental illness.

“The drive behind the disparities we observed was beyond the scope of our study, but an important question to investigate,” Curran said, adding that whether environmental conditions in prison also could be exacerbating asthma cases would be important to investigate but beyond the scope of their study as well.

“Our research highlights the lack of high-quality data available to study these important public health questions,” Curran said.

Conclusions, next steps

“Our research sought to investigate, from a national perspective, the pharmacologic treatment of several common, chronic and costly conditions,” Curran said, adding that their findings suggest the importance of measuring quality of care among incarcerated individuals along with accurate diagnosis and appropriate treatment.

“Several factors may contribute to our findings, including institutional neglect, temporary nature of many local jail stays and the high prevalence of mental illness — which tends to complicate treatment of other conditions — in the incarcerated population,” she said.

With nearly 2 million people in prisons and jails in the U.S. on any given day, the researchers said, correctional health care programs often are underfunded and understaffed. Incarcerated individuals also have higher rates of chronic illnesses than those who are not incarcerated, the researchers continued.

Considering these disparities both before and during incarceration, the researchers called for improved oversight from local and state authorities to ensure adequate pharmacologic treatment among individuals with these illnesses who have been incarcerated.

“The potential policy implications and recommendations generated by our study results relate to all the conditions we examined and health care for the incarcerated population as a whole,” Curran said.

“Target initiatives, such as additional oversight from health care agencies to further characterize and abate any undertreatment of individuals in the incarcerated populations would be beneficial,” she said.

Further, the researchers said that individuals who have been released from incarceration tend to experience poorly controlled disease, worse health-related outcomes and mortality, so improved care during incarceration could mitigate these effects.

“Improvement in care while incarcerated, including diagnosis and pharmacologic treatment for individuals who need it, may mitigate some of the disparities faced among recently incarcerated individuals once released from correctional facilities,” Curran said.

The researchers additionally said that underdiagnosis of asthma and the other conditions that were investigated is widespread, with potentially greater rates of underdiagnosis among individuals who are more likely to intersect with the criminal-legal system such as members of racial and ethnic minority groups and lower socioeconomic classes.

Additional burdens among this population include a lack of access to care outside of their incarceration, a lack of trust in clinicians while they are incarcerated, delayed treatment as they enroll in Medicaid upon their release and the high costs of treatment.

Noting the limitations of their data, the researchers said a dedicated national survey of the health and treatment of individuals who are incarcerated in the United States would help them evaluate their findings, which highlight the importance of measuring the quality of care of these individuals.

“It would be important to look at trends over time to investigate the utilization of different medications for various conditions, and to evaluate regional differences in prisons vs. jails, especially since these populations can differ dramatically,” Curran said. “An important next step would be to further investigate some of the potential drivers of the dipartites we identified.”

For more information:

Jill Curran, MS, can be reached at jcurra14@jhmi.edu.