Correctional health care systems and collaboration with academic medicine.

Abstract

AJAIL OR PRISON IS THE HEALTH CARE SETTING FOR millions of patients in the United States. Nevertheless, correctional health care remains largely an enigma to mainstream medicine and largely disregarded by academic medicine. The article by Raimer and Stobo in this issue of JAMA describes an uncommon, if not unique, relationship between academic medicine and a correctional health care system. In this model, 2 Texas medical schools assumed the responsibility for delivery and oversight of the medical care for inmates under the jurisdiction of the Texas Department of Criminal Justice. Direct university involvement in correctional health care resulted in a more structured delivery of health care services using evidence-based medicine, greater access to subspecialists (particularly through telehealth), improved clinical outcomes for chronic illnesses, and cost savings for the state of Texas. Despite the apparent improvements in the Texas correctional health care system since its reincarnation in 1994, a decade later, US academic medicine remains largely uninvolved with correctional health care elsewhere in the country. The reasons for this are uncertain and little studied but universities may overestimate security concerns, become stymied with logistical barriers, misunderstand federal restrictions on research involving prisoners, and undervalue the strategic importance of correctional medicine to public health. Correctional systems, on the other hand, may view academic medicine as intrusive and naively unaware of security concerns, while miscalculating the benefits of academic expertise in not only improving the quality of inmate health care but also maximizing the use of limited fiscal resources. The article by Raimer and Stobo poses important considerations for both universities and correctional systems at a time when delivering inmate health care is increasingly complex and expensive. Managing large numbers of inmates with multiple serious health problems is now commonplace in correctional medicine. According to information contained in a series of Bureau of Justice Statistics reports, 31% of state and 23.4% of federal inmates surveyed in 1997 had a physical impairment or mental condition; during the same year, 52% of state and 34% of federal inmates were under the influence of alcohol or other drugs at the time of their offenses; 10% of state inmates, as of mid-year 2000, were receiving psychotropic medications; and at year-end 2001, 2% of state and 1.2% of federal prison inmates were diagnosed with human immunodeficiency virus infection. The actual extent of health conditions across US jail and prison populations, however, is unknown and probably underestimated. Most published data are gleaned from inmate self-reports or represent summations of known diagnosed conditions, rather than from true random or allinclusive prevalence studies that would more accurately measure disease burden, particularly for frequently underdiagnosed conditions, such as hypertension, diabetes mellitus, chronic infectious diseases, and mental illnesses. From a clinical standpoint, managing individual patients with multiple health problems, such as substance abuse, chronic hepatitis C virus infection, human immunodeficiency virus infection, latent tuberculosis infection, and depression, is a common challenge for correctional practitioners; however, similar patients are rarely encountered by many of the physician consultants who are locally available to advise correctional practitioners. Clinical decision making within the correctional setting is further complicated by the paucity of evidence-based treatment data involving inmate populations. Standard treatment recommendations are often based on clinical trials that have involved comparatively healthier community-based populations and may not translate directly to the correctional setting. The inherent complexities of correctional medicine warrant a greater involvement of university-based medicine in multiple spheres—most importantly, training health care professionals for future careers in correctional health care, providing subspecialty consultations for difficult cases, assisting with the development of clinical practice guidelines, and evaluating treatment interventions and outcomes among inmate-patient populations. As demonstrated in the Texas correctional system, stronger links between academic and correctional medicine can be mutually rewarding. Inmates with complicated medical conditions gain access to tertiary subspecialists through telehealth without leaving the confines of prison, while university physicians