The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement.

BACKGROUND: Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use. OBJECTIVE: To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults. DESIGN: We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates. PARTICIPANTS: Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement. MAIN MEASURES: Self-reported visits to the emergency department and nights spent hospitalized. RESULTS: Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25). CONCLUSION: Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.

Exploring Parental Incarceration, US Government Support Programs, and Child Health and Well-Being: A National Cross-Sectional Study.

OBJECTIVES: To describe relationships between parental incarceration and child health and flourishing-a measure of curiosity, resilience, and self-regulation-and to identify government programs that moderate this relationship. METHODS: Using the National Survey of Children's Health data from 2016 through 2019 for children 6-17 years old, we estimated associations with logistic regression between parental incarceration and overall health and flourishing, adjusting for child, caregiver, and household factors. We secondarily examined physical health (asthma, headaches), mental health (attention deficit disorder/attention deficit hyperactivity disorder, depression), developmental needs (learning disability, special educational plan use), and educational (missing ≥11 school days, repeated grade) outcomes. We performed interaction analyses to determine whether government program participation (eg, free/reduced lunch, cash assistance) moderated relationships between parental incarceration and child outcomes. RESULTS: Children with parental incarceration accounted for 9.3% of the sample (weighted n = 4 400 000). Black, American Indian/Alaska Native, and multiracial children disproportionately experienced parental incarceration. Parental incarceration was associated with worse health (aOR, 1.31; 95% CI, 1.11-1.55) and higher odds of not flourishing (aOR, 1.66; 95% CI, 1.46-1.89). Physical health, mental health, developmental issues, and educational needs were also associated with parental incarceration. Participation in free and reduced lunch moderated the relationships between parental incarceration and general health and flourishing, and cash assistance moderated the association between parental incarceration and flourishing. For each, parental incarceration had an attenuated association with health among people who participated in government programs. CONCLUSIONS: Parental incarceration is disproportionately experienced by Black and Indigenous children and associated with worse child health and well-being. Government support program participation may mitigate negative associations between parental incarceration and child outcomes.

Health Insurance and Mental Health Treatment Use Among Adults With Criminal Legal Involvement After Medicaid Expansion.

OBJECTIVE: Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS: The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS: The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS: Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

Modern Day Consequences of Historic Redlining: Finding a Path Forward.

There is emerging evidence that structural racism is a major contributor to poor health outcomes for ethnic minorities. Structural racism captures upstream historic racist events (such as slavery, black code, and Jim Crow laws) and more recent state-sanctioned racist laws in the form of redlining. Redlining refers to the practice of systematically denying various services (e.g., credit access) to residents of specific neighborhoods, often based on race/ethnicity and primarily within urban communities. Historical redlining is linked to increased risk of diabetes, hypertension, and early mortality due to heart disease with evidence suggesting it impacts health through suppressing economic opportunity and human capital, or the knowledge, skills, and value one contributes to society. Addressing structural racism has been a rallying call for change in recent years-drawing attention to the racialized impact of historical policies in the USA. Unfortunately, the enormous scope of work has also left people feeling incapable of effecting the very change they seek. This paper highlights a path forward by briefly discussing the origins of historical redlining, highlighting the modern-day consequences both on health and at the societal level, and suggest promising initiatives to address the impact.

Relationship between criminal legal system exposure and health care utilization in US adults with diabetes: A cross-sectional study.

BACKGROUND: Black Americans have a higher prevalence of diabetes compared to White Americans and have higher rates of complications and death. Exposure to the criminal legal system (CLS) is a social risk factor for chronic disease morbidity and mortality with significant overlap with populations most likely to experience poor diabetes outcomes. However, little is known about the association between CLS exposure and healthcare utilization patterns among U.S. adults with diabetes. METHODS: Using data from the National Survey of Drug Use and Health (2015-2018) a cross-sectional, nationally representative sample of U.S. adults with diabetes was created. Negative binomial regression was used to test the association between lifetime CLS exposure and three utilization types (emergency department (ED), inpatient, and outpatient) controlling for relevant socio-demographic and clinical covariates. RESULTS: Of 11,562 (weighted to represent 25,742,034 individuals) adults with diabetes, 17.1% reported lifetime CLS exposure. In unadjusted analyses, exposure was associated with increased ED (IRR 1.30 95% CI 1.17-1.46) and inpatient utilization (IRR 1.23, 95% CI 1.01-1.50), but not outpatient visits (IRR 0.99 95% CI 0.94-1.04). The association between CLS exposure and ED (IRR 1.02, p=0.70) and inpatient utilization (IRR 1.18, p=0.12) was attenuated in adjusted analyses. Low socioeconomic status, comorbid substance use disorder, and comorbid mental illness were independently associated with health care utilization in this population. CONCLUSIONS: Among those with diabetes, lifetime CLS exposure is associated with higher ED and inpatient visits in unadjusted analyses. Adjusting for socioeconomic status and clinical confounders attenuated these relationships, thus more research is needed to understand how CLS exposure interacts with poverty, structural racism, addiction and mental illness to influence health care utilization for adults with diabetes.

Association Between Lifetime Criminal Justice Involvement and Substance Use Disorders in U.S. Adults with Diabetes.

Background: Criminal justice involvement (CJI) is a social risk in adults with both diabetes and substance use, however, the relationship between CJI, diabetes, and substance use disorders is not well studied. Methods: Data from a nationally representative sample of U.S. adults with diabetes from the National Survey of Drug Use and Health (2015-2018) were used to establish the prevalence of the following substance use disorders: alcohol, opioid, cannabis, cocaine, and methamphetamine, or a composite variable for any substance use disorder. Multiple logistic regression was used to test the association between CJI and each substance use disorder in adults with diabetes controlling for relevant covariates. Results: Of 11,594 respondents representing 25,834,422 U.S. adults with diabetes, 17.1% reported prior CJI. Prevalence of substance use disorders was significantly higher in individuals with CJI compared to those without CJI (alcohol: 8.3 vs. 2.2; opioid: 2.1 vs. 0.4; cannabis: 1.4 vs. 0.2; cocaine: 1.2 vs. 0.1; methamphetamine: 1.2 vs. 0.1; any substance: 11.86 vs. 2.78; p<0.001 for all). In fully adjusted models, odds of substance use disorders were significantly higher in individuals with CJI (alcohol: odds ratio [OR] 2.76, 95% confidence interval [CI]: 2.01-3.82; opioid: OR 5.08, 95% CI: 2.25-11.47; cannabis: OR 5.05, 95% CI: 2.60-9.81; cocaine: OR 23.62, 95% CI: 5.59-99.82; methamphetamine: OR 40.66, 95% CI: 13.23-124.95; any substance: OR 7.19, 95% CI: 4.47-11.56). Conclusion: In adults with diabetes, prevalence of substance use disorder is high among those with CJI. Interventions that target substance use disorders are needed in this population.

Association Between Social Adaptability Index Score and Lifetime Criminal Legal Involvement in U.S. Adults.

Background: Exposure to the criminal legal system is associated with negative health outcomes and profound socioeconomic health disparities. The social adaptability index (SAI) is a validated composite scale based on five indicators of socioeconomic status; a higher score predicts better health outcomes. However, little is known about the relationship between cumulative social risk factors as measured by the SAI and lifetime criminal legal involvement (CLI). Methods: Using a cross-sectional, nationally representative sample of U.S. adults, we calculated SAI score by lifetime CLI status, and used logistic regression with predictive margins to calculate risk of lifetime CLI by SAI quartile adjusting for demographic and clinical covariates. Results: A total of 213,678 participants were included, among whom 16.8% reported lifetime CLI. Mean SAI score was lower among those with lifetime CLI compared with those without (7.77, 95% confidence interval [CI]: 7.72-7.83 vs. 8.52, 95% CI: 8.50-8.55). There was a linear association between SAI quartile and predicted probability of lifetime CLI: first quartile: 23.9% (95% CI: 23.0-24.7); second quartile: 19.2% (95% CI: 18.6-19.8); third quartile: 17.5% (95% CI: 16.9-18.1); and fourth quartile: 12.5% (95% CI: 12.1-13.0). Conclusion: The SAI score is associated in a reverse linear manner with lifetime risk of CLI, suggesting that to successfully improve health outcomes among those with CLI, interventions may need to target multiple SAI components simultaneously. Interventions that successfully position individuals to achieve higher social adaptability by targeting multiple factors may reduce the health-harming effects of exposure to the criminal legal system.

Individual and Combined Effect of Diabetes and Lifetime Criminal Justice Involvement on Healthcare Utilization in US Adults, 2015-2019.

BACKGROUND: Diabetes and criminal justice involvement (CJI) are both associated with poor health outcomes and increased healthcare utilization. However, little is known about the additive effects of these risk factors when combined. This study examined the individual and combined effects of diabetes and CJI on healthcare utilization. METHODS: Data from the National Survey of Drug Use and Health (2015-2019) was used to create a cross-sectional, nationally representative sample of US adults with diabetes, CJI, combination of both, or neither. Negative binomial regression was used to test the association between those with CJI and diabetes (compared to diabetes alone) and three utilization types (outpatient, ED, and inpatient) controlling for relevant sociodemographic and clinical covariates. RESULTS: Of 212,079 respondents, representing 268,893,642 US adults, 8.8% report having diabetes alone, 15.2% report having CJI alone, and 1.8 % report both diabetes and lifetime CJI. After adjustment, those with diabetes and CJI had increased acute care utilization compared to those with diabetes alone (ED visits: IRR 1.13; 95% CI 1.00-1.28; nights hospitalized: IRR 1.34; 95% CI 1.08-1.67). There was no difference in outpatient utilization between those with both diabetes and CJI compared to those with diabetes alone (IRR 1.04, 95% CI 0.99-1.10). CONCLUSION: Individuals with complex social and health risks such as diabetes and lifetime CJI experience increased acute healthcare utilization but no difference in outpatient utilization. Tailored interventions that target both diabetes and CJI are needed to reduce unnecessary utilization in this population.

Association between mental health outcomes and lifetime criminal justice involvement in U.S. adults with diabetes.

BACKGROUND: Diabetes is a leading cause of death in the United States, and comorbid mental illness is associated with worse diabetes outcomes. Those with criminal justice involvement (CJI) have high rates of mental illness and diabetes prevalence. However, little is known about the relationship between CJI and mental illness among those with diabetes. METHODS: Using a nationally representative sample of U.S. adults with diabetes from the National Survey of Drug Use and Health (2015-2018), we investigated the relationship between CJI and mental health outcomes (depression, serious psychologic distress, serious mental illness, moderate mental illness, any mental illness, functional status). Multiple linear and logistic regression models were used to assess the relationship between CJI and each mental health outcome adjusting for multiple socio-demographic and comorbidity variables. RESULTS: Of 11,594 respondents, representing 25,834,422 adults with diabetes, 17.1% reported prior CJI. In fully adjusted models, CJI was independently associated with all mental health outcomes: depression (aOR 1.80, 95% CI: 1.41, 2.30), serious psychologic distress (aOR 1.53, 95% CI: 1.23, 1.90), serious mental illness (aOR 2.00, 95% CI: 1.58, 2.52), moderate mental illness (aOR 1.72, 95% CI 1.30, 2.26), any mental illness (aOR 1.92, 95% CI: 1.56, 2.35) and functional status (regression coefficient 3.6, 95% CI: 3.53, 3.79). CONCLUSION: Those with diabetes and criminal justice involvement experience concentrated risk for poor mental health outcomes. Our findings suggest that mental health interventions may be imperative to achieving control of diabetes in the justice-involved population.

Frequency and Duration of Incarceration and Mortality Among US Veterans With and Without HIV.

BACKGROUND: Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status. METHODS: We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study from January 2011 to August 2017 (N = 5367). The primary exposure was incarceration by 3 measures: (1) any (ever/never); (2) frequency; and (3) cumulative duration. Stratifying by HIV status and controlling for age, race, and sex, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs). RESULTS: Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI: 1.13 to 1.66) and those uninfected (AHR 1.24; 95% CI: 0.99 to 1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively, for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively. CONCLUSIONS: PWH were at increased risk of mortality after incarceration, and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk of mortality may be mitigated by improving transitional health care, especially HIV care, and reducing incarceration.

Increased levels of urinary PGE-M, a biomarker of inflammation, occur in association with obesity, aging, and lung metastases in patients with breast cancer.

Elevated levels of COX-derived prostaglandin E2 (PGE2) occur in inflamed tissues. To evaluate the potential links between inflammation and breast cancer, levels of urinary prostaglandin E metabolite (PGE-M), a stable end metabolite of PGE2, were quantified. We enrolled 400 patients with breast cancer: controls with early breast cancer (n = 200), lung metastases (n = 100), and metastases to other sites (n = 100). Patients completed a questionnaire, provided urine, and had measurements of height and weight. Urinary PGE-M was quantified by mass spectrometry. Ever smokers with lung metastasis who had not been exposed to nonsteroidal anti-inflammatory drugs (NSAIDs) had the highest PGE-M levels. PGE-M levels were increased in association with elevated body mass index (BMI; P < 0.001), aging (P < 0.001), pack-year smoking history (P = 0.02), lung metastases (P = 0.02), and recent cytotoxic chemotherapy (P = 0.03). Conversely, use of NSAIDs, prototypic inhibitors of COX activity, was associated with reduced PGE-M levels (P < 0.001). On the basis of the current findings, PGE-M is likely to be a useful biomarker for the selection of high-risk subgroups to determine the use of interventions that aim to reduce inflammation and possibly the development and progression of breast cancer, especially in overweight and obese women.