Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings

Abstract

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student's t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher's exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Fig 1. Descriptive data of emergency department visits and patient demographics.

The frequency of chief complaint type (A) and the number of visits per patient (B) were calculated for 894 emergency department visits and 574 incarcerated patients, respectively, who presented to a tertiary care, academic emergency department between January 2012 and December 2014. Average age (calculated based on 574 patients; C), gender (D), and race (E) were quantified according to the chief complaint category. Shown in percent (%) of patients unless otherwise indicated. Error bars in (C) denote age range in years. AA, African American; F, female; M, male; med, medical; psych, psychiatric; NS, no statistical difference. **** p < 0.0001, *** p = 0.0005.

Fig 2. Patients with medical or psychiatric chief complaints had more medical comorbidities than patients with trauma-related complaints.

For incarcerated patients presenting to a tertiary care, academic emergency department between January 2012 and December 2014 with medical or psychiatric and trauma-related complaints, the percent of medical, psychiatric, or substance abuse disorder (A) comorbidities was calculated. The percent of individuals with specific medical (B), psychiatric (C), and substance use disorder (D) comorbidities was quantified. Shown in percent (%) of patients. Alz, Alzheimer’s disease or dementia; anx/dep, anxiety and/or depression; Ca, cancer; CAD, coronary artery disease or history of a myocardial infarction; CHF, chronic heart failure; CKD, chronic kidney disease; Combo, combined drugs and alcohol; COPD, chronic obstructive pulmonary disease or asthma; CVA, cerebral vascular accident or history of a transient ischemic attack; DM, diabetes mellitus; EtOH, alcohol; HLD, hyperlipidemia; HTN, hypertension; PD, personality disorder; Psych, psychiatric; Schz, schizophrenia or psychotic disorder; Sub, substance abuse; Sz, seizures; Tob, tobacco. * p < 0.05, ** p ≤ 0.005, **** p < 0.0001.

Fig 3. Incarcerated trauma patients present with a range of injuries and mechanisms.

Primary, secondary, and tertiary discharge diagnoses (A), primary injury location (B), mechanism of injury (C), and reported perpetrator (D) for 278 trauma-related encounters of incarcerated patients presenting to a tertiary care, academic emergency department between January 2012 and December 2014 were calculated in absolute number (No. visits) or percent (%) of patient encounters as indicated. Amp, amputation; CTN, contusion; Fx, fracture; Gen, general; ICH, intracerebral hemorrhage; Lac, laceration; Multi, multi-organ; Unsp, unspecified; Visc, visceral injury.

Fig 4. Most trauma-related complaints were adequately managed in the emergency department by emergency medicine physicians.

Specialist consultations (A) and procedures (B) required for 278 trauma-related patient encounters for incarcerated patients presenting to a tertiary care, academic emergency department between January 2012 and December 2014 are shown in the number of patient encounters (No. visits). EM, emergency medicine; MD, medical doctor; Mult, multiple; No., number; OR, operating room; Ortho, orthopedics.

Fig 5. Patients presenting with medical or psychiatric complaints were more likely to require hospital admission than patients presenting with trauma-related complaints.

We quantified the percent of incarcerated patients presenting to a tertiary care, academic emergency department between January 2012 and December 2014 who were discharged to the correctional facility of origin (A) or admitted to the hospital (B). Primary, secondary, and tertiary discharge diagnoses were quantified for patients presenting with a medical or psychiatric chief complaint (C). Shown in percent (%) or absolute number (No. visits) of patient encounters as indicated. Cut, cutaneous; CV, cardiovascular; EMN, endocrine/metabolic/nutrition; ENT, ear/nose/throat; GI, gastroenterology; Heme, hematologic; ICU, intensive care unit; ID, infectious disease; IMCU, intermediate medical care unit; IP Psy, inpatient psychiatric facility; IR, interventional radiology; M/P, medical or psychiatric chief complaint; Med, medical; MSK, musculoskeletal; Neuro, neurologic; OB, obstetric; Opth, ophthalmology; OR, operating room; Psych, psychiatric; Resp, respiratory; RS, reproductive system; RU, renal/urinary; Tox, toxicity or intoxication. ** p = 0.003, **** p < 0.0001.

Fig 6. Incarcerated patients report barriers to medical care as contributing to emergency department presentations.

The frequency of reported barriers to access to medical care among patients presenting with medical or psychiatric and trauma-related chief complaints was quantified for incarcerated patients presenting to a tertiary care, academic emergency department between January 2012 and December 2014 (A; p = 0.10). The type of barrier to medical care (B) and the category of medication for patients reporting a lack of access to prescription medications (C) was calculated for incarcerated patients presenting with medical or psychiatric chief complaints. We calculated the rate of admission to the intensive care unit, the rate of admission to the floor or the intermediate care unit, and the overall rate of patients who were unable to be discharged to the correctional facility of origin from the emergency department (total) for patients presenting with a medical or psychiatric chief complaint who reported a barrier to medical access as contributing to the emergency department encounter to those who did not report a barrier (D; p > 0.3 for all comparisons). Patients who were unable to be discharged to the correctional facility of origin from the emergency department (total) include patients who required hospital admission, a specialty procedure (gastroenterologic, interventional radiologic, or surgical), transfer to an inpatient psychiatric facility, or patients who expired. Data shown as the percent (%) emergency department encounters. Abx, antibiotics; Anti-coag, anticoagulant; aSz, anti-epileptic; DM, diabetes mellitus; HIV, human immunodeficiency virus; ICU, intensive care unit; IMCU, intermediate care unit; Med, medical; Meds, prescription medications; Psych, psychiatric.