National Commission Assesses Management of Chronic Health Conditions Among Prisoner Populations
Staff at the National Commission on Correctional Health Care (NCCHC) measured the health outcomes of patients with chronic conditions in correctional institutions in Georgia and Michigan over time.
- Documenting the progress of patients with chronic diseases in correctional facilities improved health outcomes slightly, but the data were not statistically significant.
- Correctional systems in Georgia and Michigan met or exceeded some national standards for chronic disease control, but not others.
- Clinicians overestimated the percentage of patients with dually diagnosed diabetes and hypertension whose blood pressure was in good control.
The Robert Wood Johnson Foundation (RWJF) supported the project with a $241,876 grant from May 2002 through October 2004.
In 1997, Congress instructed the U.S. Department of Justice to set aside funding to study the health status of the nation's two million inmates. The National Commission on Correctional Health Care (NCCHC) conducted the study under a contract with the Department of Justice, and recommended ways to improve disease prevention, screening and treatment in prisons and jails.
NCCHC, based in Chicago, develops standards of care and accredits health services in correctional institutions. Its mission is to improve the quality of health care in jails, prisons and juvenile confinement facilities.
Based on the study, NCCHC published The Health Status of Soon-To-Be-Released Inmates in 2002. According to the report, inmates have high rates of:
- Communicable disease, including HIV, tuberculosis and sexually transmitted diseases.
- Chronic illness, including asthma, diabetes and hypertension.
- Mental illness.
Slightly more than half of the departments of corrections in 41 states surveyed for this project had system-wide clinical guidelines in place for screening and treating chronic diseases among inmates. Often, however, these guidelines were incomplete or out of date and failed to conform to nationally accepted standards.
In response, NCCHC began developing practice guidelines in correctional settings, distilling the best available scientific evidence to guide the diagnosis and management of hypertension, diabetes, asthma, seizure disorders and HIV. The guidelines, published in late 2001, also provide standardized definitions of good, fair and poor control.
NCCHC requires accredited health services to demonstrate that they are using these or other accepted clinical guidelines to treat chronic diseases.
RWJF has funded a number of projects concerned with chronic or communicable diseases in prisoners:
- The Hepatitis C Awareness Project in Oregon. See Grant Results on ID# 044316.
- Development of a Commission to Raise Public Awareness of Mental Health and Substance Abuse Issues in Iowa's Corrections System. See Grant Results on ID# 041849.
- Integrating Corrections and Community Health Systems Can Enhance Screening and Treatment of TB. A study of tuberculosis (TB) screening and treatment procedures in jails and community-based health care facilities in two representative California counties. See Grant Results on ID# 024726.
The goal of this project was to document the use of practice guidelines and to measure the outcomes of patients with chronic conditions in correctional institutions in Georgia and Michigan.
Ultimately, researchers hoped that the practice guidelines would establish the value of performance improvement measurement and create a model that could be used by correctional systems nationwide to bring chronic disease in its prisoner populations under control.
The departments of corrections in Georgia and Michigan, which had already developed programs to standardize their approach to chronic disease management, agreed to use NCCHC clinical guidelines to treat their prisoners. NCCHC staff trained their providers in the use of these guidelines.
Under the project, NCCHC investigators:
- Developed a strategy, with input from medical personnel in the Georgia and Michigan departments of corrections, for collecting and analyzing patient encounter forms. Clinicians completed these forms at every encounter with an inmate who had hypertension, diabetes, asthma, seizure disorders or HIV.
- Developed definitions of good, fair and poor control of selected chronic diseases, such as hypertension and diabetes, to remind physicians when further clinical interventions were appropriate.
- Tracked the progress of patients over time by collecting and analyzing data on patient visits from July 2002 through September 2004 (43,000 visits in 27 correctional institutions in Michigan and 21,209 visits in 43 correctional institutions in Georgia).
- Shared the results of the data analysis with state medical directors of corrections, who in turn shared them with their physicians providing care.
During and after the project, the principal investigator made eight presentations about measuring outcomes in correctional facilities to national audiences of correctional officials. Events included the "National Conference on Correctional Health Care" and the "National Conference on Chronic Disease Outcomes in Correctional Health Care Programs."
- The Georgia Department of Corrections required Institutional Review Board (IRB) approval. This was unanticipated, since the investigators had viewed their work as a continuous quality improvement initiative, rather than research, and the Michigan Department of Corrections waived IRB approval. The Georgia IRB approval took a year to secure, delaying submission of patient encounter forms.
- Quality control problems arose for a number of reasons. Software glitches and poor documentation initially affected the accuracy of the reports. Rates of turnover were high among correctional facility physicians, and newer doctors did not document the medical status of patients as thoroughly as those who had been in place when the project began.
According to "Using Performance Improvement Measurement to Improve Chronic Disease Management in Prisons," a book chapter published in Clinical Practices in Correctional Medicine (see the Bibliography), and to the investigators in an interview and reports to RWJF, these were the key findings:
- Documenting the progress of patients with chronic diseases appeared to result in small improvements in health outcomes. However, the increase of patients who met the NCCHC's criteria for good control did not achieve statistical significance. The investigators did not collect data on the percentage of providers who used clinical guidelines.
- Correctional systems sometimes meet benchmarks that have been established for chronic disease control, and sometimes do not. Investigators compared their findings with standards established by the National Committee on Quality Assurance (NCQA), a Washington-based nonprofit organization that accredits managed care plans. No benchmarks have been established specifically for correctional communities.
As an example, NCQA says a health care organization should be able to bring blood pressure levels below 140/90 in at least 65 percent of its patients. In 2003:
- The Michigan correctional system achieved this goal for 66 percent of its patients.
- The Georgia system met this goal for 56 percent of its patients.
- Health maintenance organizations (HMOs) and other health care organizations achieved this level of control among 49 percent of their patients.
- Clinicians overestimated the percentage of patients with diabetes and hypertension whose blood pressure met NCCHC standards for good control. According to the principal investigator, clinicians who believe their patients are in good control when they are not are unlikely to intervene appropriately.
- Clinicians in Michigan estimated that their patients with both diabetes and hypertension had good blood pressure control (defined for this dually diagnosed population as 130/80) 41 percent of the time. The data showed, however, that these patents were in good control just 24 percent of the time.
- In Georgia, clinicians believed that 48 percent of their patients with diabetes and hypertension were in good control; actually, 26 percent were.
- Anticipate the concerns that arise when conducting research among prisoners. The delays in Georgia, and its requirement for IRB approval, highlight the importance of working closely with corrections officials and providing appropriate assurances about confidentiality and project goals. (Project Director)
- Institutionalize quality improvement projects. The departure of key personnel, a special risk among political appointees, can cause a project to unravel. The use of practice guidelines and outcome measurements should be a routine part of a clinician's job so that this kind of intervention does not depend on a single champion. (Project Director)
- Offer ongoing training in the use of clinical guidelines and patient tracking forms. Both prison systems had high turnover and new clinicians did not receive the training that was offered at the outset of the project. (Project Director)
- Double the time anticipated for data collection in correctional facilities. Validating data and making necessary software changes are invariably more time-consuming than expected. (Project Director)
- A national commitment is needed to push forward quality improvement efforts in prison health care. Correctional health systems are not going to meet national standards voluntarily. RWJF should consider how to include incentives or advocate for a correctional health system with the teeth to require and monitor quality improvement. (Program Officer /Grisso)
AFTER THE GRANT
The project ended with this grant. The investigators attempted to find other state correctional institutions to undertake a similar program but none had the funds to do so.
GRANT DETAILS & CONTACT INFORMATION
Improving Chronic Disease Management in Correctional Institutions
National Commission on Correctional Health Care (Chicago, IL)
Dates: May 2002 to October 2004
Ronald Shansky, M.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Kim S, Shansky R and Schiff GD. "Using Performance Improvement Measurement to Improve Chronic Disease Management in Prisons." In Clinical Practices in Correctional Medicine, 2nd edition, Couchman R (ed.). St. Louis, Mo.: Mosby Publishers, 2006.
Report prepared by: Susan Parker
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: Jeane Ann Grisso