Johns Hopkins study: Chronic conditions may be under-treated with medication in prisons, jails

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Chronic medical conditions such as asthma, mental illness, type 2 diabetes and hepatitis may be severely undertreated in U.S. jails and prisons, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health.

The report, published Friday in JAMA Health Forum — a peer-reviewed, open-access online journal — married two data sets to compare the estimated rates of chronic conditions among incarcerated people and the estimated distribution of medication treatments to jails and prisons between 2018 and 2020.


The researchers suspected they would find evidence of under-treatment, said Dr. G. Caleb Alexander, one of the study’s co-authors and an epidemiology professor at the Bloomberg School. But the results still surprised them.

“We didn’t expect to find the magnitude of potential undertreatment that we did,” said Alexander, whose research interests focus on maximizing the use, safety and effectiveness of prescription medicines.


Alexander and his colleagues found that recently incarcerated people with type 2 diabetes represented about 0.44% of the U.S. population with the condition, but only received about 0.15% of anti-hyperglycemic medications used to treat the disease — a nearly threefold difference, the Bloomberg School said in a news release.

Incarcerated people with asthma accounted for 0.85% of the total U.S. asthma population, but just 0.15% of asthma treatment volume, according to the report. Researchers also found disparities in the treatment of other chronic diseases, including severe mental illness and HIV infection.

Previous studies of the country’s prison and jail populations — which together include nearly two million people — have found that incarcerated people tend to be sicker than those in the average population and are more likely to have at least one mental illness.

But, according to the Bloomberg School release, research has found health care provided to the population is often understaffed, underfunded and of poor quality.

It is supplied by a “patchwork of health care providers,” most often private contractors who do not widely share information about the services they provide, study co-author Brendan Saloner said in the release.

“The lack of transparency means that advocates and policymakers have a very incomplete picture of the medicines that are available during a stay in jail or prison,” said Saloner, an associate professor in the Bloomberg School’s Department of Health Policy and Management.

That also makes it challenging to study health care problems in the country’s jails and prisons. Few previous studies have examined the treatment of chronic diseases in these settings with prescription medications, Alexander said.

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For their report, the researchers generated an estimate of the prevalence of chronic conditions among incarcerated people by combining data from the National Surveys on Drug Use and Health and the U.S. Census with other reports.


They also used data from the health care technology company IQVIA to estimate the prescriptions dispensed to jails and prisons compared to the general population. Researchers made adjustments for the possibility of missing data, according to the Bloomberg School release, and note their results may underestimate disparities between the populations.

Widespread under-diagnosis of medical conditions among incarcerated people, interruptions in their continuity of care and distrust of correctional facility clinicians are barriers to people receiving treatment in prisons and jails, Alexander said.

A high prevalence of mental illness in the population also tends to complicate the treatment of other chronic conditions, Alexander said. And medications are often expensive: A full 12-week course of treatment for hepatitis C can range from $40,000 to nearly $95,000.

But medication is also one of the most safe and cost-effective treatments in health care, Alexander said. He hopes the report published Friday inspires more research and prompts leaders of correctional facilities to reassess the care they provide to their populations.

“We have potentially hundreds of thousands or millions of people that are intersecting with the criminal justice system, where we have an opportunity to help ensure and maximize the quality of their health care,” he said. “We may be falling short.”