Multimorbidity and quality of primary care after release from prison: a prospective data-linkage cohort study

People in prison often have complex healthcare needs associated with a high prevalence of mental illness, substance use problems, cognitive disability, communicable and non-communicable disease, and social disadvantage [1, 2]. Chronic health conditions frequently co-occur such that multimorbidity (the presence of more than one chronic disease in an individual) is common [3]. However, multimorbidity in prisons has not been well characterised, and the prevalence of multimorbidity among people in prisons is unknown.

The period immediately following release from prison is associated with increased risk of preventable morbidity and mortality, including suicide and self-harm, drug overdose, decompensation of disease, and preventable hospitalisation [4‐6]. Although the rate of primary care contact in people released from prison is higher than that of the general population [7, 8] continuity of care is a challenge particularly because people in prison are excluded from federally subsidised medical care (Medicare) [1]. In the United States, recently expanded eligibility for Medicaid and pre-release enrollment assistance have increased access to primary care for adults released from prison [9].

High-quality primary care has been shown to predict better health outcomes in the general population, including reduced hospitalisation, emergency department attendance, and mortality; and increased preventive healthcare, patient satisfaction, and efficiency of chronic disease management [10, 11]. In particular, continuity of care has been linked to decreased hospitalisation rates for multimorbid patients [12]. Therefore, the aims of this study were to (a) characterise multimorbidity, and (b) examine the relationship between multimorbidity in prison and quality of primary healthcare within 2 years after release from prison.

This study involved secondary analysis of data from a randomised controlled trial of a service brokerage intervention for people released from prison, which has been described previously [13]. In-prison survey data and coded prison medical records were linked prospectively with their records from Medicare (Australia’s universal health insurance scheme), the National Death Index (NDI), and correctional services. All participants provided written informed consent. This study is reported in accordance with the RECORD Statement [14].

Characteristics of the cohort at baseline, according to sex, are summarised in Table 1. During follow-up, 21 of 1046 participants (2.0%) died, and 457 (43.7%) were reincarcerated at least once. Over 2 years of follow-up, after censoring for deaths and excluding follow-up time in prison, the mean follow-up time in the community was 655 days (SD = 143.3).

Our study is the first internationally to fully characterise multimorbidity and quantify the association between multimorbidity and quality of primary care in a large cohort of adults released from prison. We found that multimorbidity was present for nearly three quarters of this cohort, which is more than four times the prevalence found in a previous study of the Australian general population [24]. We confirmed previous findings that the health profile of incarcerated women is worse than that of incarcerated men [25].

We found a rate of primary care visits per person-year, after excluding time in prison and censoring for deaths, of 7.33 (95%CI 7.20–7.45) visits per person-year, which is roughly twice the age- and sex-standardised rate for the Queensland population [7]. The health of incarcerated people tends to deteriorate after release from prison [4‐6, 26, 27] despite high rates of primary healthcare use after release from custody [7]. In the context of stigma, cultural barriers, poverty, social deprivation, multiple health risk behaviours, and complex health and social needs, adults recently released from prison may receive healthcare that, while more intensive than average, is insufficient to meet their complex health-related needs. For many of these individuals, and particularly for Indigenous people, social determinants of health rather than inadequate access to quality healthcare may be the major contributors to poor health outcomes after release from prison [28].

Our findings suggest that inadequate continuity of care may contribute to the poor health of adults released from prison, especially when multimorbidity is present. In our study, complex multimorbidity was associated with adequate continuity of care, but this was not true for moderate multimorbidity, which includes up to three morbidities. This finding remained after excluding psychiatric morbidity. We also found that Indigenous people were nearly 50% less likely to receive continuous care after release from prison, compared to non-Indigenous people.

Our findings highlight the importance of transitional care clinics, which have become more common in the United States, to improve continuity of care and health outcomes after release from prison [29, 30]. Extended eligibility and access to healthcare through Medicaid is undoubtedly beneficial, but is likely insufficient to improve health outcomes for this population.

We found that multimorbidity (both moderate and complex) was associated with having at least one long consultation within 2 years after release from prison. However, long consultations were 36% less likely for those aged 18–24 years compared to older age groups. Consistent with the literature [31], we also found that the burden of psychiatric illness in this cohort was substantial, especially for females. Previous research has highlighted the benefits of targeted support for people with serious mental illness transitioning from prison to the community [32], given that this group is also typically at higher risk of reincarceration [33].

Our study had four main limitations. First, because people in prison in Australia (as in the United States) are excluded from health insurance, we were unable to measure primary care during periods of reincarceration. Second, due to the limitations of Medicare data, we assessed only three indicators of quality of care. Other markers that would be useful to assess include: provision of preventative healthcare, technical quality of chronic disease management, referrals to allied health and specialist medical services, clinical effectiveness, and patient experience [34]. Third, we were unable to identify instances where patients were visiting multiple doctors in the same clinic, and as such we may have over-estimated continuity of care. Fourth, our data reflected patterns of healthcare use almost a decade ago. However, this remains the only study internationally that has examined linked primary care data in a large, representative, prospective cohort of adults released from prison, and we have no reason to believe that patterns of primary healthcare in this population have changed meaningfully in recent years. Replication of our study in other contexts is warranted, especially in light of the different levels of quality and access to healthcare services for people released from prison in regions and countries worldwide.

Multimorbidity and mental illness are prevalent in nearly three quarters of adults released from prisons, and are more prevalent in females. In our study, nearly half of the adults released from prison with complex multimorbidity did not receive adequate continuity of care. Younger people (18–24 years) were less likely to have long consultations, and Indigenous people were less likely to receive adequate continuity of care. Our study highlights a missed opportunity to address important health inequities through improved continuity and quality of care for people released from prison, and provides globally relevant evidence of the lack of appropriate healthcare for an already highly marginalised group.