Passports to advantage:Health and capacity building as a basis for social integration

Released prisoners are characterised by chronic social disadvantage, poor physical and mental health, and high rates of substance misuse – a continuation of problems experienced prior to imprisonment. High rates of recidivism and fatal drug overdose post-release indicate that integration of ex-prisoners is often unsuccessful. Despite this, remarkably little is known about recently released prisoners and it is thus difficult to formulate evidence-based policies for this group. The stated policy of most correctional services in Australia is one of ‘throughcare’, which implies continuity of needs- and evidence-based service provision from the moment of reception, through to return to the community and beyond. At present, however, there is a dearth of evidence-based services and support for ex-prisoners. This presentation will review the evidence regarding the experiences of released prisoners and consider models of post-release service provision. One promising model, which aims to proactively improve health and capacity and thereby promote integration, will be described. A randomised controlled trial of this model has recently been funded by the NHMRC; the rationale, aims and key features of this model will be discussed

Contact with mental health services after medically verified self-harm: A prospective data linkage study

Introduction High rates of self-harm resulting in acute health service contact have been observed in adults released from prison. Contact with health services due to self-harm is a key intervention opportunity to prevent deleterious health outcomes. Little is known about subsequent mental health service contact after discharge from acute health services. Objectives and Approach We aimed to describe mental health service contact after discharge from acute health service contacts following self-harm in a representative sample of adults released from prison. Ambulance, emergency department (ED), hospital inpatient and ambulatory mental health service records were probabilistically linked to pre-release interview data. Self-harm events after release were identified from ICD codes and coded from case notes in ambulance, ED, and hospital records. We calculated the time between discharge from ambulance, ED, or hospital after self-harm and subsequent contact with mental health services. Factors predicting the likelihood of mental health service contact were examined using multivariate logistic regression. Results Of 1307 adults released from prison, 108 (8.3%) experienced 218 self-harm events resulting in acute health service use in the community. Of these presentations, 0%, 59%, and 50% of discharges from ambulance attendances, ED and hospital, respectively, had subsequent contact with a specialist mental health service within 7 days of that acute service contact. Mental health service contact within 7 days of acute service contact was positively associated with being female (adjusted odds ratio [AOR]: 3.27; 95%CI: 1.26-8.47) and being identified by prison staff as at risk for self-harm (AOR: 3.34; 95%CI: 1.29-8.62), and was negatively associated with dual diagnosis (AOR: 0.19: 95%CI: 0.06-0.61), substance use disorder only (AOR: 0.13; 95%CI: 0.04-0.48) and physical health functioning (AOR: 0.96; 95\%CI: 0.92-0.99). Conclusion/Implications Almost half of adults with a recent history of incarceration discharged from acute health service after self-harm did not receive timely specialist mental health care. Improved integration of acute health services and ambulatory mental health services could improve outcomes for adults who present with self-harm

The Mortality After Release from Incarceration Consortium (MARIC) study: Strengths of international data linkage

Introduction Adults released from incarceration experience complex physical and mental health problems, and are at markedly increased risk of preventable death. Despite this, not enough is known about the granular epidemiology of mortality in this population to inform development of targeted, evidence-based responses. Objectives and Approach We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration from 12 countries representing 30 cohorts of adults with a history of incarceration. The combined sample size is 1,210,168, with 58,840 deaths recorded over 8,261,743 person-years of follow-up time. In this protocol paper, using a two-step, individual participant data meta-analysis (IPDM-A) methodology involving 22 MARIC cohorts, we calculated 1) a crude mortality rate (CMR; with 95% confidence intervals) for each individual cohort over the first 84 days (12 weeks) following release; and 2) a combined, meta-analysed CMR for the same period. Results Of 1,704,208 individual releases, we observed 4,018 deaths over the first 84 days. The overall CMR over the first 84 days after release was 1610.97 deaths per 100,000 person-years (95% CI: 1263.4 - 1958.5). The rate was highest on the day of release (5768.0; 95% CI: 3296.5 - 8239.4), which was significantly higher than on days 4-84. Conclusion/Implications Adults released from incarceration were at an acutely increased risk of death on the day of release, and this risk remained elevated for at least the first 12 weeks. The MARIC study will provide decisive and empirical evidence to guide clinicians and policy makers in reducing mortality in this marginalize

Early primary care physician contact and health service utilisation in a large sample of recently released ex-prisoners in Australia: prospective cohort study

Objective To describe the association between ex-prisoner primary care physician contact within 1 month of prison release and health service utilisation in the 6 months following release. Design A cohort from the Passports study with a mean follow-up of 219 (±44) days post release. Associations were assessed using a multivariate Andersen-Gill model, controlling for a range of other factors. Setting Face-to-face, baseline interviews were conducted in a sample of prisoners within 6 weeks of expected release from seven prisons in Queensland, Australia, from 2008 to 2010, with telephone follow-up interviews 1, 3 and 6 months post release. Participants From an original population-based sample of 1325 sentenced adult (≥18 years) prisoners, 478 participants were excluded due to not being released from prison during follow-up (n=7, 0.5%), loss to follow-up (n=257, 19.4%), or lacking exposure data (n=214, 16.2%). A total of 847 (63.9%) participants were included in the analyses. Exposure Primary care physician contact within 1 month of follow-up as a dichotomous measure. Main outcome measures Adjusted time-to-event hazard rates for hospital, mental health, alcohol and other drug and subsequent primary care physician service utilisations assessed as multiple failure time-interval data. Results Primary care physician contact prevalence within 1 month of follow-up was 46.5%. One-month primary care physician contact was positively associated with hospital (adjusted HR (AHR)=2.07; 95% CI 1.39 to 3.09), mental health (AHR=1.65; 95% CI 1.24 to 2.19), alcohol and other drug (AHR=1.48; 95% CI 1.15 to 1.90) and subsequent primary care physician service utilisation (AHR=1.47; 95% CI 1.26 to 1.72) over 6 months of follow-up. Conclusions Engagement with primary care physician services soon after prison release increases health service utilisation during the critical community transition period for ex-prisoners. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12608000232336)

Increased risk of death following release from incarceration: an individual participant data meta-analysis of 1,314,568 adults in eight countries.

Objectives People released from incarceration are at increased risk of death from diverse causes. We aimed to calculate the incidence of all-cause and cause-specific death after release from incarceration and identify individual-level risk factors for death. Approach We conducted a series of individual participant data meta-analyses using data from >1.3 million adults released from incarceration in eight countries from 1980-2018. We used random effects meta-analysis to estimate the pooled all-cause and cause-specific crude mortality rates (CMRs), with 95% confidence intervals (CI) for the entire follow-up period, and for specific time periods after release from incarceration, overall and stratified by age, sex, and region. Results We included 1,395,318 people, 10,164,341 person-years of follow-up time, and 72,920 deaths in our analyses. The overall pooled CMR was 727 (95%CI: 623-840) per 100,000 person-years, with no difference between males and females. The risk of death was highest during the first week following release (all-cause CMR: 1,612, 95%CI: 1048-2,287, I2=91.5%), and the three most common causes of death across the entire follow-up period were 1) alcohol and other drug poisoning (CMR=144, 95%CI: 99-197); 2) cardiovascular disease (CMR: 102, 95%CI: 85-121); and 3) cancer and other neoplasms (CMR=74, 95%CI: 85-121). Leading causes of death varied across time periods following release from incarceration. Conclusion Our findings indicate the need for routine monitoring of mortality following release from incarceration. The distribution of cause of death varies over time, such that clinical decision-making needs to be informed by the proximity to release from incarceration. The elevated risk of death in first 7 days following release highlights the urgent need for coordinated transitional care – including substance use and mental health treatment – and injury prevention initiatives

Advancing cross-sectoral data linkage to understand and address the health impacts of social exclusion: Challenges and potential solutions

The use of administrative health data for research, monitoring, and quality improvement has proliferated in recent decades, leading to improvements in health across many disease areas and across the life course. However, not all populations are equally visible in administrative health data, and those that are less visible may be excluded from the benefits of associated research. Socially excluded populations -- including the homeless, people with substance dependence, people involved in sex work, migrants or asylum seekers, and people with a history of incarceration -- are typically characterised by health inequity. Yet people who experience social exclusion are often invisible within routinely collected administrative health data because information on their markers of social exclusion are not routinely recorded by healthcare providers. These circumstances make it difficult to understand the often complex health needs of socially excluded populations, evaluate and improve the quality of health services that they interact with, provide more accessible and appropriate health services, and develop effective and integrated responses to reduce health inequity. In this commentary we discuss how linking data from multiple sectors with administrative health data, often called cross-sectoral data linkage, is a key method for systematically identifying socially excluded populations in administrative health data and addressing other issues related to data quality and representativeness. We discuss how cross-sectoral data linkage can improve the representation of socially excluded populations in research, monitoring, and quality improvement initiatives, which can in turn inform coordinated responses across multiple sectors of service delivery. Finally, we articulate key challenges and potential solutions for advancing the use of cross-sectoral data linkage to improve the health of socially excluded populations, using international examples

Self-harm following release from incarceration: Patterns and measurement issues

Introduction Despite an elevated prevalence of self-harm in the incarcerated adult population, little is known about patterns of self-harm following release from prison. Objectives and Approach Baseline self-report interviews with 1315 adults immediately prior to release from prison in Queensland, Australia, combined with interrogation of linked health data from >3750 post-release emergency department presentations, >2000 ambulance attendances, and corrections data during periods of re-incarceration. Results Approximately 5% of all contacts with medical emergency services following release from prison resulted from self-harm. These were associated with being Indigenous, having a lifetime history of a mental disorder and having been identified by prison staff as being at risk of self-harm. Agreement between self-reported self-harm and medically-verified episodes of self-harm was poor. Conclusion/Implications Emergency services contacts resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. Our findings suggest that a self-reported history of self-harm should not be considered a reliable indicator of prior self-harm, or of future self-harm risk, in incarcerated adults

Counting the cost: estimating the number of deaths among recently released prisoners in Australia

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007–08 financial year, within 4 weeks and 1 year of release. Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007–08. Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007–08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death. Results: It was estimated that among people released from prison in 2007–08, between 449 (95% CI, 380–527) and 472 (95% CI, 438–507) died within 1 year of release. Of these, between 68 (95% CI, 56–82) and 138 (95% CI, 101–183) died within 4 weeks of release. Most of these deaths were not drug-related. Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls

Two Sample Tests for High Dimensional Covariance Matrices

We propose two tests for the equality of covariance matrices between two high-dimensional populations. One test is on the whole variance-covariance matrices, and the other is on offdiagonal sub-matrices which define the covariance between two non-overlapping segments of the high-dimensional random vectors. The tests are applicable (i) when the data dimension is much larger than the sample sizes, namely the “large p, small n” situations and (ii) without assuming parametric distributions for the two populations. These two aspects surpass the capability of the conventional likelihood ratio test. The proposed tests can be used to test on covariances associated with gene ontology terms