Background

High rates of incarceration are making an impact on correctional facility health care. The world prison population has grown by 20% in the past 16 years with more than 10 million people in penal facilities.1 Since 2000, female prison population has increased by 50%, with an increase in the proportion of women and girls of 1.4% and an increase in the male prison population of 18%.1 Prison population rates vary across the world, but countries with the top three highest prison population rates include Seychelles, the United States, and St. Kitts and Nevis.1 At 2014 yearend, the United States held 1,561,500 prisoners in state and federal correctional facilities, a decrease of 15,400 prisoners from the previous year.2 However, the number of prisoners increases to nearly seven million when local correctional facilities are included.3 As the prison population grows, correctional facility health care must make changes to decrease costs.

Prisoners have higher rates of medical problems than the general population. In 2011-2012, nearly half of all federal, state and local prisoners in the United States had a current chronic medical condition.4 The most common chronic disease reported was high blood pressure, with asthma and arthritis being the second and third most common chronic conditions, respectively.4 Of those prisoners with a current chronic condition, 66% were currently taking prescription medications, and 20% were receiving medical treatment.4 Other conditions reported by prisoners and inmates included tuberculosis (TB), hepatitis B or C and other sexually transmitted diseases.4 In addition, the prison population suffers from mental illness and substance abuse.5 These complex medical problems contribute to correctional facility healthcare expenditures.5 In 2011, the cost was nearly $8 billion, a slight decrease from $8.2 billion in 2009, but the number accounts for a fifth of overall prison expenses.5 The cost per prisoner rose with a median growth of 10% and aging prisoners incurred higher per prisoner costs.5

The aging population of prisoners is another contributing factor to increased healthcare spending in correctional facilities.5 The number of state and federal prisoners in the United States aged 55 years or older increased by 204% from 1999 to 2012.5 As prisoners age while in prison, more medical problems occur. The medical problems result in increased healthcare costs for the correctional facility. It is estimated that aging prisoners incur two to three times higher costs than other inmates.6 On the contrary, the aging population of prisoners is not the only reason that healthcare costs are increasing in correctional facilities.

The location of the correctional facility is another costly expense. Correctional facilities in remote locations are at a disadvantage because health care and healthcare workers are not available in these remote locations. Premium pay must be given to entice healthcare workers to drive to the correctional facility to provide quality care, including specialized training for the healthcare workers on care of prisoners. When healthcare cannot occur in the correctional facility, other costs will be incurred to transport the prisoner to receive health care. The other expenses may include increased security or increased travel costs to transport the prisoner. All of the expenses related to the remote location of the correctional facility contribute to the healthcare expenses.

In addition to managing healthcare costs, correctional facilities must also maintain quality care. In 1976, the United States Supreme Court ordered that prisoners have a constitutional right to health care and that prisoner rights are violated when those healthcare needs are not met.5 More recently, the Affordable Care Act healthcare reform demands for improvements in the quality of care provided to prisoners.7 Correctional facilities must strategically plan to manage healthcare costs, while managing higher rates of incarcerations and improving healthcare outcomes.

Telehealth can be used to help manage health care and improve outcomes in correctional facilities. Telehealth is defined as medical information exchanged from one location to another through electronic means to improve the health status of individuals.8 It has four main modalities: synchronous, asynchronous, remote patient monitoring and mobile health.9 Synchronous is real-time, live two-way audio-visual communication between a provider and a patient. Asynchronous, also known as store and forward, is the transmission of an image via secure electronic means to a provider for evaluation. Both synchronous and asynchronous telehealth allow a provider to evaluate and/or diagnose and provide access to care for primary and specialty care services to prisoners. By providing these services via telehealth, correctional facilities can decrease costs associated with access to care, including transportation, security and healthcare costs, and improve healthcare outcomes by providing specialty services.10-12

Telehealth improves patient outcomes including decreased blood pressure in hypertension, increased glycemic control in diabetes, improved access to services, improved provider and patient satisfaction, and decreased costs and could be replicated in the correctional facility population.13-17 It is currently being used in more than 30 states in the United States, Australia, United Kingdom and Italy. The positive impact of telehealth can change correctional facility health care and should be expanded to additional correctional facilities. A preliminary search of PubMed, Cochrane Database of Systematic Reviews and JBI Database of Systematic Reviews and Implementation Reports was conducted, and no current systematic reviews on this topic were found. Telehealth has been the topic for systematic reviews on diabetes, chronic obstructive pulmonary disease and heart failure, but a systematic review on telehealth in correctional facility health care is needed to understand the effect on this unique population.18-26

Inclusion criteria

Types of participants

The current review will consider studies that include inmates over the age of 12 years who have been incarcerated in a federal, state or local correctional facility (prison, detention center or juvenile detention center) and have been evaluated for health care at the facility.

Types of intervention(s)/phenomena of interest

The current review will consider studies that evaluate the effectiveness of telehealth using audio-visual connectivity (live synchronous visits and asynchronous store and forward visits) compared to usual care in the correctional facility.

Outcomes

The current review will consider studies that include the following primary outcome measures:

Access to health care - measured by increased access to specialty services

Costs - measured by savings in dollars and mileage

The current review will consider studies that include the following secondary outcome measures:

Virologic suppression - measured by laboratory testing (CD4, CVL and HCV viral load)

Glycemic control - measured by laboratory testing of hemoglobin A1c

Blood pressure - measured by systolic and diastolic blood pressure

Lipid control - measured by laboratory testing of low density lipoprotein (LDL)

Types of studies

The current review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published from 1996 to present (20 years) will be considered for inclusion in this review due to the emergence of telehealth during that time period.

The databases to be searched include:

Cochrane Central Register of Controlled Trials

CINAHL

PubMed

Embase

Health Technology Assessments

Ovid Healthstar

The search for unpublished studies will include:

ProQuest Dissertations and Theses

Google Scholar

Initial keywords to be used will be: telehealth, telemedicine, correctional facilities, prison, penitentiary, penal institution, jail, detention centers, healthcare delivery and healthcare costs

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted for missing information or to clarify unclear data.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Appendix I: MAStARI appraisal instrument

Appendix II: MAStARI data extraction instrument

References