Publications by authors named "Benjamin A Howell"

22 Publications

  • Page 1 of 1

The Stigma of Criminal Legal Involvement and Health: a Conceptual Framework.

J Urban Health 2022 Jan 15. Epub 2022 Jan 15.

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.

The USA incarcerates more people than any other nation in the world. Exposure to the criminal legal system has been associated with a myriad of health outcomes but less is understood about what drives these associations. We argue that stigma due to criminal legal involvement, what we call criminal legal stigma, likely has a larger role in the association between incarceration and negative health outcomes than has been previously appreciated. There is limited research on the impact on health of criminal legal stigma despite abundant research on its negative social consequences. In this paper, we describe a conceptual framework of the health effects of criminal legal stigma drawing on previous research of criminal legal stigma and advances in other areas of stigma research. We outline key concepts related to stigma mechanisms, how they function at structural and individual levels, and how they might cause health outcomes. Finally, we identify potential areas for future research and opportunities for clinical interventions to remediate negative effects of stigma.
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http://dx.doi.org/10.1007/s11524-021-00599-yDOI Listing
January 2022

A review and content analysis of U.S. Department of Corrections end-of-life decision making policies.

Int J Prison Health 2021 Dec;ahead-of-print(ahead-of-print)

SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut, USA.

Purpose: With a rapidly growing population of older adults with chronic illness in US prisons, the number of people who die while incarcerated is increasing. Support for patients' medical decision-making is a cornerstone of quality care for people at the end of life (EOL). This study aims to identify, describe, and analyze existing policies regarding EOL decision-making in U.S. Departments of Corrections.

Design/methodology/approach: This study performed an iterative content analysis on all available EOL decision-making policies in US state departments of corrections and the Federal Bureau of Prisons.

Findings: This study collected and reviewed available policies from 37 of 51 prison systems (73%). Some areas of commonality included the importance of establishing health-care proxies and how to transfer EOL decision documents, although policies differed in terms of which patients can complete advance care planning documents, and who can serve as their surrogate decision-makers.

Practical Implications: Many prison systems have an opportunity to enhance their patient medical decision-making policies to bring them in line with community standard quality of care. In addition, this study was unable to locate policies regarding patient decision-making at the EOL in one quarter of US prison systems, suggesting there may be quality-of-care challenges around formalized approaches to documenting patient medical wishes in some of those prison systems.

Originality/value: To the best of the authors' knowledge, this is the first content analysis of EOL decision-making policies in US prison systems.
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http://dx.doi.org/10.1108/IJPH-06-2021-0060DOI Listing
December 2021

X-Waiver Exemption in the Treatment of Opioid Use Disorder.

JAMA 2021 08;326(5):441-442

SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1001/jama.2021.8267DOI Listing
August 2021

Changes In Health Services Use After Receipt Of Medications For Opioid Use Disorder In A Statewide Correctional System.

Health Aff (Millwood) 2021 08;40(8):1304-1311

Jennifer G. Clarke is the medical programs director at the Rhode Island Department of Corrections, in Cranston, Rhode Island.

To decrease opioid overdose mortality, prisons and jails in the US are increasingly offering medications for opioid use disorder (OUD) to incarcerated people. It is unknown how receipt of these medications in a correctional setting affects health services use after release. In this article we analyze changes in postrelease health care use after the implementation of a statewide medications for OUD program in the unified jail and prison system of the Rhode Island Department of Corrections. Using Medicaid claims data, we examined individual health care use in the community before and after receipt of medications for OUD while incarcerated. We found that inpatient admissions did not change, emergency department visits decreased, and both nonacute outpatient services and pharmacy claims increased after people received medications for OUD while incarcerated. There was no change in total health care costs paid by Medicaid. Our findings provide evidence that people's use of health care services paid for by Medicaid did not increase after they started medications for OUD in correctional settings. Given the frequent interaction of people with OUD with the criminal justice system, offering evidence-based treatment of OUD in correctional settings is an important opportunity to initiate addiction treatment.
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http://dx.doi.org/10.1377/hlthaff.2020.02156DOI Listing
August 2021

The role of social network support in treatment outcomes for medication for opioid use disorder: A systematic review.

J Subst Abuse Treat 2021 08 16;127:108367. Epub 2021 Mar 16.

Yale Institute for Network Science, Yale University, United States of America; Frank H. Netter MD School of Medicine, United States of America.

Background: Social connections can lead to contagion of healthy behaviors. Successful treatment of patients with opioid use disorder may lay in rebuilding social networks. Strong social networks of support can reinforce the benefits of medication treatments that are the current standard of care and the most effective tool physicians have to fight the opioid epidemic.

Methods: The research team conducted a systematic review of electronic research databases, specialist journals and grey literature up to August 2020 to identify randomized controlled trials of social network support in patient populations receiving medication for opioid use disorder (MOUD). The research team placed the studies into a framework of dynamic social networks, examining the role of networks before MOUD treatment is initiated, during the treatment, and in the long-term following the treatment. The research team analyzed the results across three sources of social network support: partner relationships, family, and peer networks.

Results: Of 5193 articles screened, eight studies were identified as meeting inclusion criteria. Five studies indicated that social network support had a statistically significant effect on improved MOUD treatment outcomes. We find the strongest support for the positive impact of family social network support.

Conclusions: Social networks significantly shape effectiveness of opioid use disorder treatments. While negative social ties reinforce addiction, positive social support networks can amplify the benefits of medication treatments. Targeted interventions to improve treatment outcomes can be designed and added to MOUD treatment with their effects evaluated in improving patients' odds of recovery from opioid use disorder and reversing the rising trend in opioid deaths.
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http://dx.doi.org/10.1016/j.jsat.2021.108367DOI Listing
August 2021

Medicaid Expansion Increased Medications For Opioid Use Disorder Among Adults Referred By Criminal Justice Agencies.

Health Aff (Millwood) 2021 04;40(4):562-570

Tyler N. A. Winkelman is a clinician investigator in the Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, and the codirector of the Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, both in Minneapolis, Minnesota.

Individuals involved with the US criminal justice system have high rates of opioid use disorder (OUD) but face significant barriers to evidence-based treatment. Using 2008-17 data from the Treatment Episode Data Set-Admissions, we examined trends in receipt of medications for OUD among individuals referred by criminal justice agencies and other sources both before and after Medicaid expansion. Individuals referred by criminal justice agencies were less likely to receive medications for OUD than were those referred by other sources during our study period, although this disparity narrowed slightly after Medicaid expansion. Receipt of medications for OUD increased more for individuals referred by criminal justice agencies in states that expanded Medicaid compared with those in states that did not. Medicaid expansion may improve evidence-based treatment for individuals with criminal justice involvement and OUD, although additional policy change outside the health care sector is likely needed to reduce persistent treatment disparities.
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http://dx.doi.org/10.1377/hlthaff.2020.01251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168564PMC
April 2021

The Transitions Clinic Network: Post Incarceration Addiction Treatment, Healthcare, and Social Support (TCN-PATHS): A hybrid type-1 effectiveness trial of enhanced primary care to improve opioid use disorder treatment outcomes following release from jail.

J Subst Abuse Treat 2021 09 29;128:108315. Epub 2021 Jan 29.

SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, CT, United States of America; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America. Electronic address:

Background: In 2016, at least 20% of people with opioid use disorder (OUD) were involved in the criminal justice system, with the majority of individuals cycling through jails. Opioid overdose is the leading cause of death and a common cause of morbidity after release from incarceration. Medications for OUD (MOUD) are effective at reducing overdoses, but few interventions have successfully engaged and retained individuals after release from incarceration in treatment.

Objective: To assess whether follow-up care in the Transitions Clinic Network (TCN), which provides OUD treatment and enhanced primary care for people released from incarceration, improves key measures in the opioid treatment cascade after release from jail. In TCN programs, primary care teams include a community health worker with a history of incarceration, and they attend to social needs, such as housing, food insecurity, and criminal legal system contact, along with patients' medical needs.

Methods And Analysis: We will bring together six correctional systems and community health centers with TCN programs to conduct a hybrid type-1 effectiveness/implementation study among individuals who were released from jail on MOUD. We will randomize 800 individuals on MOUD released from seven local jails (Bridgeport, CT; Niantic, CT; Bronx, NY; Caguas, PR; Durham, NC; Minneapolis, MN; Ontario County, NY) to compare the effectiveness of a TCN intervention versus referral to standard primary care to improve measures within the opioid treatment cascade. We will also determine what social determinants of health are mediating any observed associations between assignment to the TCN program and opioid treatment cascade measures. Last, we will study the cost effectiveness of the approach, as well as individual, organizational, and policy-level barriers and facilitators to successfully transitioning individuals on MOUD from jail to the TCN.

Ethics And Dissemination: Investigation Review Board the University of North Carolina (IRB Study # 19-1713), the Office of Human Research Protections, and the NIDA JCOIN Data Safety Monitoring Board approved the study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. We will disseminate study data through a web-based platform designed to share data with TCN PATHS participants and other TCN stakeholders. Clinical trials.gov registration: NCT04309565.
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http://dx.doi.org/10.1016/j.jsat.2021.108315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319218PMC
September 2021

Reporting of substance use treatment quality in United States adult drug courts.

Int J Drug Policy 2021 04 11;90:103050. Epub 2020 Dec 11.

Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States; SEICHE Center, Yale School of Medicine, New Haven, CT,  United States.

Background: Adult drug courts are growing in popularity within the Unites States, but the quality of substance use treatment within drug court programs and the impact of drug courts on health and substance use treatment outcomes is largely unknown. We appraised the quality of United States adult drug court process evaluations and the inclusion of measures of substance use treatment quality.

Methods: We systematically reviewed the adult drug court evaluations between 2008 and 2018 in accordance with recommended strategies for systematic gray literature search. We appraised evaluation quality using the Evidence for Policy and Practice Information and Coordination Center tool for process evaluations. We extracted recommended measures of substance use treatment quality, including measures related to screening and monitoring, diagnosis, service availability, service utilization, and outcomes.

Results: Our search identified 112 evaluations. Process measures were included within 68 evaluations, 45% of which had poor data reliability. We found that less than 10% of evaluations reported substance use treatment quality measures related to service utilization, overdose, and mortality, while more than 75% contained criminal justice measures, including program graduation (completion of criminal justice proceedings) and participant recidivism.

Conclusions: We found low uptake of measures of substance use treatment quality. The absence of data call into question the ability of drug courts to stem harmful substance use related health outcomes.
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http://dx.doi.org/10.1016/j.drugpo.2020.103050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046712PMC
April 2021

Validity of Incident Opioid Use Disorder (OUD) Diagnoses in Administrative Data: a Chart Verification Study.

J Gen Intern Med 2021 05 11;36(5):1264-1270. Epub 2020 Nov 11.

VA Connecticut Healthcare System, West Haven, CT, USA.

Background: An important strategy to address the opioid overdose epidemic involves identifying people at elevated risk of overdose, particularly those with opioid use disorder (OUD). However, it is unclear to what degree OUD diagnoses in administrative data are inaccurate.

Objective: To estimate the prevalence of inaccurate diagnoses of OUD among patients with incident OUD diagnoses.

Subjects: A random sample of 90 patients with incident OUD diagnoses associated with an index in-person encounter between October 1, 2016, and June 1, 2018, in three Veterans Health Administration medical centers.

Design: Direct chart review of all encounter notes, referrals, prescriptions, and laboratory values within a 120-day window before and after the index encounter. Using all available chart data, we determined whether the diagnosis of OUD was likely accurate, likely inaccurate, or of indeterminate accuracy. We then performed a bivariate analysis to assess demographic or clinical characteristics associated with likely inaccurate diagnoses.

Key Results: We identified 1337 veterans with incident OUD diagnoses. In the chart verification subsample, we assessed 26 (29%) OUD diagnoses as likely inaccurate; 20 due to systems error and 6 due to clinical error; additionally, 8 had insufficient information to determine accuracy. Veterans with likely inaccurate diagnoses were more likely to be younger and prescribed opioids for pain. Clinical settings associated with likely inaccurate diagnoses were non-mental health clinical settings, group visits, and non-patient care settings.

Conclusions: Our study identified significant levels of likely inaccurate OUD diagnoses among veterans with incident OUD diagnoses. The majority of these cases reflected readily addressable systems errors. The smaller proportion due to clinical errors and those with insufficient documentation may be addressed by increased training for clinicians. If these inaccuracies are prevalent throughout the VHA, they could complicate health services research and health systems responses.
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http://dx.doi.org/10.1007/s11606-020-06339-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131432PMC
May 2021

Service Involvement Across Multiple Sectors Among People Who Use Opioids, Methamphetamine, or Both, United States-2015-2018.

Med Care 2021 03;59(3):238-244

Hennepin Healthcare Research Institute, Minneapolis, MN.

Background: The fourth wave of the opioid crisis is characterized by increased use and co-use of methamphetamine. How opioid and methamphetamine co-use is associated with health care use, housing instability, social service use, and criminal justice involvement has not been studied and could inform future interventions and partnerships.

Objectives: To estimate service involvement across sectors among people who reported past year opioid and methamphetamine co-use, methamphetamine use, opioid use, or neither opioid nor methamphetamine use.

Research Design: We examined 2015-2018 data from the National Survey on Drug Use and Health. We used multivariable negative binomial and logistic regression models and predictive margins, adjusted for sociodemographic and clinical characteristics.

Subjects: Nonelderly US adults aged 18 or older.

Measures: Hospital days, emergency department visits, housing instability, social service use, and criminal justice involvement in the past year.

Results: In adjusted analyses, adults who reported opioid and methamphetamine co-use had 99% more overnight hospital days, 46% more emergency department visits, 2.1 times more housing instability, 1.4 times more social service use, and 3.3 times more criminal justice involvement compared with people with opioid use only. People who used any methamphetamine, with opioids or alone, were significantly more likely be involved with services in 2 or more sectors compared with those who used opioids only (opioids only: 11.6%; methamphetamine only: 19.8%; opioids and methamphetamine: 27.6%).

Conclusions: Multisector service involvement is highest among those who use both opioids and methamphetamine, suggesting that partnerships between health care, housing, social service, and criminal justice agencies are needed to develop, test, and implement interventions to reduce methamphetamine-related morbidity.
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http://dx.doi.org/10.1097/MLR.0000000000001460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878287PMC
March 2021

Substance use patterns and health profiles among US adults who use opioids, methamphetamine, or both, 2015-2018.

Drug Alcohol Depend 2020 09 2;214:108162. Epub 2020 Jul 2.

Hennepin Healthcare Research Institute, 701 Park Ave., Suite PP7.700, Minneapolis, MN, 55415, USA; Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, 716 S 7thSt, Minneapolis, MN, 55415, USA.

Background: Methamphetamine use, with and without opioids, has increased substantially, but little is known about the sociodemographic characteristics, substance use patterns, or health profiles of individuals who use methamphetamine. To design effective public health interventions, health care professionals and policymakers need data describing individuals who are using methamphetamine in the midst of the opioid crisis.

Methods: We used 2015-2018 data from the National Survey on Drug Use and Health and included non-elderly adults aged 18-64 years. We categorized respondents into three groups: use of opioids without methamphetamine use, use of methamphetamine without opioid use, or use of both opioids and methamphetamine. Multiple logistic regression models controlling for sociodemographic factors were used to compare substance use characteristics and measures of individual health between the three groups.

Results: People who used any methamphetamine were more likely to be unstably housed, low-income, and live in rural areas. Use of both opioids and methamphetamine was associated with a 132 % higher prevalence of injection needle use, and a nearly twofold higher prevalence of viral hepatitis compared with opioid use alone. One third of individuals reporting use of both opioids and methamphetamine had a severe mental illness, a 55 % higher prevalence than those using opioids alone.

Conclusions: Individuals who used opioids and methamphetamine had more complex substance use and health profiles than individuals who used opioids alone. These findings suggest public health and harm reduction approaches designed to address opioid use remain important in an era of rising methamphetamine use.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8147519PMC
September 2020

Capsule Commentary on Finlay et al., Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study.

J Gen Intern Med 2020 09;35(9):2833

National Clinician Scholars Program, Yale School of Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.

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http://dx.doi.org/10.1007/s11606-020-05975-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458992PMC
September 2020

Frequency and Duration of Incarceration and Mortality Among US Veterans With and Without HIV.

J Acquir Immune Defic Syndr 2020 06;84(2):220-227

Yale School of Medicine, New Haven, CT; and.

Background: Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status.

Methods: We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study from January 2011 to August 2017 (N = 5367). The primary exposure was incarceration by 3 measures: (1) any (ever/never); (2) frequency; and (3) cumulative duration. Stratifying by HIV status and controlling for age, race, and sex, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs).

Results: Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI: 1.13 to 1.66) and those uninfected (AHR 1.24; 95% CI: 0.99 to 1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively, for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively.

Conclusions: PWH were at increased risk of mortality after incarceration, and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk of mortality may be mitigated by improving transitional health care, especially HIV care, and reducing incarceration.
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http://dx.doi.org/10.1097/QAI.0000000000002325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228828PMC
June 2020

A Systematic Review of Advocacy Curricula in Graduate Medical Education.

J Gen Intern Med 2019 11;34(11):2592-2601

Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Background: Professionalism standards encourage physicians to participate in public advocacy on behalf of societal health and well-being. While the number of publications of advocacy curricula for GME-level trainees has increased, there has been no formal effort to catalog them.

Objective: To systematically review the existing literature on curricula for teaching advocacy to GME-level trainees and synthesize the results to provide a resource for programs interested in developing advocacy curricula.

Methods: A systematic literature review was conducted to identify articles published in English that describe advocacy curricula for graduate medical education trainees in the USA and Canada current to September 2017. Two reviewers independently screened titles, abstracts, and full texts to identify articles meeting our inclusion and exclusion criteria, with disagreements resolved by a third reviewer. We abstracted information and themes on curriculum development, implementation, and sustainability. Learning objectives, educational content, teaching methods, and evaluations for each curriculum were also extracted.

Results: After reviewing 884 articles, we identified 38 articles meeting our inclusion and exclusion criteria. Curricula were offered across a variety of specialties, with 84% offered in primary care specialties. There was considerable heterogeneity in the educational content of included advocacy curriculum, ranging from community partnership to legislative advocacy. Common facilitators of curriculum implementation included the American Council for Graduate Medical Education requirements, institutional support, and preexisting faculty experience. Common barriers were competing curricular demands, time constraints, and turnover in volunteer faculty and community partners. Formal evaluation revealed that advocacy curricula were acceptable to trainees and improved knowledge, attitudes, and reported self-efficacy around advocacy.

Discussion: Our systematic review of the medical education literature identified several advocacy curricula for graduate medical education trainees. These curricula provide templates for integrating advocacy education into GME-level training programs across specialties, but more work needs to be done to define standards and expectations around GME training for this professional activity.
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http://dx.doi.org/10.1007/s11606-019-05184-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848624PMC
November 2019

Mental Health Treatment Among Individuals Involved in the Criminal Justice System After Implementation of the Affordable Care Act.

Psychiatr Serv 2019 09 29;70(9):765-771. Epub 2019 May 29.

National Clinician Scholars Program, Yale School of Medicine, and U.S. Department of Veterans Affairs Connecticut Health Care System, New Haven, Connecticut (Howell); Division of General Internal Medicine, Yale School of Medicine, New Haven (Wang); Division of General Internal Medicine, Hennepin Healthcare, and Hennepin Healthcare Research Institute, Minneapolis (Winkelman).

Objective: The objective of this study was to assess changes in health insurance coverage and mental health treatment among individuals with and without involvement in the criminal justice system after implementation of key provisions of the Affordable Care Act (ACA).

Methods: Data from the National Survey on Drug Use and Health were used to assess changes in coverage, mental health treatment, and payer between 2011-2013 and 2014-2017 for nonelderly adults (ages 19 to 64) with and without criminal justice involvement in the past year who reported serious psychological distress. Multivariable logistic regression was used to obtain adjusted estimates.

Results: The weighted sample represented, on average, 2.0 million individuals with criminal justice involvement (total unweighted N=3,688) and 20.9 million without criminal justice involvement (total unweighted N=33,872) in each study year. Following implementation of the ACA's key provisions, health insurance coverage increased by 13.4 percentage points (95% CI=8.5-18.3) among individuals with past year criminal justice involvement and by 8.1 percentage points (95% CI=6.9-9.4) among those without. Receipt of any mental health treatment did not change significantly among individuals with criminal justice involvement (-3.4 percentage points [95% CI=-8.0 to 1.1]), whereas it increased significantly in the general population (2.2 percentage points [95% CI=0.4-3.9]).

Conclusions: Despite an increase in health insurance coverage for people with criminal justice involvement, there was no increase in mental health treatment following implementation of the ACA's key provisions. Health insurance coverage is necessary, but not sufficient, to expand access to mental health treatment for individuals involved in the criminal justice system.
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http://dx.doi.org/10.1176/appi.ps.201800559DOI Listing
September 2019

Discrepancy Between Patient Health Literacy Levels and Readability of Patient Education Materials from an Electronic Health Record.

Health Lit Res Pract 2017 Oct 9;1(4):e203-e207. Epub 2017 Nov 9.

Limited health literacy is associated with worse health outcomes. It is standard practice in many primary care clinics to provide patients with written patient education materials (PEM), which often come directly from an electronic health record (EHR). We compared the health literacy of patients in a primary care residency clinic with EHR PEM readability by grade level. We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF), and determined grade level readability for the PEM distributed for the five most common clinical diagnoses using the Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid metrics. Among 175 participants, health literacy was ≥9th grade for 76 patients (43.4%), 7th to 8th grade for 66 patients (37.7%), and ≤6th grade for 30 patients (17.1%). Average standard PEM readability by SMOG was grade 9.2 and easy-to-read PEM readability was grade 6.8. These findings suggest a discrepancy between the health literacy of most patients who were surveyed and standard PEM readability. Despite national guidelines encouraging clinicians to provide PEM at an appropriate reading level, our results indicate that PEM from EHR may not be readable for many patients. .
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http://dx.doi.org/10.3928/24748307-20170918-01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607789PMC
October 2017

Incarceration History and Uncontrolled Blood Pressure in a Multi-Site Cohort.

J Gen Intern Med 2016 12 12;31(12):1496-1502. Epub 2016 Sep 12.

Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA.

Background: Incarceration is associated with increased risk of hypertension and cardiovascular disease mortality. We used data from the Veterans Aging Cohort Study (VACS) to explore the impact of incarceration on blood pressure (BP) control.

Methods: Among hypertensive VACS participants, we measured the association between self-reported recent incarceration or past (not recent) history of incarceration and BP control in the year following the survey. To analyze the association between incarceration and BP control, we used logistic regression models adjusted for sociodemographic characteristics, clinical factors (HIV status and body mass index), and behavioral factors (history of smoking, unhealthy alcohol use, illicit drug use). We explored potential mediators including post-traumatic stress disorder (PTSD), depression, primary care engagement, and adherence to antihypertensive medications.

Results: Among the 3515 eligible VACS participants, 2304 participants met the inclusion criteria. Of these, 163 (7 %) reported recent incarceration, and 904 (39 %) reported a past history of incarceration. Participants with recent or past history of incarceration were more likely to have uncontrolled BP than those without a history of incarceration (67 % vs. 56 % vs. 51 %, p < 0.001). In multivariable analysis, recent incarceration (adjusted odds ratio [AOR] = 1.57 95 % confidence interval [CI]: 1.09-2.26), but not a past history of incarceration (AOR = 1.08 95 % CI: 0.90-1.30), was associated with uncontrolled BP compared with those who were never incarcerated.

Conclusions: Among patients with a history of hypertension, recent incarceration is associated with having uncontrolled BP following release. Interventions are needed for recently released individuals to improve hypertension outcomes.
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http://dx.doi.org/10.1007/s11606-016-3857-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130961PMC
December 2016

Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross-sectional study.

Addict Behav 2015 Nov 11;50:157-60. Epub 2015 Jun 11.

Behavioral and Urban Health Program, RTI International, San Francisco, CA, USA. Electronic address:

Background: Over 1.5 million people are incarcerated in state and federal correctional facilities in the United States. Formerly incarcerated men have significantly higher rates of mortality and morbidity than the general population, disparities that have been partially attributed to higher rates of tobacco smoking-related illnesses such as cardiovascular disease, pulmonary disease and cancer.

Methods: We compared the prevalence of smoking tobacco in a sample of 172 men who were released from California state prisons to Oakland and San Francisco between 2009 and 2011 to sub-populations of respondents to the 2009 California Health Interview Survey (CHIS). Using logistic regression, we analyzed the association between lifetime history of incarceration and self-reported smoking status.

Results: Seventy-four percent of men recently released from prison reported being current tobacco smokers. The prevalence of smoking in a demographically similar group of men in the CHIS was 24%. We found in bivariate analysis that each additional five years of history of incarceration was associated with 1.32 times greater odds of smoking (95% CI 1.02 to 1.71). Illicit substance use was associated with a 2.47 higher adjusted odds of smoking (95% CI 1.29 to 5.39). In the multivariate model adjusting for age, income, substance use and mental health, every five years of incarceration was associated with 1.23 greater odds of smoking (95% CI 0.94 to 1.63) which was not statistically significant.

Conclusions: Given the high prevalence of smoking tobacco among former prisoners and the underlying high tobacco-related mortality rates, these findings suggest that a history of incarceration may be an important determinant of smoking. Prison and parole systems may be important potential settings for smoking-cessation interventions.
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http://dx.doi.org/10.1016/j.addbeh.2015.06.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535991PMC
November 2015

Toscana virus encephalitis in a traveler returning to the United States.

J Clin Microbiol 2015 Apr 11;53(4):1445-7. Epub 2015 Feb 11.

Yale School of Medicine, Section of Infectious Diseases, New Haven, Connecticut, USA.

In Italy, Toscana virus is the most common cause of meningitis from May to October. Though only a few cases have been reported in U.S. travelers returning from Europe, most cases are likely unrecognized due to lack of familiarity with the disease. Here, we describe the case of an 82-year-old man presenting with fever, profound weakness, and hearing loss after returning to the United States following a 2-week summertime vacation in southern Italy who was ultimately diagnosed with Toscana virus encephalitis. This case should alert clinicians to the possibility of Toscana virus infection in returning travelers and provides information on how to obtain testing if Toscana virus is suspected.
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http://dx.doi.org/10.1128/JCM.03498-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365192PMC
April 2015

Computational fluid dynamics within bifurcated abdominal aortic stent-grafts.

J Endovasc Ther 2007 Apr;14(2):138-43

Division of Vascular Surgery, University of California at San Francisco, California 94143, USA.

Purpose: To assess the hemodynamic forces on a bifurcated abdominal aortic stent-graft under realistic conditions of flow, blood pressure, and sac pressure.

Methods: Computational fluid dynamics was used to study the temporal and spatial variations in surface pressure and shear through the cardiac cycle on models of bifurcated stent-grafts derived from computed tomography in 4 patients who had previously undergone endovascular repair of abdominal aortic aneurysm (AAA). The trunk, bifurcation, and limbs of the graft were analyzed separately and as parts of a unified whole. Analyses were repeated under varying conditions of sac pressure, reflecting different conditions of perigraft flow and sac diameter change.

Results: Pressure-related forces were far larger than flow-related forces in all 3 segments of all 4 cases. The largest forces acted at the bifurcation of the stent-graft. High sac pressures, seen in patients with endoleak or aneurysm dilatation, were associated with reduced transmural pressure and low-pressure-derived forces.

Conclusion: Several parameters of stent-graft design affect the magnitude and distribution of forces on a bifurcated stent-graft. The forces on a stent-graft are also affected by the pressure within the aneurysm sac, which depends on stent-graft performance.
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http://dx.doi.org/10.1177/152660280701400204DOI Listing
April 2007

Suprarenal stents and other advances in endovascular aneurysm repair.

Surg Clin North Am 2004 Oct;84(5):1319-35, vii

Division of Vascular Surgery, UCSF, 505 Parnassus Ave, M-488, San Francisco, CA 94143, USA.

The history of endovascular aneurysm repair has already passed through its phases of "endoexuberance" and "endoscepticism" and there is now a balanced and broad understanding of the technology,its limits and advantages. Current endovascular technique and stent-graft design is the refinement of the accumulated endovascular experience til now. It is important to make note of these technological features incorporated in current stent-grafts and the clinical experience that precipitated their introduction as the technology progresses and new applications are proposed.
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http://dx.doi.org/10.1016/j.suc.2004.05.001DOI Listing
October 2004
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