Correctional health care establishes itself as an industry model.
It comes as no surprise to anyone working in this field that we in corrections inherit the most challenging individuals society has to offer in terms of physical and mental health. Higher burdens of infectious diseases are well-documented. Chronic illnesses that receive, at best, episodic care and, more often, no care at all prior to reaching our gates are the norm. Patients with severe mental illness, for whom care was desperately needed but inaccessible, find themselves inside the walls of our institutions.
What many may find surprising, though, are the excellent clinical outcomes now being achieved by correctional health care professionals. In Oklahoma, a recent look at clinical outcomes demonstrated this clearly. Using outcome measurements defined by the Agency for Healthcare Research and Quality (ARHQ) and the CDC's Healthy People 2010 Database, we looked at how we are doing compared to national benchmarks. Take diabetes control for example. In our population, the percentage of individuals with diabetes whose most recent Hgb[A.sub.1]C was less than 7, was 46 percent. The 2006 National Healthcare Quality Report by AHRQ puts the national figure at 39.8 percent. Similarly, for blood pressure control (<140/90 among individuals diagnosed with hypertension), the Healthy People 2010 goal is 50 percent of the population at or below goal. In our population 67 percent of individuals with hypertension have achieved blood pressure control. The third National Health and Nutrition Examination Survey (NHANES III) revealed that only 15 percent of individuals with Coronary Artery Disease (CAD) had their LDL cholesterol at target (<100 mg/dl at that time). In our system, 60 percent of CAD patients have reached that goal LDL level.
I'm not just bragging about Oklahoma here. Other correctional medical directors I've talked to are seeing similar striking clinical outcomes. Among a population that comes to us in the worst possible shape, how is this happening? In my mind, it is attributable to three factors: a strong primary care foundation, evidence-based preventive care and chronic disease management, and a spirit of collaboration.
During the past few decades, primary care in the "free world" has experienced an erosion of support as health insurers and other payors reward a high-tech, specialty-based health care system. This approach comes at quite a cost--not only financially, but in terms of health care quality. In many cases, as a nation, we are quite far from the Healthy People 2010 goals for disease control and adherence to evidence-based treatment guidelines, and there are only two more years to get there. In correctional health care, though, we are already exceeding Healthy People 2010 goals in many areas. We are firmly grounded in primary care, and we are committed to providing universal access to basic preventive care and chronic disease management.
In health care, we are fortunate to have a large and growing scientific foundation upon which to base our practice. We also have standard methods of describing the quality of evidence upon which recommendations are based. Organizations like the Cochrane Collaboration synthesize volumes and volumes of research into practical, useful answers to everyday clinical questions. Agencies like the National Heart, Lung and Blood Institute convene expert panels to provide distillations of research into evidence-based practice guidelines. Outside corrections, however, the challenges in translating the guidelines into practice are enormous: arguments with insurance companies (for those patients lucky enough to be insured), a dozen or more formularies to keep straight, transportation problems, medication nonadherence, conflicting work schedules, and much more. The same challenges apply in corretions of course, but to a much lesser degree. It is the strength of correctional medicine that makes it possible to still provide high-quality, evidence-based primary care and achieve the kind of outcomes it does.
At the Academic and Health Policy Conference on Correctional Health Care held earlier this year in Massachusetts, there was a call to establish a research infrastructure for correctional medicine. This is further proof of the caliber of health care professionals that currently exists in corrections. If applying the evidence that was developed outside the correctional environment has helped us already exceed the Healthy People 2010 goals, imagine what we can do with evidence derived from our own populations.
None of our successes is created in a vacuum. Our strength comes from our internal collaborations as a family of corrections professionals. For example, in this issue, Dr. Melanie Spector describes an innovative approach to bringing community providers and inmates together in the form of health fairs at community corrections centers. In addition, preparing for the inevitable influenza pandemic in the correctional setting requires collaborations with public health, emergency planners and many other partners.
The American Correctional Association has led the way in forging these collaborations by bringing together the many professionals that make up the "big tent" of corrections. Groups like ACA and the forums they offer are crucial to fostering the dialogue that helps us understand and respond to each other's needs. There remains much work to be done and progress to be made, but as a team, we have proved that we are up to the challenges before us.
By Mike Jackson, M.D.
Chief Medical Officer
Oklahoma Department of Corrections