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Background: An estimated 11 million individuals are released from U.S. jails and prisons each year. Individuals with a history of incarceration have higher rates of cardiovascular disease (CVD) events and mortality compared to the general population, especially in the weeks following release from carceral facilities. Healthy sleep, associated with cardiovascular health, is an underexplored factor in the epidemiology of CVD in this population. Incarcerated people may have unique individual, environmental, and institutional policy-level reasons for being sleep deficient. The social and physical environment within carceral facilities and post-release housing may synergistically affect sleep, creating disparities in sleep and cardiovascular health. Since carceral facilities disproportionately house poor and minoritized groups, population-specific risk factors that impact sleep may also contribute to inequities in cardiovascular outcomes., Methods: This study is ancillary to an ongoing prospective cohort recruiting 500 individuals with known cardiovascular risk factors within three months of release from incarceration, the Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study. The Sleep Justice study will measure sleep health among participants at baseline and six months using three validated surveys: the Pittsburgh Sleep Quality Index (PSQI), the STOP-Bang, and the Brief Index of Sleep Control. In a subsample of 100 individuals, we will assess sleep over the course of one week using wrist actigraphy, a validated objective measure of sleep that collects data on rest-activity patterns, sleep, and ambient light levels. Using this data, we will estimate and compare sleep health and its association with CVD risk factor control in individuals recently released from carceral facilities., Discussion: The incarceration of millions of poor and minoritized groups presents an urgent need to understand how incarceration affects CVD epidemiology. This study will improve our understanding of sleep health among people released from carceral facilities and its potential relationship to CVD risk factor control. Using subjective and objective measures of sleep will allow us to identify unique targets to improve sleep health and mitigate cardiovascular risk in an otherwise understudied population., (© 2023. The Author(s).)

Many formerly incarcerated people have civil legal needs that can imperil their successful re-entry to society and, consequently, their health. We categorize these needs and assess their association with cardiovascular disease risk factors in a sample of recently released people. We find that having legal needs related to debt, public benefits, housing, or healthcare access is associated with psychosocial stress, but not uncontrolled high blood pressure or high cholesterol, in the first three months after release.

Background: People who have been incarcerated have high rates of cardiovascular risk factors, such as hypertension and smoking, and cardiovascular disease (CVD) is a leading cause of hospitalizations and mortality in this population. Despite this, little is known regarding what pathways mediate the association between incarceration exposure and increased rates of CVD morbidity and especially what incarceration specific factors are associated with this risk. The objective of this study is to better understand CVD risk in people exposed to incarceration and the pathways by which accumulate cardiovascular risk over time., Methods and Analysis: The Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study is a prospective cohort study of individuals released from incarceration with known cardiovascular risk factors. We are recruiting 500 individuals within three months after release from jail/prison. At baseline we are assessing traditional risk factors for CVD, including diet, exercise, and smoking, and exposure to incarceration-related policies, psychosocial stress, and self-efficacy. Cardiovascular risk factors are measured at baseline through point of care testing. We are following these individuals for the 12 months following the index release from incarceration with re-evaluation of psychosocial factors and clinical risk factors every 6 months. Using these data, we will estimate the direct and indirect latent effects of incarceration on cardiovascular risk factors and the paths via which these effects are mediated. We will also model the anticipated 10-year burden of CVD incidence, health care use, and mortality associated with incarceration., Discussion: Our study will identify factors associated with CVD risk factor control among people released from incarceration. Our measurement of incarceration-related exposures, psychosocial factors, and clinical measures of cardiovascular risk will allow for identification of unique targets for intervention to modify CVD risk in this vulnerable population., (© 2022. The Author(s).)

Introduction: Incarceration is associated with decreased cancer screening rates and a higher risk for hospitalisation and death from cancer after release from prison. However, there is a paucity of data on the relationship between incarceration and cancer outcomes and quality of care. In the Incarceration and Cancer-Related Outcomes Study, we aim to develop a nuanced understanding of how incarceration affects cancer incidence, mortality and treatment, and moderates the relationship between socioeconomic status, structural racism and cancer disparities., Methods and Analysis: We will use a sequential explanatory mixed-methods study design. We will create the first comprehensive linkage of data from the Connecticut Department of Correction and the statewide Connecticut Tumour Registry. Using the linked dataset, we will examine differences in cancer incidence and stage at diagnosis between individuals currently incarcerated, formerly incarcerated and never incarcerated in Connecticut from 2005 to 2016. Among individuals with invasive cancer, we will assess relationships among incarceration, quality of cancer care and mortality, and will assess the degree to which incarceration status moderates relationships among race, socioeconomic status, quality of cancer care and cancer mortality. We will use multivariable logistic regression and Cox survival models with interaction terms as appropriate. These results will inform our conduct of in-depth interviews with individuals diagnosed with cancer during or shortly after incarceration regarding their experiences with cancer care in the correctional system and the immediate postrelease period. The results of this qualitative work will help contextualise the results of the data linkage., Ethics and Dissemination: The Yale University Institutional Review Board (#2000022899) and the Connecticut Department of Public Health Human Investigations Committee approved this study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. Access to the deidentified quantitative and qualitative datasets will be made available on review of the request., Competing Interests: Competing interests: CG has received research funding, though Yale, from the NCCN Foundation (Pfizer/Astra-Zeneca) and Genentech, as well as funding from Johnson & Johnson to help devise and implement new approaches to sharing clinical trial data, and funding from Flatiron for travel to and speaking at a scientific conference. All other authors report no competing interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: More than 80% of people in jail or prison report having used illicit substances in their lifetimes. After release from incarceration, resumption of substance use carries risks, including parole revocation, exacerbation of mental health conditions, transmission of infectious diseases, and drug overdose., Methods: This cross-sectional study used baseline data from the Transitions Clinic Network (TCN, www.transitionsclinic.org ), a multi-site prospective longitudinal cohort study of post-incarceration medical care. We investigated substance use among adults, with at least one chronic health condition or age ≥ 50 years, who had been recently released from incarceration and initiated care at a TCN site. Our primary outcome was any self-reported illicit substance use (heroin or other opioids, cocaine, cannabis, amphetamines, hallucinogens, MDMA, or illicit use of prescription medications) following release from incarceration. Alcohol use post-release was a secondary outcome. Using multivariable logistic regression, we also explored factors associated with illicit substance use., Results: Among 751 participants, median age was 47; participants were mostly male (85%), non-white (47% black, 30% Hispanic), and on parole (80%). The proportion of participants reporting any illicit substance use and any alcohol use soon after release from incarceration was 18% and 23%, respectively. In multivariable regression, variables significantly associated with post-release illicit substance use were male gender (aOR = 3.91, 95% CI: 1.73-8.81), housing with friends or family (aOR = 3.33, 95% CI: 1.20-9.28), years incarcerated during latest prison term (aOR = 0.93, 95% CI: 0.89-0.98), weeks elapsed before engagement with TCN (aOR = 1.07, 95% CI: 1.03-1.10), being on parole (aOR = 0.58, 95% CI: 0.34-0.99), and having a drug use disorder (aOR = 2.27, 95% CI: 1.40-3.68)., Conclusions: Among individuals seeking medical care after release from incarceration, self-reported substance use was lower than previously reported estimates of post-incarceration substance use. Known risk factors, such as male gender and having a drug use disorder, were associated with illicit substance use, as were novel risk factors, such as less supervised housing. Though illicit substance use post-incarceration can carry severe consequences, treatment and surveillance interventions should be targeted toward individuals with greatest risk.

Importance: Timely delivery of surgery for cancer affects health care quality and outcomes. However, population-based studies characterizing the delay of surgery for melanoma in the United States have not been performed., Objective: To assess the delay of surgery for melanoma by tumor-, patient-, and physician-level characteristics., Design, Setting, and Participants: We performed a retrospective cohort study of Medicare beneficiaries diagnosed as having melanoma from January 1, 2000, through December 31, 2009, using the Surveillance, Epidemiology, and End Results-Medicare database. We included all patients undergoing surgical excision of melanoma diagnosed by means of results of skin biopsy., Exposures: Anatomic location and stage of the tumor, patient sociodemographic characteristics, prior melanoma, Elixhauser comorbidities, and the specialties of the physicians who performed the biopsy and surgery., Main Outcomes and Measures: Surgical delay, measured as the time from the biopsy to surgical excision. We estimated risk-adjusted odds ratios (ORs) and marginal probabilities of delay with 95% CIs for each covariate using mixed-effects logistic regression., Results: Our cohort consisted of 32 501 cases of melanoma. Most of the patients were white (95.4%), male (63.1%), married (47.9%), and 75 years or older (60.8%) and did not have a prior melanoma (93.7%). Melanomas were most frequently located on the head and neck (40.5%) and staged as in situ disease (48.2%). More than three-quarters of cases (25 269 [77.7%]) underwent excision within 1.5 months of biopsy. Among those treated after 1.5 months (7232 [22.3%]), 2620 (8.1% of all cases) experienced a delay of longer than 3 months. The incidence of a risk-adjusted surgical delay longer than 1.5 months was significantly increased among patients 85 years or older compared with those younger than 65 years (odds ratio [OR], 1.28 [95% CI, 1.05-1.55]; P = .02), those with a prior melanoma (OR, 1.20 [95% CI, 1.08-1.34]; P = .001), and those with an increased comorbidity burden (OR, 1.18 [95% CI, 1.09-1.27]; P < .001). Melanomas that underwent biopsy and excision by dermatologists had the lowest likelihood of delay (probability, 16% [95% CI, 14%-18%]). The highest likelihood of delay (probability, 31% [95% CI, 24%-37%]) occurred when the biopsy was performed by a nondermatologist and excised by a primary care physician. Similar findings were observed for a delay longer than 3 months., Conclusions and Relevance: Approximately 1 in 5 Medicare beneficiaries experience a delay of surgery for melanoma that is longer than 1.5 months. Those patients undergoing biopsy and surgery by dermatologists have the lowest risk for delay, highlighting potential opportunities for improved access to and coordination of dermatologic care.