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Table.  
Causes of Death
Causes of Death
1.
Kaeble  D, Glaze  L. Correctional populations in the United States, 2015. US Department of Justice Bureau of Justice Statistics Bulletin. December 2016, NCJ 250374. https://www.bjs.gov/content/pub/pdf/cpus15.pdf. Accessed March 19, 2018.
2.
World Prison Brief. Highest to lowest—prison population total. http://www.prisonstudies.org/highest-to-lowest/prison-population-total?field_region_taxonomy_tid=All. Accessed April 24, 2018.
3.
Freudenberg  N, Heller  D.  A review of opportunities to improve the health of people involved in the criminal justice system in the United States.  Annu Rev Public Health. 2016;37:313-333. doi:10.1146/annurev-publhealth-032315-021420PubMedGoogle ScholarCrossref
4.
Brown  JK. Graphic photos stir doubts about Darren Rainey’s ‘accidental’ prison death. Miami Herald. May 6, 2017. http://www.miamiherald.com/news/local/community/miami-dade/article149026764.html. Updated May 7, 2017. Accessed March 19, 2018.
5.
Estelle v Gamble, 49 US 97, 98 (1976).
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    Research Letter
    January 2019

    Postmortem Incidence of Acute Surgical- and Trauma-Associated Pathologic Conditions in Prison Inmates in Miami Dade County, Florida

    Author Affiliations
    • 1Division of Trauma and Surgical Critical Care, Ryder Trauma Center, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
    • 2Public Health Education, Florida Public Health Institute, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
    JAMA Surg. 2019;154(1):87-88. doi:10.1001/jamasurg.2018.2443

    According to the Bureau of Justice Statistics, more than 2.2 million adults were incarcerated in the United States as of 2015,1 representing 0.7% of the total population. The United States has the highest rate and number of incarcerated persons in the world.2 To date, no national statistics on surgical outcomes have been reported for the actively incarcerated prison population in the United States, to our knowledge. Florida has the third-largest incarcerated population in the country.2 Incarcerated individuals represent a vulnerable patient population, in particular with regards to medical care.3 We hypothesized that surgical access would be affected in this population and sought to quantify the postmortem incidence of acute surgical- and trauma-associated pathologic conditions of inmates in Miami Dade County, Florida.

    Methods

    From January 1, 2008, to December 31, 2014, we reviewed all medical examiner reports for any inmate who was incarcerated and died in Miami Dade County, Florida. Demographic data were recorded and comorbid medical conditions reviewed. Rates of surgical intervention were recorded. All primary causes of death determined by the medical examiner were analyzed and mortality associated with acute surgical- or trauma-specific pathologic conditions quantified. Statistical analysis was conducted from January 15, 2015, to June 30, 2016. The University of Miami Institutional Review Board determined that the proposed activity is not research involving human participants as defined by US Department of Health and Human Services and US Food and Drug Administration regulations; therefore, institutional review board review and approval by this organization are not required.

    Results

    Three hundred one cases of mortality were identified. A total of 293 individuals (97.3%) were men (median age, 57 years), 120 individuals (39.9%) were black, 122 (40.5%) were white, and 58 (19.3%) were Hispanic. A total of 153 patients (50.8%) had associated mental illness. Sixty-nine deaths (22.9%) were due to acute surgical- or trauma-associated pathologic conditions, of which 51 (73.9%) were associated with problems from emergency general surgery and 18 (26.1%) were associated with trauma. Deaths due to gastrointestinal malignant neoplasms were excluded. Thirty cases with cirrhosis as the primary cause of death were also excluded. Among the remaining 21 deaths associated with surgery, 9 (42.9%) were ascribable to bowel obstruction, including incarcerated inguinal hernia; 4 (19%) were due to other bowel perforation; and 3 (14.3%) were due to nonvariceal gastrointestinal bleeding (Table). Nine trauma-associated deaths (50.0%) were from hanging, 4 (22.1%) were from traumatic brain injury, and 3 (16.7%) were from exsanguination. A total of 7 of 21 inmates (33.3%) received surgical intervention prior to death.

    Discussion

    Almost one-fourth of all reported deaths in the inmate population of the largest county of Florida involved either pathologic conditions associated with acute surgical disease or fatal traumatic injuries. Only 33.3% of inmates with surgical emergencies identified postmortem received surgical care. These data represent, to our knowledge, the only reported incidence of surgical and traumatic disease in incarcerated patients in the United States. Our findings likely represent a gross underestimation of the total burden of surgical disease, as our analysis does not capture incarcerated individuals who did not die but incurred morbidity from delayed diagnosis or care. Nor does it capture the full spectrum of mortality in a state in which not all correctional facilities have mandatory autopsy requirements and data collection on mortality is voluntary. This point is particularly salient given the absence of available autopsy data for highly publicized cases of torture such as that of Darren Rainey.4 His death coincided with our study period and should have been included in our analysis; however, his medical examiner records were withheld from us at the time of data collection. It is unclear how many other similar, yet unpublicized, cases were withheld from us.

    The Estelle v Gamble Supreme Court case of 1976 established that all incarcerated individuals are entitled to receive medical and mental health care.5 Oversight and accountability to such standards, however, remain unclear. Given our findings, we conclude that inmates have an unrecognized burden of morbidity and mortality secondary to surgical disease for which they lack adequate access to timely care. We hypothesize that these findings stem from mechanisms of underfunding and overcrowding, as well as outsourcing of prison health care. We also hypothesize that these trends are not unique to Florida and may be paralleled in other jurisdictions with high rates of incarceration.3 The establishment of a national quality surgical database that is specific to incarcerated persons may be an appropriate initiative for acute care surgeons. Further expansion of this work is required to better define barriers to surgical evaluation, access to surgical care, and long-term morbidity in surviving postoperative inmate cohorts.

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    Article Information

    Accepted for Publication: June 4, 2018.

    Published Online: September 12, 2018. doi:10.1001/jamasurg.2018.2443

    Correction: This article was corrected on September 26, 2018, to fix a misspelled word in the title.

    Corresponding Author: Tanya L. Zakrison, MD, FRCSC, MPH, Division of Trauma and Surgical Critical Care, Ryder Trauma Center, Department of Surgery, University of Miami Miller School of Medicine, 1800 NW 10th Ave, Miami, FL 33136 (tzakrison@med.miami.edu).

    Author Contributions: Dr Zakrison and Mr Busko had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Busko, Barber, Rattan, Zakrison.

    Drafting of the manuscript: Busko, Soe-Lin, King, Zakrison.

    Critical revision of the manuscript for important intellectual content: Busko, Soe-Lin, Barber, Rattan, Zakrison.

    Statistical analysis: Busko, Rattan, Zakrison.

    Administrative, technical, or material support: Soe-Lin, Barber, Rattan, King.

    Supervision: Rattan, King, Zakrison.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Kaeble  D, Glaze  L. Correctional populations in the United States, 2015. US Department of Justice Bureau of Justice Statistics Bulletin. December 2016, NCJ 250374. https://www.bjs.gov/content/pub/pdf/cpus15.pdf. Accessed March 19, 2018.
    2.
    World Prison Brief. Highest to lowest—prison population total. http://www.prisonstudies.org/highest-to-lowest/prison-population-total?field_region_taxonomy_tid=All. Accessed April 24, 2018.
    3.
    Freudenberg  N, Heller  D.  A review of opportunities to improve the health of people involved in the criminal justice system in the United States.  Annu Rev Public Health. 2016;37:313-333. doi:10.1146/annurev-publhealth-032315-021420PubMedGoogle ScholarCrossref
    4.
    Brown  JK. Graphic photos stir doubts about Darren Rainey’s ‘accidental’ prison death. Miami Herald. May 6, 2017. http://www.miamiherald.com/news/local/community/miami-dade/article149026764.html. Updated May 7, 2017. Accessed March 19, 2018.
    5.
    Estelle v Gamble, 49 US 97, 98 (1976).
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