NSPHC Supporting Statement Part A CLEAN

Supporting Statement A for Request for Clearance:

OMB 0920- New

National Survey of Prison Health Care (NSPHC)

Contact Information:

Carol DeFrances, Ph.D.

Lead Statistician, Hospital Care Team

Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics/CDC

3311 Toledo Road

Hyattsville, MD 20782

301-458-4440

301-458-4032 (fax)

[email protected]

May 7, 2012

SUPPORTING STATEMENT

THE NATIONAL SURVEY OF PRISON HEALTH CARE (NSPHC)

The National Center for Health Statistics (NCHS) monitors the health of the Nation and gathers statistics on the use, access, quality, and cost of health care. Through its National Health Care Surveys, NCHS collects data on a diverse array of establishments, including doctor’s offices, emergency departments, outpatient departments, inpatient departments, ambulatory surgery centers, and long-term care facilities. These surveys provide data on patient demographics and clinical information such as diagnoses, procedures, vital signs, and medications, as well as information on facility characteristics such geographic location, type of ownership, and size. But what is not known from these data collections is the capacity to provide health care services to institutional populations such as prisoners, who often receive treatment in the community as well as prison facilities. Data on the structure of prison health care delivery systems will inform NCHS and will allow NCHS to explore expanding the focus of its National Health Care Surveys to institutional populations and establish steps for the routine collection of data on prison health care.

The Bureau of Justice Statistics (BJS) is the Nation’s primary source for criminal justice statistics. BJS collects, analyzes, publishes, and disseminates information on crime, criminal offenders, victims of crime, and the operation of justice systems at all levels of government. Through its omnibus surveys of prison inmates and establishment surveys of prison facilities, BJS has provided estimates of the demand or need for healthcare, as it has documented the prevalence of medical problems, chronic disease, mental illness, substance abuse and dependence, and mortality among prisoners nationwide. BJS has also provided estimates of the number of inmates who received some types of healthcare services at some point during their incarceration. BJS’s estimates of services received by inmates are limited in scope, however, as they pertain primarily to services for infectious diseases or chronic conditions but do not cover routine medical care. In addition, the estimates are national and cross-sectional in scope; therefore, they do not demonstrate the state-level variation in need or responsiveness to the need for healthcare, nor do they inform how departments of corrections deliver healthcare throughout the entirety of inmates’ stay in prison.

BJS has not, however, systematically collected data on the “supply side” of the prison healthcare issue, that is, on the structure and processes of delivery of prison health care. Jurisdiction-specific data on the structure and organization of prison healthcare service delivery are necessary to identify the varieties of models used to deliver care. Once an understanding of the models of healthcare delivery is gained, this information can then be used to begin to identify the determinants of costs of delivery of care, and ultimately to begin to quantify the quality of care.

To remedy this gap in knowledge regarding the capacity of prison facilities to deliver medical and mental health services, NCHS in partnership with BJS seeks approval to conduct the National Survey of Prison Health Care (NSPHC). The NSPHC will be a semi-structured telephone interview survey, administered to officials in the Department of Corrections (DOC) in each of the 50 States and to an official from the Federal Bureau of Prisons (BOP) seeking system-level information on the types of services delivered and the mechanisms used to deliver these services. This request seeks a one-year OMB approval to administer NSPHC in order to:

• Survey officials in State Departments of Corrections and the Bureau of Prisons.

The major goals of this survey are to:

• Collect data that will provide an overall picture of the structure of prison health care delivery systems in the United States;

• Assess the quality of the data collected;

• Inform NCHS about the feasibility of expanding its health care surveys to more systematic collection of data on prisoners;

• Inform future BJS data collections on health and health care including:

  • mode of administration

  • identification of appropriate respondents

  • availability of data on capacity to provide and utilization of health care services

  • burden;

• Understand prison systems capacities to provide data and how health data are organized and maintained;

• Inform measurement differences across prison systems;

• Assess the effectiveness of the semi-structured interview methodology for this type of data collection;

• Contribute to the body of research on identifying appropriate respondents in establishment surveys.

1. Justification

1. Circumstances Making the Collection of Information Necessary

Background

At the end of 2010, there were 1,612,395 prisoners under state and federal jurisdictions in the United States.¹ This figure is almost fourfold greater than that of the prison population in the United States 25 years ago, giving the United States the highest incarceration rate in the world at 75 inmates per 100,000 population.² Just as the U.S. general population is aging, the prison population is aging as well. In mid-year 2008 4.3% of all inmates in the US state or federal prisons, or in local jails, were over the age of 55, up from the 3.5% reported for mid-year 2004.³ Chronic diseases including asthma and hypertension are the most commonly reported among prisoners. In 2004, an estimated 44% of state prisoners reported a current medical issue other than a cold or virus. Prisoners unquestionably use health care; 8 out of 10 state inmates in 2004 reported receiving a medical examination or blood exam since admission.⁴

BJS’s last prior effort to collect data on health care in prison was in its 2000 Census of Adult State and Federal Correctional Facilities. In that collection, BJS obtained some general indicators of whether prison facilities provided medical treatment/hospitalization, geriatric care, mental health/psychiatric care, alcohol/drug treatment infectious disease testing, and mental health services. BJS’ 2000 census obtained no direct data on prison healthcare staffing, and also did not directly measure the structure of health care delivery in prisons. For example, omitted from the prior BJS effort was data on use of contracts for services and use of private or community providers to serve the needs of the prison population, the capacity for prisons to provide services and the provision of care to control infectious diseases and manage mental illness and chronic diseases within prisons.

Over the years, many correctional facilities have turned to contract services for the delivery of health care to their inmates for various reasons; studies show as many as 70% of state and federal systems utilize contract services.⁵ There are instances in which contracting is a response to court mandated improvements of correctional health care.⁶ However, contracting of health services in prisons is also claimed as a means to reduce costs. One study found that states delivering health care entirely through contracts have 31% lower health care costs per inmate compared to states that provide some services through non-contracts.⁷

A major disadvantage of involving outside contracts is the inability to integrate data collection to enhance technical capabilities of a national infectious disease surveillance system for local and state/federal facilities. Most correctional health care systems involve multiple entities (e.g., laboratories, health departments, health services contractors) in providing care, which makes it difficult to link health records for reporting to state health departments.⁸ Adequate medical data collection is essential to tracking and delivering health services to prisoners, but the extent to which prison hospitals or community hospitals treating inmates capture these data have not been examined. For example, there are no current data on how many prisons are equipped with electronic health records or the specifics of what health data are captured when care is delivered—data gaps that NSPHC intends to fill with questions related to health record maintenance.

While the collaboration between prisons and community based organizations or contracting agencies has been highlighted, there is no true understanding of the structure of prison health care delivery systems. Understanding the structure of prison health care delivery systems would entail obtaining data on health care services that are provided, who provides them, and where they are provided. Currently, there is no research that presents a broad national concept of how an inmate is provided care—whether it be inpatient or outpatient; on-site of off-site, contract or collaborative; DOC or private or community hospital.

The organization and manner of delivery of care within prison systems is critical to understanding the costs and quality of prison healthcare. Although costs and quality of healthcare are beyond the scope of this effort, this effort will measure the varieties of ways in which departments of corrections organize care, what types of services they deliver and where during incarceration they deliver services, and assess the comparability of data systems to provide additional measures of healthcare. The analysis of the data will yield information on the varieties of models of delivery, which in turn can be used subsequently to assess differences in costs of care.

NCHS partnered with BJS to identify types and sources of data within the state systems that would inform the design and development of a National Survey of Prison Health Care (NSPHC). This survey will help fill the gap in knowledge of the structure of prison health care delivery systems, including the mechanisms used to deliver health care services, the types of services being delivered, the capacity of prisons to deliver health services, and the utilization of services.

The NSPHC is being collected under the auspices of NCHS and is authorized under Section 306(b) of the Public Health Service Act (42 USC 242k) and the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42 U.S.C. 3732) (Attachment A).

Privacy Impact Assessment

The information required for the Privacy Impact Assessment is presented in the sections below.

Overview of the Data Collection System

The NSPHC will be a semi-structured interview with officials from each DOC within the 50 states and the BOP. The District of Columbia (DC) is not targeted due to the fact that since 2001 all sentenced felons in DC are placed in the BOP system. Respondents will be contacted via telephone and interviewed about the structure of their prison system’s health care delivery and types of health care services offered in their respective states. Interviews may be completed in multiple phases, where either the same respondent is contacted multiple times at their convenience, or another respondent is contacted who may provide additional data. Data which may require extra time or effort by the respondent to obtain may be solicited via follow-up email.

Items of Information to be Collected

Through the NSPHC, we will obtain data on the extent to which prison systems contract for health care services; health care staffing; provision of both general and specialty health care services, on-site, off-site, and through telemedicine; and the provision of preventive health services (including infectious disease tests and mental health screens) during the admissions process. Because of the semi-structured nature of the NSPHC, the interviewer will be able to discuss the data that are being collected to gain a better understanding of the capacity for the systems to provide the data that we are requesting, as well as their ability to provide additional data on capacity and utilization of services. In addition, we will also collect general data on aggregate numbers of inmates, the details of a prison system’s admissions process, and major challenges the prison system faces in regards to the delivery of health care.

Information in Identifiable Form (IIF)

No information in identifiable form is being collected.

Identification of Website(s) and Website Content Directed at Children Under 13 Years of Age

This study does not yet have a website. There is no website content directed at children under 13 years of age.

2. Purpose and Use of Information Collection

As an exploratory effort to gain a better understanding of models of health care delivery in prison systems and of the capacities of departments of corrections to provide data on healthcare, the NSPHC is a fundamental first step to implementing a more comprehensive set of collections and analyses of two critical issues in correctional healthcare: cost and quality.

The NSPHC will provide current, valid data on structure, capacity and utilization of health care that can serve as the building block for essential research measuring the effects of change in correctional health care. Further, an understanding of prison systems’ ability to provide data on capacity and utilization of health services and organization and maintenance of health records will allow both NCHS and BJS to make informed decisions for future data collections.

The NSPHC aims to collect data that will:

• Provide an overall picture of the structure of prison health care delivery systems in the United States;

• Identify the feasibility of prisons systems to provide data on the capacity and utilization of health care services

• Identify determinants of quality and cost of health care

• Inform measurement differences across prison systems;

• Identify how information on prisoner health care delivery is organized and maintained within the prison health care system;

Given the limited knowledge about how departments of corrections organize healthcare delivery and the corollary of whether different arrangements are more or less costly, the NSPHC will provide the data that NCHS and BJS can use to describe the various models of healthcare delivery among the states and BOP. The models of service delivery will cover the extent to which services are delivered on-site or off-site and via contract or own staff. They will describe the variation among departments in how healthcare services are staffed, and by comparing staffing arrangements among organizational structures, may also point towards potential efficiencies in staffing.

Prison populations have relatively high turnover. During a given year, about 40% of the inmates that were in prison at the start of the year are released. Admissions during a given year also are about 40% of the size of the average daily prison population. Given the relatively high prevalence of infectious disease among prisoners, and the relatively high numbers of inmates who enter from and return to communities within a year, gaining an understanding of prison systems screen inmates at intake and subsequently provide services to those with these types of diseases is important for potentially slowing the spread of infectious diseases, particularly among disadvantaged populations. The NSPHC will address this issue by measuring the prison admission or intake process, assessing what types of infectious diseases prisons screen and test for, and provide estimates of the number that were screened and tested.⁹

The prevalence of mental health problems among prison inmates is at least thrice that of the general population, and mental disorder is associated with offending and other deviant behavior in prison.¹⁰ The NSPHC will provide information on the extent to which prison systems screen for mental health problems, and the nature of mental health services delivered. This information can help to inform correctional administrators’ efforts to improve services and manage a population that poses challenges for order-maintenance within prisons.

Beyond the direct uses of the data, the NSPHC provides a basis for BJS to build upon efforts to measure the costs of correctional healthcare. BJS has used the U.S. Census Bureau’s Census of Government Finance data on correctional expenditures to derive total health care costs in state prisons. It previously reported on these costs for 2001, and BJS has analyzed Census of Government Finance data for 2008 to derive estimates of total medical costs in state prisons. (The 2008 data are the most recently available government finance data at this time.) This medical cost data are available to be used in conjunction with the NSPHC to begin to assess the extent to which the various models of healthcare delivery are associated with healthcare costs. This analysis will be a first examination of whether there is an association between the organization and delivery of services and total medical costs in state prisons.

Subsequently, BJS wants to develop an effort to measure healthcare costs more directly, and the NSPHC will help in this effort. By identifying a core set of determinants of costs—whether and which services are provided on-site or off-site, specialty (and potentially high-cost services) that are delivered, routine services delivered, and staffing arrangements—the NSPHC will inform BJS and NCHS about what services are measured well by departments of corrections, how measurement of services varies, and on the capacities of departments to provide additional information about medical services. BJS and NCHS will use methodological information in developing a subsequent effort to measure the costs of these services.

Through the semi-structured interview approach that will be used in conducting the NSPHC, BJS and NCHS will gather qualitative data on capacity and utilization of health services and challenges of delivering health care. It is this type of information that BJS will use to develop future instruments measuring correctional health and health care. For instance, NSPHC will ask about the capacity to report inmate counts, whether this information is kept in a central reporting system or requires separate contacts with individual facilities, and if possible, actual counts of inmates who were provided services. This type of information will inform the approach and the burden involved in future health care data collections. BJS plans to begin to undertake these efforts to measure costs after the completion of the NSPHC. To that end, during FY2012, through its Visiting Fellow program, BJS will seek a fellow with expertise in health care finance that can assist BJS in developing its future work on this issue.

Privacy Impact Assessment Information

No IIF is being collected.

3. Use of Improved Information Technology and Burden Reduction

NSPHC is a telephone-based survey for several reasons. Due to the fact that this is a first-time data collection, a semi-structured interview design will allow respondents to make note of any caveats to their answers even where the designers of NSPHC may not have anticipated. Further, the small universe of 51 correctional departments (50 DOCs and BOP) does not warrant a larger investment of electronic formatting since 51 surveys can be administered in-house by NCHS.

4. Efforts to Identify Duplication and Use of Similar Information

Few national level data exist concerning the administration of health care services in correctional health facilities across the United States. Most of what is known about the provision of health care is derived from inmate surveys, such as the Survey of Inmates in State and Federal Correctional Facilities (OMB No. 1121-0152) conducted by BJS. However, these data describe the medical services reported by inmates, not the overall types of services provided by correctional facilities or the overall demand for medical and mental health services within prison systems.

While data are lacking at the national level, many state DOCs, as well as the BOP, are known to collect data from prisons concerning disease prevalence and treatment, structure of health care delivery systems, staffing, and utilization. It is unknown how many states collect these data, what types are collected, or where these data reside within the state and federal systems.

This survey will help fill the gap in knowledge of the structure of prison health care delivery systems, including the mechanisms used to deliver health care services, the types of services being delivered, the capacity of prisons to deliver health services, and the utilization of services.

5. Impact on Small Businesses or Other Small Entities

No small businesses or other small entities are targeted in the universe of NSPHC administration.

6. Consequences of Collecting the Information Less Frequently

The survey is a one-time data collection. There are no legal obstacles to reducing the burden.

7. Special Circumstances Relating to the Guidelines of five CFR 1320.5

This request fully complies with the regulation 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

A.

The National Survey of Prison Health Care (NSPHC) 60-day public comment notice was published in the Federal Register, Volume 76, Number 60, Pages 17420-17421, on March 29, 2011. A copy of the notice is included as Attachment C. Two public comments were received in response to the 60-day notice. The first comment received was not relevant to the survey. The second comment was a request by a health administrator at the Oregon Department of Corrections to receive updates on any key developments of the NSPHC project, to which NCHS responded that they would keep the individual informed of the release of the 30-day notice and any other important steps of the study. Attachment D contains a copy of both comments received.

B.

NSPHC is intended to provide improved data for the use of policymakers (both governmental and non-governmental), Federal and state agencies, clinical researchers, correctional researchers and mental health professionals. Due to the broad audience and stakeholders for this project, NCHS solicited a wide spectrum of views concerning the focus of the survey.

In June 2010, NCHS received funds from the Coordinating Center for Infectious Disease (CCID), CDC, and convened a panel of experts to identify the most salient issues in prison health care delivery and the data sources available in each state. The expert meeting entitled, “Correctional Health and Health Care: Identifying and Prioritizing Data Needs,” was also intended to help determine the content of NSPHC. NCHS and BJS staff reached out to individuals from diverse professional backgrounds. The meeting attendees spanned correctional health care experts, correctional health care researchers, mental health professionals, public health professionals, correctional heath administrators, and correctional medical directors. Attachment B contains a complete list of meeting attendees and their affiliations.

In August 2010, a summary report of the meeting discussion was produced and emailed to experts for comment. Many of the findings from the expert meeting discussions were incorporated into the content of the NSPHC semi-structured interview.

In February 2011, a draft of the topic areas and potential questions for the NSPHC was sent out to the group of experts who attended the meeting to solicit their feedback on the content and potential burden of the data collection. An NCHS staff member collected the comments, held a meeting to discuss the comments with other BJS and NCHS staff members and incorporated recommended changes into the next draft.

There were no major problems about which agreement could not be reached, by any of the groups that provided input into the survey.

9. Explanation of Any Payments or Gifts to Respondents

No gifts or remuneration will be provided to respondents of the NSPHC.

10. Assurance of Confidentiality Provided to Respondents

All elements of consent will be addressed in the introduction letter signed by Dr. Edward Sondik, Director, NCHS (Attachment E) that will be mailed to identified respondents. All DOC and BOP respondents are informed that participation is voluntary and that the data are collected under the authority of Section 306 of the Public Health Service Act and the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42 U.S.C. 3732) (Attachment A).

No confidential data are being collected. NCHS 308(d) confidentiality and the Confidential Information Protection and Statistical Efficiency Act do not apply to this data collection.

Privacy Impact Assessment Information

A.

This submission has been reviewed by the NCHS Privacy Act liaison and NCHS Confidentiality Office for Privacy Act applicability and it has been determined that the Privacy Act does not apply.

B.

Data collection for the NSPHC is authorized by Section 306 of the Public Health Service Act (Title 42, U.S. Code, 242k) and the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42 U.S.C. 3732). The data collected are not deemed confidential and most of the information is considered to be the public domain.

C.

As detailed in the ERB Exemption Approval Form (Attachment G), the NSPHC does not meet the criteria for human subject research [45 CFR 46.102(f)] since the data collection will not include obtaining data from inmates directly nor will the data collected be individually identifiable. Data collected through the NSPHC include the provision and capacity to provide utilization of health care services as well as health care staffing of the state and federal prison systems. Due to the fact that the state DOCs and BOP are publicly funded, the data collect by the NSPHC are publicly available or justifiably obtainable by any member of the public. The names of individual facilities are not directly collected. Neither the names of the facilities nor the health care services offered constitute sensitive or confidential data; this is public information. Therefore, NCHS will not offer protection to names or identities of facilities or establishments in this survey. Further, prisoners are not the respondents of this survey and the NSPHC will not collect any health information about individual prisoners in these facilities.

D.

At the beginning of the NSPHC interview, respondents are informed that, “Although this survey is voluntary, we need and appreciate your cooperation to make the results comprehensive, accurate and timely.”

11. Justification for Sensitive Questions

No sensitive questions are asked about individual inmates. However, some medically sensitive information about aggregates of inmates with each state prison systems may be obtained. For example, when asking about practice and availability of certain screening tests for medical and mental health, it is possible during the semi-structured that a follow up question of how many screens were conducted may be asked in order to gain an understanding of practice of certain policies.

12. Estimates of Annualized Burden Hours and

A. Burden Hours

The NSPHC interview will be conducted with prison official(s) identified through prior research completed by an NCHS staff member. For each of the 50 DOCs and BOP (a total of 51 facilities), the survey is expected to take 4 hours to complete for a total of 204 annualized hours.

Table 1. Estimated Annualized Burden Hours

Respondents	Form	Number of respondents	Number of responses per respondent	Avg. Burden per Response (in hours)	Total Burden Hours
Prison official in DOC or BOP (Medical/Health Researcher)	NSPHC Semi-structured Interview	51	1	4	204
TOTAL					204

B. Burden Costs

The average annual response burden hours for the NSPHC are estimated to be 204. The hourly wage estimate for a Medical/Health Researcher is $30, based on the data provided by BJS. This wage estimate was cited for two other BJS data collections that required a respondent with similar level of expertise: National Prisoner Statistics (OMB No. 1121-0102: Approval expires 05/31/2011) and Death in Custody Reporting Program (OMB No. 1121-0329: Approval expires 02/28/2013). For the full survey, the burden cost is $6120 on an annualized basis. The following table shows how the respondent cost was calculated:

Table 2. Estimated Annualized Burden Costs

Type of Respondent	Response burden hours	Hourly Wage Rate	Respondent Cost
Prison official in DOC or BOP (Medical/Health Researcher)	204	$ 30	$6,120

13. Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers

None. No additional respondent capital and maintenance costs are incurred by NSPHC reporting because all DOC and BOP purchases of equipment or services are made for reasons other than to provide information or keep records for the government and are part of their usual or customary business practices.

13. Annualized Cost to the Government

NSPHC is an in-house data collection and the annualized cost to the government consists primarily of staff salaries. The estimated annual cost:

NCHS Staff $256,000

BJS Staff $43,400

Total $299,400

A large portion of the funds were obtained by NCHS from BJS through an Inter-Agency Agreement.

15. Explanation for Program Changes or Adjustments

This is a new data collection.

16. Plans for Tabulation and Publications and Project Time Schedule

The data collected from the NSPHC will be used by NCHS and BJS to produce national and state-level statistics of health care services provided in U.S. prisons. The NSPHC will be used to analyze issues such as:

-Differences in use of contracting for delivery of health care services

-Variations in health care staff-to-inmate ratios by state

-Differences in capacity for reporting health care services

-Location of specialty and diagnostic services

-Provision of health care services

-Extent of electronic health record utilization

Depending on the quality of data received, a public use file containing information collected by NSPHC as well as detailed descriptions of the survey design and data collection methodology is planned at the completion of the data collection. If feasible, the data files produced from NSPHC will also be made available at the NCHS Research Data Center to allow linkage to other data sources. In addition, a summary report of NSPHC data collection, co-authored by NCHS and BJS, is planned for 2013.

NCHS and BJS staff working on NSPHC may present findings at meetings and conferences of professional organizations, such as the American Public Health Association, AcademyHealth, American Correctional Association, and other conferences that may hold a stake in correctional health care research. The presentations would deal with specific aspects of the survey or special analyses of survey data.

The following is a projected schedule for the NSPHC:

Receive OMB Clearance……………………………………………………....Third Quarter 2012

Mail Introduction Letters/Conduct Interviews….……....….……….1 month after OMB clearance

Conduct Follow-up Calls/Emails………………………………..…2 months after OMB clearance

Prepare Dataset………………………………………...………...3-4 months after OMB clearance

Publish Report………………………………………...…………7-8 months after OMB clearance

17. Reason(s) Display of OMB Expiration Date is Inappropriate

N/A

18. Exceptions to Certification for Paperwork Reduction Act Submission

No exceptions to certification are requested.

1 Guerino, P, Harrison, P, Sabol, WJ. Prisoners in 2010. US Department of Justice, Bureau of Justice Statistics. 2010. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/p10.pdf. (OMB No. 1121-0102:Approval expires 05/31/2011)

2King’s College London. International Centre for Prison Studies. Entire world-prison population rates per 100,000 of the national population. [online]. Available from: www.prisonstudies.org [cited 2010 May 14].

3 Sabol WJ, West HC. Prison Inmates at Midyear 2008. US Department of Justice, Bureau of Justice Statistics. 2009. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/pim08st.pdf (OMB No. 1121-0102:Approval expires 05/31/2011)

4 Maruschak, LM. Medical Problems of Prisoners. US Department of Justice, Bureau of Justice Statistics. 2008. Available at: http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=1097

5 Hammett T, Kennedy S, Kuck S. 10^th NIJ/CDC National Survey of Infectious Disease in Correctional Facilities: HIV and Sexually Transmitted Diseases. Abt Associates, Inc. 2007.

6 McDonald DC. Medical Care in Prisons. Crime and Justice 26: 427-478. 1999.

7 Lamb-Mechanick D, Nelson J. Prison Health Care Survey: An Analysis of Factors Influencing Per Capita Costs. National Institute of Corrections. 2006.

8 Norton GD, Hammett T. Technical Capability Assessment of Correctional Healthcare Data Management Information Systems and Overall Readiness to Participate in the Development of a Disease Reporting System. Abt Associates, Inc. 2006.

9 Spaulding, A., Greene, C., Davidson, K., Schneidermann, M., Rich, J. “Hepatitis C in State Correctional Facilities,” Preventive Medicine, Vol. 28, 1999, pp. 92-100.

10 Felson, RB., Silver, E., Remster, B. “Mental Disorder and Offending in Prison,” Criminal Justice and Behavior, Vol, 39, No. 2, February 2012, pp. 125-143.

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