Long-term Condition Management for Prisoners: exploring prevalence and compliance with national monitoring processes

Abstract Background: Long-term conditions (LTCs) are a significant cause of morbidity and mortality and prisoner populations have a disproportionately high prevalence of risk factors for LTCs. The size and mean age of the prison population has increased rapidly in recent years. The UK Quality Outcomes Framework (QOF) is a national standardised framework embedded in community general practice with financial remuneration linked to assessment and ongoing review of key clinical outcomes pertaining to LTCs. However, healthcare in prisons in England is not linked to financial remuneration through the QOF framework and prison clinicians are not mandated to adhere to the framework. Aim: To explore prevalence of LTCs in remand prisons and measure compliance with QOF monitoring. Design and Setting: Quantitative analysis of secondary data on SystmOne. Methods: Secondary data analysis of data extracted from the prison primary care record pertaining to patient self-report of LTC, level of confirmation by supporting evidence and compliance with QOF monitoring frameworks. Results: 17% of the sample had at least one LTC, the most common condition being asthma, confirmed in 12% of the sample. Having an LTC was associated with female gender and increasing age. Prevalence rates for the other LTCs were hypertension 3%, epilepsy was 3%, coronary heart disease 2%, diabetes 2% and chronic obstructive pulmonary Qeios, CC-BY 4.0 · Article, January 6, 2021Background: Long-term conditions (LTCs) are a significant cause of morbidity and mortality and prisoner populations have a disproportionately high prevalence of risk factors for LTCs. The size and mean age of the prison population has increased rapidly in recent years. The UK Quality Outcomes Framework (QOF) is a national standardised framework embedded in community general practice with financial remuneration linked to assessment and ongoing review of key clinical outcomes pertaining to LTCs. However, healthcare in prisons in England is not linked to financial remuneration through the QOF framework and prison clinicians are not mandated to adhere to the framework. Aim: To explore prevalence of LTCs in remand prisons and measure compliance with QOF monitoring. Design and Setting: Quantitative analysis of secondary data on SystmOne. Methods: Secondary data analysis of data extracted from the prison primary care record pertaining to patient self-report of LTC, level of confirmation by supporting evidence and compliance with QOF monitoring frameworks. Results: 17% of the sample had at least one LTC, the most common condition being asthma, confirmed in 12% of the sample. Having an LTC was associated with female gender and increasing age. Prevalence rates for the other LTCs were hypertension 3%, epilepsy was 3%, coronary heart disease 2%, diabetes 2% and chronic obstructive pulmonary Qeios, CC-BY 4.0 · Article, January 6, 2021 Qeios ID: PWHD35 · https://doi.org/10.32388/PWHD35 1/13 disease 1%. Just 34% of the eligible sample had had a QOF template completed. Higher rates of completion were associated with younger age and there were also statistically significant inter-prison differences. Conclusion: There is a pressing need to embed standardised QOF monitoring systems within an integrated community/prison commissioning framework supported by connectivity between prison and community primary care records of not just the summary care record but also all activity related to QOF compliance.

timely confirmation of outstanding prescriptions), whereas the second screen covers an assessment of the need for ongoing management of long-term conditions and current immunisation status.
Once patients have undergone assessment and are established in prison there is an opportunity to obtain supporting evidence to confirm their self-report of an LTC by obtaining confirmation from either their community GPs or arranging the necessary clinical tests, thus permitting the health risks posed by LTCs to be more proactively managed. In community general practice in England, the key framework to achieve this objective is the Quality and Outcomes Framework [10] (in Scotland such information is collected and presented through Primary Care Information Dashboards [11] ). Such a national standardised framework is now embedded in community general practice with financial remuneration linked to assessment and ongoing review of key clinical outcomes pertaining to LTCs. However, healthcare in prisons in England is not linked to financial remuneration through the QOF framework and prison clinicians are not mandated to adhere to the framework.
Rather, the only mandated process is that of all prisoners upon reception into prison undergoing the screening process outlined above. Such a screening process places less of an emphasis upon clinical outcomes than that outlined in the QOF framework. Therefore, since compliance with QOF monitoring processes is voluntary in prisons, it is possible that an opportunity to improve clinical outcomes associated with LTCs is being missed. Therefore, in response to such a gap in service provision, we explored the topic of the assessment and management of LTCs in four remand prisons. By extracting routinely collected clinical data, we explored the prevalence of LTCs, compliance with both first and second assessment, and also QOF monitoring processes.

Methods
After acquiring the necessary national ethics, prison National Research Committee and local governance approvals, data was extracted retrospectively from the clinical records of all new entrants to four remand (two male and two female) prisons between June 1st and June 30 th , 2015. All relevant data recorded in the clinical record within 12-months of arrival was extracted. Data extraction took place between June 2016 and June 2018. The rationale for retrospective data collection was that the research activity did not bias routine clinical practice which would have been a risk had data been collected prospectively. Data pertaining to the following were extracted: demographics (including age, gender, ethnic background and sentence status); length of stay in prison (categorised as less than or greater than six months); prevalence of the following "tracer" physical health LTCs: diabetes, asthma, hypertension, coronary heart disease, chronic obstructive pulmonary disease, epilepsy; prevalence of co-morbid mental health conditions; proportion of QOF templates completed -and whether completion was full or partial; time to completion of QOF template; supporting evidence for the long-term conditions defined as any one of: confirmation from the community GP, biochemical test or medication history. The above LTCs were selected as tracer conditions because they are the physical health LTCs that commonly present in prison first night receptions and because of their potential to cause significant morbidity and mortality. The LTCs were identified by the researchers through examining the patient's individual clinical record to retrieve self-reported information of the condition and whether it was confirmed by "supporting evidence." Supporting evidence was defined as any one of evidence of prescribed medication(s) indicated for the condition, Qeios, CC-BY 4.0 · Article, January 6, 2021 confirmation from patient's community GP of the LTC or biomedical/clinical test confirming prevalence of the condition. The following biomedical/clinical tests were regarded as supporting evidence for prevalence: Diabetes -defined as an HbA1c of 48mmol/mol (6.5%) or above Asthma -(FEV1/FVC) ratio of less than 70% but positive reversibility test as diagnosed on spirometry (i.e. an increase in FEV1 from baseline of >12% in response to bronchodilators) Hypertension -blood pressure greater than 140/90 mmHg or higher confirmed by either: a) Ambulatory Blood Pressure Monitoring (ABPM) to confirm the diagnosis. ABPM confirmed a diagnosis through ensuring that at least two measurements per hour are taken during the person's usual waking hours, e.g. between 08:00 and 22:00 hours, and using the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension OR b) Home Blood Pressure Monitoring (HBPM) to confirm a diagnosis of hypertension through ensuring that for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and blood pressure is recorded twice daily, ideally in the morning and evening and blood pressure recording continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.
Coronary Heart Disease -diagnosed by cardiologist from radiological findings COPD -spirometry highlighting airflow obstruction defined as FEV1 < 80% predicted and FEV1/FVC < 0.7 which does not show reversibility to bronchodilator therapy Epilepsy -diagnosed by a neurologist (with or without supporting tests such as EEG or MRI) Following data extraction, analysis was undertaken to assess: Prevalence of associated co-morbid physical and mental health conditions Proportion of prisoners still resident in the receiving study prison 6 months after entering and proportion with physical health or mental health conditions Proportion with a physical health LTC that had the relevant QOF template completed either partially or in full (prisoners residing in the prison for less than one-month were excluded to acknowledge the significant throughput of prisoners on short sentences in remand prisons which acts as a barrier to effective monitoring of LTCs).

Time to completion of QOF template
Qualification of the professional completing the QOF template Demographic associations with QOF completion Agreement between self-report in the primary care consultation of the LTC and confirmation with supporting evidence Descriptive statistics are presented as mean (standard deviation (SD) or n (%). Logistic regression analysis was undertaken of clinical data and the following statistical tests were undertaken: t-tests (continuous data), chi-square tests (categorical data) or Mann Whitney tests (ordinal data). Kappa was used to measure agreement between self-reported LTC and confirmation by supporting evidence. A P-value of <0.05 was considered to indicate statistical significance. Data analysis was undertaken in IBM SPSS Statistics for Windows (version 24).

Results
In total, data was retrieved from the clinical records of 1,126 prisoners. Table 1 highlights the prisoner characteristics.
Of the prisoners, 185 (17%) had at least one LTC. Regarding the association between total number of LTCs (i.e. diabetes, hypertension, asthma, CHD and COPD) and demographic characteristics, there was a significant difference by gender (P <0.001) and age (P <0.001), but not ethnicity (P =0.153). Females were more likely to have an LTC (OR 2.12; 95% CI: 1.50, 3.00), and having an LTC was associated with older age (OR 1.05; 95% CI: 1.04, 1.07). Table 2 highlights the number of prisoners with each of the LTCs in each of the prison sites as confirmed by supporting evidence (i.e. met the inclusion criteria for QOF monitoring). 221 LTCs were confirmed by supporting evidence, and the most common condition was asthma, which was confirmed in 12% (135) of the sample. Epilepsy is excluded from this table since the epilepsy indicator was a "register only" (i.e. no clinical assessment required) in the 2015-16 QOF framework.
The prevalence rates of co-morbid mental health conditions in prisons were 31.5% for depression, 24.9% for opioid dependence, 16% for alcohol dependence, 4.2% for schizophrenia, 19.9% for other psychotic illness and 26.5% for other neurotic illness. The prevalence rate for deep vein thrombosis (presented in this paper as a physical co-morbid condition associated with the co-morbid mental health condition of opioid dependence) was 1.7%. Regarding residence in the receiving prison at six months, just 11% (124) were still resident in the receiving study prison, whilst 75% (839) had been released and 14% (155) had been transferred to another prison. Compared to those no longer in prison at six months, for those still in the receiving study prison, there was no significant difference in the prevalence of either a physical health LTC (OR 1.19, P=0.487, 95% CI: 0.73, 1.93) or co-morbid mental health condition (OR 1.35, P=0.112, 95% CI: 0.93, 1.97). Table 3 highlights QOF completion rates for each of the tracer conditions and shows low levels of QOF completion as evidenced in Table 4. Just 34% (38/112) had a full QOF completed and 11 part-completed. There was significant variation for time to completion with a range of 5-358 days. 35 of the QOF templates were completed by a nurse and just one completed by a healthcare assistant (2 missing data). All of the 11 part-completed templates were undertaken by nursing professionals. In our linked paper reporting qualitative findings, such a prospect was universally welcomed by participants and, in addition to better meeting acute health need, it was felt that such a development would support seamless monitoring of QOF activity between community and prison. Therefore, this presents an opportunity to introduce QOF monitoring systems, possibly supported by an integrated community/prison commissioning framework to enable future connectivity between prison and community primary care records of not just the "summary care record" (a minimum dataset comprising: current medication; allergies and details of any previous bad reactions to medicines; name, address, date of birth and NHS number of the patient), [13] but also all activity related to QOF compliance.