Exclusion of Non-English Speaking, Recently Released Prisoners

As primary care providers in the San Francisco Bay Area (at Alameda County Medical Center), California, we appreciate the publication by Wang et al. showing that transitional care reduces emergency department (ED) use by recently released prisoners.¹ Based on our experience with similar patients, we would like to make the following comments.

The study included only English-speaking, recently released prisoners who were either older than 50 years or had at least one chronic illness.¹ In their study, excluding non-English speaking participants creates a bias toward the null hypothesis. Hispanics are the fastest growing subgroup of prisoners in the United States.² Hispanics accounted for 15% of the US prison population in 2011² and nearly 40% of the Californian prison population in 2010.³ More specifically, Hispanics older than 50 years accounted for 16.9% of the Californian prison population in 2010.³ Therefore, we can estimate that 18 500 Hispanics older than 50 years were released from Californian prisons in 2010. Based on US Census data from 2007, 29.1% (5384) of those released Hispanics prisoners spoke English either not well or not at all.⁴

Several characteristics further increase the vulnerability of this population. Hispanic inmates have a lower education level compared with White and African American inmates.⁵ Additionally, in the US Hispanic population, chronic illnesses account for four of the top five leading causes of death.⁶ These numbers suggest that Wang et al. may have underestimated the relevant population at risk. In regards to health care, non-English speaking released prisoners are an especially vulnerable population, and should be accordingly studied and targeted for interventions.

We recalculated the “absolute reduction in any ED use” shown in Table 2 of the study by Wang et al.¹ We found an absolute reduction of 13.7% (the difference between expedited primary care [39.2%] and transitions clinics [25.5%]) instead of the 15% reported in the article.

The publication by Wang et al. makes a useful contribution by demonstrating that a primary care-based care management program with a community health worker reduces ED visits¹ and therefore decreases health care costs. About two thirds of the released prisoners in the US will return to prison at least once in three years.⁷ Providing continuity of care between prison stays will improve health care both within and outside of the prison system.