Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study

Fiona G. Kouyoumdjian; Lori Kiefer; Wendy Wobeser; Alejandro Gonzalez; Stephen W. Hwang

doi:10.9778/cmajo.20150098

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Figure 1
Flow diagram of inclusion in final sample of people admitted to provincial custody in Ontario in 2000. Note: IKN = a unique encrypted health card number, MCSCS = Ontario Ministry of Community Safety and Correctional Services, RPD = Registered Persons Database. *Numbers of people and of IKNs do not sum because of overlap in people and IKNs from deterministic and probabilistic linkage. †This number represents the number of combinations of people and IKNs.
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Figure 2
Relative risk of death in people admitted to provincial custody in 2000 compared with the general population,* by age group and sex. 95% confidence intervals shown with vertical lines. *Death rates between 2000 and 2012 for those incarcerated in 2000 and for the Ontario population aged 15 and older in 2006.
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Figure 3
Standardized mortality ratio for all causes, overdose and suicide, by period postrelease from first admission to provincial custody in 2000, n = 46 442.* Standardized to the Canadian population in 2000. 95% confidence intervals shown with vertical lines. *Excludes 960 people who were transferred to federal custody.

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Table 1: Characteristics and rates of death between 2000 and 2012 in people admitted to provincial correctional facilities in Ontario in 2000 (n Table 1: Characteristics and rates of death between 2000 and 2012 in people admitted to provincial correctional facilities in Ontario in 2000 (n = 48 166)

Characteristic		Men			Women
Characteristic		No. (% of men)	Person-years	Mortality per 1000 person-years	No. (% of women)	Person-years	Mortality per 1000 person-years
All		43 419 (100)	522 742.3	7.1	4747 (100)	57 260.9	7.3
Age at baseline, yr	15-19	4054 (9.3)	50 046.6	2.6	411 (8.7)	5095.6	1.8
	20-24	8257 (19.0)	101 957.8	2.7	752 (15.8)	9273.0	2.6
	25-29	6349 (14.6)	77 710.5	4.0	684 (14.4)	8389.9	4.2
	30-34	6942 (16.0)	84 628.7	4.9	878 (18.5)	10 695.1	5.9
	35-39	6936 (16.0)	83 512.4	7.2	901 (19.0)	10 734.8	9.0
	40-44	5009 (11.5)	59 340.1	10.5	567 (11.9)	6711.4	11.3
	45-49	2805 (6.5)	32 486.1	14.4	306 (6.4)	3521.9	16.5
	50-54	1565 (3.6)	17 658.8	18.7	117 (2.5)	1350.2	17.8
	55-59	771 (1.8)	8274.2	28.5	74 (1.6)	851.3	17.6
	60-64	395 (0.9)	3967.5	40.1	32 (0.7)	360.2	25.0
	65-69	206 (0.5)	1965.9	50.4	21 (0.4)	231.8	25.9
	70-74	85 (0.2)	793.4	51.7	≤ 5* (≤ 0.1)	45.5	≤ 109.8*
	75-79	37 (0.1)	331.2	54.3	0 (0.0)	-	-
	≥ 80	8 (0.0)	69.1	≤ 72.4*	0 (0.0)	-	-
Race	Aboriginal	3005 (6.9)	35 972.0	8.4	460 (9.7)	5468.6	9.0
	Black	5374 (12.4)	66 137.4	3.1	596 (12.6)	7367.3	2.0
	Declined to specify	47 (0.1)	583.4	≤ 8.6*	≤ 5* (≤ 0.1)	37.0	0.0
	East Asian	545 (1.3)	6682.8	3.7	35 (0.7)	435.2	0.0
	Hispanic	392 (0.9)	4817.7	2.9	28 (0.6)	347.0	≤ 14.4*
	Other	1431 (3.3)	17 625.6	3.1	124 (2.6)	1527.1	≤ 3.3*
	South Asian	897 (2.1)	10 922.4	4.6	54 (1.1)	665.2	≤ 7.5*
	Southeast Asian	725 (1.7)	8872.6	4.2	70 (1.5)	877.1	≤ 5.7*
	Unknown	454 (1.0)	5470.4	5.3	72 (1.5)	869.1	9.2
	West Asian/Arab	572 (1.3)	7100.6	2.3	26 (0.5)	324.3	0.0
	White	29 977 (69.0)	358 557.4	8.3	3279 (69.1)	39 342.8	8.6
Neighbourhood income quintile	Missing	7862 (18.1)	96 907.8	3.3	910 (19.2)	11 200.8	3.9
	1 (lowest)	13 336 (30.7)	159 367.3	8.3	1693 (35.7)	20 362.9	7.6
	2	8381 (19.3)	100 458.6	7.9	858 (18.1)	10 302.9	8.7
	3	5892 (13.6)	70 743.8	7.4	573 (12.1)	6920.5	7.4
	4	4674 (10.8)	56 102.0	7.8	393 (8.3)	4698.7	8.7
	5 (highest)	3274 (7.5)	39 162.8	8.1	320 (6.7)	3775.0	10.1
Admissions to provincial custody 2000-2012	1	14 238 (32.8)	169 333.2	7.8	1885 (39.7)	22 714.8	5.9
	2-4	14 678 (33.8)	175 775.7	7.6	1392 (29.3)	16 653.5	8.0
	≥ 5	14 503 (33.4)	177 633.4	5.9	1470 (31.0)	17 892.6	8.3
Transferred to federal facility 2000-2012	No	38 680 (89.1)	464 590.0	7.4	4480 (94.4)	53 968.8	7.5
Transferred to federal facility 2000-2012	Yes	4739 (10.9)	58 152.2	4.8	267 (5.6)	3292.1	3.3
Total time in provincial custody 2000-2012	< 1 wk	8006 (18.4)	95 893.8	6.5	1358 (28.6)	16 406.6	5.4
	1 wk to < 1 mo	5676 (13.1)	67 742.7	7.8	863 (18.2)	10 251.7	8.5
	1 mo to < 3 mo	6971 (16.1)	82 747.9	8.6	787 (16.6)	9436.5	8.5
	3 mo to < 6 mo	6072 (14.0)	72 872.6	7.6	628 (13.2)	7479.5	10.0
	6 mo to < 1 yr	6132 (14.1)	73 685.2	7.9	534 (11.2)	6514.6	7.8
	1 yr to < 2 yr	5384 (12.4)	65 483.8	6.8	395 (8.3)	4895.8	5.5
	2 yr to < 3 yr	2445 (5.6)	30 188.5	4.9	114 (2.4)	1430.7	4.9
	≥ 3 yr	2733 (6.3)	34 127.7	3.5	68 (1.4)	845.4	≤ 5.9*

*To decrease the risk of identifying individuals, we indicated ≤ 5 as the number of people and used 5 as the numerator to calculate the percentage in cells in which there were 5 or fewer persons, and we used 5 as the numerator to calculate mortality in categories in which there were 5 or fewer deaths.

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Table 2: Observed and expected* deaths between 2000 and 2012 for people admitted to provincial correctional facilities in Ontario in 2000, by ICD-9 chapter and for selected preventable causes of death

Cause of death	Observed deaths, no.	Expected deaths, no.	Standardized mortality ratio (95% CI)	Mean age at death, yr
All deaths†	4126	1037	4.0 (3.9-4.1)	47.5
Cause unknown	130	-	-	43.4
By ICD-9 chapter
1. Infectious and parasitic diseases	224	30.2	7.4 (6.5-8.5)	48.2
HIV	96	11.4	8.5 (6.9-10.3)	43.3
Sepsis	24	7.5	3.2 (2.1-4.8)	56.3
Viral hepatitis	87	6.4	13.5 (10.8-16.7)	51.1
2. Neoplasms	600	380.3	1.6 (1.5-1.7)	56.1
Breast‡	7	7.5	0.9 (0.4-1.9)	54.7
Cervix‡	≤ 5**	**	3.6 (1.0-9.3)	41.0
Colon, rectum and anus	37	35.9	1.0 (0.7-1.4)	60.8
3. Endocrine, nutritional and metabolic diseases, and immunity disorders	120	39.2	3.1 (2.5-3.7)	52.4
Diabetes	90	27.3	3.3 (2.7-4.1)	53.3
4. Diseases of the blood and blood-forming organs	≤ 5**	**	0.5 (0.1-1.9)	44.5
5. Mental disorders	174	20.5	8.5 (7.3-9.9)	47.5
6. Diseases of the nervous system and sense organs	61	36.3	1.7 (1.3-2.2)	49.2
Epilepsy	19	3.7	5.2 (3.1-8.1)	46.3
7. Diseases of the circulatory system	653	212.9	3.1 (2.8-3.3)	54.3
Cerebrovascular disease	80	32.1	2.5 (2.0-3.1)	54.8
Hypertensive disease	15	5.1	3.0 (1.7-4.9)	52.1
Ischemic heart disease	416	123.6	3.4 (3.1-3.7)	55.7
8. Diseases of the respiratory system	135	46.5	2.9 (2.4-3.4)	56.4
Pneumonia	39	12.5	3.1 (2.2-4.3)	55.1
9. Diseases of the digestive system	303	48.3	6.3 (5.6-7.0)	51.5
10. Diseases of the genitourinary system	18	11.4	1.6 (0.9-2.5)	57.7
12. Diseases of the skin and subcutaneous tissue	≤ 5**	**	3.1 (0.6-9.0)	59.3
13. Diseases of the musculoskeletal system and connective tissue	≤ 5**	**	0.3 (0.0-1.1)	62.5
14. Congenital anomalies	≤ 5**	**	0.1 (0.0-0.8)	50.0
16. Symptoms, signs, and ill-defined conditions	123	32.6	3.8 (3.1-4.5)	43.0
17. Injury and poisoning	1575	226.4	7.0 (6.6-7.3)	39.9
Accidental falls	59	8.8	6.7 (5.1-8.7)	50.2
Events of undetermined intent	132	15.2	8.7 (7.3-10.3)	40.5
Excessive cold	11	1.3	8.6 (4.3-15.4)	47.3
Homicide	169	11.4	14.8 (12.7-17.2)	33.2
Legal intervention	10	0.3	37.0 (17.8-68.1)	34.0
Overdose	563	27.7	20.3 (18.7-22.1)	41.4
Suicide and self-inflicted injury	340	78.4	4.3 (3.9-4.8)	39.4
By risk factor§
Alcohol-related diseases	243	6.1	40.0 (35.2-45.4)	51.8
Drug-related diseases¶	58	4.0	14.5 (11.0-18.7)	42.5
Smoking-related diseases	337	52.5	6.4 (5.8-7.1)	57.9

Note: CI = confidence intervals. ICD-9 = International Classification of Diseases, 9th revision.

*Expected rates are adjusted for age, and we used age groups of 5 years for people aged ≥ 15 in Canada in 2006, unless otherwise specified.

†Standardized to the Ontario population in 2006.

‡Includes women only.

§These are diseases that are attributable in whole or in part to the risk factor as defined by Statistics Canada,⁴¹ and these data include people aged 25 and older only.

¶For some age strata, the number of deaths was too low for Statistics Canada to report (i.e., < 5), and we assumed the maximum number of 4 expected deaths to provide the most conservative estimate of the standardized mortality ratio.

**To decrease the risk of identifying individuals, we indicated ≤ 5 in cells in which there were 5 or fewer observed deaths and left the number of expected deaths blank.