-->PONE-D-25-43064-->-->Prevalence of Criminal Legal-Involvement Among Emergency Department Patients: Insights from the 2023 National Survey on Drug Use and Health-->-->PLOS One

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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-->5. Review Comments to the Author

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Reviewer #1: This paper presents an analysis of the relationship between emergency department utilization and recent or lifetime criminal legal involvement using data from the 2023 national survey on drug use and health. The paper presents an interesting analysis that certainly has interest and utility in our current social and policy environment. However, the analysis lacks a certain degree of clarity in its methodology—specifically related to matters of sampling and measurement—and its significance or impact for practitioners and policymakers in general.

To begin with the significance or impact of this analysis, the utility of the author's findings to policy or practice is not sufficiently articulated in the manuscript. Throughout the abstract as well as the manuscript itself (including on page 4 in the introduction, page 5 in the introduction, and page 15 and 16 in the discussion), the authors repeatedly mention the need for emergency medicine providers to better understand and address or to better identify and treat the specific needs of people presenting to an emergency department with a history of criminal legal involvement. However, what those specific patient needs or provider actions that might be is never clearly articulated in the draft, and I am struggling to imagine what particular, individualized intervention any healthcare practitioner could take that would target an underlying structural driver of the surface level biological or psychological concern they are there to treat. In other words, how should a healthcare provider treat a person presenting to the emergency department with a substance use related issue any differently based on their history (or lack thereof) of criminal legal involvement?

I don't mean to throw the baby out with the bathwater and say that healthcare providers have nothing to offer in terms of structural supports to the people that they serve. Nevertheless, the authors failed to clarify how the needs of patient presenting to an emergency department with a mental illness or substance use related concern would be fundamentally different according to that individual's current or prior criminal legal involvement. The practical details of this distinction is of the utmost importance to the argument that the authors appear to be trying to make. Yet it is glaringly absent from the paper. Only in the discussion section do the authors begin to theorize how criminal legal involvement of any kind might have a direct impact on the likelihood of someone's presentation to the emergency department, identifying lasting trauma from criminal legal involvement as a driver of behavioral health concerns or lack of access to basic life needs and financial resources as a driver of emergency department utilization. (Importantly, the authors don't explicitly identify these as plausible mechanisms explaining their findings, but they absolutely should.) Yet those plausible mechanisms don't to address at all how people with past criminal legal involvement might somehow present differently to an emergency department or how the needs they present with might be fundamentally different or how they should be addressed in some specific, targeted way. In other words, it's not at all clear how healthcare providers are supposed to treat people with criminal legal involvement differently or understand their problems through some different framework.

On page 16 the authors do make a couple of suggestions about what that could look like in a practical sense, but those suggestions are limited to a brief mention of connecting patients with reentry focused resources, which—I feel quite strongly should be noted is not a healthcare provider's job; That is the job of jails and prisons and existing state-run reentry services—and building collaborations and supports across hospital departments, which would be a benefit to all patients presenting with behavioral health issues not just those with criminal legal involvement. So, in the end, it's not at all clear what practitioners or policymakers are supposed to do with the information provided in this manuscript especially insofar as the authors are focusing on individual level health care practices more so than structural changes or population level policy changes that might begin to address the problematic relationships their analysis identifies.

With regard to measurement and method, I understand that the authors are limited to the indicators that were already included in the national survey on drug use and health. However, it seems to me that the problems with using a measurement like arrest and booking as an indicator for criminal legal involvement should be obvious and openly discussed both in the plan for analysis and in the limitations section of the paper. What arrest and booking is able to measure is, in a way, NEW episodes of criminal legal involvement. Or perhaps even ongoing episodes of criminal legal involvement. I'm thinking here of someone who has been on community supervision for 18 months after release from a period of incarceration has not been arrested or booked during that time period. That person absolutely has been subject to criminal legal involvement during the past 12 months but that would not be identified by the measures used in the study. Thus one major problem with this measurement is the fact that people who are under community supervision or some other degree of criminal legal involvement that has not resulted in an arrest on a booking in the past 12 months cannot be identified and assigned to the treatment group as appropriate.

Further, the sampling limitations that are inherent in the national survey on drug use and health methodology need to be articulated in the methods section, not just the limitations section and the impact of those sampling challenges on the results that the authors have produced and need to be discussed much more thoroughly and clearly in the paper. Lots of other scholars have addressed the deeply ironic sampling challenges with this survey, so the authors are well within their rights to cite out to other works that have already produced this kind of analysis of the surveys sampling structure and the problems it injects into its data. But it has to be brought up explicitly ahead of the analysis in paper.

A few minor comments follow:

1) In the opening lines of the paper, the authors make reference to “Western countries.” This term can be a bit problematic and it's usually best to avoid using it whenever possible. If the authors simply mean that the United States has incarcerated more people than other countries in Europe and North America, say that. If the author is mean that the United States has the highest incarceration rate of countries with GDP above a certain amount, say that. It's always preferable to just say what you mean instead of glossing it with squishy and problematic terms like “western.”

2) There seems to be a citation missing at the end of the second sentence, ending in the phrase “drug related crime.”

3) The authors use the term prisoners at the end of the first paragraph. This term is not preferred.

4) On page 4 the authors refer to other sources of care that are decreasing in the United States. It would be helpful to state explicitly what those are.

5) The authors do a good job in the measures section of explaining what the term booked means, but a brief explanation of how that connects to other forms of criminal legal involvement (as in being booked is the gateway to other forms of criminal legal involvement like prosecution, drug court, community service, probation, etc.) would be helpful.

6) On page 14 the authors state that their findings suggest associations between criminal legal involvement and emergency department use persist over time. In this context, the term persists suggests a temporal model of causality between criminal legal involvement and emergency department utilization that is not supported by this study and seems plausible but unlikely given the other bodies of evidence that exist, many of which the authors are already referring to. Put another way, many socioeconomic factors themselves are predictive of both criminal legal involvement and emergency department utilization, so if the authors want to suggest that an effect of criminal legal involvement persists over time they need to establish that something is an effect of criminal legal involvement. Whether through their own data or through reference to other literature, they have not done so here.

7) The study mentioned in the discussion that shows very low levels of criminal legal involvement among emergency department patients via an analysis of electronic health records seems important context for the introduction.

Reviewer #2: This is an interesting manuscript on an important topic which is the impact of criminal justice involvement in use of emergency departments. There are a few areas where the grammar needs to be reviewed and some spelling errors (see line 135 "non-Hispanic Back should be "Black").

The authors effectively highlight the intersection of incarceration, substance use, mental health, and healthcare access, particularly in ED settings. The justification for focusing on lifetime CLI rather than only recent involvement is persuasive and adds depth to the study's relevance.

The dataset is nationally representative but has its drawbacks which are discussed in the limitations section.

The methodology is robust, employing descriptive statistics, logistic regression, and propensity score weighting to account for confounding variables. The paper would benefit from a little more discussion of the use of both logistic regression and propensity score analysis, and how they complement each other and why both are needed, especially with respect to Table 4.

While it is not a novel finding that formerly incarcerated individuals access the ED for healthcare, and that these are important social determinants of health, the manuscript adds incrementally to our knowledge of the impact of incarceration on healthcare-seeking behavior.

The authors advocate for screening and tailored interventions in EDs, which is a logical extension of their findings. However, as the authors note, that could be a heavy lift as most EDs do not collect that information and the authors themselves state that it is not clear or established how data on previous incarceration would be collected in that setting.

Finally, the paper could use additional discussion on whether findings from these data are truly generalizable.

Reviewer #3: Authors: This study uses a retrospective cohort design from publicly available nationally representative sample to look at criminal legal system involvement among those with a past year emergency department visit. This is a novel question that has not been previously undertaken to my knowledge. It can be an important question, given that health disparities are well described amongst people with justice involvement, compared with the general population, and identifying these individuals may provide an opportunity for targeted health system interventions such as linkage to peers, medical legal partnerships, rapid housing and targeted primary care programs.

This manuscript will benefit from more clearly laying out the current state of knowledge on this topic and what specifically this study adds, as well as the specific research question. I do believe that with moderate edits, this manuscript can contribute meaningfully to the literature on healthcare delivery and quality of community care delivery for previously incarcerated people, especially where they most often access care- in the emergency department.

Title: Suggest remove hyphen from title.

Abstract: Not clear to the average reader why this is a problem. No mention of health risks, so why should EDs care if there is past CLI? Opportunity to more clearly state the problem in the intro. Advise reorder the results for ED visits among CLI line 45-46 in abstract so that consistent with reporting order in the sentences prior. It is otherwise more confusing for the reader.

Introduction:

As currently written it is challenging to follow and could be tightened. The authors present a broad overall epidemiology of incarceration in the US, of substance use disorder treatment for those with CLI, then social determinants, and then to the role of the ED in the life of people with CLI. I suggest really tightening and getting to the health risks right away and then the way this population uses the ED and why identifying CLI might be helpful in the ED. Why is it any more helpful that just identifying the SUD or the mental health condition? These patients are also often unstably housed and with many social determinant needs. Again, why is this helpful? What might the ED do different for this population than any other population with SUD or mental health conditions? Line 78-79 mentions this vaguely, but being more specific would be helpful in setting up the value of this line of inquiry. Additionally would be most helpful to summarize the literature on ED use for this population and what the gaps really are. As currently written this introduction does not present in detail what are the past findings on ED use for this populations and what are the limitations of the current body of research. This would set up for a stronger final paragraph where the authors can more clearly and specifically define the research question. For example, the first author has previously published work that established that frequent ED visits are associated with subsequent jail incarceration and that the ED is a place for intervention to prevent incarceration- how does this study build off of that work? Is the question what is spelled out in second sentence of the abstract? Is this really what you sought to assess?: “We sought to assess lifetime and past year CLI among those reporting an ED visit for any reason, for substance use and for mental health.” Having read through the manuscript this does not appear to be the primary question, your methods and results sections focus much more on differential use of the ED for people with and without CLI, so is the question how people with CLI use the ED or is the question what percent of people going to an ED have CLI? If your question is as stated, then Table 1 makes sense, but then why Table 2 and related analysis? What does this study add that data linkage studies that have linked jail and ED records have not addressed (see Easter et al, Journal of Correctional Healthcare, 2023; Humphreys, JUH, 2017) and what does this add beyond the work of Joseph Frank et al in JGIM that you cited but really didn’t expand upon- they did a similar analysis, why is this study needed and different?

Methods:

Why did the authors not include the question about probation or parole in defining CLI? Past studies have. If there was a strong rationale, would explicate here. If not including this, why not call this variable what it is, which is prior incarceration, not the broader conceptualization of criminal legal system involvement which typically includes incarceration and community supervision through probation and parole.

Also, why the decision to use one year of NSDUH data instead of combining multiple years to increase sample of people with recent CLI and different ED use?

Why did the authors feel that propensity score matching was necessary when past studies using NSDUH with this population have not employed this approach, especially given that there are not that many other variables to control for between CLI and non-CLI? It would be add to your methods if you describe the need for this methodology more and what deficits it responds to in prior studies using NSDUH.

Discussion: Overall the discussion feels more compelling than the introduction and gets the reader to make sense of the results. I think one thing that could be teased out more is what health systems would even do about any prior lifetime CLI exposure? The argument to identify recent release or recent CLI is certainly more supported by the literature and feels more actionable.

281-283- unclear what this sentence means

296-298- in fact, data from NSDUH suggest that the increase in Medicaid post ACA expansion was not associated with increased engagement among people with CLI. (Howell et al, Psych Services, 2023), so this would be helpful to add here and contextualize your findings based on these past findings.

Table 2: N should be in first row for CLI vs no CLI.

Reviewer #4: 1. Introduction

- this section could focus on statements which directly support the scientific question at hand. The second and third paragraphs do not seem to fit where they have been placed.

- The problems created by the MIEP go much further than access to health insurance - it creates a siloed carceral health system and prevents funding for transitional services. This is a nice review of the matter, it would be worthwhile to update the sentence begining line 71 on page 2: https://pmc.ncbi.nlm.nih.gov/articles/PMC11281997/

- the first paragraph on page 5, is not very scholarly. While there are many gaps in knowledge about CLI and ED utliization, there is a not a dearth of studies on the matter either. Moreover, many of the studies that you cite use the same datasource as this paper, so more clearly identifying the precise gap in knowledge would strengthen the scientific rigor of this introduction.

Methods

- Is there any reason that the authors did not combine this data set with 2022 or 2021? The N for several outcome groups is very small, limiting interpretation of these results. Datasets can be combined per NSDUH recommended procedures (though I believe 2020 should not be combined so you may be limited is 2021-2023.

- Given the outcome is healthcare utlization, and variables on other comorbid health conditions is available in the dataset, it seems appropriate to control for these as well.

- I deeply appreciate the sentiment of the sentence beginning line 137 on page 7 but I believe that the phrase "criminal tendencies" is not scientific and could be removed; consider naming structural racism as the underlying mechanism at play (citation if you need it : https://www.nejm.org/doi/10.1056/NEJMms2025396)

- it does not appear the authors applied the necessary survey weights to analyze this data - see NSDUH codebook for guideance. If it was in fact done, it should be described in the methods

- analysis plan for table 1 is not presented

- in general, the methods and results are not clearly described. I would reccomend looking at each table, describing the methods for that table first, then the second table, then the third, etc.... Then do the same for the results.

Results

- there is no statistical analysis applied to the results in table 1 (ie p-values)

- this is touched on above, but the presentation of the results needs to be more explicit about what is there. table 2 does not appear to be described in the methods or the results

Discussion

- I would recommend that the authors focus their discussion specifically on exploring conversation tied directly to the findings.

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Reviewer #1: No

Reviewer #2: Yes:  Grace Reynolds-Fisher

Reviewer #3: No

Reviewer #4: No

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-->PONE-D-25-43064R1-->-->Prevalence of Criminal Legal Involvement Among Emergency Department Patients: Insights from the National Survey on Drug Use and Health 2021-2023-->-->PLOS One

Dear Dr. Eswaran,

Thank you for submitting your manuscript to PLOS ONE. This revision was extremely responsive to the reviewers comments and very nearly meets all of the PLOS ONE publication criteria. The reviewers did identify a few small changes that are needed to ensure that the study is clearly and accurately reported. Therefore, we invite you to submit a revised version of the manuscript that addresses the last few points raised during the review process.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

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-->6. Review Comments to the Author

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Reviewer #1: I want to congratulate the authors on a much improved manuscript and acknowledge how thoroughly and seriously they addressed the comments received in the prior round of review. I have only very minor comments to offer at this stage, the most substantial of the bunch refer to the methods section and should be very quick to resolve.

INTRO

--The abbreviation "ED" is not defined at first use

--The authors write "5x" rather than "five times"

--Typically, numerals less than 10 are spelled out (i.e. it should be "six months" rather than "6 months"). I will defer to the journal's style guide on this one

--Typically, U.S. is only used as an adjective (i.e. U.S. residents) and United States is only used as a noun (i.e. in the United States)

--There appears to be an extra carriage return on line 92

METHODS

--The mention of sampling limitations in the first paragraph is good, but the authors should further clarify how this is likely affecting the results. Right now, that impact on results is insinuated but not stated explicitly.

--It does not appear as though the authors took steps to control for for multiple comparison in their chi-squared analyses (listed in Table 2). This may be de facto handled by the fact that the table only indicates when p<0.001, but at least some mention of the authors awareness of the risk of false discovery and source of confidence in their presented data should be made. Even as a footnote to the table would be fine.

RESULTS

at least one of the "p"s in table 2 is capitalized.

Reviewer #2: (No Response)

Reviewer #4: The authors have thoroughly and adequately responded to the the reviewers comments. I ave no additional comments.

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Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

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Prevalence of Criminal Legal Involvement Among Emergency Department Patients: Insights from the National Survey on Drug Use and Health 2021-2023

PONE-D-25-43064R2

Dear Dr. Eswaran,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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