Patterns of Health Care Usage in the Year Before Suicide: A Population-Based Case-Control Study.
ABSTRACT: To compare the type and frequency of health care visits in the year before suicide between decedents and controls.Cases (n=86) were Olmsted County, Minnesota, residents whose death certificates listed "suicide" as the cause of death from January 1, 2000, through December 31, 2009. Each case had 3 age- and sex-matched controls (n=258). Demographic, diagnostic, and health care usage data were abstracted from medical records. Conditional logistic regression was used to analyze differences in the likelihood of having had psychiatric and nonpsychiatric visits in the year before death, as well as in visit types and frequencies 12 months, 6 months, and 4 weeks before death.Cases and controls did not significantly differ in having had any health care exposure (P=.18). Suicide decedents, however, had a significantly higher number of total visits in the 12 months, 6 months, and 4 weeks before death (all P<.001), were more likely to have carried psychiatric diagnoses in the previous year (odds ratio [OR], 8.08; 95% CI, 4.31-15.17; P<.001), and were more likely to have had outpatient and inpatient mental health visits (OR, 1.24; 95% CI, 1.05-1.47; P=.01 and OR 6.76; 95% CI, 1.39-32.96; P=.02, respectively). Only cases had had emergency department mental health visits; no control did.Given that suicide decedents did not differ from controls in having had any health care exposure in the year before death, the fact alone that decedents saw a doctor provides no useful information about risk. Compared with controls, however, decedents had more visits of all types including psychiatric ones. Higher frequencies of health care contacts were associated with elevated suicide risk.
Project description:This article examines mental health care utilization and psychiatric diagnoses among US military personnel who died by suicide. We employed an existing electronic health record dataset including 800 US military suicide decedents and 800 matched controls. Suicide decedents were more likely to have received outpatient and inpatient mental health care and to have been diagnosed with depression, bipolar, and nonaffective psychotic disorders. Younger decedents and those in the US Marine Corps were less likely to receive MH care before suicide. Given that approximately half of the suicide decedents in our sample had no mental health care visits before their death, our study suggests the need for programs to increase treatment engagement by at-risk individuals. Such programs could address barriers to care such as stigma regarding mental illness and concerns that seeking mental health care would damage a service member's career.
Project description:Prior research has shown that a substantial portion of suicide decedents access health care in the weeks and months before their death. We examined whether this is true among soldiers.The sample included the 569 Regular Army soldiers in the U.S. Army who died by suicide on active duty between 2004 and 2009 compared to 5,690 matched controls. Analyses examined the prevalence and frequency of health care contacts and documentation of suicide risk (i.e., the presence of prior suicidal thoughts and behaviors) over the year preceding suicide death. Predictors of health care contact and suicide risk documentation were also examined.Approximately 50% of suicide decedents accessed health care in the month prior to their death, and over 25% of suicide decedents accessed health care in the week prior to their death. Mental health encounters were significantly more prevalent among suicide decedents (4 weeks: 27.9% vs. 7.9%, ?2 = 96.2, p < .001; 52 weeks: 59.4% vs. 33.7%, ?2 = 120.2, p < .001). Despite this, risk documentation was rare among suicide decedents (4 weeks: 13.8%; 52 weeks: 24.5%). Suicide decedents who were male, never married, and non-Hispanic Black were less likely to access care prior to death. Number of mental health encounters was the only predictor of suicide risk documentation among decedents at 4 weeks (OR = 1.14) and 52 weeks (OR = 1.05) prior to their death.Many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. However, in most cases, there was no documentation of prior suicidal thoughts or behaviors, highlighting the need for improvements in risk detection and prediction. Increasing the frequency, scope, and accuracy of risk assessments, especially in mental health care settings, may be particularly useful. (PsycINFO Database Record
Project description:OBJECTIVE:The authors sought to develop and validate models using electronic health records to predict suicide attempt and suicide death following an outpatient visit. METHOD:Across seven health systems, 2,960,929 patients age 13 or older (mean age, 46 years; 62% female) made 10,275,853 specialty mental health visits and 9,685,206 primary care visits with mental health diagnoses between Jan. 1, 2009, and June 30, 2015. Health system records and state death certificate data identified suicide attempts (N=24,133) and suicide deaths (N=1,240) over 90 days following each visit. Potential predictors included 313 demographic and clinical characteristics extracted from records for up to 5 years before each visit: prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency department care, and routinely administered depression questionnaires. Logistic regression models predicting suicide attempt and death were developed using penalized LASSO (least absolute shrinkage and selection operator) variable selection in a random sample of 65% of the visits and validated in the remaining 35%. RESULTS:Mental health specialty visits with risk scores in the top 5% accounted for 43% of subsequent suicide attempts and 48% of suicide deaths. Of patients scoring in the top 5%, 5.4% attempted suicide and 0.26% died by suicide within 90 days. C-statistics (equivalent to area under the curve) for prediction of suicide attempt and suicide death were 0.851 (95% CI=0.848, 0.853) and 0.861 (95% CI=0.848, 0.875), respectively. Primary care visits with scores in the top 5% accounted for 48% of subsequent suicide attempts and 43% of suicide deaths. C-statistics for prediction of suicide attempt and suicide death were 0.853 (95% CI=0.849, 0.857) and 0.833 (95% CI=0.813, 0.853), respectively. CONCLUSIONS:Prediction models incorporating both health record data and responses to self-report questionnaires substantially outperform existing suicide risk prediction tools.
Project description:Relative to traditional fee-for-service Medicare, managed care plans caring for Medicare beneficiaries may be better positioned to promote recommended services and discourage burdensome procedures with little clinical value at the end of life.To compare end-of-life service use for enrollees in Medicare Advantage health maintenance organizations (MA-HMO) relative to similar individuals enrolled in traditional Medicare (TM).For a national cohort of Medicare decedents continuously enrolled in MA-HMOs or TM in their year of death, 2003-2009, we obtained hospice enrollment information and individual-level Healthcare Effectiveness Data and Information Set utilization measures for MA-HMO decedents for up to 1 year before death. We developed comparable claims-based measures for TM decedents matched on age, sex, race, and location.Hospice use in the year preceding death was higher among MA than TM decedents in 2003 (38% vs. 29%), but the gap narrowed over the study period (46% vs. 40% in 2009). Relative to TM, MA decedents had significantly lower rates of inpatient admissions (5%-14% lower), inpatient days (18%-29% lower), and emergency department visits (42%-54% lower). MA decedents initially had lower rates of ambulatory surgery and procedures that converged with TM rates by 2009 and had modestly lower rates of physician visits initially that surpassed TM rates by 2007.Relative to comparable TM decedents in the same local areas, MA-HMO decedents more frequently enrolled in hospice and used fewer inpatient and emergency department services, demonstrating that MA plans provide less end-of-life care in hospital settings.
Project description:<h4>Background</h4>High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital.<h4>Methods</h4>We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care.<h4>Results</h4>In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, <i>p</i> < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, <i>p</i> < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care.<h4>Interpretation</h4>Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.
Project description:OBJECTIVE:Intimate partner (IP) problems are risk factors for suicide among men. However, there is little understanding of why some male suicide decedents who had such problems killed their partners before death (i.e., "IP homicide-suicide"), while most of these decedents did not. To inform prevention efforts, this study identified correlates of IP homicide among male suicide decedents with known IP problems. METHODS:We examined IP homicide correlates among male suicide decedents aged 18+ years who had known IP problems using 2003-2015 National Violent Death Reporting System data. Prevalence odds ratios and 95% confidence intervals were estimated for demographic, incident, and circumstance variables. IP homicide-suicide narratives were examined to identify additional prevention opportunities. RESULTS:An estimated 1,504 (5.0%) of 30,259 male suicide decedents who had IP problems killed their partner. IP homicide-suicide perpetration was positively correlated with suicide by firearm and precipitating civil legal problems but negatively correlated with mental health/substance abuse treatment. An estimated 33.7% of IP homicide-suicides occurred during a breakup; 21.9% of IP homicide-suicide perpetrators had domestic violence histories. CONCLUSIONS:Connections between the criminal justice and mental health systems as well as stronger enforcement of laws prohibiting firearm possession among domestic violence offenders may prevent IP homicide-suicides.
Project description:Importance:The Veterans Health Administration (VHA) serves a population of veterans with a high prevalence of comorbid health conditions and increased risk for suicide. Objective:To replicate the findings of a previous study and assess whether exposure to angiotensin receptor blockers (ARBs) is associated with differential suicide risk compared with angiotensin-converting enzyme inhibitors (ACEIs) among veterans receiving VHA care. Design, Setting, and Participants:This nested case-control design included all suicide decedents from 2015 to 2017 with a VHA inpatient or outpatient encounter in the prior year and with either an active ACEI or ARB prescription in the 100 days prior to death. Using a 4:1 ratio, controls were matched to cases by age, sex, and hypertension and diabetes diagnoses. Controls were alive at the time of the death of the matched case, had a VHA encounter within the previous year, and had either an active ACEI or ARB medication fill within 100 days before the death of the matched case. Exposures:An active ACEI or ARB prescription within 100 days before the death of the case. Main Outcomes and Measures:Cases were suicide decedents from 2015 to 2017 per National Death Index search results included in the Veteran Affairs/Department of Defense Mortality Data Repository. Results:Among 1309 cases, the median (interquartile range [IQR]) age was 68 (60-76) years and among 5217 controls, the median (IQR) age was 67 (60-76) years, and 1.9% of veterans in both groups were female. ARBs were received by 20.2% of controls and 19.6% of cases; ACEIs were received by 79.8% of controls and 80.4% of cases. The crude suicide odds ratio for ARBs vs ACEIs was 0.966 (95% CI, 0.828-1.127). Controlling for covariates, the adjusted odds ratio for ARBs was 0.985 (95% CI, 0.834-1.164). Sensitivity analyses using only those covariates that differed significantly between groups, restricting to veterans ages 65 and older, dropping matching criteria, and adjusting for the quantity and temporal proximity of ACEI and ARB exposure in the 100 days prior to the index date, had consistent findings. Conclusions and Relevance:This case-control study did not identify differences in suicide risk by receipt of ARBs vs ACEIs in analyses specific to veterans receiving VHA care in contrast with findings from the referent study.
Project description:OBJECTIVE:Although mental health conditions are risk factors for suicide, limited data are available on suicide mortality associated with specific mental health conditions in the U.S. population. This study aimed to fill this gap. METHODS:This study used a case-control design. Patients in the case group were those who died by suicide between 2000 and 2013 and who were patients in eight health care systems in the Mental Health Research Network (N=2,674). Each was matched with 100 general population patients from the same system (N=267,400). Diagnostic codes for five mental health conditions in the year before death were obtained from medical records: anxiety disorders, attention deficit-hyperactivity disorder (ADHD), bipolar disorder, depressive disorders, and schizophrenia spectrum disorder. RESULTS:Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men. CONCLUSIONS:Half of those who died by suicide had at least one diagnosed mental health condition in the year before death, and most mental health conditions were associated with an increased risk of suicide. Findings suggest the importance of suicide screening and providing an approach to improve awareness of mental health conditions.
Project description:<h4>Importance</h4>Measuring health care utilization and costs before death has the potential to initiate health care improvement.<h4>Objective</h4>To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system.<h4>Design, setting, and participants</h4>This population-based cohort included 966?436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015.<h4>Exposures</h4>Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure.<h4>Main outcomes and measures</h4>Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups.<h4>Results</h4>Among 966?436 decedents (483?038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231?634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758?770 decedents (78.5%) had at least 1 hospitalization episode of care, 266?987 (27.6%) had at least 1 intensive care unit admission, and 856?026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37?984 (45.6%) in 2005 to 39?474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45?535 [94.2%]; top 6%-50%, 401?022 [92.2%]; bottom 50%, 409?469 [84.7%]) and 1 year of life (top 5%, 43?007 [89.0%]; top 6%-50%, 381?732 [87.8%]; bottom 50%, 380?859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223?262 [51.3%]) and bottom 50% (288?480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16?916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates.<h4>Conclusions and relevance</h4>In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.
Project description:<h4>Importance</h4>Timely outpatient follow-up care after psychiatric hospitalization is an established mental health quality indicator and considered an important component of suicide prevention, yet little is known about whether follow-up care is associated with a reduced risk of suicide soon after hospital discharge.<h4>Objective</h4>To evaluate whether receipt of outpatient care within 7 days of psychiatric hospital discharge is associated with a reduced risk of subsequent suicide among child and adolescent inpatients and examine factors associated with timely follow-up care.<h4>Design, setting, and participants</h4>This population-based, retrospective, longitudinal cohort study used Medicaid data from 33 states linked with National Death Index data. The study population included all youths aged 10 to 18 years who were admitted to a psychiatric hospital from January 1, 2009, to December 31, 2013. Data analysis was completed from October 9, 2019, through May 15, 2020.<h4>Exposure</h4>Mental health follow-up visits received within 7 days of hospital discharge.<h4>Main outcomes and measures</h4>Suicides occurring in the 8 to 180 days after hospital discharge. Logistic regression modeled the association between demographic, clinical, and mental health service history factors and receipt of an outpatient visit within 7 days after discharge. Poisson regression estimated the association between suicide risk and outpatient visits within 7 days after discharge, adjusting for confounding using inverse probability of treatment weights from the logistic model.<h4>Results</h4>Of the total 139 694 youths admitted to a psychiatric hospital, 51.9% were female, 31.1% were aged 10 to 13 years, and 68.9% were aged 14 to 18 years. A total of 56.5% of the youths received a mental health follow-up visit within 7 days of discharge, and this was associated with a significantly lower odds of suicide (adjusted relative risk, 0.44; 95% CI, 0.23-0.83; P = .01) during the 8 to 180 days postdischarge period. Youths with longer lengths of stay (4-5 days: adjusted odds ratio [AOR], 1.20 [95% CI, 1.17-1.24]; 6-7 days: AOR, 1.47 [95% CI, 1.43-1.52]; 8-12 days AOR, 1.75 [95% CI, 1.69-1.81]; 13-30 days: AOR, 1.71 [95% CI, 1.63-1.78]), prior outpatient mental health care (AOR, 1.58; 95% CI, 1.51-1.65), and foster care placement (AOR, 1.32; 95% CI, 1.28-1.37) were more likely to receive 7-day follow-up, whereas those who were non-Hispanic Black (AOR, 0.82; 95% CI, 0.79-0.84), were older (AOR, 0.82; 95% CI, 0.80-0.84), were medically ill (AOR, 0.77; 95% CI, 0.74-0.81), and had managed care insurance (AOR, 0.88; 95% CI, 0.87-0.91) were less likely to receive follow-up visits.<h4>Conclusions and relevance</h4>In this cohort study, risk of suicide during the 6 months after psychiatric hospitalization was decreased among youth who had an outpatient mental health visit within 7 days after discharge. Addressing disparities in timely continuity of care may help advance health equity agendas.