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Yin Y, Workman TE, Blosnich JR, Brandt CA, Skanderson M, Shao Y, Goulet JL, Zeng-Treitler Q. Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis. Int J Public Health 2024; 69:1606855. [PMID: 38770181 PMCID: PMC11103011 DOI: 10.3389/ijph.2024.1606855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.
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Affiliation(s)
- Ying Yin
- Washington DC VA Medical Center, United States Department of Veterans Affairs, Washington, DC, United States
- Biomedical Informatics Center, The George Washington University, Washington, DC, United States
| | - T. Elizabeth Workman
- Washington DC VA Medical Center, United States Department of Veterans Affairs, Washington, DC, United States
- Biomedical Informatics Center, The George Washington University, Washington, DC, United States
| | - John R. Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Pittsburgh, PA, United States
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, West Haven, CT, United States
| | - Melissa Skanderson
- VA Connecticut Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, West Haven, CT, United States
| | - Yijun Shao
- Washington DC VA Medical Center, United States Department of Veterans Affairs, Washington, DC, United States
- Biomedical Informatics Center, The George Washington University, Washington, DC, United States
| | - Joseph L. Goulet
- Pain, Research, Informatics, Multi-Morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Qing Zeng-Treitler
- Washington DC VA Medical Center, United States Department of Veterans Affairs, Washington, DC, United States
- Biomedical Informatics Center, The George Washington University, Washington, DC, United States
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Lynch KE, Livingston NA, Gatsby E, Shipherd JC, DuVall SL, Williams EC. Alcohol-attributable deaths and years of potential life lost due to alcohol among veterans: Overall and between persons with minoritized and non-minoritized sexual orientations. Drug Alcohol Depend 2022; 237:109534. [PMID: 35717789 DOI: 10.1016/j.drugalcdep.2022.109534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unhealthy alcohol use is disproportionally experienced by individuals with minoritized sexual orientations. Unlike the general US population, for whom the burden of alcohol as it relates to mortality is consistently monitored across time with national survey data, the impact of unhealthy alcohol use among veterans with minoritized sexual orientations, for whom addressing substance use is a national priority, is largely unknown. METHODS Using Alcohol Use Disorders Identification Test Consumption data from the Department of Veterans Affairs electronic health record and underlying cause of death from National Death Index from 2014 to 2018 we quantified alcohol consumption and related mortality among veterans with (n = 102,085) and without minoritized sexual orientations (n = 5300,521). Age adjusted rates of alcohol attributed deaths (AAD) per 100,000 persons and years of potential life lost (YPLL) were estimated by sexual orientation, sex, and sexual orientation stratified by sex. RESULTS Alcohol attributable deaths (n = 21,861) were higher among veterans with minoritized sexual orientations than veterans without after adjustment for age (486.5 deaths/100,000 versus 309.7 deaths/100,000, respectively). Veterans with minoritized sexual orientations also experienced more YPLL (13,772.8 years/100,000 versus 7618.9 years/100,000). Years of potential life lost per AAD was higher in women (33.2 years) than men (18.7 years). CONCLUSIONS Alcohol consumption results in substantial disability and death among veterans, particularly veterans with minoritized sexual orientations. Findings suggest need for increased alcohol-related services for all VA patients, and potential targeted approaches to for veterans with minoritized sexual orientations and women to offset risk for, and years of potential life lost from, alcohol attributable death.
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Affiliation(s)
- Kristine E Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, USA.
| | - Nicholas A Livingston
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130, USA; Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118, USA
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - Jillian C Shipherd
- Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118, USA; Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130, USA; LGBTQ+ Health Program, Veterans Health Administration, 810 Vermont Avenue NW, Washington, DC 20420, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, 3980 15th Avenue NW, Seattle, WA 98195, USA; Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound 1660 S Columbian Way, Seattle, WA 98108, USA
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Bragazzi NL, Khamisy-Farah R, Converti M. Ensuring equitable, inclusive and meaningful gender identity- and sexual orientation-related data collection in the healthcare sector: insights from a critical, pragmatic systematic review of the literature. Int Rev Psychiatry 2022; 34:282-291. [PMID: 36151822 DOI: 10.1080/09540261.2022.2076583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In several countries, no gender identity- and sexual orientation-related data is routinely collected, if not for specific health or administrative/social purposes. Implementing and ensuring equitable and inclusive socio-demographic data collection is of paramount importance, given that the LGBTI community suffers from a disproportionate burden in terms of both communicable and non-communicable diseases. To the best of the authors' knowledge, there exists no systematic review addressing the methods that can be implemented in capturing gender identity- and sexual orientation-related data in the healthcare sector. A systematic literature review was conducted for filling in this gap of knowledge. Twenty-three articles were retained and analysed: two focussed on self-reported data, two on structured/semi-structured data, seven on text-mining, natural language processing, and other emerging artificial intelligence-based techniques, two on challenges in capturing sexual and gender-diverse populations, eight on the willingness to disclose gender identity and sexual orientation, and, finally, two on integrating structured and unstructured data. Our systematic literature review found that, despite the importance of collecting gender identity- and sexual orientation-related data and its increasing societal acceptance from the LGBTI community, several issues have to be addressed yet. Transgender, non-binary identities, and also intersex individuals remain often invisible and marginalized. In the last decades, there has been an increasing adoption of structured data. However, exploiting unstructured data seems to overperform in identifying LGBTI members, especially integrating structured and unstructured data. Self-declared/self-perceived/self-disclosed definitions, while being respectful of one's perception, may not completely be aligned with sexual behaviours and activities. Incorporating different levels of information (biological, socio-demographic, behavioural, and clinical) would enable overcoming this pitfall. A shift from a rigid/static nomenclature towards a more nuanced, dynamic, 'fuzzy' concept of a 'computable phenotype' has been proposed in the literature to capture the complexity of sexual identities and trajectories. On the other hand, excessive fragmentation has to be avoided considering that: (i) a full list of options including all gender identities and sexual orientations will never be available; (ii) these options should be easily understood by the general population, and (iii) these options should be consistent in such a way that can be compared among various studies and surveys. Only in this way, data collection can be clinically meaningful: that is to say, to impact clinical outcomes at the individual and population level, and to promote further research in the field.
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Affiliation(s)
- Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, Canada
| | - Rola Khamisy-Farah
- Clalit Health Services, Akko, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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Lynch KE, Shipherd JC, Gatsby E, Viernes B, DuVall SL, Blosnich JR. Sexual orientation-related disparities in health conditions that elevate COVID-19 severity. Ann Epidemiol 2021; 66:5-12. [PMID: 34785397 PMCID: PMC8601164 DOI: 10.1016/j.annepidem.2021.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 01/19/2023]
Abstract
Purpose The Veterans Health Administration (VA) is the largest single integrated healthcare system in the US and is likely the largest healthcare provider for people with minoritized sexual orientations (e.g., gay, lesbian, bisexual). The purpose of this study was to use electronic health record (EHR) data to replicate self-reported survey findings from the general US population and assess whether sexual orientation is associated with diagnosed physical health conditions that may elevate risk of COVID-19 severity among veterans who utilize the VA. Methods A retrospective analysis of VA EHR data from January 10, 1999–January 07, 2019 analyzed in 2021. Veterans with minoritized sexual orientations were included if they had documentation of a minoritized sexual orientation within clinical notes identified via natural language processing. Veterans without minoritized sexual orientation documentation comprised the comparison group. Adjusted prevalence and prevalence ratios (aPR) were calculated overall and by race/ethnicity while accounting for differences in distributions of sex assigned at birth, age, calendar year of first VA visit, volumes of healthcare utilization, and VA priority group. Results Data from 108,401 veterans with minoritized sexual orientation and 6,511,698 controls were analyzed. After adjustment, veterans with minoritized sexual orientations had a statistically significant elevated prevalence of 10 of the 11 conditions. Amongst the highest disparities observed were COPD (aPR:1.24 [95% confidence interval:1.23–1.26]), asthma (1.22 [1.20–1.24]), and stroke (1.26 [1.24–1.28]). Conclusions Findings largely corroborated patterns among the general US population. Further research is needed to determine if these disparities translate to poorer COVID-19 outcomes for individuals with minoritized sexual orientation.
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Affiliation(s)
- Kristine E Lynch
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City, UT, USA.
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Program, Veterans Health Administration, Washington, DC, USA; National Center for PTSD, Women's Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Benjamin Viernes
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City, UT, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City, UT, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Lynch KE, Viernes B, Schliep KC, Gatsby E, Alba PR, DuVall SL, Blosnich JR. Variation in Sexual Orientation Documentation in a National Electronic Health Record System. LGBT Health 2021; 8:201-208. [PMID: 33625876 DOI: 10.1089/lgbt.2020.0333] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose: The purpose of this study was to determine variation in sexual minority (SM) sexual orientation documentation within the electronic medical records of the Veterans Health Administration (VHA). Methods: Documentation of SM sexual orientation was retrospectively extracted from clinical notes and administrative data in the VHA from October 1, 1999 to July 1, 2019. The rate of documentation overall and by calendar year was calculated, and differences across patient, provider, and clinic characteristics were evaluated. Results: Approximately 1.4% of all VHA Veterans (n = 115,911) had at least one documentation of SM sexual orientation, including 79,455 men and 36,456 women. The rate of documentation increased from 81.01/100,000 in 2000 to 568.84/100,000 in 2018. The majority of documentations (58.7%) occurred in mental health settings by non-MD mental health/social work counselors, whereas only 9.6% occurred in primary care settings. Although 99% of these Veterans had a primary care visit, only 19% had SM status recorded in that setting. Conclusion: Documentation patterns of SM sexual orientation varied considerably in the VHA with notable gaps in primary care. Diverse approaches to culturally competent training for primary care clinicians and patient-facing collection strategies could facilitate documentation of sexual orientation.
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Affiliation(s)
- Kristine E Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Benjamin Viernes
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Karen C Schliep
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Patrick R Alba
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Lynch KE, Gatsby E, Viernes B, Schliep KC, Whitcomb BW, Alba PR, DuVall SL, Blosnich JR. Evaluation of Suicide Mortality Among Sexual Minority US Veterans From 2000 to 2017. JAMA Netw Open 2020; 3:e2031357. [PMID: 33369662 PMCID: PMC7770555 DOI: 10.1001/jamanetworkopen.2020.31357] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Identification of subgroups at greatest risk for suicide mortality is essential for prevention efforts and targeting interventions. Sexual minority individuals may have an increased risk for suicide compared with heterosexual individuals, but a lack of sufficiently powered studies with rigorous methods for determining sexual orientation has limited the knowledge on this potential health disparity. OBJECTIVE To investigate suicide mortality among sexual minority veterans using Veterans Health Administration (VHA) electronic health record data. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study used data on 8.1 million US veterans enrolled in the VHA after fiscal year 1999 that were obtained from VHA electronic health records from October 1, 1999 to September 30, 2017. Data analysis was carried out from March 1, 2020 to October 31, 2020. EXPOSURE Veterans with documentation of a minority sexual orientation. Documentation of sexual minority status was obtained through natural language processing of clinical notes and extraction of structured administrative data for sexual orientation in VHA electronic health records. MAIN OUTCOMES AND MEASURES Suicide mortality rate using data on the underlying cause of death obtained from the National Death Index. Crude and age-adjusted mortality rates were calculated for all-cause death and death from suicide among sexual minority veterans compared with the general US population and the general population of veterans. RESULTS Among the 96 893 veterans with at least 1 sexual minority documentation in the electronic health record, the mean (SD) age was 46 (16) years, 68% were male, and 70% were White. Of the 12 591 total deaths, 3.5% were from suicide. Veterans had a significantly higher rate of mortality from suicide (standardized mortality ratio, 4.50; 95% CI, 4.13-4.99) compared with the general US population. Suicide was the fifth leading cause of death in 2017 among sexual minority veterans (3.8% of deaths) and the tenth leading cause of death in the general US population (1.7% of deaths). The crude suicide rate among sexual minority veterans (82.5 per 100 000 person-years) was higher than the rate in the general veteran population (37.7 per 100 000 person-years). CONCLUSIONS AND RELEVANCE The results of this population-based cohort study suggest that sexual minority veterans have a greater risk for suicide than the general US population and the general veteran population. Further research is needed to determine whether and how suicide prevention efforts reach sexual minority veterans.
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Affiliation(s)
- Kristine E. Lynch
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Elise Gatsby
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Benjamin Viernes
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Karen C. Schliep
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Family and Preventive Medicine, The University of Utah, Salt Lake City
| | - Brian W. Whitcomb
- Department of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Patrick R. Alba
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Scott L. DuVall
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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