Suicide among veterans in 16 states, 2005 to 2008: comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on data from the National Death Index, the National Violent Death Reporting System, and VHA administrative records

Harnessing national data systems to understand circumstances surrounding veteran suicide: linking Department of Veterans Affairs and National Violent Death Reporting System Data

BACKGROUND

Veterans are at elevated risk for suicide compared to non-Veteran U.S. adults. Data sources and analyses to inform prevention efforts, especially for those who do not use Department of Veterans Affairs (VA) healthcare services, are needed. This study aimed to link VA and CDC's National Violent Death Reporting System (NVDRS) data to create a novel data source to characterize the circumstances precipitating and preceding suicide among Veterans, including among those who did not use VA healthcare.

METHODS

Multi-variable, multi-stage, deterministic linkage of VA-Department of Defense (DoD) Mortality Data Repository (MDR) and NVDRS-Restricted Access Database suicide and undetermined intent mortality records within 189 state-year strata (42 states, 2012-2018). Three linkage stages: (1) exact (matched on: age, sex, death date, underlying cause of death, day of month of birth, first initial of last name); (2) probable (all but one variable matched); (3) possible (all but 2 variables matched). Linkage success and accuracy of NVDRS-documented military history were assessed.

RESULTS

Across all state-years, 22,019 matches (89.20% of 24,685 MDR Veteran records) were identified (65.47% exact). When high missingness (2 + matching variables in > 10% of records; n = 23) or incomplete reporting (n = 12) state-years were excluded, match rate increased to 94.29% (77.15% exact). NVDRS-documented military history (ever served) was accurate for 87.79% of matched records, with an overall sensitivity of 84.62%. Sensitivity was lower for female (61.01%) and younger (17-39 years; 77.51%) Veterans.

CONCLUSIONS

Accurate linkage of VA-DoD and NVDRS data is feasible and offers potential to improve understanding of circumstances surrounding suicide among Veterans.

Rates and Correlates of Suicidality in VA Intensive Case Management Programs

There has been extensive concern about suicide among veterans, but no study has examined rates and correlates of suicidality in the highly vulnerable group of veterans receiving Veterans Health Administration (VHA) intensive case management services. Veterans participating in a national program evaluation were surveyed at the time of program entry and 6 months later. Sociodemographic and clinical characteristics were documented along with elements of program service delivery. Chi square tests were used to compare rates of suicidality (defined as either having made or threatened an attempt) at baseline and at the 6-month follow-up. Analysis of variance was also used to compare suicidal and non-suicidal veterans at follow-up. Logistic regression analysis was then used to identify independent correlates of suicidality 6 months after program entry. Among the 9921 veterans who later completed follow-up assessments 989 (10.0%) had reported suicidal behavior at program entry as compared to only 250 (2.51%) at 6 months (p < 0.0001). Multivariable logistic regression analysis showed suicidality at 6 months to be associated with suicidality at admission, increased subjective distress on the Brief Symptom Inventory (especially on depression items), violent behavior and decreased quality of life since admission, along with a greater likelihood of receiving crisis intervention, but not other services. Among veterans receiving intensive case management services from VHA, suicidal behavior declined by 75% from admission to 6 months (10-2.5%) and was associated with suicidality prior to program entry, worsening subjective symptoms and greater receipt of crisis intervention services.

Mortality after electroconvulsive therapy

BACKGROUND

There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths.

AIMS

We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year.

METHOD

We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching.

RESULTS

Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths.

CONCLUSIONS

There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.

Factors Associated With Access to and Receipt of Liver Transplantation in Veterans With End-stage Liver Disease

IMPORTANCE

Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy.

OBJECTIVE

To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021.

EXPOSURES

Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated.

MAIN OUTCOMES AND MEASURES

Referral, wait-listing, and liver transplantation.

RESULTS

Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral.

CONCLUSIONS AND RELEVANCE

In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.

Veterans Undergoing Total Hip and Knee Arthroplasty: 30-day Outcomes as Compared to the General Population

INTRODUCTION

The Veterans Affairs (VA) health system is vital to providing joint replacement care to our retired service members but has come under recent scrutiny. The purpose of this study was to compare the short-term outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) between the VA cohort and the general cohort.

METHODS

We retrospectively reviewed 10.460 patients with primary THA and TKA from the Veterans Affairs Corporate Data Warehouse. As a control group, we queried the American College of Surgeons-National Surgical Quality Improvement Program database and identified 58,820 patients with primary THA and TKA over the same time period. We compared length of stay, mortality rates, 30-day complication rates, and 30-day readmissions. We performed a multivariate logistic regression analysis to identify the independent effect of the VA system on adverse outcomes.

RESULTS

Veterans are more likely to be men (93% versus 41%, P < 0.001) and have increased rates of medical comorbidities (all P < 0.001). The rate of short-term complications (all P < 0.001) were all higher in the VA cohort. When controlling for demographics and medical comorbidities, VA patients were more likely to have a readmission (P < 0.001), prolonged length of stay > 4 days (P < 0.001), and experience a complication within 30 days (P < 0.001).

DISCUSSION

Despite controlling for higher rates of medical comorbidities, VA patients undergoing primary THA and TKA had poorer short-term outcomes than the civilian cohort. Additional research is needed to ensure our veteran cohort is appropriately optimized and address the discrepancy with the outcomes of the civilian.

Grade 1 Acute on Chronic Liver Failure Is a Predictor for Subsequent Grade 3 Failure

BACKGROUND AND AIMS

Acute on chronic liver failure (ACLF) results in extremely high short-term mortality in patients with underlying cirrhosis. The European Association for the Study of the Liver criteria grade ACLF severity from 1 (least severe) to 3 (most severe) based on organ failures (OFs) that develop after an acute decompensation (AD). However, the implications of surviving low-grade ACLF in terms of risk of subsequent high-grade ACLF are unclear.

APPROACH AND RESULTS

We conducted a retrospective cohort study of patients with compensated cirrhosis in the Veterans Health Administration database from January 2008 to June 2016. Propensity matching for grade 1 (G1) ACLF, followed by Cox regression, was used to model risk of subsequent grade 3 (G3) ACLF. Stratified analyses of different ADs and OFs were also performed. We identified 4,878 patients with well-matched propensity scores. G1 ACLF events conferred a significantly increased risk of subsequent G3 ACLF relative no previous G1 ACLF (hazard ratio, 8.69; P < 0.001). When stratified by AD, patients with ascites or hepatic encephalopathy were significantly more likely to develop G3 ACLF relative to those with gastrointestinal bleed or infection as an AD (P < 0.001). Risk of G3 ACLF also varied significantly by type of OF characterizing previous G1 ACLF, with liver, coagulation, and circulatory failure posing the highest increased risk.

CONCLUSIONS

Patients who recover from G1 ACLF have substantially increased risk of later developing G3 ACLF as compared to those who never have G1 ACLF. Moreover, reversible decompensations for G1 ACLF have a lower risk of G3 ACLF, and liver-intrinsic OFs confer a much higher risk of G3 ACLF. These findings have implications for prognosis, future surveillance, and triaging early transplant evaluation.

Reevaluating Suicide Mortality for Veterans With Data From the VA-DoD Mortality Data Repository, 2000-2010

OBJECTIVE

The Department of Veterans Affairs and Department of Defense Mortality Data Repository (MDR) compiles National Death Index records for all veterans and military service members. This study aimed to compare MDR findings with those from a preexisting data source.

METHODS

Veteran suicide rates estimated from death certificates were replicated with the MDR. Annual suicide rates were computed for veterans overall, by gender, and by Veterans Health Administration service utilization and compared with rates for adult nonveterans by using standardized mortality ratios (SMRs).

RESULTS

Suicide rates and SMRs differed between the data sources. The 2010 MDR-derived veteran suicide rate was 27.4 deaths per 100,000 veterans, compared with an earlier estimate of 35.9. Differences were greater for females. Divergence was attributed to improved accuracy identifying veteran suicide decedents in the MDR.

CONCLUSIONS

Conditions with low base rates can be major public health problems, and minor misclassification can substantially affect surveillance accuracy, prevention efforts, and the validity of study findings.

Risk prediction scores for acute on chronic liver failure development and mortality

BACKGROUND & AIMS

Acute on chronic liver failure (ACLF) causes high short-term mortality in patients with previously stable chronic liver disease. To date there are no models to predict which patients are likely to develop ACLF, and existing models to predict ACLF mortality are based on limited cohorts. We sought to create novel risk prediction scores using a large cohort of patients with cirrhosis.

METHODS

We performed a retrospective cohort study of 74 790 patients with incident cirrhosis in the Veterans Health Administration database using randomized 70% derivation/30% validation sets. ACLF events were identified per the European ACLF criteria. Multivariable logistic regression was used to derive prediction models for developing ACLF at 3, 6 and 12 months, and ACLF mortality at 28 and 90 days. Mortality models were compared to model for end-stage liver disease (MELD), MELD-sodium and the Chronic Liver Failure Consortium (CLIF-C) ACLF score.

RESULTS

Models for the developing ACLF had very good discrimination (concordance [C] statistics 0.83-0.87) at all timepoints. Models for ACLF mortality also had good discrimination at 28 and 90 days (C-statistics 0.79-0.82), and were superior to MELD, MELD-sodium and the CLIF-C ACLF score. The calibration of the novel models was excellent at all timepoints.

CONCLUSION

We have obtained highly-predictive models for developing ACLF, as well as for ACLF short-term mortality in a diverse United States cohort. These may be used to identify outpatients at significant risk of ACLF, which may prompt closer follow-up or early transplant referral, and facilitate decision making for patients with diagnosed ACLF, including escalation of care, expedited transplant evaluation or palliation.

Social Ties and Suicidal Ideation Among Veterans Referred to a Primary Care-Mental Health Integration Program

OBJECTIVE

This study examined associations between three indices of social ties (perceived social support, frequency of negative social exchanges, and degree of social integration) and suicidal ideation among veterans referred by their primary care provider for a behavioral health assessment.

METHODS

The sample included 15,277 veterans who completed a mental health and substance use assessment on referral to a Primary Care-Mental Health Integration (PCMHI) program. Data on sociodemographic factors, mental health and substance use conditions (e.g., depression, anxiety, and substance use), perceived general health, the three indices of social ties, and suicidal ideation were extracted from clinical interviews.

RESULTS

The mean±SD age of the sample was 51.3±15.9, most (89%) were men, and about half (48%) were white. Most met criteria for at least one mental health or substance use condition on PCMHI assessment, and 39% reported either low- or high-severity suicidal ideation, as measured by the Paykel Suicide Scale. Logistic regression analyses indicated that after adjustment for sociodemographic factors, perceived health, and comorbid mental health and substance use conditions, each of the three social tie indices was uniquely associated with higher odds of reporting suicidal ideation, compared with no ideation.

CONCLUSIONS

Findings underscore the value of assessing multiple indices of social ties when examining suicidal ideation among high-risk veterans in primary care experiencing behavioral health issues. Incorporating an assessment of the quality of patients' social interactions and level of social integration into routine PCMHI practice has the potential to enhance screening and intervention efforts aimed at reducing suicidal ideation.

Incidence and Mortality of Acute-on-Chronic Liver Failure Using Two Definitions in Patients with Compensated Cirrhosis

The term acute-on-chronic liver failure (ACLF) is intended to identify patients with chronic liver disease who develop rapid deterioration of liver function and high short-term mortality after an acute insult. The two prominent definitions (European Association for the Study of the Liver [EASL] and Asian Pacific Association for the Study of the Liver [APASL]) differ, and existing literature applies to narrow patient groups. We sought to compare ACLF incidence and mortality among a diverse cohort of patients with compensated cirrhosis, using both definitions. This was a retrospective cohort study of patients with incident compensated cirrhosis in the Veterans Health Administration from 2008 to 2016. First ACLF events were identified for each definition. Incidence rates were computed as events per 1,000 person-years, and mortality was calculated at 28 and 90 days. Among 80,383 patients with cirrhosis with 3.35 years median follow-up, 783 developed EASL and APASL ACLF, 4,296 developed EASL ACLF alone, and 574 developed APASL ACLF alone. The incidence rate of APASL ACLF was 5.7 per 1,000 person-years (95% confidence interval [CI]: 5.4-6.0), and the incidence rate of EASL ACLF was 20.1 (95% CI: 19.5-20.6). The 28-day and 90-day mortalities for APASL ACLF were 41.9% and 56.1%, respectively, and were 37.6% and 50.4% for EASL ACLF. The median bilirubin level at diagnosis of EASL-alone ACLF was 2.0 mg/dL (interquartile range: 1.1-4.0). Patients with hepatitis C or nonalcoholic fatty liver disease had among the lowest ACLF incidence rates but had the highest short-term mortality. Conclusion: There is significant discordance in ACLF events by EASL and APASL criteria. The majority of patients with EASL-alone ACLF have preserved liver function, suggesting the need for more liver-specific ACLF criteria.

Factors associated with suicide among adolescents and young adults not in mental health treatment at time of death

BACKGROUND

Suicide is the third-leading cause of death among Illinois residents aged 15 to 24 years. The Illinois Violent Death Reporting System (IVDRS) was developed to help prevent these deaths by providing timely, complete data. Understanding the circumstances surrounding suicide for those aged 15 to 24 years who are not receiving mental health treatment can help others: (1) recognize signs of potential crisis and (2) connect them to mental health treatment.

METHODS

The IVDRS data were collected from five Illinois counties-Cook, DuPage, Kane, McHenry, and Peoria-from 2005 to 2010. All cases with the manner suicide, aged 15 to 24 years, were extracted for analysis. Data were described using frequencies and percentages, and statistical differences between groups were determined using χ analysis.

RESULTS

There were a total of 386 suicides in those aged 15 to 24 years in IVDRS from 2005 to 2010. Most 15- to 19-year-olds (67%) and 20- to 24-year-olds (78%) were not receiving mental health treatment at the time of death. Among those not receiving mental health treatment, 22% and 13% of those aged 15 to 19 and 20 to 24 years, respectively, had disclosed their intent to commit suicide to another. One third were identified as being depressed or in a depressed mood (not necessarily a clinical diagnosis) in both age groups. One quarter in both age groups experienced a crisis (current, acute precipitating, or forthcoming event) within 2 weeks of their suicides.

CONCLUSIONS

The majority of adolescents and young adults were not in mental health treatment at the time death. Among those not in mental health treatment at the time of death, the 15- to 19-year-olds were more likely to share their suicidal intentions than the 20- to 24-year-olds.

LEVEL OF EVIDENCE

Epidemiological study, level IV.

Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans

The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.

Unmet Mental Healthcare Need and Suicidal Ideation Among U.S. Veterans

INTRODUCTION

Suicide prevention remains a national priority, especially among vulnerable populations. With increasing trends in suicide among Veterans, understanding the underlying factors associated with such an outcome is imperative. In this study, the association between unmet mental healthcare need and suicidal ideation among U.S. Veterans was evaluated.

METHODS

The National Survey on Drug Use and Health, 2008-2013, was used to identify those with mental illness, resulting in a total sample of 2,015 Veterans. Data were analyzed in July 2015. Survey-weighted descriptive and logistic regression analyses were conducted with p<0.05 used to establish significance.

RESULTS

Sixteen percent of Veterans reported unmet mental healthcare need and 18% had past-year suicidal ideation. After adjusting for confounders, unmet mental healthcare need was associated with increased likelihood of suicidal ideation (AOR=4.11) in the study population. Other characteristics, such as participating in a governmental assistance program and alcohol dependency in the past year, demonstrated 66% and 103% increased odds of suicidal ideation, respectively.

CONCLUSIONS

Unmet mental healthcare need is a critical aspect of suicidal ideation among Veterans. Improved access to care for such at-risk populations through means of integrated care is needed to ensure reduced burden of suicide among Veterans.

Military Sexual Trauma and Suicide Mortality

INTRODUCTION

The Veterans Health Administration health system uses a clinical reminder in the medical record to screen for military sexual trauma. For more than 6 million Veterans, this study assessed associations between military sexual trauma screen results and subsequent suicide mortality.

METHODS

For Veterans who received Veterans Health Administration services in fiscal years 2007-2011 and were screened for military sexual trauma (5,991,080 men; 360,774 women), proportional hazards regressions evaluated associations between military sexually trauma and suicide risk. Models were adjusted for age, rural residence, medical morbidity, and psychiatric conditions, obtained from medical records at the year military sexual trauma screening occurred. Analyses were conducted in 2014.

RESULTS

Military sexual trauma was reported by 1.1% of men and 21.2% of women. A total of 9,017 Veterans completed suicide during the follow-up period. Hazard ratios for military sexual trauma were 1.69 (95% CI=1.45, 1.97) among men and 2.27 (95% CI=1.76, 2.94) among women. Suicide risk associated with military sexual trauma remained significantly elevated in adjusted models.

CONCLUSIONS

Study results are among the first population-based investigations to document sexual trauma as a risk factor for suicide mortality. Military sexual trauma represents a clinical indicator for suicide prevention in the Veterans Health Administration. Results suggest the importance of continued assessments regarding military sexual trauma and suicide risks and of collaboration between military sexual trauma-related programs and suicide prevention efforts. Moreover, military sexual trauma should be considered in suicide prevention strategies even among individuals without documented psychiatric morbidity.

Treatment of veterans with mental health symptoms in VA primary care prior to suicide

OBJECTIVE

We describe Veterans Affairs (VA) primary care received by veterans with mental health symptoms in the year prior to suicide to identify opportunities to improve care.

METHOD

Death certificate data from 11 states were linked to VA national patient care data for veterans who died by suicide in 2009 and had received VA care. We identified 118 age-, sex- and clinician-matched case-control pairs (suicide decedents and living controls) with mental health symptoms. Using McNemar's chi-square and paired t tests, we compare primary care follow-up received during the year prior to death.

RESULTS

Cases and controls received similar primary care clinician follow-up and treatment for mental health symptoms. Cases were less likely than controls to fill 90 or more total days of an antidepressant during the year (P=.02), despite no differences in prescription orders from clinicians (P=.05). Cases and controls were equally likely to fill 90 or more consecutive days of an antidepressant (P=.47). Across both groups, 48% (n=113) received assessment for suicidal ideation in primary care.

CONCLUSION

We identified two areas to improve primary care for veterans at risk for suicide: monitoring antidepressant treatment adherence and improving suicidal ideation assessment and follow-up for veterans with mental health symptoms.

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs

OBJECTIVES

The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions.

METHODS

Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year.

RESULTS

Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%.

CONCLUSIONS

Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.

Rationale and study protocol for a two-part intervention: Safety planning and structured follow-up among veterans at risk for suicide and discharged from the emergency department

There are no evidence-based, brief interventions to reduce suicide risk in Veterans. Death by suicide is a major public health problem. This article describes a protocol, Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment [SAFE VET], developed for testing the effectiveness of a brief intervention combining a Safety Planning Intervention with structured follow-up (SPI-SFU) to reduce near-term suicide risk and increase outpatient behavioral health treatment engagement among Veterans seeking treatment at Veteran Affairs Medical Center (VAMC) emergency departments (EDs) who are at risk for suicide. In addition to describing study procedures, outcome measures, primary and secondary hypotheses, and human subjects' protection issues, the rationale for the selection of SPI-SFU as the intervention is detailed, as are safety considerations for the unique study setting and sample.

A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan

OBJECTIVES

We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain-the polytrauma clinical triad (PCT)-independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans.

METHODS

We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009-2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB.

RESULTS

Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI]=1.5, 2.4) or attempt and ideation (OR=2.6; 95% CI=1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR=2.3; 95% CI=2.0, 2.6; attempt: OR=2.0; 95% CI=1.4, 2.9; ideation and attempt: OR=1.8; 95% CI=1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR=4.2; 95% CI=3.6, 4.8) or substance abuse (OR=4.7; 95% CI = 3.9, 5.6).

CONCLUSIONS

Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases.

Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among US veterans

IMPORTANCE

Centralization of specialized health care services such as organ transplantation and bariatric surgery is advocated to improve quality, increase efficiency, and reduce cost. The effect of increased travel on access and outcomes from these services is not fully understood.

OBJECTIVE

To evaluate the association between distance from a Veterans Affairs (VA) transplant center (VATC) and access to being waitlisted for liver transplantation, actually having a liver transplant, and mortality.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of veterans meeting liver transplantation eligibility criteria from January 1, 2003, until December 31, 2010, using data from the Veterans Health Administration's integrated, national, electronic medical record linked to Organ Procurement and Transplantation Network data.

MAIN OUTCOMES AND MEASURES

The primary outcome was being waitlisted for transplantation at a VATC. Secondary outcomes included being waitlisted at any transplant center, undergoing a transplantation, and survival.

RESULTS

From 2003-2010, 50,637 veterans were classified as potentially eligible for transplant; 2895 (6%) were waitlisted and 1418 of those were waitlisted (49%) at 1 of the 5 VATCs. Of 3417 veterans receiving care at a VA hospital located within 100 miles from a VATC, 244 (7.1%) were waitlisted at a VATC and 372 (10.9%) at any transplant center (VATC and non-VATCs). Of 47,219 veterans receiving care at a VA hospital located more than 100 miles from a VATC, 1174 (2.5%) were waitlisted at a VATC and 2523 (5.3%) at any transplant center (VATC and non-VATCs). In multivariable models, increasing distance to closest VATC was associated with significantly lower odds of being waitlisted at a VATC (odds ratio [OR], 0.91 [95% CI, 0.89-0.93] for each doubling in distance) or any transplant center (OR, 0.94 [95% CI, 0.92-0.96] for each doubling in distance). For example, a veteran living 25 miles from a VATC would have a 7.4% (95% CI, 6.6%-8.1%) adjusted probability of being waitlisted, whereas a veteran 100 miles from a VATC would have a 6.2% (95% CI, 5.7%-6.6%) adjusted probability. In adjusted models, increasing distance from a VATC was associated with significantly lower transplantation rates (subhazard ratio, 0.97; 95% CI, 0.95-0.98 for each doubling in distance). There was significantly increased mortality among waitlisted veterans from the time of first hepatic decompensation event in multivariable survival models (hazard ratio, 1.03; 95% CI, 1.01-1.04 for each doubling in distance). For example, a waitlisted veteran living 25 miles from a VATC would have a 62.9% (95% CI, 59.1%-66.1%) 5-year adjusted probability of survival from first hepatic decompensation event compared with a 59.8% (95% CI, 56.3%-63.1%) 5-year adjusted probability of survival for a veteran living 100 miles from a VATC.

CONCLUSIONS AND RELEVANCE

Among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of being waitlisted, receiving a liver transplant, and greater likelihood of death. The relationship between these findings and centralizing specialized care deserves further investigation.

Associations between body mass index and suicide in the veterans affairs health system

OBJECTIVES

Associations between BMI and suicide risks and methods for individuals receiving care in the Veterans Health Administration (VHA) health system were evaluated.

DESIGN AND METHODS

For 4,005,640 patients in fiscal years 2001-2002, multivariable survival analyses assessed associations between BMI and suicide, through FY2009. Covariates included demographics, psychiatric, and nonpsychiatric diagnoses, receipt of VHA mental health encounters, and regional network. Among suicide decedents, multivariable Generalized Estimating Equations (GEE) regression examined associations between BMI and suicide method.

RESULTS

1.3% of patients were underweight, 24.3% normal weight, 40.6% overweight, and 33.8% obese. Underweight was associated with increased suicide risk (adjusted hazard ratio [AHR] = 1.17, 95% CI: 1.01, 1.36) compared to normal. Overweight and obese status were associated with lower risk (AHR = 0.78, 95% CI: 0.74, 0.82; AHR = 0.63, 95% CI: 0.60, 0.66, respectively). Among suicide decedents, high lethality methods were most common among underweight and least common among obese individuals. Adjusting for covariates, BMI was not associated with method lethality, yet some associations were observed between BMI and specific methods.

CONCLUSION

Among VHA patients, BMI was negatively associated with suicide risks. These differences may partly relate to choice of suicide method. Low BMI offers an additional resource for clinical suicide risk assessments.

The effects of misclassification biases on veteran suicide rate estimates

OBJECTIVES

We assessed the impact that possible veteran suicide misclassification biases (i.e., inaccuracy in ascertainment of veteran status on the death certificate and misclassification of suicide as other manner of death) have on veteran suicide rate estimates.

METHODS

We obtained suicide mortality data from the 2003-2010 National Violent Death Reporting System and the 2003-2010 Department of Defense Casualty Analysis System. We derived population estimates from the 2003-2010 American Community Survey and 2003-2010 Department of Veterans Affairs data. We computed veteran and nonveteran suicide rates.

RESULTS

The results showed that suicide rates were minimally affected by the adjustment for the misclassification of current military personnel suicides as veterans. Moreover, combining suicides and deaths by injury of undetermined intent did not alter the conclusions.

CONCLUSIONS

The National Violent Death Reporting System is a valid surveillance system for veteran suicide. However, more than half of younger (< 25 years) male and female suicides, labeled as veterans, were likely to have been current military personnel at the time of their death and misclassified on the death certificate.