Suicide Risk Among Hospitalized Versus Discharged Deliberate Self-Harm Patients: Generalized Random Forest Analysis Using a Large Claims Data Set.
Suicide Risk Among Hospitalized Versus Discharged Deliberate Self-Harm Patients: Generalized Random Forest Analysis Using a Large Claims Data Set.
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DOI：
10.1016/j.amepre.2021.08.028
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发表时间：
2022-04
影响因子：
5.5
通讯作者：
Schoenbaum M
中科院分区：
文献类型：
--
作者：
Goldman-Mellor SJ;Bhat HS;Allen MH;Schoenbaum M
在急诊科（ED）中，因故意自残的病人自杀率极高。通常建议这些患者住院治疗，但关于住院治疗预防自杀效果的证据很少。指示的混淆和实施随机设计的挑战是这一领域进步的障碍。我们使用了2009-2012年加州57,312名自残ED患者的数据，这些数据与死亡率记录有关。我们估计住院和出院患者的12个月和30天自杀风险naïve。然后，我们应用广义随机森林（GRF）方法估计住院治疗对自杀的平均治疗效果，对可观察到的协变量进行调节。对性别和年龄特异性亚组分别计算相关性。分析于2019年2月至2021年8月进行。在naïve分析中，每个亚组中住院患者的自杀风险明显高于出院患者。在通过GRF方法计算观察到的共变量的12个月模型中，与相应的出院患者相比，住院男性每1000名患者的自杀率高出5.4 (95% CI: 3.0, 7.8)， 10-29岁住院患者每1000名患者的自杀率高出2.4(1.1,3.6)，≥50岁的患者每1000名患者的自杀率高出5.8（0.5,11.2）。在GRF分析中，住院治疗与女性和30-49岁患者的自杀没有显著相关。30天GRF模型的模式相似。急诊科人员倾向于将自残的高自杀风险患者送入医院；我们的研究表明，这一目标已基本实现。通过可观察协变量控制混杂的分析没有发现住院治疗降低自杀风险的明确证据，也不能排除医源性影响的可能性。
Suicide rates are extremely high among emergency department (ED) patients seen for deliberate self-harm. Inpatient hospitalization is often recommended for these patients, but evidence on the suicide-prevention effects of hospitalization is scarce. Confounding by indication and challenges to implementing randomized designs are barriers to advances in this field. We used 2009–2012 statewide data on 57,312 self-harm ED patients from California, linked to mortality records. We estimated naïve 12-month and 30-day suicide risks among patients who were hospitalized vs. discharged. We then applied generalized random forest (GRF) methods to estimate the average treatment effect of hospitalization on suicide, conditioning on observable covariates. Associations were calculated separately for gender- and age-specific subgroups. Analyses were conducted February 2019-August 2021. In naïve analyses, suicide risk was significantly higher in hospitalized vs. discharged patients in each subgroup. In 12-month models accounting for observed covariates via GRF methods, hospitalized males had 5.4 more suicides per 1,000 patients (95% CI: 3.0, 7.8), hospitalized patients aged 10–29 had 2.4 (1.1, 3.6) more suicides per 1,000, and those aged ≥50 had 5.8 (0.5,11.2) more suicides per 1,000, compared to corresponding discharged patients. Hospitalization was not significantly associated with suicide among females nor among patients aged 30–49 in GRF analyses. Patterns were similar in 30-day GRF models. ED personnel intend to hospitalize the self-harm patients with high suicide risk; our study suggests this goal is largely realized. Analyses that control for confounding by observable covariates did not find clear evidence that hospitalization reduces suicide risk, and could not rule out the possibility of iatrogenic effects.
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