Veteran Interactions with VA Primary Care Prior to Suicide

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Anticipated Impacts on Veterans' Healthcare: Study results have the potential to 1) identify gaps and barriers within the primary care setting in the identification and treatment of veterans at high risk for suicide completion, 2) identify specific characteristics of patients seen in VA primary care that are associated with high risk of suicide completion, 3) identify patient, provider and system characteristics that are associated with receipt of care related to suicide prevention, and 4) shape healthcare and suicide prevention efforts to the unique needs of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Project Background: Prior research suggests that veterans are twice as likely to die by suicide compared to non-veteran civilians, and each year, as many as 6,500 veterans take their own lives. Many patients visit healthcare clinicians prior to suicide. Primary care clinicians may be in a unique position to intervene with these patients. Unfortunately, little is known about the characteristics of patients who make contact with primary care clinicians prior to suicide, as well as the content of these patient-clinician interactions. It is thus unclear what opportunities may exist within primary care for intervening with individuals at highest risk for suicide. Project Objectives: The goal of this project is to inform VA suicide prevention strategies by describing and evaluating the VA primary care received by veteran suicide decedents in the year prior to death. Specifically, we will 1) describe characteristics of, and healthcare received by suicide decedents in VA primary care settings in the year prior to death, and compare this healthcare to healthcare received by a matched sample of veterans who did not complete suicide; 2) evaluate content of last interactions of veteran suicide decedents with VA primary care teams; and 3) describe characteristics of, and VA primary care received by OEF/OIF veteran suicide decedents and compare these characteristics and care to those of other veteran patient groups. Project Methods: This is a retrospective descriptive and case-control study. We will link National Violent Death Reporting System Data (NVDRS) from 10 States with the VA Decision Support System (DSS) to identify veterans who completed suicide from 2005 to 2009 and who received VA healthcare in the 12 months prior to death. NVDRS data include demographic information (including patient identifiers), means of death, and other variables. DSS will provide additional demographic, clinical (general medical and psychiatric diagnoses), and healthcare utilization (types and numbers of visits, medications) data. The OEF/OIF Roster will be used to identify OEF/OIF status and will provide military history information for the subgroup of OEF/OIF veterans. We will conduct medical record review using VA VistAWeb to access individual medical records (including progress notes) from all VA sites within participating states, and gather information on the content of healthcare visits. Medical record review variables include whether clinicians screened or assessed for depression, substance use disorder, post-traumatic stress disorder, suicidal ideation, predisposing and protective factors for suicide, reasons for last contacts, and presence of emotional distress at last contacts. Analyses will be stratified by sex. We will summarize demographic and clinical characteristics, variables describing primary care team assessments, and clinical actions taken for veterans who completed suicide. We will compare characteristics of, and healthcare received by, suicide decedents to those of a 1:1 control sample of age, sex, and primary care provider-matched veterans who did not complete suicide. Robust estimates of the standard errors will be used to adjust for clustering within states. Regression models will be adjusted for covariates identified in preliminary analyses. We will also compare characteristics of and healthcare received by OEF/OIF veterans to 1:2 matched control samples of 1) other veterans who completed suicide, and 2) OEF/OIF veterans who did not complete suicide.