Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States of America.
Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States of America.
PLoS One. 2023 Apr 11;18(4):e0283633. doi: 10.1371/journal.pone.0283633. eCollection 2023.
United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas.
To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019.
VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation.
Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR).
12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9.
VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.
美国退伍军人的自杀风险高于非退伍军人。农村地区的退伍军人比城市地区的退伍军人风险更高。冠状病毒大流行加剧了自杀的风险因素，尤其是在农村地区。
研究退伍军人事务部（VA）的普遍自杀风险筛查（于 2020 年 11 月实施）与退伍军人接受筛查和后续评估的可能性之间的关联，以及在 2019 年使用 VA 心理健康服务的患者的筛查后自杀行为。
VA 的自杀风险识别策略（Risk ID）于 2018 年 10 月实施，是一个全国性的、标准化的自杀风险筛查和评估过程。2020 年 11 月，VA 扩大了 Risk ID，要求每年进行普遍的自杀筛查。因此，我们在 2019 年至少有 1 次 VA 心理健康护理就诊的退伍军人（n=1,654,180；农村 n=485,592，城市 n=1,168,588）中评估了政策开始前后感兴趣的结果。在普遍筛查前 6 个月和实施后 6、12 和 13 个月比较了经过回归调整的结果。
患者健康问卷（I-9，VA 的历史自杀筛查）、哥伦比亚自杀严重程度风险量表（C-SSRS）筛查、VA 综合自杀风险评估（CSRE）和自杀行为和过量报告（SBOR）上的第 9 项。
在普遍筛查实施 12 个月后，有 130 万名退伍军人（研究队列的 80%）接受了自杀风险筛查或评估，其中有 91%的亚队列在普遍筛查实施后 12 个月内至少接受过一次心理健康就诊。在研究队列中，至少有 20%的退伍军人在心理健康护理环境之外接受了筛查。在有阳性筛查结果的退伍军人中，有 80%接受了后续的 CSRE。调整协变量的模型表明，通过 C-SSRS 每月额外筛查了 89,160 名退伍军人，每月通过 C-SSRS 或 I-9 筛查了 30,106 名退伍军人。与城市退伍军人相比，每月有 7720 名农村退伍军人通过 C-SSRS 额外筛查，每月有 9226 名农村退伍军人通过 C-SSRS 或 I-9 额外筛查。
VA 通过 VA 的 Risk ID 计划实施的普遍筛查要求增加了有心理健康护理需求的退伍军人的自杀风险筛查。普遍的筛查方法对于农村退伍军人可能特别有利，他们的自杀风险通常更高，但由于获得护理的障碍较高，与医疗保健系统的互动，尤其是在专业护理环境中，较少。该计划提供的见解为全国的医疗系统提供了有价值的见解。
