Variation in patterns of health care before suicide: A population case-control study

Abstract Background The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. Objective To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. Design Case-Control Study. Setting Eight healthcare systems across the United States. Participants 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. Measurements Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. Results Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. Limitations Participant race/ethnicity was not available. The sample did not include uninsured individuals. Conclusions This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.