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Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study
  1. Peter J Kaboli1,2,
  2. Matthew R Augustine3,4,
  3. Bjarni Haraldsson1,
  4. Nicholas M Mohr1,5,
  5. M Bryant Howren1,6,
  6. Michael P Jones1,7,
  7. Ranak Trivedi8,9
  1. 1 Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA, USA
  2. 2 Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
  3. 3 James J Peters VA Medical Center, Department of Medicine, Bronx, NY, USA
  4. 4 Icahn School of Medicine at Mount Sinai, Department of Medicine, New York, NY, USA
  5. 5 Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
  6. 6 Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
  7. 7 Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
  8. 8 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
  9. 9 Division of Public Mental Health and Population Sciences, Deptartment of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
  1. Correspondence to Dr Peter J Kaboli, Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa, IA 52242, USA; peter.kaboli{at}


Background Veteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA).

Objective To examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors.

Methods Retrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011–2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%–90%, 90.1%–95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution.

Results From 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100 000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%–82.2%) to 65.4% (IQR 53.9%–79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%–90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%–95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time.

Conclusions High VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution.

  • mental health
  • hospital medicine
  • health policy
  • report cards

Data availability statement

No data are available. All data are subject to the rules of availability assigned by the US Department of Veterans Affairs.

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Data availability statement

No data are available. All data are subject to the rules of availability assigned by the US Department of Veterans Affairs.

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  • Contributors All authors contributed to the planning, conduct and reporting of the work presented. PJK is responsible for the overall content as guarantor. Planning: PJK, MBH, RT. Conduct: PJK, NMM, MRA, BH, MPJ. Reporting: PJK, MRA, BH, NMM, MBH, MBJ, RT.

  • Funding This material is based on work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, VA Office of Rural Health and the Office of Research and Development, and Health Services Research and Development (HSR&D) Service through the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center (CIN 13-412).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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