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National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide
  1. Brian Shiner1,2,
  2. Daniel J Gottlieb3,
  3. Maxwell Levis1,2,
  4. Talya Peltzman3,
  5. Natalie B Riblet1,2,
  6. Sarah L Cornelius3,
  7. Carey J Russ1,2,
  8. Bradley V Watts2,4
  1. 1Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
  2. 2Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
  3. 3Research Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
  4. 4Office of Systems Redesign and Improvement, United States Department of Veterans Affairs, Washington, District of Columbia, USA
  1. Correspondence to Dr Brian Shiner, Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, VT 05009, USA; brian.shiner{at}va.gov

Abstract

Background Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system.

Methods We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates.

Results Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR.

Conclusion There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

  • mental health
  • quality measurement
  • qualitative research

Data availability statement

Data on United States Department of Veterans Affairs (VA) users were obtained from the VA corporate data warehouse (CDW), which requires VA approvals and credentials to access. Data on suicide among VA users were obtained from the VA-Deparmment of Defense Mortality Data Repository (MDR). Our data use agreements do not allow us to share CDW or MDR data. Deidentified suicide risk for the US general population, calculated using county-level estimates for the years 2013–2017, was obtained from the Centers for Disease Control and Prevention (CDC)'s Wide-Reaching online Data for Epidemiologic Research (WONDER) database, which is publicly available online (https://wonder.cdc.gov/). WONDER data are provided for the purpose of statistical reporting and analysis; the CDC prohibits the use of WONDER data for the purpose of identifying individuals.

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Data availability statement

Data on United States Department of Veterans Affairs (VA) users were obtained from the VA corporate data warehouse (CDW), which requires VA approvals and credentials to access. Data on suicide among VA users were obtained from the VA-Deparmment of Defense Mortality Data Repository (MDR). Our data use agreements do not allow us to share CDW or MDR data. Deidentified suicide risk for the US general population, calculated using county-level estimates for the years 2013–2017, was obtained from the Centers for Disease Control and Prevention (CDC)'s Wide-Reaching online Data for Epidemiologic Research (WONDER) database, which is publicly available online (https://wonder.cdc.gov/). WONDER data are provided for the purpose of statistical reporting and analysis; the CDC prohibits the use of WONDER data for the purpose of identifying individuals.

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Footnotes

  • Contributors All contributors meet the ICMJE-recommended criteria for to be listed as authors on this manuscript. Each author made substantial contributions to conception and design (BS, DG, ML, TP and BVW), acquisition of data (BS, DG and TP), or analysis and interpretation of data (BS, DG, ML, TP, NR, SLC, CJR and BVW). Each author was involved in drafting the manuscript (BS and ML) or revising it critically for important intellectual content (BS, DG, ML, TP, NR, SLC, CJR, BVW). All authors gave the final approval of the version to be published, participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was funded by the VA National Center of Patient Safety Center of Inquiry Program (PSCI-WRJ-SHINER) as well as the VA Office of Rural Health (ORH15533). The opinions expressed hereinare those of the authors and not necessarily those of the funders.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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