1054 — Suicide Mortality among VHA Patients: Assessing Associations with Rurality and Distance to VA Providers
McCarthy JF (VA National Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC)), Valenstein M
(SMITREC), Ilgen MA
(SMITREC), Ignacio R
(SMITREC), Blow FC
Understanding suicide risks among health system patients can inform suicide prevention and policy decisions. This study evaluates whether suicide risks differ in association with rurality of patient residence and health system geographic accessibility. We hypothesized that suicide risks are greater among patients in rural settings and among those living farther from VA providers. Also, we hypothesized that firearms are used more often as a method for suicide in rural areas.
Using VA inpatient and outpatient encounter records, we identified all VHA patients in fiscal years (FYs) 2001 or 2002 who were alive at the start of FY2002 (N = 5,043,060). Vital status and cause of death were assessed from VHA population-based National Death Index searches. Cox proportional hazards regression was used to assess suicide risk through the end of FY2007. Covariates, assessed at baseline, included age, sex, VISN, and psychiatric diagnoses. Rurality of residence was categorized according to definitions used by the VA Office of Rural Health. Health system geographic accessibility was assessed as miles to the nearest VA outpatient provider. Method of suicide was categorized as death by firearms, poisoning, or other causes.
32.8% of patients resided in rural areas and 1.5% in highly rural areas. 29.1% resided > 15 miles from VA providers. 9518 suicide deaths were identified, and the overall suicide rate was 35.5/100,000. Controlling for distance and other measures, suicide rates were 23% greater in rural areas (39.9/100,000) and 34% greater in highly rural areas (43.5/100,000) as compared to urban areas (32.4/100,000). In urban and highly rural areas, distance was associated with increased suicide risks. Among suicide decedents, suicide by firearms was more common in rural (76.6%) than in urban areas (61.0%).
Among VHA patients, suicide risks were greater in rural and highly rural areas, as compared to urban areas; geographic accessibility may also have distinct effects on risks; and method of suicide differed across settings.
VA may need to enhance access to mobile crisis teams and develop and extend telephone-based and tele-health services in rural areas. Future studies should assess social and cultural factors that may influence suicide mortality.