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2023 HSR&D/QUERI National Conference Abstract

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1062 — Primary care patient perspectives on VA’s population-based suicide risk screening program (Risk ID): Mixed methods study

Lead/Presenter: Steven Dobscha,  COIN - Portland
All Authors: Dobscha SK (HSRD Center to Improve Veteran Involvement in Care, Portland, OR), Newell Summer B (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Elliott VJ (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Rynerson AL (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Gade PR (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Niederhausen M (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Salvi A (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Bahraini N (HSRD Center to Improve Veteran Involvement in Care, Portland, OR) Denneson LM (HSRD Center to Improve Veteran Involvement in Care, Portland, OR)

Objectives:
In recent years, organizations including the Veterans Health Administration (VHA) have implemented population-based (universal) suicide risk screening in ambulatory settings, including primary care. However, relatively little is known about patient perspectives on suicide risk screening programs. The main objective of this mixed-methods study was to characterize VHA primary care patient perspectives regarding VHA’s Suicide Risk Identification Strategy (Risk-ID) program, which was implemented in late 2018.

Methods:
Between February and October 2021, a national sample of 2,001 veterans who were screened in primary care were mailed surveys; sampling was stratified by initial screen (Columbia Suicide Severity Rating Scale Screener; C-SSRS) result and biological sex (as reported in the Corporate Data Warehouse). Initial mailings were sent within 2 weeks of screening, and up to three reminder mailings were sent to non-respondents at three-week intervals. Survey respondents were compensated $35 for their participation. Eight-hundred sixty-eight veterans (43%) returned surveys, and 30 survey respondents were purposively-identified (to optimize diversity across patient characteristics) and invited to participate in follow-up qualitative interviews. Quantitative data were weighted for non-response, sample stratification group, and timing of survey administration over the sampling period. An interdisciplinary qualitative analysis team applied a conventional-directed hybrid approach to conduct the thematic analysis.

Results:
Quantitative: Overall, the average age of respondents was 61 (SD = 16), and the majority were male (58%) and white (68%) and non-Hispanic (91%). Within the respondent group, Veterans with a positive C-SSRS were younger, more likely to be male, less likely to report as spiritual, more likely to report a VA service-connected disability, and more likely to have a prior-year diagnosed mental health condition, compared to Veterans with negative C-SSRS screens. Overall, 94% (weighted data) reported that it is appropriate for primary care providers to ask veterans about thoughts of suicide; 91% felt it was appropriate for nurses and medical assistants to ask about these thoughts as well. Fifty-three percent felt it is appropriate to ask about these thoughts at every doctor’s visit, while 35% felt that screening frequency should depend on the veteran’s symptoms; these attitudes were not significantly associated with C-SSRS result. Qualitative: Veterans who participated in interviews reported that they are “used to” being screened for suicide risk, but some reported that repeated screenings can take time away from other patient concerns, and sometimes felt redundant and impersonal. Veterans reported substantial variability in clinician communication—how much they “felt heard”, as well as with care planning and coordination after being screened. Some veterans who screened positive reported smooth and helpful transitions to working with mental health specialists, while others felt like they had not been offered sufficient treatment options.

Implications:
Most veterans treated in VA primary care feel that routine suicide risk screening is appropriate, and half feel that screening should be done at every doctor’s visit. Veterans’ experiences and attitudes vary more substantially following initial screening.

Impacts:
Additional staff education and/or systems changes are needed to support effective clinical responses following initial screening.