Lead/Presenter: Steven Zeliadt,
COIN - Seattle/Denver
All Authors: Zeliadt SB (Seattle/Denver COIN, Department of Health Systems and Population Health, University of Washington, Seattle, WA), Fu V (VA HSR&D COIN for Veteran Centered and Value-Driven Care, Seattle, WA) DeFaccio R (VA HSR&D COIN for Veteran Centered and Value-Driven Care, Seattle, WA) Chen C (VA HSR&D COIN for Veteran Centered and Value-Driven Care, Seattle, WA) Reed D (VA HSR&D COIN for Veteran Centered and Value-Driven Care, Seattle, WA) Carey E (Seattle/Denver COIN, Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO) Hee Wai T (University of Washington School of Public Health, Seattle, WA) Coggeshall S (VA HSR&D COIN for Veteran Centered and Value-Driven Care, Seattle, WA) Etingen B (Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines IL) Bolton RE (Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA) Mohr D (VA Boston Healthcare System, Boston University School of Public Health) Bokhour BG (VA Bedford Healthcare System, University of Massachusetts Medical School)
VHA is implementing Whole Health (WH), a cutting-edge approach to care centered around the health team getting to know each Veteran as a person, collaboratively developing a personalized health plan with them based on each Veteranâ€™s values, needs, and goals, and connecting Veterans to activities and interventions which promote self-care and skill-building. Our objective was to partner with Office of Patient-Centered Care and Cultural Transformation to understand the role of WH in helping VA reduce adverse overdose and suicide events.
The study was conducted at 18 national WH Flagship Program sites between FY18-21. Veterans entered the study based on observed VA primary care or other outpatient utilization and were followed until the end of FY21, 12 months after their last observed outpatient encounter, or death. We assessed whether Veterans used WH each quarter across the four-year period, defined as ?2 connected encounters of any core Whole Health activity, including Taking Charge of My Life and Health, Pathway, Whole Health Coaching, and other WH-aligned classes. Person-years was the unit of analysis. Veterans contributed exposure time to WH for two quarters after WH utilization was identified; those who did not continue to use WH services were reassigned back to the conventional care group. Adverse events during follow-up periods were obtained from VHAâ€™s national Suicide Behavior and Overdose Report. Incidence rate ratios were calculated comparing event rates associated with WH utilization to conventional care utilization.
We identified 103,896 patients who utilized WH services (with 74,099 person-years of follow-up time) and a comparison cohort of 1,297,170 conventional care patients who used standard VHA care over the same time-period (with 3,467,127 person-years of follow-up time). Among WH users, 96% contributed exposure time to both WH and conventional care groups. WH users had higher rates of many complex mental health and other comorbidities compared to conventional care users, including: depression (37.6% vs 18.0%), opioid use (14.9% vs 6.9%), and obesity (33.8% vs 13.2%). Rates of non-fatal suicide events over the 4-year period were considerably higher among WH users compared to conventional care users (2.52 vs 0.57 per 100 person years; Incidence rate ratio (IRR) = 4.45; 95% CI: 4.25-4.67), and rates of non-fatal overdose events were higher among WH users (0.89 vs 0.19 per 100 person years; IRR = 4.74; 95%CI: 4.38-5.14). Efforts to match WH users to conventional care users are ongoing and will provide a counterfactual comparison population within which to assess the treatment effect associated with WH, as well as methodologic tools for evaluating other suicide prevention efforts across VHA.
WH appears to have an important role in VHAâ€™s efforts to reduce suicide among Veterans, as early WH implementation highlights that Veterans with elevated suicide risk are engaging in WH services. This is critical as VHA is working to engage Veterans with complex mental health conditions in services, especially during the COVID-19 pandemic.
Understanding how WH engagement can help Veterans at risk for adverse suicide and overdose events is a critical priority for expansion of Whole Health.