Veterans with Minimal Documentation of Rationale for High-Risk Flag Inactivation Are More Likely to Attempt Suicide

BACKGROUND:
High-risk flags for suicide in medical records indicate that Veterans are receiving enhanced care and alert treating providers to Veterans’ high-risk status. Recent research has shown that, following flag inactivation, the risk of suicide remains high, suggesting a need to improve inactivation protocols. In this study, researchers reviewed the medical records of a national sample of Veterans with a recent documented suicide attempt who received a high-risk flag for suicide (n=224) to categorize provider documentation of the rationale and procedures for high-risk flag inactivation, examine patient and facility characteristics associated with flag inactivation documentation type, and study the association between documentation type and subsequent suicide attempts. The mean age of participants was 44 years, with more women (n=132, 59%) than men. Most of the sample identified as White (n=145, 65%), while 55 (25%) identified as Black/African American. Flag inactivation documentation fell into one of two categories: documentation stating that the patient no longer met criteria for the high-risk flag (minimal documentation; n=98, 44%), and documentation that included a review of one or more criteria for high-risk flag inactivation (more than minimal documentation; n=126, 56%).

FINDINGS:

• Veterans with minimal documentation (vs. more than minimal) of high-risk flag inactivation were more likely to attempt suicide after flag inactivation (26% vs. 13%).
• The type of flag inactivation documentation was not associated with patient, provider, or facility characteristics.

IMPLICATIONS:

• Findings suggest a potential protective effect of high-risk flags among Veterans who have previously attempted suicide.
• There is a need to better understand current flag inactivation procedures and how flag inactivation determinations affect subsequent suicide risk, and to develop standardized procedures to reduce risk of premature high-risk flag inactivation.

LIMITATIONS:

• Medical record documentation likely does not fully capture clinical activity around flag inactivation.
• The data sources available to ascertain suicide attempts might not capture all suicide attempts and might not be completely accurate.

AUTHOR/FUNDING INFORMATION:
This study was supported by HSR&D (IIR 17-131). All authors are part of HSR&D’s Center to Improve Veteran Involvement in Care in Portland, OR. Dr. Chen was supported by a Career Development Award (CDA 18-185).

Denneson LM, Hannon SA, McDonald KL, Chen JI, O’Neil ME. Inactivation of High-Risk Flags for Suicide in the Veterans Health Administration: Association of Documentation Variation with Suicide Attempts. Psychological Services. November 2, 2023;online ahead of print.