Social Determinants and Military Veterans' Suicide Ideation and Attempt: a Cross-sectional Analysis of Electronic Health Record Data.

BACKGROUND: Health care systems struggle to identify risk factors for suicide. Adverse social determinants of health (SDH) are strong predictors of suicide risk, but most electronic health records (EHR) do not include SDH data. OBJECTIVE: To determine the prevalence of SDH documentation in the EHR and how SDH are associated with suicide ideation and attempt. DESIGN: This cross-sectional analysis included EHR data spanning October 1, 2015-September 30, 2016, from the Veterans Integrated Service Network Region 4. PARTICIPANTS: The study included all patients with at least one inpatient or outpatient visit (n = 293,872). MAIN MEASUREMENTS: Adverse SDH, operationalized using Veterans Health Administration (VHA) coding for services and International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes, encompassed seven types (violence, housing instability, financial/employment problems, legal problems, familial/social problems, lack of access to care/transportation, and nonspecific psychosocial needs). We defined suicide morbidity by ICD-10 codes and data from the VHA's Suicide Prevention Applications Network. Logistic regression assessed associations of SDH with suicide morbidity, adjusting for socio-demographics and mental health diagnoses (e.g., major depression). Statistical significance was assessed with p < .01. KEY RESULTS: Overall, 16.4% of patients had at least one adverse SDH indicator. Adverse SDH exhibited dose-response-like associations with suicidal ideation and suicide attempt: each additional adverse SDH increased odds of suicidal ideation by 67% (AOR = 1.67, 99%CI = 1.60-1.75; p < .01) and suicide attempt by 49% (AOR = 1.49, 99%CI = 1.33-1.68; p < .01). Independently, each adverse SDH had strong effect sizes, ranging from 1.86 (99%CI = 1.58-2.19; p < .01) for legal issues to 3.10 (99%CI = 2.74-3.50; p < .01) for non-specific psychosocial needs in models assessing suicidal ideation and from 1.58 (99%CI = 1.10-2.27; p < .01) for employment/financial problems to 2.90 (99%CI = 2.30-4.16; p < .01) for violence in models assessing suicide attempt. CONCLUSIONS: SDH were strongly associated with suicidal ideation and suicide attempt even after adjusting for mental health diagnoses. Integration of SDH data in EHR could improve suicide prevention.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016.

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

Characteristics of Opioid Prescriptions to Veterans With Cirrhosis.

BACKGROUND & AIMS: Despite increased risks for adverse effects in patients with cirrhosis, little is known about opioid prescriptions for this population. We aimed to assess time trends in opioid prescribing and factors associated with receiving opioids among patients with cirrhosis. METHODS: Among Veterans with cirrhosis, identified using national Veterans Health Administration data (2005-2014), we assessed characteristics of patients and their prescriptions for opioids. We calculated the annual proportion of patients receiving any opioid prescription. Among opioid recipients, we assessed prescriptions that were long-term (>90 days' supply), for high doses (>100 MME/day), or involved combinations of opioids and acetaminophen or benzodiazepine. We evaluated patient characteristics independently associated with long-term and any opioid prescriptions using mixed-effects regression models. RESULTS: Among 127,239 Veterans with cirrhosis, 97,974 (77.0%) received a prescription for an opioid. Annual opioid prescriptions increased from 36% in 2005 to 47% in 2014 (P < .01). Among recipients of opioids, the proportions of those receiving long-term prescriptions increased from 47% in 2005 to 54% in 2014 (P < .01), and19%-21% received prescriptions for high-dose opioids. Prescriptions for combinations of opioids and acetaminophen decreased from 68% in 2005 to 50% in 2014 (P < .01) and for combinations of opioids and benzodiazepines decreased from 24% to 19% over this time (P < .01). Greater probability of long-term opioid prescriptions was independently associated with younger age, female sex, white race, hepatitis C, prior hepatic decompensation, hepatocellular carcinoma, mental health disorders, nicotine use disorders, medical comorbidities, surgery, and pain-related conditions. CONCLUSION: Among Veterans with cirrhosis, 36%-47% were prescribed opioids in each year. Mental health disorders and hepatic decompensation were independently associated with long-term opioid prescriptions.