Differences in Health Care Utilization in the Year Before Suicide Death: A Population-Based Case-Control Study.

OBJECTIVE: To compare health care usage between suicide decedents and living controls in the year before suicide in a large representative US population. PATIENTS AND METHODS: Cases (n=1221) and controls (n=3663) belonged to an integrated health care system from January 1, 2009, through December 31, 2014. Cases and controls were matched for age and sex in a 1:3 ratio, with diagnostic and/or billing codes used to enumerate and classify health care visits in the year before the index suicide. Matched analysis via conditional logistic regression related odds of suicide to visit type. A generalized estimating equation model was used to compare timing and frequency of visits between cases and controls. RESULTS: In the year before death, cases had an increased odds of both inpatient hospitalizations and emergency department nonmental health visits (odds ratio [OR], 1.55; 95% CI, 1.27-1.88; P<.001 and OR, 1.42; 95% CI, 1.26-1.60; P<.001) but not outpatient nonmental health visits (OR, 1.00; 95% CI, 0.99-1.01; P=.63). Decedents increased health care utilization closer to suicide death and had significantly more health care visits than did controls 3 months before suicide (6 vs 2; P=.01) but not 9 to 12 months before suicide (4 vs 2; P=.07). At all time points, cases used more mental health care services than did controls. CONCLUSION: Compared with controls, suicide decedents had emergency department visits and more inpatient hospitalizations, both mental health and nonmental health related. As death approached, cases' frequency of health care usage increased. The only category in which cases and controls did not differ was in the frequency of outpatient nonmental health visits.

Weren't Asked, Didn't Tell: Prevalence of Communication of Suicidal Ideation in Suicide Decedents During the Last Year of Life.

OBJECTIVE: To explore what percentage of suicide decedents (SDs) vs controls were assessed for suicidality at medical appointments in the year before death. PATIENTS AND METHODS: Using the Rochester Epidemiology Project, 66 SDs dying in Olmsted County, Minnesota, between January 1, 2000, and December 31, 2009, were identified and matched with 141 age- and sex-matched controls. Blinded chart review determined how often providers screened and subjects endorsed suicidal ideation (SI). Positive indicators included chart notes recording SI and/or Patient Health Questionnaire-9 scored more than 0 on question 9. RESULTS: We found that only 29 of 66 (43.9%) SDs and 14 of 141 (9.9%) controls had been screened at any point by any means (P < .001). Only 25.8% (17 of 66) of SDs expressed SI, whereas 58.6% of screened SDs (17 of 29) did so, though none at final appointments before death. No control ever expressed SI. While the majority of both cases and controls went unscreened, providers were more likely to screen SDs (P < .001; odds ratio [OR], 9.0; 95% CI, 3.6-22.0), even with controlling for mental health diagnoses (P = .02; OR, 3.6; 95% CI, 1.2-10.6). CONCLUSIONS: With providers screening less than half of SDs at any point in the year before death, and less than 60% of SDs ever endorsing SI, including none at final appointments, the findings of this naturalistic study bring into question both current screening practices and screening effectiveness. Nonetheless, when SDs were screened, they were significantly more likely to endorse SI than were controls, not 1 of whom ever expressed SI. Taken together, these data suggest that patients expressing SI at any point are at elevated risk for eventual suicide.

Patterns of Health Care Usage in the Year Before Suicide: A Population-Based Case-Control Study.

OBJECTIVE: To compare the type and frequency of health care visits in the year before suicide between decedents and controls. PATIENTS AND METHODS: Cases (n=86) were Olmsted County, Minnesota, residents whose death certificates listed "suicide" as the cause of death from January 1, 2000, through December 31, 2009. Each case had 3 age- and sex-matched controls (n=258). Demographic, diagnostic, and health care usage data were abstracted from medical records. Conditional logistic regression was used to analyze differences in the likelihood of having had psychiatric and nonpsychiatric visits in the year before death, as well as in visit types and frequencies 12 months, 6 months, and 4 weeks before death. RESULTS: Cases and controls did not significantly differ in having had any health care exposure (P=.18). Suicide decedents, however, had a significantly higher number of total visits in the 12 months, 6 months, and 4 weeks before death (all P<.001), were more likely to have carried psychiatric diagnoses in the previous year (odds ratio [OR], 8.08; 95% CI, 4.31-15.17; P<.001), and were more likely to have had outpatient and inpatient mental health visits (OR, 1.24; 95% CI, 1.05-1.47; P=.01 and OR 6.76; 95% CI, 1.39-32.96; P=.02, respectively). Only cases had had emergency department mental health visits; no control did. CONCLUSION: Given that suicide decedents did not differ from controls in having had any health care exposure in the year before death, the fact alone that decedents saw a doctor provides no useful information about risk. Compared with controls, however, decedents had more visits of all types including psychiatric ones. Higher frequencies of health care contacts were associated with elevated suicide risk.

Endovascular treatment of distal thoracic aortic transection associated with severe thoracolumbar spinal fracture.

Endovascular repair has become the first line of treatment in most patients with blunt aortic injury. The most common mechanism is deceleration injury affecting the aortic isthmus distal to the origin of the left subclavian artery. Injuries of the distal thoracic aorta are uncommon. We report the case of a 25-year-old male patient who presented with paraplegia and distal thoracic aortic pseudoaneurysm associated with severe thoracolumbar vertebral fracture and displacement after a motocross accident. Endovascular repair was performed using total percutaneous technique and conformable C-TAG thoracic stent-graft (WL Gore, Flagstaff, AZ). Following stent-graft placement and angiographic confirmation of absence of endoleak, thoracolumbar spinal fixation was performed in the same operative procedure. This case illustrates a multispecialty approach to complex aortic and vertebral injury and the high conformability of newer thoracic stent-grafts to adapt to tortuous anatomy.

Impact of a structured multidisciplinary intervention on quality of life of older adults with advanced cancer.

BACKGROUND: Patients experience reductions in quality of life (QOL) while receiving cancer treatment and several approaches have been proposed to address QOL issues. In this project, the QOL differences between older adult (age 65+) and younger adult (age 18-64) advanced cancer patients in response to a multidisciplinary intervention designed to improve QOL were examined. METHODS: This study was registered on ClinicalTrials.gov, NCT01360814. Newly diagnosed advanced cancer patients undergoing radiation therapy were randomized to active QOL intervention or control groups. Those in the intervention group received six multidisciplinary 90-minute sessions designed to address the five major domains of QOL. Outcomes measured at baseline and weeks 4, 27, and 52 included QOL (Linear Analogue Self-Assessment (LASA), Functional Assessment of Cancer Therapy-General (FACT-G)) and mood (Profile of Mood States (POMS)). Kruskall-Wallis methodology was used to compare scores between older and younger adult patients randomized to the intervention. RESULTS: Of 131 patients in the larger randomized controlled study, we report data on 54 evaluable patients (16 older adults and 38 younger adults) randomized to the intervention. Older adult patients reported better overall QOL (LASA 74.4 vs. 62.9, p = 0.040), higher social well-being (FACT-G 91.1 vs. 83.3, p = 0.045), and fewer problems with anger (POMS anger-hostility 95.0 vs. 86.4, p = 0.028). Long-term benefits for older patients were seen in the anger-hostility scale at week 27 (92.2 vs. 84.2, p = 0.027) and week 52 (96.3 vs. 85.9, p = 0.005). CONCLUSIONS: Older adult patients who received a multidisciplinary intervention to improve QOL while undergoing advanced cancer treatments benefited differently in some QOL domains, compared to younger adult patients. Future studies can provide further insight on how to tailor QOL interventions for these age groups.