Letters
Author Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia (Hampton, Budnitz); Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland (Daubresse, Alexander); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Chang). Corresponding Author: Lee M. Hampton, MD, MSc, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-4, Atlanta, GA 30329 (lhampton @cdc.gov). Published Online: January 14, 2015. doi:10.1001/jamapsychiatry.2014.2412. Author Contributions: Dr Hampton had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hampton, Alexander, Budnitz. Acquisition, analysis, or interpretation of data: Hampton, Daubresse, Chang, Budnitz. Drafting of the manuscript: Hampton. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Hampton, Daubresse, Chang. Administrative, technical, or material support: All authors. Study supervision: Alexander, Budnitz. Conflict of Interest Disclosures: Dr Alexander is an ad hoc member of the Food and Drug Administration’s Drug Safety and Risk Management Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. No other disclosures were reported. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Additional Contributions: The following contributed to data collection and adverse drug event case review: Joel Friedman, BS, Herman Burney, BS, Mary Cowhig, MHA, Thomas Schroeder, MS, and Ray Colucci, RN (Consumer Products Safety Commission); and Kathleen Rose, RN, and Kelly Weidenbach, DrPH (Centers for Disease Control and Prevention). Messrs Friedman, Burney, Schroeder, and Colucci and Ms Cowhig’s work on adverse drug event data collection and case review was funded by the Centers for Disease Control and Prevention.
Suicide in a Health Maintenance Organization Population
Results | During the 11-year study, the annual HMO network membership ranged from 182 183 to 293 228 and was demographically representative of southeast Michigan, with approximately 25% older than the age of 65 years, 55% female, and 40% white. On average each year, approximately 65% of members were patients, and approximately 60% of patients were MH patients. There were 160 suicides among all HMO members (Table 1). The mean annual suic ide rate for members was 5.77 per 100 000 and did not significantly change over the study period (P = .20) (Table 2), whereas the annual suicide rate in the general population of the state of Michigan inc reased signific antly (P < .001) (mean, 10.82 per 100 000). The mean annual suicide rate among patients (6.38 per 100 000) and nonpatient members (4.47 per 100 000) was similar to that for all members (5.77 per 100 000), and likewise did not change (Table 2). Suicide rates declined for MH patients (P < .04) but increased for non-MH patients (P < .01).
The US Surgeon General and the Institute of Medicine have called for health care systems to help reduce the number of suicides.1,2 However, the few assessments of suicide in such systems have examined specific patient groups rather than the entire population of health plan members.3,4 Here we report, to our knowledge, the first information on suicide for the entire membership of a large health maintenance organization (HMO) network.
Discussion | This report presents the first description of suicide rates in the entire membership of a large HMO. To our knowledge, the only other available studies examining suicide in insured populations within the United States are limited to 2 specific patient populations: military veterans4 and patients receiving treatment for depression.3 In our sample, the first to include nonpatient members, the annual suicide
1. Olfson M, Blanco C, Liu SM, Wang S, Correll CU. National trends in the office-based treatment of children, adolescents, and adults with antipsychotics. Arch Gen Psychiatry. 2012;69(12):1247-1256. 2. Kupfer DJ, Kuhl EA, Regier DA. DSM-5: the future arrived. JAMA. 2013;309(16): 1691-1692. 3. American Psychiatric Association. Choosing Wisely. http://www.psychiatry.org /choosingwisely. Accessed August 21, 2014. 4. Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71(9):1006-1014. 5. Consumer Products Safety Commission. National Electronic Injury Surveillance System (NEISS). http://www.cpsc.gov/en/Research--Statistics /NEISS-Injury-Data/. Accessed December 3, 2014. 6. National Center for Health Statistics, Centers for Disease Control and Prevention. Ambulatory health care data. http://www.cdc.gov/nchs/ahcd/ahcd _questionnaires.htm. Accessed May 31, 2013.
294
Methods | We identified all suicides among the membership of our HMO network between 1999 and 2010, determining the date and cause of death using official state mortality records. We linked these data to the medical record by name, sex, address, date of birth, and social security number. Using the Centers for Disease Control and Prevention’s external cause of injury mortality matrix, we designated as suicides all deaths with International Statistical Classification of Diseases, Tenth Revision codes X60-X84 or Y87.0. The Centers for Disease Control and Prevention first used this scheme to classify deaths in 1999, the first year of our study period. We characterized suicides among 5 study groups: all individuals enrolled in our HMO network (members); all members who did (patients) or did not (nonpatient members) access health care network services during that membership year; and patients who did (mental health [MH] patients) or did not (non-MH patients) make at least 1 visit to the network’s specialty MH services department that year. We defined suicide rates in accordance with the State of Michigan’s vital statistics (ie, per 100 000 population), effectively keeping risk time constant based on the nature of the HMO membership. We used standard linear regression, with annual suicide rate as the dependent variable, to evaluate rates over time with statistical significance defined as P < .05. The institutional review boards at Henry Ford Hospital and the State of Michigan approved this project; patient consent was waived.
JAMA Psychiatry March 2015 Volume 72, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Oakland University User on 06/01/2015
jamapsychiatry.com
Letters
Table 1. Characteristics of HMO Network Member Suicides No. (%)a Members
MH Specialty
Characteristic
All
Nonpatient
Patients
Nonpatients
Patients
Total suicides
160 (100)
41 (26)
119 (74)
84 (53)
35 (21)
0-39
23 (14)
10 (24)
13 (11)
9 (11)
40-64
85 (53)
20 (49)
65 (55)
41 (49)
24 (69)
≥65
52 (33)
11 (27)
41 (34)
34 (40)
7 (20)
Age, y
Author Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia (Hampton, Budnitz); Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland (Daubresse, Alexander); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Chang). Corresponding Author: Lee M. Hampton, MD, MSc, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-4, Atlanta, GA 30329 (lhampton @cdc.gov). Published Online: January 14, 2015. doi:10.1001/jamapsychiatry.2014.2412. Author Contributions: Dr Hampton had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hampton, Alexander, Budnitz. Acquisition, analysis, or interpretation of data: Hampton, Daubresse, Chang, Budnitz. Drafting of the manuscript: Hampton. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Hampton, Daubresse, Chang. Administrative, technical, or material support: All authors. Study supervision: Alexander, Budnitz. Conflict of Interest Disclosures: Dr Alexander is an ad hoc member of the Food and Drug Administration’s Drug Safety and Risk Management Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. No other disclosures were reported. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Additional Contributions: The following contributed to data collection and adverse drug event case review: Joel Friedman, BS, Herman Burney, BS, Mary Cowhig, MHA, Thomas Schroeder, MS, and Ray Colucci, RN (Consumer Products Safety Commission); and Kathleen Rose, RN, and Kelly Weidenbach, DrPH (Centers for Disease Control and Prevention). Messrs Friedman, Burney, Schroeder, and Colucci and Ms Cowhig’s work on adverse drug event data collection and case review was funded by the Centers for Disease Control and Prevention.
Suicide in a Health Maintenance Organization Population
Results | During the 11-year study, the annual HMO network membership ranged from 182 183 to 293 228 and was demographically representative of southeast Michigan, with approximately 25% older than the age of 65 years, 55% female, and 40% white. On average each year, approximately 65% of members were patients, and approximately 60% of patients were MH patients. There were 160 suicides among all HMO members (Table 1). The mean annual suic ide rate for members was 5.77 per 100 000 and did not significantly change over the study period (P = .20) (Table 2), whereas the annual suicide rate in the general population of the state of Michigan inc reased signific antly (P < .001) (mean, 10.82 per 100 000). The mean annual suicide rate among patients (6.38 per 100 000) and nonpatient members (4.47 per 100 000) was similar to that for all members (5.77 per 100 000), and likewise did not change (Table 2). Suicide rates declined for MH patients (P < .04) but increased for non-MH patients (P < .01).
The US Surgeon General and the Institute of Medicine have called for health care systems to help reduce the number of suicides.1,2 However, the few assessments of suicide in such systems have examined specific patient groups rather than the entire population of health plan members.3,4 Here we report, to our knowledge, the first information on suicide for the entire membership of a large health maintenance organization (HMO) network.
Discussion | This report presents the first description of suicide rates in the entire membership of a large HMO. To our knowledge, the only other available studies examining suicide in insured populations within the United States are limited to 2 specific patient populations: military veterans4 and patients receiving treatment for depression.3 In our sample, the first to include nonpatient members, the annual suicide
1. Olfson M, Blanco C, Liu SM, Wang S, Correll CU. National trends in the office-based treatment of children, adolescents, and adults with antipsychotics. Arch Gen Psychiatry. 2012;69(12):1247-1256. 2. Kupfer DJ, Kuhl EA, Regier DA. DSM-5: the future arrived. JAMA. 2013;309(16): 1691-1692. 3. American Psychiatric Association. Choosing Wisely. http://www.psychiatry.org /choosingwisely. Accessed August 21, 2014. 4. Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71(9):1006-1014. 5. Consumer Products Safety Commission. National Electronic Injury Surveillance System (NEISS). http://www.cpsc.gov/en/Research--Statistics /NEISS-Injury-Data/. Accessed December 3, 2014. 6. National Center for Health Statistics, Centers for Disease Control and Prevention. Ambulatory health care data. http://www.cdc.gov/nchs/ahcd/ahcd _questionnaires.htm. Accessed May 31, 2013.
294
Methods | We identified all suicides among the membership of our HMO network between 1999 and 2010, determining the date and cause of death using official state mortality records. We linked these data to the medical record by name, sex, address, date of birth, and social security number. Using the Centers for Disease Control and Prevention’s external cause of injury mortality matrix, we designated as suicides all deaths with International Statistical Classification of Diseases, Tenth Revision codes X60-X84 or Y87.0. The Centers for Disease Control and Prevention first used this scheme to classify deaths in 1999, the first year of our study period. We characterized suicides among 5 study groups: all individuals enrolled in our HMO network (members); all members who did (patients) or did not (nonpatient members) access health care network services during that membership year; and patients who did (mental health [MH] patients) or did not (non-MH patients) make at least 1 visit to the network’s specialty MH services department that year. We defined suicide rates in accordance with the State of Michigan’s vital statistics (ie, per 100 000 population), effectively keeping risk time constant based on the nature of the HMO membership. We used standard linear regression, with annual suicide rate as the dependent variable, to evaluate rates over time with statistical significance defined as P < .05. The institutional review boards at Henry Ford Hospital and the State of Michigan approved this project; patient consent was waived.
JAMA Psychiatry March 2015 Volume 72, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Oakland University User on 06/01/2015
jamapsychiatry.com
Letters
Table 1. Characteristics of HMO Network Member Suicides No. (%)a Members
MH Specialty
Characteristic
All
Nonpatient
Patients
Nonpatients
Patients
Total suicides
160 (100)
41 (26)
119 (74)
84 (53)
35 (21)
0-39
23 (14)
10 (24)
13 (11)
9 (11)
40-64
85 (53)
20 (49)
65 (55)
41 (49)
24 (69)
≥65
52 (33)
11 (27)
41 (34)
34 (40)
7 (20)
Age, y
