Mitigating Racial Bias in Health Care Algorithms: Improving Fairness in Access to Supportive Housing.

Algorithms for guiding health care decisions have come under increasing scrutiny for being unfair to certain racial and ethnic groups. The authors describe their multistep process, using data from 3,465 individuals, to reduce racial and ethnic bias in an algorithm developed to identify state Medicaid beneficiaries experiencing homelessness and chronic health needs who were eligible for coordinated health care and housing supports. Through an iterative process of adjusting inputs, reviewing outputs with diverse stakeholders, and performing quality assurance, the authors developed an algorithm that achieved racial and ethnic parity in the selection of eligible Medicaid beneficiaries.

Association of 7-Day Follow-Up With 6-Month Suicide Mortality Following Hospitalization for Suicidal Thoughts or Behaviors Among Older Adults.

OBJECTIVE: To evaluate whether timely follow-up outpatient mental health care is associated with reduced short-term suicide risk following hospitalization for suicidal thoughts or behaviors. METHODS: Retrospective cohort analysis using 2015 Medicare data for adults aged ≥ 65 years who were hospitalized for suicidal ideation or behaviors (n = 36,557) linked with the National Death Index. Adjusted risk ratios (ARR) estimated the association between 7-day follow-up and suicide risk at 30-, 90-, and 180-days, adjusted for confounding by indication using inverse probability of treatment weights of observable covariates. RESULTS: Overall, 39.3% of patients received 7-day follow-up, which was associated with 41% higher risk of suicide within 180 days. Follow-up care was associated with higher suicide risk for Medicare Advantage enrollees, patients with no recent prior mental health care, and those admitted for suicidal behaviors. CONCLUSION: Results suggest 7-day follow-up care was not associated with lower post-discharge suicide risk. For this high-risk group, suicide-specific interventions may be needed during the critical postdischarge period.

Implementing Peer Specialists in Suicide Prevention Efforts in the Veterans Health Administration.

OBJECTIVE: The Veterans Health Administration (VHA) recognizes peer support as an underused intervention in suicide prevention. PREVAIL is a peer-based suicide prevention intervention that was designed and piloted with non-veteran patients recently hospitalized for suicidal thoughts or behaviors. The purpose of this study was to elicit veteran and stakeholder feedback to inform the adaptation of PREVAIL for piloting with veterans flagged for high suicide risk. METHODS: Semi-structured interviews were conducted with multiple stakeholders from a VHA medical center in the northeast. Interviews focused on the perceived benefits and concerns of peer specialists directly addressing suicide risk with veterans. Interviews were recorded, transcribed, and analyzed using rapid qualitative analysis. RESULTS: Interviewees included clinical directors (n = 3), suicide prevention coordinators (n = 1), outpatient psychologists (n = 2), peer specialists (n = 1), and high-risk veterans (n = 2). Overall, peer specialists were viewed as possessing many distinct strengths in engaging and helping high-risk veterans as part of a team approach. Concerns included liability, adequate training, clinical supervision and support, and self-care for peer specialists. CONCLUSIONS: Findings indicated support and confidence that peer support specialists would be a valuable addition and could help fill existing gap in VHA's suicide prevention efforts.

Associations Between Inpatient Induction on Medications for Opioid Use Disorder and Postdischarge Medications for Opioid Use Disorder Adherence, Overdose, and Service Use.

OBJECTIVES: This study aimed to examine outcomes of a pilot program designed to increase inpatient medications for opioid use disorder (MOUD) induction and to support MOUD adherence after discharge. METHODS: This retrospective cohort analysis examined Medicaid adults diagnosed with opioid use disorder discharged from 2 freestanding inpatient withdrawal management facilities between October 1, 2018, and December 31, 2019. Participants had ≥90 days of continuous Medicaid enrollment before and after admission. Odds ratios (ORs) examined associations of inpatient MOUD induction with discharge against medical advice, 7- and 30-day all-cause hospital readmission, and postdischarge MOUD adherence. Mixed-effect models examined changes associated with MOUD induction and postdischarge MOUD adherence in acute service utilization and opioid overdose in the 90-day postdischarge period. RESULTS: Of the 2332 patients discharged, 493 started MOUD inpatient care (21.1%), with most initiating buprenorphine (76.5%). Induction of MOUD was associated with a lower likelihood of discharge against medical advice (OR, 0.49; 95% confidence interval [CI], 0.37-0.64), 30-day all-cause hospital readmission (OR, 0.61; 95% CI, 0.47-0.80), and higher odds of postdischarge MOUD adherence (OR, 3.83; 95% CI, 3.06-4.81). In the 90 days after discharge, MOUD adherent patients had significant reductions in emergency department visits for behavioral health, inpatient days, withdrawal management episodes, and opioid overdoses compared with the 90-day preadmission period. CONCLUSIONS: Inpatient MOUD induction is associated with a higher likelihood of short-term MOUD adherence after discharge, which in turn is associated with significant reductions in short-term service utilization and opioid overdose after discharge.

Predictive modeling of service discontinuation in transitional age youth with recent behavioral health service use.

OBJECTIVE: To develop and test predictive models of discontinuation of behavioral health service use within 12 months in transitional age youth with recent behavioral health service use. DATA SOURCES: Administrative claims for Medicaid beneficiaries aged 15-26 years in Connecticut. STUDY DESIGN: We compared the performance of a decision tree, random forest, and gradient boosting machine learning algorithms to logistic regression in predicting service discontinuation within 12 months among beneficiaries using behavioral health services. DATA EXTRACTION: We identified 33,532 transitional age youth with ≥1 claim for a primary behavioral health diagnosis in 2016 and Medicaid enrollment of ≥11 months in 2016 and ≥11 months in 2017. PRINCIPAL FINDINGS: Classification accuracy for identifying youth who discontinued behavioral health service use was highest for gradient boosting (80%, AUC = 0.86), decision tree (79%, AUC = 0.84), and random forest (79%, AUC = 0.86), as compared with logistic regression (71%, AUC = 0.71). CONCLUSIONS: Predictive models based on Medicaid claims can assist in identifying transitional age youth who are at risk of discontinuing from behavioral health care within 12 months, thus allowing for proactive assessment and outreach to promote continuity of care for younger persons who have behavioral health needs.

Suicide risk in first year after dementia diagnosis in older adults.

INTRODUCTION: Receiving a diagnosis of Alzheimer's disease or related dementias (ADRD) can be a pivotal and stressful period. We examined the risk of suicide in the first year after ADRD diagnosis relative to the general geriatric population. METHODS: We identified a national cohort of Medicare fee-for-service beneficiaries aged ≥ 65 years with newly diagnosed ADRD (n = 2,667,987) linked to the National Death Index. RESULTS: The suicide rate for the ADRD cohort was 26.42 per 100,000 person-years. The overall standardized mortality ratio (SMR) for suicide was 1.53 (95% confidence interval [CI] = 1.42, 1.65) with the highest risk among adults aged 65 to 74 years (SMR = 3.40, 95% CI = 2.94, 3.86) and the first 90 days after ADRD diagnosis. Rural residence and recent mental health, substance use, or chronic pain conditions were associated with increased suicide risk. DISCUSSION: Results highlight the importance of suicide risk screening and support at the time of newly diagnosed dementia, particularly for patients aged < 75 years.

Factors Associated With 7-Day Follow-Up Outpatient Mental Healthcare in Older Adults Hospitalized for Suicidal Ideation, Suicide Attempt, and Self-Harm.

OBJECTIVE: Older adults are one of the fastest growing age groups seeking emergency care for suicidal ideation and self-harm. Timely follow-up outpatient mental healthcare is important to suicide prevention, yet little is known about predictors of care continuity following hospital discharge. This study identified patient-, hospital-, and regional-level factors associated with 7-day follow-up outpatient mental healthcare in suicidal older adults. METHODS: Retrospective cohort analysis using 2015 Medicare data for adults aged ≥65 years hospitalized for suicidal ideation, suicide attempt, or deliberate self-harm (n = 27,257) linked with the American Hospital Association survey and Area Health Resource File. Rates and adjusted risk ratios stratified by patient, hospital, and regional variables were assessed for 7-day follow-up outpatient mental healthcare. RESULTS: Overall, 30.3% of patients received follow-up mental healthcare within 7 days of discharge. However, follow-up rates were higher for patients with any mental healthcare within 30 days prehospitalization (43.7%) compared to patients with no recent mental healthcare (15.7%). Longer length of stay and care in psychiatric hospitals were associated with higher odds of follow-up. For patients with no mental healthcare in the 30 days prehospitalization, discharge from hospitals that were large, system-affiliated, academic medical centers, or provided hospitalist-based care were associated with lower odds of follow-up. Females were more likely to receive 7-day follow-up, whereas non-white patients were less likely to receive follow-up care. CONCLUSION: Timely follow-up is influenced by multiple patient, hospital, and community characteristics. Findings highlight the need for quality improvement to promote successful transitions from inpatient to outpatient care.

Comparisons between suicide in persons with serious mental illness, other mental disorders, or no known mental illness: Results from 37 U.S. states, 2003-2017.

BACKGROUND: Suicide is a leading cause of death in persons with schizophrenia and other serious mental illnesses (SMI), however, little is known about the characteristics and circumstances of suicide decedents with SMI in the US compared to those with other or no known mental illness. METHODS: This study was a retrospective analysis of suicide deaths in individuals aged ≥18 years from the National Violent Death Reporting System, 2003-2017. Odds ratios compared sociodemographic and clinical characteristics, cause of death, precipitating circumstances, and post-mortem toxicology results. All analyses were stratified by gender. RESULTS: Of the 174,001 suicide decedents, 8.7% had a known SMI, 33.0% had other mental disorders, and 58.2% had no known mental illness. Relative to persons with other mental disorders, SMI decedents were younger and more likely to have previous suicide attempts and co-occurring drug use. Problems with intimate partners, poor physical health, and recent institutional release were the most common precipitating circumstances for SMI decedents. Firearms were the most common suicide method for males with SMI. Although 67.0% male and 76.0% of female SMI decedents were currently in treatment, toxicology results suggest many were not taking antipsychotic or antidepressant medications at the time of death. CONCLUSIONS: Persons with SMI are over-represented in suicide deaths. Efforts to improve treatment of co-occurring substance use disorders, continuity of care following hospitalization, medication adherence, and to reduce access to firearms are important suicide prevention strategies.

Association of Suicide Prevention Interventions With Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systematic Review and Meta-analysis.

Importance: To prevent suicide deaths, acute care settings need tools to ensure individuals at risk of suicide access mental health care and remain safe until they do so. Objective: To examine the association of brief acute care suicide prevention interventions with patients' subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Data Sources: Ovid MEDLINE, Scopus, CINAHL, PsychINFO, Embase, and references of included studies using concepts of suicide, prevention, and clinical trial to identify relevant articles published January 2000 to May 2019. Study Selection: Studies describing clinical trials of single-encounter suicide prevention interventions were included. Two reviewers independently reviewed all articles to determine eligibility for study inclusion. Data Extraction and Synthesis: Two reviewers independently abstracted data according to PRISMA guidelines and assessed studies' risk of bias using the Cochrane Risk of Bias tool. Data were pooled for each outcome using random-effects models. Small study effects including publication bias were assessed using Peter and Egger regression tests. Main Outcomes and Measures: Three primary outcomes were examined: subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Suicide attempts and linkage to follow-up care were measured using validated patient self-report measures and medical record review; odds ratios and Hedges g standardized mean differences were pooled to estimate effect sizes. Depression symptoms were measured 2 to 3 months after the encounter using validated self-report measures, and pooled Hedges g standardized mean differences were used to estimate effect sizes. Results: A total of 14 studies, representing outcomes for 4270 patients, were included. Pooled-effect estimates showed that brief suicide prevention interventions were associated with reduced subsequent suicide attempts (pooled odds ratio, 0.69; 95% CI, 0.53-0.89), increased linkage to follow-up (pooled odds ratio, 3.04; 95% CI, 1.79-5.17) but were not associated with reduced depression symptoms (Hedges g = 0.28 [95% CI, -0.02 to 0.59). Conclusions and Relevance: In this meta-analysis, breif suicide prevention interventions were associated with reduced subsequent suicide attempts. Suicide prevention interventions delivered in a single in-person encounter may be effective at reducing subsequent suicide attempts and ensuring that patients engage in follow-up mental health care.

Suicide in Older Adults With and Without Known Mental Illness: Results From the National Violent Death Reporting System, 2003-2016.

INTRODUCTION: Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults. Recent data suggest that many U.S. adults who die from suicide do not have a known mental health condition. This study compares the characteristics and precipitating circumstances of geriatric suicide decedents with and without known mental illnesses. METHODS: This study was a retrospective analysis of suicide deaths for adults aged ≥65 years from the National Violent Death Reporting System, 2003-2016 (n=26,884). ORs compared sociodemographic and clinical characteristics, cause of death, and precipitating circumstances based on coroner/medical examiner and law enforcement reports. Data were collected and analyzed in 2019. RESULTS: Most older male (69.1%) and female (50.2%) suicide decedents did not have a known mental illness. A physical health problem was the most prevalent precipitating circumstance but was more common among older adults without known mental illness. Past suicide attempt, disclosure of suicidal intent, depressed mood, and substance use were more common among those with a known mental illness. More than three fourths of suicide decedents did not disclose their suicidal intent. Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of male and 44.6% of female decedents) compared with those with known mental illness (70.5% of male and 30.0% of female decedents). CONCLUSIONS: Most older adults who die from suicide do not have a known mental health condition. The rapidly growing U.S. geriatric population calls for more effective methods to identify and treat at-risk older adults, particularly those who are male.

Self-Harm, Suicidal Ideation, and Attempted Suicide in Older Adults: A National Study of Emergency Department Visits and Follow-Up Care.

OBJECTIVE: Emergency department visits for self-harm and suicidal ideation have increased for US older adults. The purpose of this study was to examine discharge disposition, clinical recognition of mental disorder, and 30-day follow-up mental health outpatient care of older adults treated in emergency departments for suicide attempt (SA), suicidal ideation (SI), or deliberate self-harm (DSH). METHODS: Retrospective cohort analysis using 2015 Medicare claims for adults ≥65 years of age with suicide-related emergency encounters (N = 52,383). Demographic, clinical, and service use characteristics from claims were merged with county-level Area Health Resource File data. Rates and adjusted risk ratios were assessed for discharge to the community, mental health diagnosis in the emergency department, and outpatient mental health visits with 30 days after the emergency encounter. RESULTS: Encounters for SA (7.8%) and SI (17.2%) were less likely than those for DSH (29.1%) to be discharged to the community. Among community discharges, SA (95.6%) and SI (95.1%) encounters were more likely than DSH (52.3%) encounters to be diagnosed with a mental disorder in the emergency department. Encounters for SA (52.1%) and SI (59.9%) were also more likely than DSH (31.3%) encounters to receive follow-up mental care. CONCLUSIONS: Although most older adults treated in EDs for suicide-related reasons are hospitalized, a substantial proportion of patients discharged back to the community do not receive follow-up mental healthcare within 30 days.

National study of emergency department disposition for high suicide risk geriatric patients.

OBJECTIVE: To examine predictors of hospitalization among older adults at high risk for suicide treated in emergency departments (EDs). METHODS: This retrospective cohort analysis used national 2015 Medicare claims for adults ≥65 years with ED visits for suicide ideation or deliberate self-harm (N = 50,472) merged with data from the Area Health Resource File. Rates and adjusted risk ratios (ARR) of hospital admission were assessed. RESULTS: A majority of ED episodes resulted in hospital admission (81.9%) with most being admitted to a psychiatric unit (62.8%). Visits for self-harm with suicide ideation were most likely to result in hospitalization (94.7%) compared to suicide ideation alone (84.0%) or self-harm alone (73.1%). Current diagnosis of depression, bipolar, anxiety, cognitive, and personality disorder were associated with hospitalization. Co-occurring mental and substance use disorders were the most predictive mental health condition of admission. Overall, severity of current medical comorbidity was the strongest predictor of hospital admission. CONCLUSIONS: Most older adults treated in EDs for suicide ideation or self-harm are hospitalized. Medical morbidity plays a more prominent role than other patient factors in admission status.

Deliberate self-harm in older adults: A national analysis of US emergency department visits and follow-up care.

OBJECTIVE: To examine mental health care received by older adults following emergency department (ED) visits for deliberate self-harm. METHODS: This retrospective cohort analysis examined 2015 Medicare claims for adults ≥65 years of age with ED visits for deliberate self-harm (N = 16 495). We estimated adjusted risk ratios (ARR) for discharge disposition, ED coding of mental disorder, and 30-day follow-up mental health outpatient care. RESULTS: Most patients (76.9%) were hospitalized with lower likelihoods observed for African American patients (ARR = 0.86, 99% CI = 0.79-0.94) and patients with either one medical comorbidity (ARR = 0.91, 99% CI = 0.83-0.99) or two to three comorbidities (ARR = 0.93, 99% CI = 0.88-0.99). Hospitalization was associated with recent depression (ARR = 1.09, 99% CI = 1.03-1.16) and recent psychiatric inpatient care (ARR = 1.13, 99% CI = 1.04-1.22). Among patients discharged to the community (n = 3818), 56.4% received an ED mental disorder diagnosis. Predictors of an ED mental disorder diagnosis included younger age (65-69 years; ARR = 1.53, 99% CI = 1.31-1.78), recent mental health care in ED (ARR = 1.50, 99% CI = 1.29-1.74) or outpatient (ARR = 1.62, 99% CI = 1.44-1.82) settings, recent diagnosis of mental disorder (ARR = 1.61, 99% CI = 1.43-1.80), and other/unknown lethality methods of self-harm (ARR = 1.24, 99% CI = 1.01-1.52). Among community discharged patients, 39.0% received 30-day follow-up outpatient mental health care, which was most strongly predicted by an ED diagnosis of mental disorder (ARR = 2.65, 99% CI = 2.25-3.12) and prior outpatient mental health care (ARR = 2.62, 99% CI = 2.28-3.00). CONCLUSION: Most older adult Medicare beneficiaries who present to EDs with self-harm are hospitalized. Of those who are discharged to the community, many are not diagnosed with mental disorder in the ED or receive timely follow-up mental health care.

A Pay-for-Performance Initiative to Reduce Pediatric Psychiatric Inpatient Length of Stay.

This column presents results of a pay-for-performance (P4P) initiative to reduce psychiatric inpatient length of stay for Medicaid-covered youths at eight hospitals in Connecticut in 2008 (N=715), 2009 (N=1,408), and 2010 (N=782). Compared with the 2007 baseline, average length of stay decreased by 25% (from 18.1 to 13.6 days) by the end of the P4P program, with concurrent nonsignificant decreases in 7- and 30-day readmissions. Readmitted youths tended to access postdischarge care sooner and use more community-based services during the first 180 days postdischarge. Additional research is needed, but the P4P program appears to have contributed to shortening inpatient stay without apparent adverse outcome on increases in postdischarge service use.

Improved Sleep, Diet, and Exercise in Adults with Serious Mental Illness: Results from a Pilot Self-Management Intervention.

Compared to the general population, adults with serious mental illnesses have elevated rates of medical morbidity resulting in a reduced life expectancy of approximately 15 years. Chronic disease self-management programs for adults with serious mental and chronic medical illnesses show some promise in improving physical health-related outcomes, yet none of them address sleep quality. Poor sleep affects a majority of adults with serious mental illness and is robust risk factor for physical morbidity and premature mortality. This pilot project examined the impact of a 14-week educational and support group that included sleep quality as a cornerstone in promoting wellness and self-management in 78 adults with serious mental illness and poor health. Results provide preliminary data that the self-management program was associated with significant improvements in self-reported sleep quality at post-intervention. At 3-month follow-up, participants reported additional increases in sleep quality as well as in healthy diet and exercise frequency. Addressing sleep quality as part of self-management and wellness programs may be a viable approach to assist adults with chronic mental and physical illnesses to adopt health-promoting changes.

Predicting time to readmission in patients with recent histories of recurrent psychiatric hospitalization: a matched-control survival analysis.

The most robust predictor of future psychiatric hospitalization is the number of previous admissions. About half of psychiatric inpatients with histories of repeated hospitalizations are readmitted within 12 months. This study sought to determine which patient characteristics predicted time-to-readmission within 12 months after controlling for the number of previous hospitalizations in 75 adults with recent histories of recurrent admissions and 75 matched controls. Results revealed multiple clinical and demographic between-group differences at index hospitalization. However, the only predictors of shorter time-to-readmission in multivariate Cox proportional hazards were unemployment (hazards ratio = 9.26) and residential living status (hazards ratio = 2.05) after controlling for prior hospitalizations (hazard ratio = 1.24). Unemployment and residential living status were not proxies of psychosis or moderated by illness severity or comorbid substance use. Results suggest that early psychiatric readmission may be more influenced by residential and employment status than by severe mental illness.

Enabling or Engaging? The Role of Recovery Support Services in Addiction Recovery.

Recovery capital-the quantity and quality of internal and external resources to initiate and maintain recovery-is explored with suggestions for how recovery support services (RSS) (nontraditional, and often nonprofessional support) can be utilized within a context of comprehensive addiction services. This article includes a brief history of RSS, conceptual and operational definitions of RSS, a framework for evaluating RSS, along with a review of recent empirical evidence that suggests that rather than enabling continued addiction, recovery supports are effective at engaging people into care, especially those who have little recovery capital, and/or who otherwise would likely have little to no "access to recovery."

Characteristics of inpatients with a history of recurrent psychiatric hospitalizations: a matched-control study.

OBJECTIVE: This study examined the association between patient characteristics and inpatient hospitalization among patients with a history of recurrent psychiatric hospitalizations (two or more hospitalizations in the 18 months before the index hospitalization) (N=75) and patients without such a history (N=75). METHODS: Characteristics at the time of the index hospitalization and 48-month inpatient utilization rates (24 months before and 24 months after the index hospitalization) were extracted from medical records. Backwards stepwise regression models were used to identify characteristics independently associated with inpatient utilization. RESULTS: Psychotic disorder and unemployment at the time of index hospitalization were independently associated with higher inpatient utilization over the 48 months. Only the number of hospitalizations in the prior 24 months predicted the number of readmissions after the index hospitalization. CONCLUSIONS: Psychosis and unemployment seem to have an independent effect on the number of hospitalizations.