This year, the United States will likely reach a grim milestone: suicides are expected to reach an all-time high of 40,000. Surprisingly, nearly half of suicide victims had contact with a healthcare provider within 30 days of their suicide, according to a study published in the American Journal of Psychiatry in 2002, demonstrating the challenges providers face in effectively assessing suicide risk.
As healthcare providers, we have an opportunity to address what the National Institute of Mental Health has called the "under-recognized public health crisis." People who commit suicide see healthcare providers in the critical days before their death. Unfortunately, we aren't always "seeing" them.
At the same time, the country is poised to make healthcare more readily available to millions more under the Patient Protection and Affordable Care Act, which is expected to increase the demands on primary care doctors' offices, hospitals and the healthcare system as a whole. In fact, a study recently published in the Annals of Family Medicine indicated an additional 8,000 primary care physicians will be needed by 2025 just to treat patients who obtain insurance coverage under the law.
Part-and-parcel with the PPACA is the requirement that hospitals conduct community health needs assessments. Improved behavioral health service is among the top identified community needs.
How do we as healthcare workers meet the increased demand for our time and at the same time address the challenge of rising suicides among our patients?
The answer: better and more efficient mental health screening and suicide risk assessment.
Assessing suicide risk has come a long way in recent years, due in large part to the scientific community's increased focus on reliable and valid instruments. One key advancement has been with patient self-reported versions of instruments. Additionally, the implementation of such instruments using technology enables a quick, efficient and effective structure to collect, review and, when necessary, act on suicide risk data.
The need for effective, efficient and reliable assessment
Effectively and efficiently identifying someone at risk for suicide through a repeatable process has historically been challenging. The typical approach is to add a few uncomfortable questions to a laundry list that probes overall patient condition during an examination.
Additionally, primary care physicians — who see an increasing number of patients on a daily basis and expect that to continue with the healthcare reform law — say the time required to thoroughly evaluate the physical, emotional and mental condition of each patient is not available. Some primary care physicians estimate that 50 to 60 percent of the patients they see each day have an underlying emotional or mental health issue. Yet, even after spending time with a patient who may be at risk for suicide, physicians are uncomfortable with the current approach to this difficult assessment.
For hospitals, The Joint Commission has included suicide prevention in its national patient safety goals. It reported that suicide risk had not been adequately assessed in 60 percent of inpatient suicides, making it one of the top five sentinel events investigated by the organization since 1995.
In 2011, The Joint Commission addressed suicide in acute care settings in a sentinel event alert, emphasizing the need for more prevention efforts. In addition, the National Institute of Mental Health has funded a $12 million, multi-site study on suicide prevention in acute care settings. The five-year study is set to conclude this November. The liability hospitals face when patients commit suicide in inpatient settings prompted the study.
Suicides outside the hospital setting are also a significant liability for healthcare providers. In one case, Providence Health Center in Waco, Texas, its Providence DePaul Center and a physician were found liable for failing to properly evaluate and retain a suicidal patient who left the facility and eventually committed suicide. A jury awarded $400,000 in wrongful death damages and $400,000 in survival damages.
There is a path forward.
Innovative suicide risk assessment: Leveraging technology, cost savings
In pharmaceutical product development, the Food and Drug Administration has mandated prospective monitoring of suicidal ideation and behavior for certain classes of drugs. As a component of this mandate, the FDA has recommended scientifically proven assessments such as the Columbia-Suicide Severity Rating Scale for assessing suicide risk. These assessments provide a consistent series of questions that help to identify those who are the most at risk for suicide. There are a number of patient self-reported versions available, including one for the C-SSRS. Such assessments can be readily incorporated into our daily healthcare environment.
Clinical researchers have used electronic patient self-reported suicide risk assessment tools to ensure the safety of patients enrolled in clinical trials for new drug development. AVERT™ is one such system. It has been used in more than 100,000 assessments of over 32,000 patients at more than 3,000 patient care sites. Healthcare providers can realize the same benefits clinical researchers have found in electronic suicide risk assessments.
Electronic assessments not only address the critical shortcomings of current approaches — inconsistent application of questions, inadequate probing of patients and reluctance to disclose suicidal ideation or behaviors when asked directly by a clinician — but also reduce costs. For midsized hospitals, total annual costs associated with training staff to use paper suicide risk assessments and using and recording results from the assessments can be more than $1.4 million. In addition to these costs, institutions will face the indeterminate costs of a false negative, which may result in patients injuring themselves, or worse, committing suicide.
Electronic patient self-reported systems enable patients to complete the assessment privately via the Web, an electronic tablet or their phones and are patient-friendly. People can complete them in just over three minutes, and the results are reported immediately to their healthcare provider. If the assessment finds the patient to be at risk for suicide, an alert will instantly be issued and the appropriate follow-up can be immediately provided.
Improving care, providing community benefit
In the context of increased demands resulting from the PPACA, healthcare providers have an opportunity to provide community benefit through quick, efficient and effective suicide risk assessment. Systems like AVERT, which leverage good technology and good science, can help them do that.
As suicides reach an all-time high in our country, we have the potential to save lives.
Jean Paty is chief regulatory and scientific advisor of outcomes for ERT. ERT provides high-quality patient safety and efficacy endpoint data collection solutions for use in healthcare and clinical research.
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