Deaths by suicide following discharge from Scottish hospitals

Transcription

1 Deaths by suicide following discharge from Scottish hospitals Nadine Dougall Lecturer NMAHP Research Unit University of Stirling

2 Background: an urgent public health issue suicides in Scotland in 2011, age-standardised rate ~15/ 100,000 of population - Leading cause of mortality in young people - Suicide rate for men 3 times that for females male suicide rate in Scotland double the rate of England Data Management through e-social Science (DAMES) CI: Dr Paul Lambert, University of Stirling; ESRC 1.28M

3 Background: - Much has been published about risk of suicide after discharge from psychiatric hospitals. - Studies have rarely pooled data across different clinical settings. - Contact with healthcare services affords opportunities to discuss suicidal ideation.

4 Background: - Scotland is a good laboratory for electronic hospital records research, some of the best health service data in the world - Unique Community Health Index (CHI) number was introduced in the 1970s - CHI number in widespread use secondary & primary care - Now about 10M records available, held in datasets called Scottish Morbidity Records (held by NHS Information Services Division)

5 Aims: - To explore feasibility of using a linked dataset of general and psychiatric hospital records with all suicide deaths data in Scotland for the last 30 years in analyses of several research questions.

6 Research questions: 1. What number/ proportion of deaths had hospital records? 2. What were the characteristics of those with and without hospital records or CHI number? 3. What differences existed by gender for those with hospital records? 4. What differences existed by type of hospital for suicide rates after last discharge?

7 Methods: Study design Retrospective single group data study of all who died by suicide aged 15y+ during Permissions Research Ethics Committee, NHS CG and R&D

8 Methods: Data linkage: 1. All deaths by suicide (National Records of Scotland) 2. NHS general hospital records 3. NHS psychiatric hospital records Linked on unique Community Health Index (CHI) no. Only exclusion: Aged 15y with no upper age limit at time of death

9 Methods: Substantial methodological problem: Hospital records for each person s episode of care contain a main diagnosis and many secondary diagnoses ICD-9 & 1999 onwards ICD-10 ICD catalogues do not cross-map Used a software tool to re-code all ICD9 & 10 diagnoses into 260 broad common categories

10 Methods: Why was it important to re-code ICD9 & 10? Permits us to look at disease along the life course for each individual e.g. for every person who had a last visit to a general hospital, we can establish diagnosis, comorbidities, no. previous visits, previous episodes of self-harm etc This level of detail is powerful in any data analysis, yields insights that are not possible with summary data

11 RESULTS Research question 1 What number and proportion of deaths had linked hospital records?

12 Results: Deaths by suicide Scotland Figure 1: Numbers with hospital records and/ or CHI numbers deaths people with CHI no people with one or more hospital records (68%) Total records = 85278* The largest UK study using NHS hospital records of those dying by suicide More than 2/3 rd s had hospital records CHI: Community Health Index number

13 RESULTS Research question 2 What were the characteristics of those with and without hospital records or a CHI number?

14 Results: Deaths by suicide Scotland Table 2: Characteristics of those with & without hospital records 1. People with hospital records Proxy: seen by GP & hospital (secondary care) 2. People no hospital records, but had CHI # Proxy: seen by GP (primary care) 3. No hospital records or CHI # Proxy: Never seen GP or hospital (community care) No. people % of total 68% 19% 13% Mean age % married People with no records tended to be older People with hospital records less likely to be married

15 RESULTS Research question 3 What differences existed by gender for those with hospital records?

16 Results: Deaths by suicide Scotland Table 3: Characteristics of those who had hospital records People with hospital records All Males Females No. deaths (100%) 8004 (72%) 3152 (28%) Mean age (s.d.) 43.3 (16.8) 42.1 (16.4) 46.1* (17.3) Married/ 37.3% 37.2% 37.8% cohabiting Area mean Carstairs a Gender split and age similar to national data Females significantly older Similar cohabitation status and area deprivation by gender a. Carstairs index of deprivation quintiles, (1991); *p<0.05

17 RESULTS Research question 4 What differences existed by type of hospital for suicide rates after last discharge?

18 Results: Deaths by suicide Scotland Table 4: Last recorded discharge from general or psychiatric hospital prior to suicide Category of discharge All (%) Suicide within 1 month of discharge Suicide within 1 year of discharge Last discharge psychiatric 2412 (15%) 707 (31%) 1783 (30%) hospital Last discharge general 8744 (53%) 1564 (69%) 4066 (70%) hospital No prior hospital records 5255 (32%) - - Sub-totals (100%) 2271 (14%) (100%) 5849 (36%) (100%) 14% & 36% of all suicides occurred within 1month & 1year of hospital discharge, respectively. More than 2/3 rds of these were after discharge from general hospital 1/5 th with hospital records died by suicide within one month discharge* and more than a half (52%) within one year of discharge** *=2271/ 11156; **=5849/11156

19 RESULTS Of all deaths occurring within 1m or 1y of discharge, >2/3 rd s of them followed from general hospital Raised additional research questions. 5. What psychiatric morbidity had been recorded at last visit or at any time previously?

20 Results: Table 5: Psychiatric morbidity of those with last discharge from general hospital All (%) Suicide 1m of discharge Median time last discharge to death Psychiatric disorder a recorded at last hospital visit 1188 (14%) 271 (17%) 5 months Previous psychiatric disorder a recorded but not at last visit No psychiatric disorder a recorded at any time in lifetime 1899 (22%) 5657 (65%) Subtotals 8744 (100%) 550 (35%) 743 (48%) 1564 (100%) 5 months 27 months - 14% had a recorded psychiatric diagnosis at last visit 22% no psychiatric diagnosis at last visit but did have a prior diagnosis The median time to death was much shorter for those with psych diagnosis recorded at ANY time a psychiatric diagnoses broadly equate to codes ICD 9 & Chapter F, ICD 10

21 RESULTS Of all deaths occurring within 1m or 1y of discharge, >2/3 rd s of them followed from general hospital Prompted additional research questions 6. What proportion of the last general hospital episodes could have been for self-harming behaviour? Almost half (46%; n=3984) of people last discharged from general hospital had a recorded diagnosis of injury or poisoning More than half were younger men (15-45y), by far the largest category

22 Summary: Clinical findings 1. In 30 years, 1/5 th of deaths by suicide occurred within one month of hospital discharge. 2. >2/3 rds of deaths within one month of discharge were from general hospital; 1/3 rd from psychiatric hospital. 3. Almost half of all last discharged from general hospital had a diagnosis of injury or poisoning ; by far the biggest category were younger men. 4. >2/3 rds who die by suicide have at least one hospital record, leaving about 1/3 rd who do not. These data do not include A&E attenders - likely to be conservative estimates.

23 Summary: Implications for practice? 1. Suicide prevention activity within general hospital settings deserve more attention: Previous psychiatric history is highly relevant There is indicated need for better information flow between secondary and primary care. 2. There also remains a need to focus on community/ primary care prevention activity Implications for research: Further research to identify risk factors post-discharge is required. Further insights could be gained with detailed examination of other main diagnoses e.g. Cancer, CHD Exploring differences along the timespan of the study

24 THANK YOU University of Stirling: Paul Lambert, Margaret Maxwell, Alison Dawson National escience Centre: Richard Sinnott, Susan McCafferty, John Watt NHS Information Services Division: Anthea Springbett, Carole Morris, David Clarke National Records of Scotland: Frank Dixon Nadine Dougall Lecturer NMAHP Research Unit University of Stirling