1. Linking Data to Understand Veteran Suicide and Direct Effective Prevention Programs Claire Hoffmire, PhD Department of Veterans Affairs VISN2 Center of Excellence for Suicide Prevention

2. VETERANS HEALTH ADMINISTRATION Suicide Mortality Surveillance: The Cornerstone of Suicide Prevention Effective surveillance systems: – Inform the development of targeted prevention strategies that have the potential to meaningfully reduce suicide burden – Help to evaluate the impact of existing and newly implemented prevention programs. National suicide surveillance systems: – National Violent Death Reporting System (NVDRS) – NDI – VA State Mortality Project National priority to improve suicide surveillance – 2012 National Strategy for Suicide Prevention goal “Increase the timeliness and usefulness of national surveillance systems relevant to suicide prevention and improve the ability to collect, analyze, and use this information for action.”

3. National Average: 11.44/100,000 Data obtained from WISQARS Fatal Injury Reports: http://www.cdc.gov/injury/wisqars

4. NVDRS Coverage

6. VETERANS HEALTH ADMINISTRATION Suicide among U.S. Veterans Percentage of all Suicides Identified as Veterans 6

7. VETERANS HEALTH ADMINISTRATION Estimated Number of Veterans Who Die From Suicide Each Day 7

8. VETERANS HEALTH ADMINISTRATION The State Mortality Data Project “The Department of Veterans Affairs believes that a comprehensive suicide prevention program requires timely and accurate information beyond that acquired from it’s internal patient population.” – 2012 Suicide Data Report – Overcome delay’s associated with national mortality data – Accurately identify true Veterans – Understand suicide among all Veterans – Evaluate differences and changes in outcomes among VHA utilizing Veterans A State-VA Collaborative Project – In 2010 VA Secretary Shinseki requested collaboration and support from all U.S states – Data on all known suicides reported from 1999 through 2015 – Will be used, in part, to fulfill Public Law 111.163 to determine the number of Veterans who died from suicide 1999-2009

9. VETERANS HEALTH ADMINISTRATION Project Status: May 2013 Data Requested from death certificates – SSN, Name, DOB, DOD, Age, Sex, Race/ethnicity, Marital status, Education, ICD-10 Cause of death, State & County of residence, County of death, Veteran Status, Industry, occupation Project Barriers – Inconsistent availability of requested information in all states – State barriers to providing non-resident data – State preference to provide de-indentified data due to conflicting interpretation of Social security laws

10. Project Status * * * * * In Negotiation

11. VETERANS HEALTH ADMINISTRATION Linking to VA Data Validation of Veteran Status – Partnership with the DOD to accurately identify all Veterans – Preliminary evidence indicates that death certificate misclassification exists – Improve comparison of Veterans to non-Veterans Identification of VHA service utilization – Directly compare VHA & non-VHA Veterans for the first time – Medical information also available for VHA users Inclusion of state data in suicide mortality repositories – VA Suicide Data Repository State records, annual VA NDI all-cause search, SPAN, VCL, expanded VA-DoD NDI search – VA-DoD collaborative Data Repository VA-DoD NDI search, limited DoD service record, DoDSER

12. VETERANS HEALTH ADMINISTRATION Comparing SDR to National Suicide Surveillance Efforts State Mortality Project NDINVDRS Nationally Representative XX Veteran Identification X (validated) X (misclassification exists) X (misclassification exists) Health Information X (VHA Veterans) X (Family/friend reported) Circumstantial Information X (limited) X (Family/friend reported) Time LagDetermined by states 2-3 years18-24 months

13. VETERANS HEALTH ADMINISTRATION State Mortality Project Preliminary Findings: Death Certificate misclassification of Veteran status 1999-2008 overall Sensitivity Estimates Males: 90% Females: 68% 18-39 years: 84% 40-64 years: 92%

14. VETERANS HEALTH ADMINISTRATION The Veteran population is changing 14

15. VETERANS HEALTH ADMINISTRATION Joining Forces to Save Lives: Why initiate or continue State-VA Partnerships? The Veteran population is changing making accurate and timely surveillance of Veteran suicide mortality more critical than ever Veterans make up nearly 20% of all suicide decedents – Nearly 8,000 Veterans die by suicide every year – In the next 5 years, the NAASP set a goal to save 20,000 lives = 4,000 lives annually Partnering with the VA can greatly improve the accuracy of Veteran status reporting on death certificates Coverage far exceeds that of NVDRS and can inform its expansion VA and DoD can add critical information to inform prevention VA Secretary Shinseki has requested the help of State Health Departments to improve our understanding of Veteran suicide and save lives

16. VETERANS HEALTH ADMINISTRATION State suicide death certificates VA-DOD NDI search The Ultimate Goal: Identify all Veteran Suicides All Veteran Suicides VHA Veterans We’re working together to close this gap!

17. VETERANS HEALTH ADMINISTRATION Acknowledgements Jan Kemp, RN, PhD – VA National Mental Health Program Director Robert Bossarte, PhD – Acting Associate Director, COE Kenneth Conner, PsyD, MPH – Director, COE Rebecca Piegari, MS – Statistician, COE Brady Stephens, MS – Statistician, COE Heather Shaw, BS – Research Assistant, COE Janet McCarten, PhD – Health Science Specialist, COE Participating State Health Department POCs