Frequency of Clinicians’ Assessments for Access to Lethal Means in Persons at Risk for Suicide

Abstract

Objective

We measured the frequency of clinicians’ assessments for access to lethal means, including firearms and medications in patients at risk of suicide from electronic medical and mental health records in outpatient and emergency settings.

Methods

We included adult patients who reported suicide ideation on the PHQ-9 depression screener in behavioral health and primary care outpatient settings of a large integrated health system in the U.S. and those with suicidal behavior treated in the emergency department. Two separate natural language processing queries were developed on medical record text documentation: (1) assessment for access to firearms (8,994 patients), (2) assessment for access to medications (4,939 patients).

Results

Only 35% of patients had documentation of firearm or medication assessment in the month following treatment for suicidal behavior in the emergency setting. Among those reporting suicidal ideation in outpatient setting, 31% had documentation of firearm assessment and 23% for medication assessment. The accuracy of the estimates was very good for firearm assessment (F1 = 89%) and medication assessment in the outpatient setting (F1 = 91%) and fair for medication assessment in the emergency setting (F1 = 70%) due to more varied documentation styles.

Conclusions

Lethal means assessment following report of suicidal ideation or behavior is low in a nonacademic health care setting. Until health systems implement more structured documentation to measure lethal means assessment, such as discrete data field, NLP methods may be used to conduct research and surveillance of this important prevention practice in real-world settings.

Keywords:

• Electronic health records
• firearms
• lethal means
• natural language processing
• suicide

ACKNOWLEDGMENTS

We would like to thank Rachel Kramer, M. A. for assisting with editing and formatting of this manuscript for publication. Additionally, we would like to thank Christopher Lawton, B. A. who assisted with chart reviews for the medication access assessment NLP query.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

AUTHOR CONTRIBUTIONS

Dr. Boggs developed the grant proposal, led the work to develop and test the NLP queries for lethal means assessment, conducted chart reviews for the firearm query and drafted the manuscript. Ms. Quintana organized the study team, tracked the budget, and performed chart reviews for the firearm and medication queries. Mr. Powers completed all of the data programing including selection of the cohort and NLP query development. Mr. Hochberg is a licensed mental health provider with several years’ experience working within the health system studies. He provided input on terms to watch for to identify lethal means assessment and provided and assisted with interpretation of unclear documentation. Dr. Beck oversaw the project and assisted with communicating results to key stakeholders. All authors reviewed the final manuscript and provided input.

DATA AVAILABILITY

The Python code for the natural language processing queries is included in the supplemental appendix. The electronic health record source data is not available to the public due ethical and legal protections of identifiable medical and mental health treatment information.

Additional information

Funding

This research was supported in part by an internal pilot grant program – Strategic Allocation of Resources Committee – Kaiser Permanente Colorado.

Notes on contributors

Jennifer M. Boggs

Jennifer M. Boggs, LeeAnn M. Quintana, J. David Powers, Steve Hochberg, and Arne Beck, Institute for Health Research, Kaiser Permanente Colorado, Aurora CO, USA

LeeAnn M. Quintana

Jennifer M. Boggs, LeeAnn M. Quintana, J. David Powers, Steve Hochberg, and Arne Beck, Institute for Health Research, Kaiser Permanente Colorado, Aurora CO, USA

J. David Powers

Jennifer M. Boggs, LeeAnn M. Quintana, J. David Powers, Steve Hochberg, and Arne Beck, Institute for Health Research, Kaiser Permanente Colorado, Aurora CO, USA

Steve Hochberg

Jennifer M. Boggs, LeeAnn M. Quintana, J. David Powers, Steve Hochberg, and Arne Beck, Institute for Health Research, Kaiser Permanente Colorado, Aurora CO, USA

Arne Beck

Jennifer M. Boggs, LeeAnn M. Quintana, J. David Powers, Steve Hochberg, and Arne Beck, Institute for Health Research, Kaiser Permanente Colorado, Aurora CO, USA