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Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder

Veterans account for 18% of all US deaths by suicide and are at 21% greater risk for death by suicide than members of the general population. As a result, VA identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. Per VA policy, patients with new suicide risk flags are expected to have weekly clinical contacts during the first month after PRF initiation, with monthly visits encouraged thereafter. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among 474,946 VA patients who received a substance use disorder (SUD) diagnosis in FY2012. Substance use disorders are of particular interest because the rate of suicide among Veterans with an SUD is the third-highest among psychiatric disorders, and Veterans with opioid use disorders are at even greater risk. Using VA administrative data, investigators assessed both short-term (3 months) and longer-term (12 months) healthcare use before and after PRF initiation. They also identified demographic (i.e., age, race, engagement in OEF/OIF, homeless status, and service-connected disability) and clinical characteristics (i.e., mental health, SUD, suicide-related and pain diagnoses, and medical comorbidity) predictive of new PRF initiation.


  • Consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2.3 and 4.1 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one.
  • ED visits decreased by 45% in the three months following initiation of a PRF.
  • Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses.


  • Suicide risk PRFs in an electronic medical record and subsequent follow-up are feasible in diverse healthcare systems and increased service use for those Veterans with flags initiated.


  • Activation of a flag is based on clinician judgment and may vary regionally or by individuals initiating such flags.
  • Data on suicides or suicide attempts, as well as on flag continuation or removal following PRF activation were unavailable for analysis, preventing examination of the impact of increased healthcare utilization on these specific outcomes.

This study was partly funded by HSR&D. Dr. Hawkins and Ms. Malte are part of HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care.

PubMed Logo Berg J, Malte C, Reger M, and Hawkins E. Medical Records Flag for Suicide Risk: Predictors and Subsequent Use of Care among Veterans with Substance Use Disorders. Psychiatric Services. June 8, 2018; Epub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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