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JAMA psychiatry. 2025 Apr 9. doi: 10.1001/jamapsychiatry.2025.0325 Q122.52024

Clinician Suicide Risk Assessment for Prediction of Suicide Attempt in a Large Health Care System

临床医生自杀风险评估在大型医疗保健系统中预测自杀企图的风险 翻译改进

Kate H Bentley  1  2, Chris J Kennedy  1  2, Pratik N Khadse  1, Jasmin R Brooks Stephens  1, Emily M Madsen  1  3, Matthew J Flics  1, Hyunjoon Lee  1  3  4, Jordan W Smoller  1  2  3, Taylor A Burke  1  2

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作者单位

  • 1 Center for Precision Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston.
  • 2 Department of Psychiatry, Harvard Medical School, Harvard University, Boston, Massachusetts.
  • 3 Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston.
  • 4 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
  • DOI: 10.1001/jamapsychiatry.2025.0325 PMID: 40202745

    摘要 中英对照阅读

    Importance: Clinical practice guidelines recommend suicide risk screening and assessment across behavioral health settings. The predictive accuracy of real-world clinician assessments for stratifying patients by risk of future suicidal behavior, however, remains understudied.

    Objective: To evaluate routine clinical suicide risk assessment for prospectively predicting suicide attempt.

    Design, setting, and participants: This electronic health record-based, prognostic study included 89 957 patients (≥5 years of age) with a structured suicide risk assessment (based on the Suicide Assessment Five-step Evaluation and Triage framework) that was documented by 2577 clinicians during outpatient, inpatient, and emergency department encounters at 12 hospitals in the Mass General Brigham health system between July 2019 and February 2023.

    Main outcomes and measures: The primary outcome was an emergency department visit with a suicide attempt code recorded in the electronic health record within 90 days or 180 days of the index suicide risk assessment. The predictive performance of suicide risk assessments was evaluated on a temporal test set first using stratified prevalence (clinicians' overall risk estimates from a single suicide risk assessment item indicating minimal, low, moderate, or high risk) and then using machine learning models (incorporating all suicide risk assessment items).

    Results: Of the 812 114 analyzed suicide risk assessments from the electronic health record, 58.81% were with female patients and 3.27% were with patients who were Asian, 5.26% were Black, 3.02% were Hispanic, 77.44% were White, and 11.00% were of Other or Unknown race. After suicide risk assessments were conducted during outpatient encounters, the suicide attempt rate was 0.12% within 90 days and 0.22% within 180 days; for inpatient encounters, the rate was 0.79% within 90 days and 1.29% within 180 days; and for emergency department encounters, the rate was 2.40% within 90 days and 3.70% within 180 days. Among patients evaluated during outpatient encounters, clinicians' overall single-item risk estimates had an area under the curve (AUC) value of 0.77 (95% CI, 0.72-0.81) for 90-day suicide attempt prediction; among patients evaluated during inpatient encounters, the AUC was 0.64 (95% CI, 0.59-0.69); and among patients evaluated during emergency department encounters, the AUC was 0.60 (95% CI, 0.55-0.64). Incorporating all clinician-documented suicide risk assessment items (87 predictors) via machine learning significantly increased the AUC for 90-day risk prediction to 0.87 (95% CI, 0.83-0.90) among patients evaluated during outpatient encounters, 0.79 (95% CI, 0.74-0.84) among patients evaluated during inpatient encounters, and 0.76 (95% CI, 0.72-0.80) among patients evaluated during emergency department encounters. Performance was similar for 180-day suicide risk prediction. The positive predictive values for the best-performing machine learning models (with 95% specificity) ranged from 3.6 to 10.1 times the prevalence for suicide attempt.

    Conclusions and relevance: Clinicians stratify patients for suicide risk at levels significantly above chance. However, the predictive accuracy improves significantly by statistically incorporating information about recent suicidal thoughts and behaviors and other factors routinely assessed during clinical suicide risk assessment.

    Keywords:prediction of suicide attempt; health care system

    重要性:临床实践指南建议在行为健康环境中进行自杀风险筛查和评估。然而,现实世界中临床医生的评估在根据未来自杀行为的风险对患者进行分层方面的预测准确性仍然研究不足。

    目的:评估常规临床自杀风险评估对未来自杀企图的前瞻性预测能力。

    设计、设置和参与者:这项基于电子健康记录的研究包括在麻省总医院布里格姆医疗系统12家医院的门诊、住院和急诊科就诊期间,由2577名临床医生对89,957名患者(≥5岁)进行结构化自杀风险评估。该研究涵盖了从2019年7月至2023年2月的时间段。

    主要结果指标:主要结局是在索引自杀风险评估后的90天或180天内,急诊科就诊时在电子健康记录中记录有自杀企图代码。使用分层流行率(单一自杀风险评估条目指示的临床医生整体风险估计:极低、低、中等和高风险)以及机器学习模型(纳入所有自杀风险评估项目),对自杀风险评估的预测性能进行了评价。

    结果:在从电子健康记录分析的812,114项自杀风险评估中,58.81%是女性患者,3.27%为亚裔、5.26%为非裔、3.02%为西班牙裔、77.44%为白人,其余11.00%为其他或未知种族。在门诊就诊后进行自杀风险评估的患者中,90天内的自杀企图率为0.12%,180天内为0.22%;住院期间的自杀企图率分别为90天内0.79%和180天内1.29%;急诊科就诊后的自杀企图率分别为90天内2.40%和180天内3.70%。在门诊评估患者中,临床医生的整体单一项目风险估计值对90天内的自杀企图预测的曲线下面积(AUC)为0.77(95%CI, 0.72-0.81),住院评估患者的AUC为0.64(95% CI, 0.59-0.69),急诊科就诊时评估患者的AUC为0.60(95% CI, 0.55-0.64)。通过机器学习纳入所有临床医生记录的自杀风险评估项目(87个预测因子)显著提高了门诊患者、住院患者和急诊患者在90天内的风险预测AUC,分别为0.87 (95% CI, 0.83-0.90)、0.79 (95% CI, 0.74-0.84) 和 0.76(95%CI, 0.72-0.80)。对于180天自杀风险预测,表现类似。最有效的机器学习模型(具有95%特异性)的阳性预测值范围从自杀企图流行率的3.6倍到10.1倍。

    结论和意义:临床医生能够根据自杀风险对患者进行分层,其水平显著高于随机猜测。然而,通过统计方法纳入近期自杀想法和行为以及在临床自杀风险评估中常规评估的其他因素的信息,可以显著提高预测准确性。

    关键词:临床医生自杀风险评估; 自杀企图预测; 卫生保健系统

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    期刊名:Jama psychiatry

    缩写:JAMA PSYCHIAT

    ISSN:2168-622X

    e-ISSN:2168-6238

    IF/分区:22.5/Q1

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