Patterns of health service use in the last year of life among those who died by suicide

A significant proportion of people who die by suicide have contact with the health system in their last year of life. These contacts points provide a potential touch point for suicide prevention activities. As Clapperton et al. (2021) argue, many prevention activities focus on people who access hospitals. However, Clapperton et al. (2021) also show significant proportions of people who die by suicide (particularly men) do not attend hospitals in their last year of life. It is important to focus not just on people who use services but also on people who do not access services.

Through this project we have used the National Integrated Health Services Information Analysis Asset (NIHSI AA) version 0.5 to look at patterns of health service use in the last year of life for people who have died by suicide. The main value add of this project, compared to earlier studies, comes from fact that the NIHSI AA includes both Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data. This is an important distinction as we show that people who die by suicide are considerably more likely to access MBS and PBS services in their last year of life than hospital services. 

While this project provides the most comprehensive analysis of health service use in the last year of life for people who die by suicide it does have some important limitations. First the NIHSI AA does not include all health services. For example, it does not include community or residential mental health services. Second the emergency department (ED) data in the NIHSI AA does not identify intentional self-harm well as intentional self-harm is not identified well in ED data in most States and Territories (AIHW 2022a).  

An additional limitation of this analysis relates to the fact that not all mental services under the MBS are billed as specific mental health items — some are billed under general GP items (AIHW 2022b). 

The project has been established to measure and compare the patterns of health service use of Australians in their last year of life.

Specifically, in this analysis we aim to:

  • measure the patterns of health service use in the last year of life
  • identify key factors related to variation in the patterns of health service use in the last year of life such as age and sex.

Using linked datasets including the National Deaths Index, National Hospital Morbidity Database, National Non-admitted Patient Emergency Department Care Database, MBS and PBS, the NIHSI AA presents descriptive statistics to answer the research questions. While the MBS and PBS databases include national data, hospital data pertains to only New South Wales, Victoria (excluding Albury-Wodonga), South Australia and Tasmania public hospitals within the NIHSI AA v0.5. Admitted patient information also contains information from private hospitals in Victoria. To ensure accurate comparisons with hospitals data, only deaths registered in these jurisdictions are included in the analysis.

The analysis population was those who had died between 1 July 2010 and 31 December 2017 in the linked National Deaths Index. Only people whose age at death was between 15 to 64 years were included in the analysis. This was due to people in this age range making up the majority of those who die from suicide and to allow for better comparisons with deaths from other causes, which mostly occur in people older than 65 (AIHW 2022c). In the analysis population, people aged 15­­­–64 years represented 82% of suicides (10,013 suicide deaths).

For further information on the dataset and methods used, visit Technical notes – Data sources.

People who died by suicide accessed fewer health services in their last year of life than those who died from other causes

Overall, 49% of 15–64 year olds who died by suicide did not have any contact with the hospital (emergency department (ED) presentation or hospital separation), compared to 24% who died by other causes. This is similar to results from Clapperton et al. (2021), who found that 50% of people who died by suicide in Victoria did not have any ED presentations or hospital separations in their last year of life, using data from the Victorian Suicide Register and including all age groups. 

In addition to looking at overall access to hospitals it is also worth exploring access to individual services and how access to these services vary by age and sex.

  • Females (59%) who died by suicide were considerably more likely than males to attend hospital for any reason in their last year of life than men (48%).  There is also variation by age and sex with females aged 34–44 being the most likely to attend hospital (61%) and males aged 55–64 being the least likely to attend (45%).
  • Females (53%) were more likely than males to attend an emergency department for any reason in their last year of life than males (44%). The highest rate was for females aged 25–34 (56%) while the lowest rate is for males aged 55–64 (39%).
  • 9% of females and 6% of males who died by suicide had a mental health related ED presentation in their last year of life.
  • While it is not possible to identify intentional self-harm ED presentations in the NIHSI AA it is possible to identify intentional self-harm ED presentations in Victoria. Clapperton et al. (2021) found that the vast majority of both males (92%) and females (84%) who died by suicide did not attend hospital for intentional self-harm in their last year of life as either an admitted patient or in an emergency department.
  • A higher proportion of females (47%) who died by suicide were an admitted patient in hospital in their last year of life than males (32%). The highest proportion was for females aged 45–54 (49%) while the lowest proportion was for men aged 15–24 (26%).
  • Only 13% of women and 6% of men who died by suicide were an admitted patient in hospital for intentional self-harm in their last year of life.
  • Females (30%) who died by suicide were more likely than males (19%) to have had a mental health hospitalisation (this excludes ED presentations) in their last year of life.
  • Both females (90% v 59%) and males (79% v 48%) who died by suicide were considerably more likely to have used MBS services than hospital services in their last year of life.
  • Females who died by suicide (57%) were considerably more likely to have used MBS mental health services than males (37%) in their last year of life.
  • Females (71%) who died by suicide were also more likely than males (50%) to have had a PBS mental health prescription in their last year of life.

The interactive data visualisation shows the proportion of health services used in the last year of life for people who died by suicide and for people who died by other causes. The service type can also be selected. It is displayed by age group from 15-64 and sex for deaths between 1 July 2010 and 31 December 2017.

Of those who died from suicide from 1 July 2010 and 31 December 2017:

  • 11% did not access any of the health services analysed in their last year of life
  • Over 1 in 10 males (13%) who died by suicide did not access a service in their last year of life. Males were less likely to have accessed any services than females in every age group.
  • Overall, younger age groups and males had higher proportions of not accessing a service in their last year of life compared to older age groups and females.
  • Males aged 15–24 who died by suicide had the highest proportion of not accessing services in their last year of life (19%), while females aged 55–64 years who died of other causes had the lowest proportion (2.6%).
  • Around 10% of females aged 15–24 who died by suicide did not use any of the health services analysed in their last year of life.

The data visualisation shows the amount of health services used in the last year of life for people who died by suicide and for people who died by other causes. It is displayed by age groups between 15-64 and sex for deaths registered between 1 July 2010 and 31 December 2017. For males and females of all age groups a higher percentage of services was used when the cause of death was not suicide.

People who died by suicide had more ED presentations in their last year of life than those who died by other causes

Of those who did access a health service in their last year of life, MBS and PBS services represented the highest proportion of services among those who died by either suicide or other causes. For those who died by suicide, the next most prevalent health service after MBS and PBS was ED presentations (3.8%) then hospital separations (2.4%).

  • Out of the four selected service groups, the proportion of ED presentations and hospital separations decreased in those who died by suicide with increasing age, for both males and females.
  • MBS services also decreased with increasing age among those who died by suicide. For instance, the proportion of MBS services out of the four selected service groups was 64% in females aged 15–24 and 47% in females aged 55–64.

The interactive data visualisation shows the type of health services used in the last year of life. The user can display the data by female, male or persons. Data is categorised by age groups from 15-64, causes of death by suicide and other causes of death and service type used between 1 July 2010 and 31 December 2017.

Young people who died by suicide had higher health service use than those who died by other causes

Suicide is the leading cause of death among people aged 15–44, while chronic diseases feature more prominently among people aged 45 and over. In general people who die by suicide are younger than people who die by other causes (AIHW 2022c). This is reflected in these data for health service use. For example, among those who died by suicide and had any hospital contact in last year of life (including ED), 59% of those hospital contacts were in the 15–44 age group, compared to 17% of the same age who died of other causes. Most people who died by other causes and had a hospital contact were aged 45–64 (83%). Any mental health, suicidal ideation or intentional self-harm hospitalisations or ED mental health presentations also follow this pattern.

  • Of those who presented to ED and died from suicide, one quarter (25%) were people aged 35–44, whereas only 11% of those who presented to ED and died from other causes were in this age group.
  • Out of those who died by suicide, the average number of services per person for any mental health MBS services was higher than for those who died by other causes, across all age groups.
 

The interactive data visualisation shows health services used in last year of life for those that died by suicide or other causes, by age group for deaths between 1 July 2010 and 31 December 2017. The user can display the data by measure (proportion of people, proportion of services, average number of services per person), sex (males, females, persons) and service type used.

A higher proportion of health services occurred in the month prior to death

Among those who died by suicide, the highest proportion of hospital contacts (ED or hospital separation) occur 1 month prior to death (18%), out of a 12 month period. This might indicate increased risk following the use of some services. However, the average number of services is similar across all months meaning that those who did receive a service one month prior to death did, on average, not attend more often than in previous months. Note that in this analysis, people who died in hospital or during their ED presentation were excluded to capture their service use prior to death, except for those who had an intentional self-harm diagnosis during their episode of care (see Technical notes – Data sources for an explanation on analytical method used).

Per person, of those who died by suicide:

  • The average number of any MBS mental health or mental health treatment plan service is higher than those who died from other causes between 12 months and 1 month prior to death.
  • The average number of any MBS service decreases sharply between 3 months prior to death and 1 month prior to death, while remaining somewhat steady in those who died from other causes.

The interactive data visualisation shows service use in the 12 months leading up to death. Users can display data by measure (proportion of people, proportion of services, average number of services per person), sex (males, females, persons) and service type. Most health services occur in the month prior to death.

Among those who died by suicide:

  • The cumulative total proportion of ED mental health presentations in the lead up to death is lower than those who died from other causes between 12 to 2 months prior to death, indicating lower service usage until 1 month prior to death.
  • The cumulative total proportion of any MBS service is lower than those who died by other causes between 12 to 1 month/s prior to death.

The interactive data visualisation shows the cumulative service use by sex and cause of death in the 12 months leading up to death. Users can display data by sex and service type.

The AIHW will undertake further analysis on these data including multivariate modelling. While these data are informative more insights can be gained by looking at how the use of these various health services compares to the population in general. For example, while the majority of people who die by suicide did not have a mental health hospitalisation in their last year of life they are considerably more likely to have done so than the population in general.

Australian Institute of Health and Welfare (AIHW) (2022a) Suicide and self-harm monitoring: Intentional self-harm hospitalisations, AIHW, Australian Government, accessed 14 October 2022.

Australian Institute of Health and Welfare (2022b) Mental health services in Australia, AIHW, Australian Government, accessed 09 September 2022.

AIHW (2022c) Deaths in Australia, AIHW, Australian Government, accessed 13 September 2022.

AIHW (2021) Suicide & self-harm monitoring: Social factors and deaths by suicide, AIHW, Australian Government, , accessed 01 February 2022.

Clapperton A, Dwyer J, Millar C, Tolhurst P and Berecki-Gisolf J (2021) ‘Sociodemographic characteristics associated with hospital contact in the year prior to suicide: A data linkage cohort study in Victoria, Australia’, PLoS ONE, 16(6): e0252682, doi:10.1371/journal.pone.0252682.