From 17 years to 17 months: Implementation of suicide risk assessment

Translating study findings into practice often involves long delays.

Dr. Greg Simon discusses the fast uptake of a new system for predicting patients’ suicide risk, arising from work by the Mental Health Research Network.

By Greg Simon, MD, MPH, senior investigator, Kaiser Permanente Washington Health Research Institute and psychiatrist, Washington Permanente Medical Group

Many a paper about improving the quality of health care begins by lamenting the apocryphal 17-year delay from research to implementation.  The original evidence for that much-repeated 17-year statistic is pretty thin: a single table published in a relatively obscure journal.  But the 17-year statistic is frequently cited because it quantifies a widely recognized problem.  Long delays in the implementation of research evidence are the norm throughout health care.

Given that history, I’ve been especially proud of the health systems in our Mental Health Research Network (MHRN) for their rapid and energetic implementation of suicide prevention programs.  Last month, Kaiser Permanente Washington started implementing MHRN-developed suicide risk prediction models.  Therapists and psychiatrists at our Capitol Hill Mental Health clinic in Seattle now see pre-visit alerts in the electronic health record for patients who are at high risk of a suicide attempt over the next 90 days.  Implementation started only 17 months—not 17 years—after we published evidence that those models accurately predict short-term risk of suicide attempt or suicide death.

I certainly have experience developing other evidence-based interventions that are still waiting for robust uptake—some for longer than 17 years.  For those interventions, our published papers, PowerPoint presentations, and impressive p-values never prompted much action.  Our experience with suicide risk prediction models has been almost the opposite: Health system leaders are pushing for faster implementation.  For months we’ve received frequent queries from regional and national Kaiser Permanente leaders: “When are you rolling out those risk prediction scores in our clinics?” 

In the middle of celebrating Kaiser Permanente’s rapid implementation of risk prediction models, I learned that our colleagues at HealthPartners were three months ahead of us.  I hadn’t realized that health plan care managers at HealthPartners have been using MHRN risk prediction scores to identify people at high risk for suicidal behavior since July.  In true Minnesota fashion, they just did the right thing with no boasting or fanfare.  Reducing the publication-to-implementation gap from 17 years to 14 months doesn’t have quite the same poetic symmetry as reducing it to 17 months.  But I’ll take faster progress over poetic symmetry.

Why did we see so little delay in our health systems’ implementation of suicide risk prediction models and other suicide prevention programs? 

In part, it’s because the model, which analyzes data from electronic health records along with results from standardized depression questionnaires, is relatively easy to implement and can deliver substantial benefits: The findings we published last year in American Journal of Psychiatry showed that patients whom the model identified as being in the highest 1 percent of predicted risk were 200 times more likely to attempt suicide.

Equally important, we didn’t need to do any marketing to create demand for this suicide prevention program.  Health system leaders had highlighted the priorities and problems needing solutions.  The specific demand regarding risk prediction models was clear:  The questionnaire providers had been using to identify suicide risk was the best available tool,  but we wanted something better.  To overcome the tool’s limitations, clinicians and health system leaders asked:  Can you improve on this?  We weren’t telling health system leaders what we thought they needed.  We were trying to build what they told us they needed.

When I now hear researchers or intervention developers lament the 17-year delay, I ask myself how that complaint might sound in some other industry.  I imagine giving this report to a board of directors: “We developed and tested an innovative product that our customers really should want.  We’ve spent 17 years getting the word out, but our market share is still trivial.  What’s wrong with our customers?”  I doubt the board of directors would say, “Let’s keep doing the same thing!”  Instead, they’d probably ask, “What are our customers trying to tell us about what they need?”

What’s heartening to me is that the MHRN and our health systems are now moving quickly to put in place proven evidence-based strategies. We are producing bigger studies in less time, and I’m confident that clinicians and administrators are ready to put what we’ve learned to use. I can imagine a time in the near future when clinicians and researchers lament a 17-month wait. Why not 17 weeks?