State Variation in Long-Term Care Availability, Regulation, and Cost and Suicide Mortality Among Older Adults in the United States: 2010–2015

  • Matthew C. Lohman
    Address correspondence to Matthew Lohman, PhD, Department of Epidemiology and Biostatistics, University of South Carolina, Arnold School of Public Health, 915 Greene St, Rm 454, Columbia, SC 29208.
    Department of Epidemiology and Biostatistics, University of South Carolina, Arnold School of Public Health, Columbia, SC, USA
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  • Tomohiro M. Ko
    Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA

    Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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  • Ashley Rapp
    Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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  • Erica Bennion
    Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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  • Briana Mezuk
    Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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      Residential long-term care (LTC) facilities may be key settings for the prevention of suicide among older adults; however, little is known about the relationship between statewide policies determining characteristics of LTC facilities and suicide mortality. The primary goal of this study was to evaluate the association between state policies regarding availability, regulation, and cost of LTC and suicide mortality among adults aged 55 and older in the United States over a 5-year period.


      Longitudinal ecological study.

      Setting and Participants

      LTC residents from 16 states reporting mortality data to the National Violent Death Reporting System (NVDRS) from 2010 to 2015.


      We linked suicide data from the NVDRS and data sources on LTC services and regulations for 16 states. We applied a natural language-processing algorithm to identify suicide deaths related to LTC. We used fixed effect regression models to assess whether state variation in LTC characteristics is related to variation in the rate of suicide (both overall and related to LTC) among older adults.


      There were 25,040 suicides among those aged 55 and older reported to the NVDRS during the study period; 382 suicides were determined to be associated with LTC in some manner. After adjusting for state-level characteristics, greater average nursing home capacity was significantly associated with increase in the cumulative incidence of suicide related to LTC (β = 0.087, SE = 0.026, P < .01), but not overall suicide incidence. Neither cost nor regulation measures were significantly associated with state-level LTC-related suicide incidence.

      Conclusions and Implications

      State-level variations in LTC facility capacity are related to variation in LTC-related suicide incidence among older adults. Given the challenges of preventing suicide among older adults through facility- or individual-level interventions, policies governing the features and provision of LTC services may therefore serve as a means for public health suicide prevention.


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