Oregon Veteran Combat Status: Collection, Quality, and Analysis Vivian Siu, MPH, MURP Mortality Research Analyst Center for Health Statistics Oregon Public Health Division

Overview Oregon 2011 HB3611 Data collection and initial outreach Data quality and assurance Data analysis Future Plans

2011 Oregon’s HB 3611 If a decedent’s death was caused by suicide, the person who submits the death certificate to the county registrar or to the Center for Health Statistics, or as otherwise directed by the State Registrar of the Center for Health Statistics, shall make reasonable efforts to ascertain and shall notify the center through the electronic death certificate system: Whether the decedent was a veteran; and If the decedent was a veteran, whether the decedent served in combat and, if so, where the decedent served.

Data Collection – Oregon Center for Health Statistics Added two questions in death certificate Collect responses for ALL death records Timing: demographic information and manner of death Useful in comparing the occurrence among groups Only appear in Electronic death system, not paper records. Require submitting supplemental forms if paper filing.

Veteran Status Question Death Certificate include question on veteran status. Ever in US Armed Forces? U.S. Standard Certificate of Death

New Questions on OVERS (Oregon’s EDRS)

Initial Outreach Measures Letter about law change Four death newsletters – updates Instructional materials Worksheets Reference Lists Supplemental Forms Instructional documents and video http://1.usa.gov/SUIEFU Newsletter: August 2011, March 2012, August 2012, March 2013

Data Assurance and Control – Data Quality Early monitoring High percent of Unknown/Missing information Time point Percent Veteran’s Combat Status Unknown or Missing Early Feb, 2012 52.0% First Quarter 40.1% Second Quarter 36.7% Third Quarter 34.9% End of 2012 34.4%

Data Assurance and Control - Data Quality 2012 Veteran Status and Combat Status Data by Unknown and Missing Responses 2012 Response Veteran Status (% Total, n=15725) Combat Status (% Veterans, n=8740) Unknown 0.8% 33.8% Missing information N/A 0.6%

Each data point is a funeral home

Data Assurance and Control – Comparative Table Comparative table- funeral listing and performance over time

Data Assurance and Control – Suicide Focused Editing Identify individual record with missing or unknown information if manner of death was suicide. Registration Manager’s outreach: Funeral homes Individual cases

Registration Manager follow-up Why so many unknown/missing data? Questions not asked True unknown Individual calls for suicides cases 148 veteran suicide deaths 32 unknown combat status after follow up about 1/3 are actual unknowns 2/3 have to amend the death certificate Funeral home tone and attitude improved over time More cooperative

Data Analysis - Analytic Sample Analysis based on 2012 death data Population 18 years or older Male population Oregon residence and occurrence

Data Analysis- Death by Veteran Status, 2012

Data Analysis- Veteran Deaths by Combat Status, 2012

Combat Status and Suicide Deaths

Combat Status and Unintentional Injury Deaths

Combat Status and Homicide Deaths

Combat Status and Percent Suicide Deaths Related to Firearm

Combat Veterans by Combat Zone Percent Combat Vet. Deaths by… World War II (n=1582) Korea (n=589) Vietnam and Cold War Era Conflicts (n=666) Persian Gulf/ Afghanistan (n=42) Other or Unknown (n=141) Natural Causes 96.0% 95.9% 94.0% 50.0% 93.6% External Causes 4.0% 4.1% 6.0% 6.4%

Caution when analyzing or interpreting data Sex -- More male veterans than female veterans Age -- Age-adjustment Distribution of age -- Larger numbers of veterans in older age groups Cause of death -- Varies by age groups

Analysis Plan Multiple years data for more detailed summary in CHS annual report Confidentiality Improve confidence in statistical analysis Analyzed by the Injury Prevention Program Work with Oregon Department of Veterans’ Affairs

What can be done on Quality Assurance Continue follow-up of suicide deaths among veterans Future newsletters Regular automated reporting Prioritize resources- general vs. suicide deaths Goal setting Letters to specific funeral homes that did not improve over time.

Each data point is a funeral home

Cycle of collection, quality and analysis

Special Thank You Lisa Millet, Manager, Injury Prevention Section, Center for Prevention & Health Promotion Xun Shen, Epidemiologist, Injury Prevention Section, Center for Prevention & Health Promotion Jennifer Woodward, Oregon State Registrar, Center for Health Statistics, Center for Health Practice Joyce Grant-Worley, Manager, Statistics Unit, Center for Health Statistics, Center for Health Practice

Contact Vivian Siu, MPH, MURP vivian.w.siu@state.or.us (971) 673-1150 JoAnn Jackson, MBA Registration Manager and VSCP liaison Joann.jackson@state.or.us (971) 673-1160