Describing county-level clustering patterns of suicide among Veterans Health Administration patients and all American adults, 2018–2019, using exploratory spatial data analysis

A. R. Cunningham; V. Lebakula; A. G. Cosby; A. Kapadia; J. Trafton; A. Peluso

doi:10.1016/j.annepidem.2025.08.014

Describing county-level clustering patterns of suicide among Veterans Health Administration patients and all American adults, 2018–2019, using exploratory spatial data analysis

A. R. Cunningham, V. Lebakula, A. G. Cosby, A. Kapadia, J. Trafton, A. Peluso

Research output: Contribution to journal › Article › peer-review

Abstract

Purpose: Veterans account for 7 % of the adult American population but nearly 14 % of the country's adult suicides. With a distinct geodemographic profile, veterans represent an important subpopulation for spatial analysis, and their access to Veterans Health Administration (VHA) care can make them a uniquely reachable group for policy interventions and research. Better understanding of VHA patterns in context can inform prevention strategies. Methods: Hotspot analysis, a type of exploratory spatial data analysis (ESDA), was used to identify county-level clusters with high or low empirical Bayesian smoothed suicide rates among VHA patients in 2018–2019. A parallel analysis was conducted for all American adults. Clusters were then described using county-level characteristics previously linked to suicide prevalence. Results: Clusters among VHA patients and the general population often overlapped and shared similar features. Cold spots were associated with lower elevations, higher incomes, and higher education levels, whereas hotspots were associated with higher elevations. All cold spots in the general population and most clusters among VHA patients occurred in metropolitan areas, however VHA hotspots also occurred in metropolitan areas. Conclusions: Juxtaposing VHA and general adult ESDA results elucidates patterns of VHA suicides in context, highlighting spatial clusters as targets for interventions and research.

Original language	English
Pages (from-to)	148-153
Number of pages	6
Journal	Annals of Epidemiology
Volume	110
DOIs	https://doi.org/10.1016/j.annepidem.2025.08.014
State	Published - Oct 2025

Funding

This work was supported by the Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. This research used resources of the Knowledge Discovery Infrastructure at Oak Ridge National Laboratory, which is supported by the Office of Science of the U.S. Department of Energy under Contract No. DE-AC05–00OR22725 and the Department of Veterans Affairs Office of Health Informatics and by VA-DoD Joint Incentive fund under IAA No. 36C10B21M0005. Office of Science of the U.S. Department of Energy. This manuscript has been authored by UT-Battelle, LLC, under contract DE-AC05–00OR22725 with the US Department of Energy (DOE). The US government retains and the publisher, by accepting the article for publication, acknowledges that the US government retains a nonexclusive, paid-up, irrevocable, worldwide license to publish or reproduce the published form of this manuscript, or allow others to do so, for US government purposes. DOE will provide public access to these results of federally sponsored research in accordance with the DOE Public Access Plan (http://energy.gov/downloads/doe-public-access-plan)

Keywords

Exploratory spatial data analysis (ESDA)
Hotspot analysis
Suicide
Veterans Health Administration (VHA)

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10.1016/j.annepidem.2025.08.014

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title = "Describing county-level clustering patterns of suicide among Veterans Health Administration patients and all American adults, 2018–2019, using exploratory spatial data analysis",

abstract = "Purpose: Veterans account for 7 \% of the adult American population but nearly 14 \% of the country's adult suicides. With a distinct geodemographic profile, veterans represent an important subpopulation for spatial analysis, and their access to Veterans Health Administration (VHA) care can make them a uniquely reachable group for policy interventions and research. Better understanding of VHA patterns in context can inform prevention strategies. Methods: Hotspot analysis, a type of exploratory spatial data analysis (ESDA), was used to identify county-level clusters with high or low empirical Bayesian smoothed suicide rates among VHA patients in 2018–2019. A parallel analysis was conducted for all American adults. Clusters were then described using county-level characteristics previously linked to suicide prevalence. Results: Clusters among VHA patients and the general population often overlapped and shared similar features. Cold spots were associated with lower elevations, higher incomes, and higher education levels, whereas hotspots were associated with higher elevations. All cold spots in the general population and most clusters among VHA patients occurred in metropolitan areas, however VHA hotspots also occurred in metropolitan areas. Conclusions: Juxtaposing VHA and general adult ESDA results elucidates patterns of VHA suicides in context, highlighting spatial clusters as targets for interventions and research.",

keywords = "Exploratory spatial data analysis (ESDA), Hotspot analysis, Suicide, Veterans Health Administration (VHA)",

author = "Cunningham, \{A. R.\} and V. Lebakula and Cosby, \{A. G.\} and A. Kapadia and J. Trafton and A. Peluso",

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year = "2025",

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doi = "10.1016/j.annepidem.2025.08.014",

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T1 - Describing county-level clustering patterns of suicide among Veterans Health Administration patients and all American adults, 2018–2019, using exploratory spatial data analysis

AU - Cunningham, A. R.

AU - Lebakula, V.

AU - Cosby, A. G.

AU - Kapadia, A.

AU - Trafton, J.

AU - Peluso, A.

PY - 2025/10

Y1 - 2025/10

N2 - Purpose: Veterans account for 7 % of the adult American population but nearly 14 % of the country's adult suicides. With a distinct geodemographic profile, veterans represent an important subpopulation for spatial analysis, and their access to Veterans Health Administration (VHA) care can make them a uniquely reachable group for policy interventions and research. Better understanding of VHA patterns in context can inform prevention strategies. Methods: Hotspot analysis, a type of exploratory spatial data analysis (ESDA), was used to identify county-level clusters with high or low empirical Bayesian smoothed suicide rates among VHA patients in 2018–2019. A parallel analysis was conducted for all American adults. Clusters were then described using county-level characteristics previously linked to suicide prevalence. Results: Clusters among VHA patients and the general population often overlapped and shared similar features. Cold spots were associated with lower elevations, higher incomes, and higher education levels, whereas hotspots were associated with higher elevations. All cold spots in the general population and most clusters among VHA patients occurred in metropolitan areas, however VHA hotspots also occurred in metropolitan areas. Conclusions: Juxtaposing VHA and general adult ESDA results elucidates patterns of VHA suicides in context, highlighting spatial clusters as targets for interventions and research.

AB - Purpose: Veterans account for 7 % of the adult American population but nearly 14 % of the country's adult suicides. With a distinct geodemographic profile, veterans represent an important subpopulation for spatial analysis, and their access to Veterans Health Administration (VHA) care can make them a uniquely reachable group for policy interventions and research. Better understanding of VHA patterns in context can inform prevention strategies. Methods: Hotspot analysis, a type of exploratory spatial data analysis (ESDA), was used to identify county-level clusters with high or low empirical Bayesian smoothed suicide rates among VHA patients in 2018–2019. A parallel analysis was conducted for all American adults. Clusters were then described using county-level characteristics previously linked to suicide prevalence. Results: Clusters among VHA patients and the general population often overlapped and shared similar features. Cold spots were associated with lower elevations, higher incomes, and higher education levels, whereas hotspots were associated with higher elevations. All cold spots in the general population and most clusters among VHA patients occurred in metropolitan areas, however VHA hotspots also occurred in metropolitan areas. Conclusions: Juxtaposing VHA and general adult ESDA results elucidates patterns of VHA suicides in context, highlighting spatial clusters as targets for interventions and research.

KW - Exploratory spatial data analysis (ESDA)

KW - Hotspot analysis

KW - Suicide

KW - Veterans Health Administration (VHA)

UR - https://www.scopus.com/pages/publications/105014646142

U2 - 10.1016/j.annepidem.2025.08.014

DO - 10.1016/j.annepidem.2025.08.014

M3 - Article

C2 - 40840572

AN - SCOPUS:105014646142

SN - 1047-2797

VL - 110

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EP - 153

JO - Annals of Epidemiology

JF - Annals of Epidemiology

ER -

Describing county-level clustering patterns of suicide among Veterans Health Administration patients and all American adults, 2018–2019, using exploratory spatial data analysis

Abstract

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Keywords

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