Trends in SA-related ED visits
Figure S1 shows the sex- and age-standardized incidence rate of SA-related ED visits among adolescents from 2016 to 2019, which increased from 57.5/105 in 2016 to 135.5/105 in 2019. The APC increased by 35.61% overall and by 17.95% among males and 46.26% among females (p < 0.001) (Fig. 1-A). Moreover, the APC increase was steeper in the mid-adolescence patients (aged 14–16 years) than that in the late-adolescence patients (aged 17–19 years) (APC, 51.12% vs. 26.98%; p < 0.001) (Fig. 1-B).
Figure S2 shows the ED disposition among SA-related ED visits from 2016 to 2019. The discharge group had the highest proportion of SA-related ED visits compared with the disposition group (from 66.7% in 2016 to 71.4% in 2019). The proportions in the GW admission and death subgroups decreased from 2016 and 2019 (17.9% vs. 14.8% and 1.9% vs. 1.1%, respectively). The proportions in the transfer and ICU admission subgroups also changed slightly from 2016 and 2019 (4.0% vs. 5.0% and 9.3% vs 8.7%, respectively).
Comparison Between The Discharge And Hospitalization Groups And Corresponding Subgroups
From 2016 and 2019, the total number of SA-related ED visits was 125,255. To estimate the demographic and clinical characteristics of adolescents with SA-related ED visits compared between the discharge group and hospitalization groups, we excluded 112,575 including adults (aged > 20 years) and children (aged < 14 years), and we also 482 patients with missing data, 555 patients in the transfer group, and 181 patients in the death group. Thus, 11,462 adolescents were included in the final analysis (Fig. 2).
All the patients were classified into the discharge (n = 8,456) or hospitalization group (n = 3,006) based on the type of disposition. In the discharge group, there were 3,231 patients in the AMA subgroup, 4,970 in the discharged to home subgroup, and 255 in the others subgroup. In the hospitalization group, there were 1,958 patients in the GW admission subgroup and 1,048 patients in the ICU admission subgroup.
Table 1 presents the overall demographic and clinical characteristics of patients in the discharge and hospitalization groups. There were significant differences in patient age group, sex, EMS use, KTAS score, year of ED visit, methods of SA, major treatment subject, time from event to arrival, time of arrival, number of hospital beds, and length of stay between the two groups. Conversely, no significant differences were noted in insurance type, season at ED visit, and ED region between the discharge and hospitalization groups. Interestingly, the data showed that the most common method of SA was poisoning, especially in the hospitalization group (69.7%, which was significantly higher than that in the discharge group; p < 0.0001). However, the most common method of SA in the discharge group was cutting and piercing (48.2%). Overall, > 50% of patients with SA-related ED visits reported over 600 beds in the hospital where they were hospitalized. The proportion of > 6 h length of stay was higher in the hospitalization group than in the discharge group (31.9% vs. 19.6%, respectively).
Table 1
Demographic and clinical characteristics of adolescent patients with suicide attempt-related ED visits from 2016 to 2019
Variable | Total (n = 11,462) | Discharge group (n = 8,456) | Hospitalization group (n = 3,006) | p value |
| n(%) | n(%) | n(%) | |
Age | | | | |
14–16 years | 4,317 (37.6) | 3,066 (36.3) | 1,251 (41.6) | < .0001 |
17–19 years | 7,145 (62.3) | 5,390 (63.7) | 1,755 (58.3) | |
Female sex | 7,476 (65.2) | 5,357 (63.3) | 2,119 (70.4) | < .0001 |
Insurance type | | | | |
NHI | 9,213 (80.4) | 6,840 (80.8) | 2,373 (78.9) | 0.069 |
Medicaid | 1,005 (8.8) | 721 (8.5) | 284 (9.5) | |
Other | 1,244 (10.9) | 895 (10.5) | 349 (11.6) | |
EMS use | 4,669 (40.7) | 3,337 (39.4) | 1,332 (44.3) | < .0001 |
KTAS score | | | | |
1–3 | 6,390 (55.7) | 3,987 (47.1) | 2,403 (79.9) | < .0001 |
4–5 | 5,072 (44.2) | 4,469 (52.8) | 603 (20.0) | |
Year | | | | |
2016 | 1,894 (16.5) | 1,344 (15.8) | 550 (18.3) | 0.011 |
2017 | 2,266 (19.7) | 1,677 (19.8) | 589 (19.5) | |
2018 | 3,410 (29.7) | 2,514 (29.7) | 896 (29.8) | |
2019 | 3,892 (33.9) | 2,921 (34.5) | 971 (32.3) | |
Season | | | | |
Spring | 2,760 (24.0) | 2,028 (24.0) | 732 (24.3) | 0.774 |
Summer | 3,263 (28.4) | 2,401 (28.4) | 862 (28.6) | |
Fall | 3,115 (27.1) | 2,320 (27.4) | 795 (26.4) | |
Winter | 2,324 (20.2) | 1,707 (20.2) | 617 (20.5) | |
Method of suicide attempts | | | | |
Poisoning | 5,009 (43.7) | 2,916 (34.5) | 2,093 (69.7) | < .0001 |
Cutting and piercing | 4,507 (39.4) | 4,070 (48.2) | 437 (14.5) | |
Others | 1,937 (16.9) | 1,464 (17.3) | 473 (15.7) | |
Major treatment subject | | | | |
Psychiatry | 2,076 (18.1) | 1,715 (20.3) | 361 (12.0) | < .0001 |
Time from event to arrival (h) | 1.1 (0.6–3.9) | 1.0 (0.6–3.0) | 2.0 (0.7–6.0) | < .0001 |
Time of arrival | | | | |
07:00–14:59 | 2,693 (23.5) | 1,822 (21.5) | 871 (28.9) | < .0001 |
15:00–22:59 | 4,414 (38.5) | 3,236 (38.2) | 1,178 (39.1) | |
23:00–06:59 | 4,355 (38.0) | 3,398 (40.1) | 957 (31.8) | |
Region | | | | |
Urban | 5,379 (46.9) | 4,014 (47.5) | 1,365 (45.4) | 0.051 |
Rural | 6,083 (53.0) | 4,442 (52.5) | 1,641 (54.5) | |
Hospital beds | | | | |
≥ 600 | 5,508 (48.0) | 3,996 (47.2) | 1,512 (50.3) | 0.004 |
300–599 | 1,433 (12.5) | 1,050 (12.4) | 383 (12.7) | |
< 300 | 4,521 (39.4) | 3,410 (40.3) | 1,111 (36.9) | |
Length of stay ≥ 6 h | 2,626 (22.9) | 1,665 (19.6) | 961 (31.9) | < .0001 |
Note. NHI, national health insurance. |
Sensitivity Analysis Of Comparisons Among The Disposition Subgroups
Table 2 shows the comparison of the characteristics of patients with SA-related ED visits in the discharge group. Except for the season of ED visit and time from event to arrival, most characteristics differed significantly among the subgroups. In the AMA subgroup, the proportion of female and late-adolescence patients was higher than that in the other discharge subgroups (73.0% vs. 57.5–54.1% in females and 68.2% vs. 60.8–63.5% in late-adolescence patients, respectively). In addition, the proportion of patients with a severe (1–3) KTAS score (64.4%), EMS use (49.7%), poisoning as the method of SA (50.0%), psychiatry as the major treatment subject (34.2%), hospital beds over 600 (56.1%), and > 6 h length of stay (29.1%) was significantly higher in the AMA subgroup than in other discharge subgroups.
Table 2
Comparison of characteristics of patients who attempted suicide based on discharge subgroups
Variable | Discharge (n = 8,456) | Discharged AMA (n = 3,231) | Discharged to home (n = 4,970 ) | Others (n = 255) | p value |
| n(%) | n(%) | n(%) | n(%) | |
Age | | | | | |
14–16 years | 3,066 (36.3) | 1,026 (31.7) | 1,947 (39.1) | 93 (36.4) | < .0001 |
17–19 years | 5,390 (63.7) | 2,205 (68.2) | 3,023 (60.8) | 162 (63.5) | |
Female sex | 5,357 (63.3) | 2,360 (73.0) | 2,859 (57.5) | 138 (54.1) | < .0001 |
Insurance type | | | | | |
NHI | 6,840 (80.8) | 2,693 (83.3) | 3,959 (79.7) | 188 (73.7) | < .0001 |
Medicaid | 721 (8.5) | 264 (8.2) | 426 (8.6) | 31 (12.1) | |
Other | 895 (10.5) | 274 (8.5) | 585 (11.7) | 36 (14.1) | |
EMS use | 3,337 (39.4) | 1,606 (49.7) | 1,624 (32.6) | 107 (41.9) | < .0001 |
KTAS score | | | | | |
1–3 | 3,987 (47.1) | 2,082 (64.4) | 1,793 (36.0) | 112 (43.9) | < .0001 |
4–5 | 4,469 (52.8) | 1,149 (35.5) | 3,177 (63.9) | 143 (56.0) | |
Year | | | | | |
2016 | 1,344 (15.8) | 447 (13.8) | 820 (16.5) | 77 (30.2) | < .0001 |
2017 | 1,677 (19.8) | 579 (17.9) | 1,036 (20.8) | 62 (24.3) | |
2018 | 2,514 (29.7) | 986 (30.5) | 1,480 (29.7) | 48 (18.8) | |
2019 | 2,921 (34.5) | 1,219 (37.7) | 1,634 (32.8) | 68 (26.6) | |
Season | | | | | |
Spring | 2,028 (24.0) | 793 (24.5) | 1,177 (23.6) | 58 (22.7) | 0.918 |
Summer | 2,401 (28.4) | 912 (28.2) | 1,415 (28.4) | 74 (29.0) | |
Fall | 2,320 (27.4) | 890 (27.5) | 1,356 (27.2) | 74 (29.0) | |
Winter | 1,707 (20.2) | 636 (19.6) | 1,022 (20.5) | 49 (19.2) | |
Method of suicide attempts | | | | | |
Poisoning | 2,916 (34.5) | 1,614 (50.0) | 1,220 (24.6) | 82 (32.1) | < .0001 |
Cutting and piercing | 4,070 (48.2) | 1,268 (39.3) | 2,674 (53.8) | 128 (50.2) | |
Others | 1,464 (17.3) | 346 (10.7) | 1,073 (21.6) | 45 (17.6) | |
Major treatment subject | | | | | |
Psychiatry | 1,715 (20.3) | 1,105 (34.2) | 591 (11.8) | 19 (7.5) | < .0001 |
Time from event to arrival (h) | 1.0 (0.6–3.0) | 1.2 (0.7–3.3) | 1.0 (0.5–2.9) | 1.0 (0.5–2.3) | 0.430 |
Time of arrival | | | | | |
07:00–14:59 | 1,822 (21.5) | 702( 21.7) | 1,050 (21.1) | 70 (27.4) | 0.005 |
15:00–22:59 | 3,236 (38.2) | 1,200 (37.1) | 1,961 (39.4) | 75 (29.4) | |
23:00–06:59 | 3,398 (40.1) | 1,329 (41.1) | 1,959 (39.4) | 110 (43.1) | |
Region | | | | | |
Urban | 4,014 (47.5) | 1,805 (55.8) | 2,132 (42.9) | 77 (30.2) | < .0001 |
Rural | 4,442 (52.5) | 1,426 (44.1) | 2,838 (57.1) | 178 (69.8) | |
Hospital beds | | | | | |
≥ 600 | 3,996 (47.2) | 1,813 (56.1) | 2,106 (42.3) | 77 (30.2) | < .0001 |
300–599 | 1,050 (12.4) | 163 (5.0) | 824 (16.5) | 63 (24.7) | |
< 300 | 3,410 (40.3) | 1,255 (38.8) | 2,040 (41.0) | 115 (45.1) | |
Length of stay ≥ 6 h | 1,665 (19.6) | 943 (29.1) | 675 (13.5) | 47 (18.4) | < .0001 |
Note. NHI, national health insurance; AMA: against medical advice |
Table 3 shows the comparison of characteristics of patients with SA-related ED visits in the hospitalization group. Characteristics such as age group, insurance type, EMS use, KTAS score, method of SA, major treatment subject, number of hospital beds, and length of stay were significantly different between the GW and ICU admission subgroups. Overall, > 90% of patients in the ICU admission subgroup had a severe KTAS score. In addition, poisoning was the method of SA for 79.5% of patients in the ICU admission subgroup. Only 1.1% of patients in the ICU admission subgroup had psychiatry as the major treatment subject. The proportion of patients with a > 6 h length of stay in EDs was higher in the GW admission subgroup than in the ICU admission subgroup (38.9% vs. 18.8%).
Table 3
Characteristics of patients who attempted suicide based on hospital admission subgroups
Variable | Hospitalization (n = 3,006) | General ward admissions (n = 1,958) | Intensive care unit admissions (n = 1,048) | p value |
| n(%) | n(%) | n(%) | |
Age | | | | |
14–16 years | 1,251 (41.6) | 863 (44.1) | 388 (37.0) | 0.0002 |
17–19 years | 1,755 (58.3) | 1,095 (55.9) | 660 (63.0) | |
Female sex | 2,119 (70.4) | 1,364 (69.6) | 755 (72.0) | 0.172 |
Insurance type | | | | |
NHI | 2,373 (78.9) | 1,579 (80.6) | 794 (75.8) | 0.002 |
Medicaid | 284 (9.45) | 179 (9.1) | 105 (10.0) | |
Other | 349 (11.6) | 200 (10.2) | 149 (14.2) | |
EMS use | 1,332 (44.3) | 793 (40.5) | 539 (51.4) | < .0001 |
KTAS score | | | | |
1–3 | 2,403 (79.9) | 1,455 (74.3) | 948 (90.4) | < .0001 |
4–5 | 603 (20.0) | 503 (25.6) | 100 (9.5) | |
Year | | | | |
2016 | 550 (18.3) | 361 (18.4) | 189 (18.0) | 0.115 |
2017 | 589 (19.5) | 384 (19.6) | 205 (19.5) | |
2018 | 896 (29.8) | 607 (31.0) | 289 (27.5) | |
2019 | 971 (32.3) | 606 (31.0) | 365 (34.8) | |
Season | | | | |
Spring | 732 (24.3) | 484 (24.7) | 248 (23.6) | 0.273 |
Summer | 862 (28.6) | 579 (29.6) | 283 (27.0) | |
Fall | 795 (26.4) | 501 (25.6) | 294 (28.0) | |
Winter | 617 (20.5) | 394 (20.1) | 223 (21.2) | |
Method of suicide attempt | | | | |
Poisoning | 2,093 (69.7) | 1,260 (64.4) | 833 (79.5) | < .0001 |
Cutting and piercing | 437 (14.5) | 410 (20.9) | 27 (2.6) | |
Others | 473 (15.7) | 286 (14.6) | 187 (17.8) | |
Major treatment subject | | | | |
Psychiatry | 361 (12.0) | 350 (17.9) | 11 (1.1) | < .0001 |
Time from event to arrival (h) | 2.0 (0.8–6.0) | 2.0 (0.8–6.4) | 2.0 (0.8–5.4) | |
Time of arrival | | | | |
07:00–14:59 | 871 (28.9) | 588 (30.0) | 283 (27.0) | 0.205 |
15:00–22:59 | 1,178 (39.1) | 752 (38.4) | 426 (40.7) | |
23:00–06:59 | 957 (31.8) | 618 (31.5) | 339 (32.3) | |
Region | | | | |
Urban | 1,365 (45.4) | 901 (46.0) | 464 (44.3) | 0.360 |
Rural | 1,641 (54.5) | 1,057 (54.0) | 584 (55.7) | |
Hospital beds | | | | |
≥ 600 | 1,512 (50.3) | 1,051 (53.6) | 461 (43.9) | < .0001 |
300–599 | 383 (12.7) | 227 (11.5) | 156 (14.8) | |
< 300 | 1,111 (36.9) | 680 (34.7) | 431 (41.1) | |
Length of stay ≥ 6 h | 961 (31.9) | 763 (38.9) | 198 (18.8) | < .0001 |
Note. NHI, national health insurance. |
Figure S3 shows the comparison of the annual trends in SA-related ED visits from 2016 to 2019 based on the type of disposition, including the death, transfer, and discharge groups. In the death group, the proportion of patients pronounced dead on arrival decreased but that of patients who had an out of hospital cardiac arrest increased from 2016 and 2019. In the transfer group, the proportion of patients transferred due to insufficient beds increased but that due to requests from the patient or guardian decreased. In the discharge group, the proportion of patients who requested discharge AMA increased. Table S1 presents the top 10 most common diagnoses by the type of disposition. The most common diagnosis in the discharge group was open-wound injury, while poisoning or toxic effect was the most common in the GW and ICU admission subgroups.