Preventing Firearm-Related Death and Injury

Provider Perspectives on Addressing Firearm Safety with Older Adults in Primary Care

OBJECTIVES

Chronic conditions, including mild cognitive impairment and depression, place older adults at high risk of firearm suicide. Approximately 40% of older adults have access to a firearm, and many do not store their firearms safely. However, firearm counseling occurs infrequently in clinical settings. Using by the Ottawa Decision Support Framework (ODSF) to conceptualize the decisional support needed by patients and their providers to facilitate firearm counseling, we explore provider perspectives on desired resources for addressing firearm safety with older adult patients.

METHODS

From March - August 2022, we conducted 21 semi-structured interviews with primary care providers caring for older adults. We report deductive concepts as well as emergent themes.

RESULTS

Major themes were identified from the three components of the ODSF; decisional needs, decision support and decisional outcomes. Themes included: provider self-efficacy to conduct firearm counseling, clinical workflow considerations, stories for change, patient diagnosis implications, and caregiver involvement.

CONCLUSIONS

There is a need for decision aids in the clinical setting that facilitate firearm counseling and promotes shared decision-making about firearm storage.

CLINICAL IMPLICATIONS

Implementing a decision aid in the clinical setting can improve provider self-efficacy to conduct firearm counseling and help reduce risk factors associated with firearm-related harm among older adults.

Determining who military service members deem credible to discuss firearm safety for suicide prevention

OBJECTIVES

To examine rankings of credible sources for discussing secure storage within a representative sample of firearm-owning service members, and examine how combinations of demographic variables impact the ranking of credible sources.

METHODS

The probability-based sample was collected with the help of Ipsos. Participants were US service members who owned a firearm at the time of the survey (n = 719).

RESULTS

The total sample ranked service members, Veterans, and members of law enforcement as the most credible sources and faith leaders, casual acquittances, and celebrities as the least credible sources. Black men ranked the NRA as a highly credible source whereas Black females ranked the NRA as one of the least preferred sources. Regardless of political preference, those who lived in non-metropolitan rural environments ranked members of law enforcement as highly credible sources. Those who lived in non-metropolitan rural and urban settings and identified as liberal ranked the National Shooting Sports Foundation as a highly credible source.

CONCLUSIONS

Law enforcement officers, military members, and Veterans are ranked as highly credible sources by most subgroups of firearm-owning service members. Leveraging these voices in firearm safety conversations is necessary, may increase adherence to secure storage recommendations, and ultimately reduce suicide.

Increasing the Acceptability of Lethal Means Safety Counseling for Firearms: Tips and Scripts

In lethal means safety counseling (LMSC), clinicians encourage patients to limit their access to common and lethal means of suicide, especially firearms. However, previous studies have shown that clinicians may hesitate to deliver this evidence-based intervention, in part because of concerns that patients might not find such discussions acceptable. Based on a published review of 18 qualitative studies examining diverse perspectives on LMSC, we discuss strategies that may help clinicians increase the acceptability of LMSC among their patients and present supporting scripts, rationales, and resources. The studies included in the review examined the perspectives of clinicians, patients, firearm owners, and other relevant groups across a wide range of clinical settings on LMSC for firearms. The authors of these studies recommend that clinicians approach LMSC in a nonjudgmental manner with awareness of their own biases, demonstrate cultural competency by acknowledging the role of firearms in patients' lives, and adapt LMSC to patients' previous experiences with firearms, safety, and injury. Clinicians may also want to contextualize and provide a rationale for LMSC, decide whether or not to directly ask about access to firearms, and recommend a range of storage options tailored to the patient. Free locking devices or discount coupons for purchasing such devices may increase the acceptability and efficacy of these discussions. The strategies recommended in this paper are the first to be based on a comprehensive set of relevant studies. Future research is needed to examine whether these strategies do in fact increase the acceptability of LMSC and promote other outcomes such as increased feasibility and efficacy.

Emergency medical services (EMS) clinicians' views on EMS-delivered interventions to promote secure firearm storage practices

INTRODUCTION

Lethal means safety counseling (LMSC) to promote secure firearm storage may reduce the risk of firearm-involved deaths, including suicide. We examined if emergency medical services (EMS) clinicians, including emergency medical technicians and paramedics, may be suitable LMSC messengers.

METHOD

We conducted a web-based survey of 229 US EMS clinicians.

RESULTS

While few EMS clinicians supported EMS-delivered LMSC to all patients (17.0%), most supported EMS-delivered LMSC to patients in an acute suicidal crisis (64.2%) or with a known suicide attempt history (55.9%). Barriers to EMS-delivered LMSC included lack of training (73.4%), perceptions that LMSC is outside EMS clinicians' scope of practice (58.1%), and lack of standard operating procedures (56.3%). Most reported at least some interest in receiving training on EMS-delivered LMSC (67.7%). Participants holding more accurate beliefs about the link between firearm storage practices and suicide risk, as well as the efficacy of LMSC, were more likely to support EMS-delivered LMSC across patient scenarios (ORs = 2.18-5.21, ps <0.01) and express interest in receiving LMSC training (ORs = 3.78-5.43, ps <0.001).

CONCLUSION

Given that many EMS clinicians interface with patients at elevated suicide risk, targeted LMSC training may be strategic; however, research is needed to determine if and how EMS clinicians might be viable LMSC messengers.

The association of alcohol use and heavy drinking with subsequent handgun carrying among youth from rural areas

PURPOSE

Alcohol use and handgun carrying are more prevalent among youth in rural than urban areas and their association may be stronger among rural adolescents. Alcohol use may be modifiable with implications for reducing handgun carrying and firearm-related harm. We examined the association between lagged alcohol use and subsequent handgun carrying in rural areas and examined variation in the association by developmental stages, hypothesizing that it would be stronger among adolescents than youth adults.

METHODS

We used a longitudinal sample of 2,002 adolescents from ages 12 to 26 growing up in 12 rural communities in 7 states with surveys collected from 2004 to 2019. We estimated the association of lagged past-month alcohol use on handgun carrying in the subsequent 12 months using population-average generalized estimating equations with logistic regression on multiply imputed data.

FINDINGS

During adolescence (ages 12-18), those who drank heavily had 1.43 times the odds (95% CI = [1.01, 2.03]) of subsequent handgun carrying compared to those who did not drink alcohol, and those who consumed alcohol but did not drink heavily had 1.30 times the odds of subsequent handgun carrying compared to those who did not drink (95% CI = [0.98, 1.71]). During young adulthood (ages 19-26), associations of alcohol use (OR = 1.28; 95% CI = [0.94, 1.63]) and heavy drinking (OR = 1.38; 95% CI = [1.08, 1.68]) were similar to adolescence.

CONCLUSIONS

Alcohol use and subsequent handgun carrying were positively associated during adolescence and young adulthood among individuals who grew up in rural areas, similar to findings in urban areas. Reducing alcohol use may be an important strategy to prevent handgun carrying and firearm-related harm among young people in rural areas.

The Era of Progress on Gun Mortality: State Gun Regulations and Gun Deaths from 1991 to 2016

BACKGROUND

The recent rise of gun violence may lead to the perception that the problem of gun mortality in the United States is intractable. This article provides evidence to counter this perception by bringing attention to the period spanning from 1991 to 2016 when most US states implemented more restrictive gun laws. Over this period, the United States experienced a decline in household gun ownership, and gun-related deaths fell sharply.

METHODS

The main analysis examines the conditional association between the change in gun regulations at the state level and the change in gun mortality from 1991 to 2016. We include a range of robustness checks and two instrumental variable analyses to allow for stronger causal inferences.

RESULTS

We find strong, consistent evidence supporting the hypothesis that restrictive state gun policies reduce overall gun deaths, homicides committed with a gun, and suicides committed with a gun. Each additional restrictive gun regulation a given state passed from 1991 to 2016 was associated with -0.21 (95% confidence interval = -0.33, -0.08) gun deaths per 100,000 residents. Further, we find that specific policies, such as background checks and waiting periods for gun purchases, were associated with lower overall gun death rates, gun homicide rates, and gun suicide rates.

CONCLUSION

State regulations passed from 1991 to 2016 were associated with substantial reductions in gun mortality. We estimate that restrictive state gun policies passed in 40 states from 1991 to 2016 averted 4297 gun deaths in 2016 alone, or roughly 11% of the total gun deaths that year.

Bystander intervention to prevent firearm injury: A qualitative study of 4-H shooting sports participants

This qualitative study examines how youth and adult members of 4-H Shooting Sports clubs perceive firearm injury risk and risk reduction, and the applicability of a bystander intervention (BI) risk reduction framework in this community. Semistructured interviews were conducted with 11 youth and 13 adult members of 4-H Shooting Sports clubs across nine US states from March to December of 2021 until thematic saturation was reached. Deductive and inductive thematic qualitative analyses were performed. Six overarching themes emerged: (1) The tendency to view firearm injury as predominantly unintentional in nature; (2) Acknowledgment of a wide array of risks for firearm injury; (3) Perceived barriers to bystander action to prevent firearm injury including knowledge, confidence, and consequences of action; (4) Facilitators of bystander action including a sense of civic responsibility; (5) Direct and indirect strategies to address potential risks for firearm injury; and (6) Belief that BI skills training would be useful for 4-H Shooting Sports. Findings lay the groundwork for applying BI skills training as an approach to firearm injury prevention in 4-H Shooting Sports, similar to how BI has been applied to other types of injury (i.e., sexual assault). 4-H Shooting Sports club members' sense of civic responsibility is a key facilitator. Prevention efforts should attend to the broad array of ways in which firearm injury occurs, including suicide, mass shootings, homicide, and intimate partner violence, as well as unintentional injury.

Firearm injury prevention counseling for patients with traumatic brain injury: a survey of brain injury physicians

Background

Survivors of traumatic brain injury are at increased risk for firearm-related injuries, including suicide.

Aims

To determine current practices of Brain Injury Medicine (BIM) physicians and their rehabilitation teams in assessing patients' access to firearms and in providing firearm safety education, and the impact of having received training on this topic on physicians' likelihood of inquiring about patients' access to firearms.

Methods

14-item web-based cross-sectional survey of 86 U.S. physiatrists board-certified in BIM.

Results

81% of respondents indicated they believe BIM physicians should counsel their patients on firearm safety but only 12.9% reported always doing so. Fifteen percent reported always inquiring about their patients' access to firearms. 88.2% indicated having never received formal training on firearm injury prevention counseling. Physicians who received such training had 7.5 times higher odds of reporting at least sometimes inquiring about patients' access to firearms than those who were not trained [95% confidence interval (1.94, 28.64)]. They also had 5.7 times higher odds for reporting being at least moderately comfortable providing patients firearm safety counseling [95% CI: (1.39, 23.22)].

Conclusion

While most BIM specialists who responded to this survey believe they should counsel patients on firearm safety, few always or usually do so. Moreover, most do not routinely inquire about their patients' access to firearms. The provision of firearm injury prevention training to BIM physicians was strongly associated with an increased likelihood they will inquire about their patients' access to guns and with an improved comfort level in providing counseling on this subject matter.

School Nurses Can Reduce Firearm Injuries and Deaths

The increasing incidents of school shootings in recent years have resulted in America's students, teachers, and staff feeling vulnerable. The most effective approach to creating safe and supportive school environments requires a comprehensive, coordinated effort including school-wide, district-wide, and community-wide strategies. School nurses, healthcare partners embedded in school communities, can guide these efforts. This article reviews data on school located gun violence through a public health lens, as well as outlines a framework for levels of prevention, including downstream, midstream, and upstream strategies. Finally, the article includes evidence-based examples, models, and tools for each level of prevention.

Association of medical conditions and firearm suicide among legal handgun purchasers in California: a case-control study

BACKGROUND

Suicide is a pressing public health problem, and firearm owners are at especially elevated risk. Certain health conditions are markers of suicide risk, but more research is needed on clinical risk markers for suicide among firearm owners specifically. Our goal was to examine associations of emergency department and inpatient hospital visits for behavioral and physical health conditions with firearm suicide among handgun purchasers.

METHODS

This was a case-control study of 5415 legal handgun purchasers in California who died between January 1, 2008, and December 31, 2013. Cases were firearm suicide decedents; controls were motor vehicle crash decedents. Exposures were emergency department and hospital visits for six categories of health diagnoses in the 3 years prior to death. To account for selection bias due to deceased controls, we used probabilistic quantitative bias analysis to generate bias-adjusted estimates.

RESULTS

There were 3862 firearm suicide decedents and 1553 motor vehicle crash decedents. In multivariable models, suicidal ideation/attempt (OR 4.92; 95% CI 3.27-7.40), mental illness (OR 1.97; 95% CI 1.60-2.43), drug use disorder (OR 1.40; 95% CI 1.05-1.88), pain (OR 1.34; 95% CI 1.07-1.69), and alcohol use disorder (OR 1.29; 95% CI 1.01-1.65) were associated with higher odds of firearm suicide. When adjusting for all conditions simultaneously, only the associations for suicidal ideation/attempt and mental illness remained significant. Quantitative bias analysis indicated that observed associations were generally biased downward. For example, the bias-adjusted OR for suicidal ideation/attempt was 8.39 (95% simulation interval 5.46-13.04), almost twice that of the observed OR.

CONCLUSIONS

Diagnoses for behavioral health conditions were markers for firearm suicide risk among handgun purchasers, even for conservative estimates that did not adjust for selection bias. Encounters with the healthcare system may provide opportunities to identify firearm owners at high risk of suicide.

Rural-Urban Variation in the Association of Adolescent Violence and Handgun Carrying in the United States, 2002-2019

Importance

Adolescent handgun carrying is associated with increased risk of firearm-related violence. Most evidence on adolescent handgun carrying is from urban areas, but these findings may not generalize to rural areas.

Objective

To examine differences in associations of adolescent interpersonal violence with handgun carrying across the rural-urban continuum.

Design, Setting, and Participants

This cross-sectional study used nationally representative data from the US National Survey on Drug Use and Health among adolescents aged 12 to 17 years from 2002 to 2019 to estimate time-varying prevalence ratios (PRs) and prevalence differences (PDs) between interpersonal violence and handgun carrying across the rural-urban continuum. Analyses were conducted in April to July 2022.

Exposures

Any past-year serious fighting, group fighting, and attacking with intent to harm.

Main Outcomes and Measures

Any past-year handgun carrying. Associations were estimated within county rural-urban strata using the US Department of Agriculture's Rural-Urban Continuum Codes.

Results

In each year, the sample included a weighted count of almost 25 million adolescents, with 50.9% (95% CI, 50.2%-51.6%) males and 24.7% (95% CI, 23.8%-25.6%) Hispanic adolescents, 13.5% (95% CI, 12.8%-14.2%) non-Hispanic Black adolescents, and 51.8% (95% CI, 50.8%-52.8%) non-Hispanic White adolescents in 2019. More rural counties had less racial and ethnic diversity. For example, 81.1% (95% CI, 75.9%-85.4%) of adolescents were non-Hispanic White in the most rural counties vs 43.1% (95% CI, 41.7%-44.6%) of adolescents were non-Hispanic White in the most urban counties in 2019. Adolescent handgun carrying increased over time, with the largest increases in the most rural counties, where the prevalence of adolescent handgun carrying increased from 5.2% (95% CI, 3.8%-7.0%) in 2003 to 12.4% (95% CI, 8.9%-16.9%) in 2019. PRs for the association of violence and handgun carrying were greater in more urban counties. For example, in the most urban counties in 2019, adolescents involved in a group fight had 3.7 (95% CI, 2.9-4.8) times the prevalence of handgun carrying vs those not involved in a group fight; this PR was 3.1 (95% CI, 1.6-5.6) in the most rural counties. PDs were similar and, in some cases, larger in rural areas. For example, in the most urban counties in 2019, handgun carrying prevalence was 7.5% (95% CI, 5.7%-9.5%) higher among adolescents who were involved in a group fight compared with those who were not; this PD was 21.8% (95% CI, 8.2%-37.8%) in the most rural counties, where handgun carrying was more common.

Conclusions and Relevance

This cross-sectional study found that associations of interpersonal violence with handgun carrying were stronger in relative terms in urban areas than in rural areas; however, a higher percentage of rural than urban adolescents carried handguns, resulting in a greater absolute prevalence of handgun carrying associated with violence in rural areas than in urban areas. These findings suggest opportunities for preventing handgun carrying-related harms may differ between rural and urban communities.

Firearm safety counseling among caregivers of high-school age teens: Results from a National Survey

Firearms are the leading cause of death for high-school age teens. To inform prevention efforts, we characterize the prevalence of healthcare provider (HCP) counseling of caregivers of teens around firearm safety, safety conversation elements, and caregiver receptivity towards counseling. A cross-sectional web survey (6/24/2020-7/22/2020) was conducted among caregivers (n = 2924) of teens (age:14-18). Weights were applied to generate nationally representative estimates. Bivariate analyses and multivariate regressions were examined. Among respondents, 56.0% were women, 75.1% were non-Hispanic White, and mean (SD) age was 47.4. Firearm safety was the least discussed topic among caregivers reporting their teen received HCP preventative counseling (14.9%). For caregivers receiving counseling, the most common issues discussed were household firearms screening (75.7%); storing firearms locked (66.8%); and storing firearms unloaded (53.0%). Only 24.6% of caregivers indicated firearm safety was an important issue for teen HCPs to discuss and only 21.9% trusted teen HCPs to counsel about firearm safety. Female caregivers (aOR = 1.86;95%CI = 1.25-2.78), those trusting their teen's HCP to counsel on firearm safety (aOR = 9.63;95%CI = 6.37-14.56), and those who received teen HCP firearm safety counseling (aOR = 5.14;95%CI = 3.02-8.72) were more likely to favor firearm safety counseling. Caregivers of teens with prior firearm safety training (aOR = 0.50;95%CI = 0.31-0.80) were less likely to agree that firearm safety was an important preventative health topic. In conclusion, few caregivers receive preventive counseling on firearm safety from their teen's HCP, with trust a key barrier to effective intervention delivery. Future research, in addition to understanding barriers and establishing effective strategies to increase safety practices, should focus on increasing provider counseling competency.

A mixed methods protocol to implement universal firearm injury risk screening and intervention among youth and adults in emergency departments across a large US health system

BACKGROUND

Firearm injury is a leading cause of preventable death in the USA. Healthcare providers are uniquely poised to focus on firearm safety and injury prevention from an apolitical harm reduction lens; however, few providers and healthcare settings incorporate firearm injury prevention strategies into usual care. We outline the first protocol to determine how to implement universal Firearm Injury and Mortality Prevention (FIMP) strategies that identify and address firearm access and violence risk in healthcare settings as part of routine care using the Consolidated Framework for Implementation Research (CFIR) to inform implementation and evaluation.

METHODS

The components of our FIMP strategy, including universal screening, intervention for patients at risk, and resources, will be developed from existing evidence-based strategies for firearm access and violence risk (intervention characteristics). The implementation process will include components of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use, adapted to FIMP (implementation process). To engage stakeholders, harmonize language, and garner support, an Executive Advisory Board (EAB) will be formed, consisting of the site- and system-level stakeholders (inner setting) and community stakeholders, including influential figures such as local religious and spiritual leaders, individuals with lived experience, and community-based organizations (outer setting). Pre-implementation surveys will identify the characteristics of individuals and guide the development of education prior to implementation. Patient-level screening data will be analyzed to identify the risk factors, implementation will be evaluated using mixed methods, and a limited-efficacy study will evaluate whether strategies were successful in driving behavior change.

DISCUSSION

This study protocol has breakthrough and methodological innovations, by addressing FIMP as part of usual care to directly mitigate firearm injury risk among youth, adults, and household members (e.g., children) and by using rigorous methods to inform healthcare industry implementation of FIMP strategies. The expected outcomes of this study protocol will provide a solid basis for larger-scale dissemination and evaluation of implementation, effectiveness, and usability across broader pediatric and adult healthcare settings. This project will advance the implementation science and have a positive impact on the health of our patients and communities by preventing firearm injury and mortality and shifting the paradigm to view FIMP through a public health lens.

Trends and Disparities in Firearm Fatalities in the United States, 1990-2021

IMPORTANCE

Firearm fatality rates in the United States have reached a 28-year high. Describing the evolution of firearm fatality rates across intents, demographics, and geography over time may highlight high-risk groups and inform interventions for firearm injury prevention.

OBJECTIVE

To understand variations in rates of firearm fatalities stratified by intent, demographics, and geography in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed firearm fatalities in the US from 1990 to 2021 using data from the Centers for Disease Control and Prevention. Heat maps, maximum and mean fatality rate graphs, and choropleth maps of county-level rates were created to examine trends in firearm fatality rates by intent over time by age, sex, race, ethnicity, and urbanicity of individuals who died from firearms. Data were analyzed from December 2018 through September 2022.

MAIN OUTCOMES AND MEASURES

Rates of firearm fatalities by age, sex, race, ethnicity, urbanicity, and county of individuals killed stratified by specific intent (suicide or homicide) per 100 000 persons per year.

RESULTS

There were a total of 1 110 421 firearm fatalities from 1990 to 2021 (952 984 among males [85.8%] and 157 165 among females [14.2%]; 286 075 among Black non-Hispanic individuals [25.8%], 115 616 among Hispanic individuals [10.4%], and 672 132 among White non-Hispanic individuals [60.5%]). All-intents total firearm fatality rates per 100 000 persons declined to a low of 10.1 fatalities in 2004, then increased to 14.7 fatalities (45.5% increase) by 2021. From 2014 to 2021, male and female firearm homicide rates per 100 000 persons per year increased from 5.9 to 10.9 fatalities (84.7% increase) and 1.1 to 2.0 fatalities (87.0% increase), respectively. Firearm suicide rates were highest among White non-Hispanic men aged 80 to 84 years (up to 46.8 fatalities/100 000 persons in 2021). By 2021, maximum rates of firearm homicide were up to 22.5 times higher among Black non-Hispanic men (up to 141.8 fatalities/100 000 persons aged 20-24 years) and up to 3.6 times higher among Hispanic men (up to 22.8 fatalities/100 000 persons aged 20-24 years) compared with White non-Hispanic men (up to 6.3 fatalities/100 000 persons aged 30-34 years). Males had higher rates of suicide (14.1 fatalities vs 2.0 fatalities per 100 000 persons in 2021) and homicide (10.9 fatalities vs. 2.0 fatalities per 100 000 persons in 2021) compared with females. Metropolitan areas had higher homicide rates than nonmetropolitan areas (6.6 fatalities vs 4.8 fatalities per 100 000 persons in 2021). Firearm fatalities by county level increased over time, spreading from the West to the South. From 1999 to 2011 until 2014 to 2016, fatalities per 100 000 persons per year decreased from 10.6 to 10.5 fatalities in Western states and increased from 12.8 to 13.9 fatalities in Southern states.

CONCLUSIONS AND RELEVANCE

This study found marked disparities in firearm fatality rates by demographic group, which increased over the past decade. These findings suggest that public health approaches to reduce firearm violence should consider underlying demographic and geographic trends and differences by intent.

Prevalence of prescription and illicit drugs in suicides by non-poisoning means in the National Violent Death Reporting System 2003-2017

Background: Prescription and illicit drugs are important social environmental variables in many suicides regardless of their role as an immediate cause of death. Objectives: To investigate the presence of prescription and illicit drugs, either through mention in the death record or toxicology reports, among suicides attributed to nonpoisonous causes to identify patterns of risk. Methods: Using the 2003-2017 National Violent Death Reporting System (NVDRS), we examined the presence of prescription and illicit drugs among 143,175 suicides (119,563 males 23,612 females) due to firearms and suffocation/hanging. The presence of drugs (opioids, stimulants, benzodiazepines, muscle relaxants, and cannabis) was determined from toxicology reports and text searches of coroner/medical examiner and law enforcement summaries. We fit multivariable logistic regression models to estimate associations between drug class and suicide method adjusting for decedent characteristics. Results: Overall prescription and illicit drugs were present in 22% of firearm deaths and 28% of suffocation deaths. Among victims with toxicology reports, over 20% tested positive for benzodiazepines. Benzodiazepines were mentioned in 4% of firearm and 5% of suffocation suicides without toxicology testing. Stimulants were more likely to occur in suffocation than firearm deaths among victims with toxicology testing (aOR = 1.44, 95% CI: 1.33-1.56) and without toxicology testing (aOR = 1.61, 95% CI: 1.31-1.98). Conclusions: Benzodiazepines were most frequently identified in both toxicology reports and narratives of suicides by firearms or suffocation. Better distinction of the presence of prescription and illicit drugs in the environment versus apparent ingestion among non-poisoning suicides are needed to inform prevention approaches.

Gun violence restraining orders in California, 2016-2018: case details and respondent mortality

Background

Gun violence restraining orders (GVROs), implemented in California in 2016, temporarily prohibit individuals at high risk of violence from purchasing or possessing firearms and ammunition. We sought to describe the circumstances giving rise to GVROs issued 2016–2018, provide details about the GVRO process and quantify mortality outcomes for individuals subject to these orders (‘respondents’).

Methods

For this cross-sectional description of GVRO respondents, 2016–2018, we abstracted case details from court files and used LexisNexis to link respondents to mortality data through August 2020.

Results

We abstracted information for 201 respondents with accessible court records. Respondents were mostly white (61.2%) and men (93.5%). Fifty-four per cent of cases involved potential harm to others alone, 15.3% involved potential harm to self alone and 25.2% involved both. Mass shooting threats occurred in 28.7% of cases. Ninety-six and one half per cent of petitioners were law enforcement officers and one-in-three cases resulted in arrest on order service. One-year orders after a hearing (following 21-day emergency/temporary orders) were issued in 53.5% of cases. Most (84.2%) respondents owned at least one firearm, and firearms were removed in 55.9% of cases. Of the 379 respondents matched by LexisNexis, 7 (1.8%) died after the GVRO was issued: one from a self-inflicted firearm injury that was itself the reason for the GVRO and the others from causes unrelated to violence.

Conclusions

GVROs were used most often by law enforcement officers to prevent firearm assault/homicide and post-GVRO firearm fatalities among respondents were rare. Future studies should investigate additional respondent outcomes and potential sources of heterogeneity.

Changes in Health Care Spending, Use, and Clinical Outcomes After Nonfatal Firearm Injuries Among Survivors and Family Members : A Cohort Study

BACKGROUND

Despite increasing awareness of firearm-related deaths, evidence on the clinical and economic implications of nonfatal firearm injuries is limited.

OBJECTIVE

To measure changes in clinical and economic outcomes after nonfatal firearm injuries among survivors and their family members.

DESIGN

Cohort study.

SETTING

MarketScan Medicare and commercial claims data, 2008 to 2018.

PARTICIPANTS

6498 survivors of firearm injuries matched to 32 490 control participants and 12 489 family members of survivors matched to 62 445 control participants.

INTERVENTION

Exposure to nonfatal firearm injury as a survivor or family member of a survivor.

MEASUREMENTS

Changes in health care spending, use, and morbidity from preinjury through 1 year postinjury relative to control participants, on average and by type and severity of firearm injury.

RESULTS

After nonfatal firearm injury, medical spending increased $2495 per person per month (402%) and cost sharing increased $102 per person per month (176%) among survivors relative to control participants (P < 0.001) in the first year after injury, driven by an increase in the first month of $25 554 (4122%) in spending and $1112 (1917%) in cost sharing per survivor (P < 0.001). All categories of health care use increased relative to the control group. Survivors had a 40% increase in pain diagnoses, a 51% increase in psychiatric disorders, and an 85% increase in substance use disorders after firearm injury relative to control participants (P < 0.001), accompanied by increased pain and psychiatric medications. Family members had a 12% increase in psychiatric disorders relative to their control participants (P = 0.003). These overall clinical and economic changes were driven by intentional firearm injuries and more severe firearm injuries.

LIMITATION

Precision of diagnostic codes and generalizability to other patient populations, including Medicaid and uninsured patients.

CONCLUSION

In survivors, nonfatal firearm injuries led to increases in psychiatric disorders, substance use disorders, and pain diagnoses, alongside substantial increases in health care spending and use. In addition, mental health worsened among family members.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Talking about firearm injury prevention with patients: a survey of medical residents

BACKGROUND

Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention.

METHOD

A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers.

RESULTS

The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms.

CONCLUSIONS

Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Stakeholder perceptions of lethal means safety counseling: A qualitative systematic review

INTRODUCTION

Lethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice.

METHODS

To better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research.

FINDINGS

Of the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC.

CONCLUSION

This synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt].

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].

Lethal Means Assessment in Psychiatric Emergency Services: Frequency and Characteristics of Assessment

OBJECTIVE

Lethal means safety is an effective suicide prevention strategy with demonstrated results at the population level, yet individual-level uptake is less well understood.

METHODS

Using automated data extraction methods, we conducted an investigation of electronic health records from psychiatric emergency service (PES) patients from January 1, 2012 to December 31, 2017 at a busy urban medical center in the Pacific Northwest. At each PES mental health evaluation, every patient received a Suicide Risk Assessment during which providers used an electronic template with standardized fields to record lethal means access and other suicide risk factors.

RESULTS

We assessed 32,658 records belonging to 15,652 patients. Among all visits, 69.9% (n = 22,824) had some documentation of lethal means assessment. However, 54.1% (n = 17,674) of all visits lacked some or all potential documentation detail. Additionally, among 59.6% of visits in which a patient had documented access to lethal means, the specific means available were not indicated. Across the twenty risk and demographic factors we assessed, the prevalence of documentation did not vary by any given risk factor and only varied minimally by age and race. For example, when comparing visits which indicated family history of suicide to those which indicated no family history of suicide, the prevalence ratio was 0.99 (95% CI: 0.95, 1.03).

CONCLUSION

Despite the high-risk patient population, mental health focus of the facility, and the presence of a standardized tool, lethal means documentation was suboptimal. In alignment with recent recommendations, our findings indicate that additional focus on implementation is needed to improve documentation of lethal means assessment.HighlightsFifteen times larger than prior comparable studiesFindings demonstrate persistent under-documentation patterns in new setting and regionStandardized methods likely needed to improve documentation detail and frequency.

Handgun purchasing characteristics and firearm suicide risk: a nested case-control study

Background

Firearms are the most lethal method of suicide and account for approximately half of all suicide deaths nationwide. We describe associations between firearm purchasing characteristics and firearm suicide.

Methods

Data on all legal handgun transactions in California from 1996 to 2015 were obtained from the California Department of Justice Dealer’s Record of Sale database. Handgun purchasers were linked to mortality data to identify those who died between 1996 and 2015. To account for variation in timing and duration of observation time, analyses were stratified by birth cohort. The primary analysis focused on those aged 21–25 in 1996. A secondary analysis tested associations among those aged 50–54 in 1996. Using incidence density sampling, purchasers who died by firearm suicide (cases) were each gender-matched to 5 purchasers (controls) who remained at risk at the case’s time of death. We examined the characteristics of purchasers and transactions, focusing on the transaction closest in time to the case’s death. Data were analyzed with conditional logistic regression.

Results

There were 390 firearm suicides among the younger cohort and 512 firearm suicides among the older cohort. Across both cohorts, older age at first purchase and the purchase of a revolver were associated with greater risk of firearm suicide. For example, among the younger cohort, those who purchased a revolver versus semiautomatic pistol had 1.78 times the risk of firearm suicide (95% CI 1.32, 2.40) in multivariable models. Other associations varied across cohorts, suggesting cohort or age effects in purchasing patterns.

Conclusions

Findings add to the evidence on firearm suicide risk and may help inform prevention strategies and future research.

Clinical strategies for reducing firearm suicide

Suicide is complex, with psychiatric, cultural, and socioeconomic roots. Though mental illnesses like depression contribute to risk for suicide, access to lethal means such as firearms is considered a key risk factor for suicide, and half of suicides in the USA are by firearm. When a person at risk of suicide has access to firearms, clinicians have a range of options for intervention. Depending on the patient, the situation, and the access to firearms, counseling on storage practices, temporary transfer of firearms, or further intervention may be appropriate. In the USA, ownership of and access to firearms are common and discussing added risk of access to firearms for those at risk of suicide is not universally practiced. Given the burden of suicide (particularly by firearm) in the USA, the prevalence of firearm access, and the lethality of suicide attempts with firearms, we present the existing evidence on the burden of firearm suicide and what clinicians can do to reduce their patients' risk. Specifically, we review firearm ownership in the USA, firearm injury epidemiology, risk factors for firearm-related harm, and available interventions to reduce patients' risk of firearm injury and death.

Firearm Practices, Perceptions of Safety, and Opinions on Injury Prevention Strategies Among California Adults

IMPORTANCE

Safe firearm storage and other interventions may reduce pediatric firearm deaths and injuries.

OBJECTIVE

To compare firearm ownership and storage practices, opinions on firearm injury prevention strategies, and perceptions of safety among adults in California households with and without children and/or adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used data from the 2018 California Safety and Well-being Survey, a California-representative, probability-based internet survey. Respondents were part of the Ipsos KnowledgePanel, an online research panel that uses address-based sampling and provides survey weights to produce estimates representative of the adult population of California.

MAIN OUTCOMES AND MEASURES

Topics included firearm storage practices, opinions on interventions to reduce pediatric firearm injury, and perceptions of household safety related to firearm ownership. Respondents were stratified by firearm ownership and household presence or absence of children and/or adolescents. Weighted percentages and 95% CIs are presented.

RESULTS

Of 5232 invited panel members, 2558 (48.9%) completed the survey. Among respondents, 52.5% (95% CI, 49.3%-55.7%) were women, 42.9% (95% CI, 39.9%-45.9%) were White, 30.0% (95% CI, 26.8%-32.9%) lived in homes with children, and the mean (SD) age was 48.0 (17.1) years. Among those in homes with children, more than two-thirds of individuals who owned firearms (70.6% [95% CI, 50.1%-85.2%]) and more than half of individuals who did not own firearms but lived in homes with guns (54.9% [95% CI, 37.9%-70.8%]) reported that they believed a firearm in the home made it safer. Half of those who owned firearms (52.3% [95% CI, 34.9%-69.2%]) and more than three-quarters of individuals who did not own firearms but lived in homes with guns (78.4% [95% CI, 57.5%-90.7%]) reported it was always appropriate for parents to inquire about unlocked guns in homes where their children play. Among those who had previously owned at least 1 gun but no longer did, 13.3% (95% CI, 7.1%-23.8%) reported getting rid of guns at least in part due to concern for the safety of a child in the home. Nearly two-thirds of those who owned firearms living with children and/or adolescents (64.5% [95% CI, 46.5%-79.2%]) did not store all firearms in the most secure manner (ie, unloaded and locked up), compared with 36.4% (95% CI, 29.4%-44.1%) of individuals who owned firearms but did not live with children.

CONCLUSIONS AND RELEVANCE

In this study, although a substantial percentage of individuals who owned guns and lived with children did not store all firearms as recommended, parents and caregivers who owned firearms reported being amenable to interventions that reduce young people's risk of firearm-related harm. Future work should investigate acceptable risk reduction and safe storage interventions.

Firearm purchasing and firearm violence during the coronavirus pandemic in the United States: a cross-sectional study

BACKGROUND

Firearm violence is a significant public health problem in the United States. A surge in firearm purchasing following the onset of the coronavirus pandemic may have contributed to an increase in firearm violence. We sought to estimate the state-level association between firearm purchasing and interpersonal firearm violence during the pandemic.

METHODS

Cross-sectional study of the 48 contiguous states and the District of Columbia from January 2018 through July 2020. Data were obtained from the National Instant Criminal Background Check System (a proxy for firearm purchasing) and the Gun Violence Archive. Using negative binomial regression models, we estimated the association between cumulative excess firearm purchases in March through July 2020 (measured as the difference between observed rates and those expected from autoregressive integrated moving average models) and injuries (including nonfatal and fatal) from intentional, interpersonal firearm violence (non-domestic and domestic violence).

RESULTS

We estimated that there were 4.3 million excess firearm purchases nationally from March through July 2020 and a total of 4075 more firearm injuries than expected from April through July. We found no relationship between state-level excess purchasing and non-domestic firearm violence, e.g., each excess purchase per 100 population was associated with a rate ratio (RR) of firearm injury from non-domestic violence of 0.76 (95% CI: 0.50-1.02) in April; 0.99 (95% CI: 0.72-1.25) in May; 1.10 (95% CI: 0.93-1.32) in June; and 0.98 (95% CI: 0.85-1.12) in July. Excess firearm purchasing within states was associated with an increase in firearm injuries from domestic violence in April (RR: 2.60; 95% CI: 1.32-5.93) and May (RR: 1.79; 95% CI: 1.19-2.91), though estimates were sensitive to model specification.

CONCLUSIONS

Nationwide, firearm purchasing and firearm violence increased substantially during the first months of the coronavirus pandemic. At the state level, the magnitude of the increase in purchasing was not associated with the magnitude of the increase in firearm violence. Increases in purchasing may have contributed to additional firearm injuries from domestic violence in April and May. Results suggest much of the rise in firearm violence during our study period was attributable to other factors, indicating a need for additional research.

Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic

OBJECTIVES

Increased rates of firearm ownership, school closures, and a suspected decrease in supervision during the coronavirus disease 2019 (COVID-19) pandemic place young children at increased risk of firearm injuries. We measured trends in firearm injuries in children and inflicted by children discharging a firearm during the pandemic and correlated these changes with a rise in firearm acquisition.

METHODS

In this cross-sectional study with an interrupted time series analysis, we used multiyear data from the Gun Violence Archive. We compared trends in (1) firearm injuries in children younger than 12 years old and (2) firearm injuries inflicted by children younger than 12 years old during the pre-COVID-19 period (March to August in the years 2016-2019) and during the first 6 months of the COVID-19 pandemic (March 2020 to August 2020). Linear regression models were developed to evaluate the relationship between firearm injuries and new firearm acquisitions.

RESULTS

There was an increased risk of (1) firearm injuries in young children (relative risk = 1.90; 95% confidence interval 1.58 to 2.29) and (2) firearm injuries inflicted by young children (relative risk = 1.43; 95% confidence interval 1.14 to 1.80) during the first 6 months of the COVID-19 pandemic as compared to the pre-COVID-19 study period. These increased incidents correlate with an increase in new firearm ownership (P < .03).

CONCLUSIONS

There has been a surge in firearm injuries in young children and inflicted by young children during the first 6 months of the COVID-19 pandemic. There is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds

BACKGROUND

Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied.

METHODS

An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression.

RESULTS

Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF.

CONCLUSION

RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

Lethal Means Counseling for Suicidal Adults in the Emergency Department: A Qualitative Study

Introduction

Lethal means counseling (to reduce access to firearms or other suicide methods) is a recommended critical yet challenging component of care of suicidal patients. Questions remain about communication strategies for those in acute crisis.

Methods

This qualitative study was an analysis of semi-structured interviews with English-speaking, community-dwelling adults with a history of lived-experience of suicidal ideation or attempts in themselves or a family member. We used a mixed inductive and deductive approach to identify descriptive themes related to communication and decision-making.

Results

Among 27 participants, 14 (52%) had personal and 23 (85%) had family experience with suicide ideation or attempts. Emergent themes fell into two domains: (1) communication in a state of high emotionality; and (2) specific challenges in communication: initiating, maintaining engagement, considering context.

Conclusion

Engaging suicidal individuals in lethal means counseling may be more effective when messaging and approaches consider their emotional state and communication challenges.

Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve?

INTRODUCTION

Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED).

METHODS

We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate.

RESULTS

A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home.

CONCLUSIONS

Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

Preventing Suicide Through Better Firearm Safety Policy in the United States

The U.S. suicide rate continues to increase, despite federal investment in developing preventive behavioral health care interventions. Important determinants of suicide-social, economic, and circumstantial-have little or no connection to psychopathology. Firearm injuries account for over half of suicides, and firearm access is perhaps the most important modifiable determinant. Thus gun safety policy deserves special attention as a pathway to suicide prevention. This article summarizes arguments for several recommended statutory modifications to firearm restrictions at the state level. The policy challenge is to develop and implement evidence-based strategies to keep guns out of the hands of people at highest risk of suicide, without unduly infringing the rights of a large number of gun owners who are unlikely to harm anyone. Recommendations for states include expansion and refinement of legal criteria prohibiting firearm purchase, possession, or access to better align with suicide risk, including prohibition for persons with brief involuntary psychiatric holds or repeated alcohol-impaired driving convictions; enactment of extreme risk protection order laws, which allow temporary removal of firearms from persons who are behaving dangerously, and entering purchase prohibition data for these persons in the FBI's background-check database; and adoption of an innovative policy known as precommitment against suicide as well as voluntary self-enrollment in the FBI's background-check database.

Understanding the Role of Law in Reducing Firearm Injury through Clinical Interventions

Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies.

California Public Opinion On Health Professionals Talking With Patients About Firearms

Medical and public health organizations have recommended that health professionals discuss firearm safety with patients at risk for gun-related injury, yet few health professionals do so. Concerns that patients may view conversations about firearms as inappropriate have been reported in prior studies. Using state-representative data from the 2018 California Safety and Wellbeing Survey, this study found that most Californians report gun safety conversations with health professionals to be at least sometimes appropriate when these conversations involved a patient who had a known risk factor for firearm-related harm (depending on the risk factor, 83.7-90.2 percent among all respondents and 70.0-91.2 percent among firearm owners). Majorities of respondents also found intervention by health professionals for those at imminent risk to be at least sometimes appropriate (depending on the intervention, 84.0-89.9 percent among all respondents and 82.6-91.0 percent among firearm owners). These findings can inform health policy and education on clinical strategies for preventing firearm-related harm.

Lethal Means Assessment and Counseling in the Emergency Department: Differences by Provider Type and Personal Home Firearms

OBJECTIVE

This study examined emergency department (ED) and behavioral health (BH) provider attitudes and behaviors related to lethal means screening and counseling of patients with suicide risk, specifically examining differences by provider type and whether providers had firearms in their own home.

METHODS

Emergency department providers (physicians and mid-level practitioners) and behavioral health (BH) providers at four Colorado EDs completed an anonymous, web-based survey.

RESULTS

Fewer ED providers (35%) than BH providers (81%) felt confident in their ability to counsel patients about lethal means (p < .001). In multivariable analysis, the only clinical or provider factor associated with often or almost always asking patients about firearm access was provider type, with BH providers more likely than ED providers to ask in all scenarios (OR: 5.58, 95% CI 1.68-18.6). Behaviors and attitudes about lethal means counseling did not vary by whether the provider had firearms at home. Almost all providers said that additional training and protocols about how to help patients make firearm storage decisions would be helpful.

CONCLUSIONS

Gaps in ED-delivered lethal means counseling persist, highlighting directions for future provider education and protocol development.

Firearm suicide mortality among emergency department patients with physical health problems

PURPOSE

Individuals with poor physical and mental health may face elevated risk for suicide, particularly suicide by firearm.

METHODS

This retrospective cohort study used statewide, longitudinally linked emergency department (ED) patient record and mortality data to examine 12-month incidence of firearm suicide among ED patients presenting with a range of physical health problems. Participants included all residents presenting to a California ED in 2009-2013 with nonfatal visits for somatic diagnoses hypothesized to increase suicide risk, including myocardial infarction, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, cancer, back pain, headache, joint disorder, and injuries. For each patient diagnostic group, we calculated rates of firearm suicide per 100,000 person-years and standardized mortality ratios (SMRs) relative to the demographically matched California population.

RESULTS

Firearm suicide rates per 100,000 person-years ranged from 9.6 (among patients presenting with unintentional injury) to 55.1 (patients with cancer diagnoses), with SMRs from 1.48 to 7.45 (all p < 0.05). SMRs for patients with cardiovascular conditions ranged from 2.45 to 5.10. Men and older individuals had higher firearm suicide rates, and there was substantial between-group variability in the proportion of suicide decedents who used a firearm.

CONCLUSIONS

ED patients presenting with deliberate self-harm injuries, substance use, and cancer were especially at risk for firearm suicide. To avoid missed suicide prevention opportunities, EDs should implement evidence-based suicide interventions as a best practice for their patients.

Firearm ownership and perceived risk of personal firearm injury

Despite evidence that firearm access in the home is a strong risk factor for firearm injury, firearms are owned more often for self-protection than for any other reason. In this cross-sectional study, we describe the association between firearm ownership and perceived risk of personal firearm injury using logistic regressions applied to data from the 2018 California Safety and Well-being Survey. Most respondents (57.7%) reported being very/somewhat worried about gun violence happening to them. Compared with non-owners in households without firearms, firearm owners were 60% (adjusted OR (aOR) 0.40, 95% CI: 0.27 to 0.58) less likely to be worried about gun violence happening to them; non-owners living in homes with firearms were 46% (aOR 0.54, 95% CI: 0.33 to 0.88) less likely. This suggests an underestimation of actuarial risk that conflicts with the available evidence, with important implications for public health messaging.

Counseling on Access to Lethal Means-Emergency Department (CALM-ED): A Quality Improvement Program for Firearm Injury Prevention

INTRODUCTION

Suicide is the 10^th leading cause of death in the United States, with firearms reported as the cause of death in up to 50% of these cases. Our goal was to evaluate the feasibility of the Counseling on Access to Lethal Means intervention in the Emergency Department (CALM-ED) by non-physician personnel.

METHODS

We conducted this single-center, prospective, quality improvement study (QI) in an urban, academic ED with over 90,000 annual patient visits. The study looked at adult patients who were discharged after presenting to the ED with suicidal crisis. Assessment of access to lethal means was conducted at the bedside, followed by a counseling session regarding safe storage of lethal means and follow-up via telephone call 48-72 hours after ED discharge. We collected data on patient's sociodemographics, psychiatric history, access to lethal means, lethal means storage methods, the patient's specific plans for lethal means storage after discharge, and post-discharge follow-up care.

RESULTS

Of 215 eligible patients, 166 voluntarily agreed to participate in CALM-ED, of whom 84 (51%) reported access to lethal means. Following the intervention, 75% of patients described a specific storage plan for their lethal means. Patients with and without access to firearms were equally likely to participate in the follow-up telephone call.

CONCLUSION

An ED-based CALM QI intervention is feasible for implementation by non-physician personnel and is well received by patients and families. This intervention has the potential to help saves lives at times of suicide crisis.

Views on Firearm Safety Among Caregivers of People With Alzheimer Disease and Related Dementias

IMPORTANCE

The population of adults with Alzheimer disease and related dementias (ADRD) is increasing, and many people with ADRD have access to firearms. Little is known, however, about how caregivers of people with ADRD think about or address firearm safety.

OBJECTIVE

To assess views on firearm safety risks among caregivers of persons with ADRD, experiences of caregivers with health care professional-delivered counseling, and their preferred sources of information about firearm safety.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a probability-based online survey (National Firearms Survey, July 30 to August 11, 2019) with weights used to generate nationally representative estimates of adults living in households with firearms to assess firearm safety views of English-speaking adults 35 years or older. Respondents for the National Firearm Survery were drawn from I KnowledgePanel, a frame with approximately 55 000 US adults selected on an ongoing basis using address-based sampling methods.

MAIN OUTCOMES AND MEASURES

Caregivers were asked whether the person with ADRD owned or had access to firearms. Additional ADRD-related measures assessed perceptions about the likelihood of types of firearm injuries involving people with ADRD, support for firearm safety counseling by health care professionals with regard to dementia, and history of ever having received such counseling.

RESULTS

Of 6712 invited panel members, 4030 completed the survey (completion rate, 65%). For this analysis, we excluded the youngest participants (aged 18-34 years; n = 498); among the remaining 3532 participants, 124 reported being caregivers for persons with ADRD. Of the 124 caregivers, 51% were female and the mean (SD) age was 60 (12.5) years. Most participants (71%; 95% CI, 69%-72%) thought that a person with ADRD was more likely to hurt someone else unintentionally than intentionally hurt themselves or someone else. Many participants thought health care professionals should always (45%; 95% CI, 43%-47%) or sometimes (34%; 95% CI, 32%-37%) talk about firearm safety with caregivers or patients with dementia, but only 5% of caregivers (95% CI, 2%-12%) reported that a health care professional had ever spoken to them about firearm safety. Among the 41% (95% CI, 31%-51%) of caregivers who lived with a person with dementia, 31% (95% CI, 18%-49%) said the person with dementia could access firearms in the home.

CONCLUSIONS AND RELEVANCE

In this study, few caregivers of adults with ADRD reported having received health care professional counseling about firearm safety, although most thought health care professionals should provide such counseling. These findings raise concerns about home firearm access among adults with ADRD and indicate potential opportunities for enhanced education by health care professionals and community organizations.