Battle over Florida legislation casts a chill over gun inquiries

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study

Importance

US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention.

Objective

To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters.

Design, Setting, and Participants

Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs).

Main Outcomes and Measures

Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives.

Results

Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews.

Conclusions and Relevance

In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Question

Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond?

Findings

In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access.

Meaning

In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms.

Importance

Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective

To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design, Setting, and Participants

Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main Outcomes and Measures

Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results

Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and Relevance

In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

"What Will Happen If I Say Yes?" Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms

OBJECTIVE

Addressing firearm access is recommended when patients are identified as being at risk of suicide. However, the practice of assessing firearm access is controversial, and no national guidelines exist to inform practice. This study qualitatively explored patient perspectives on a routine question about firearm access to optimize the patient centeredness of this practice in the context of suicide risk.

METHODS

Electronic health record data were used to identify primary care patients reporting depressive symptoms, including suicidal thoughts, within 2 weeks of sampling. Participants completed a semistructured telephone interview (recorded and transcribed), which focused broadly on the experience of being screened for suicidality and included specific questions to elicit beliefs and opinions about being asked a standard firearm access question. Directive (deductive) and conventional (inductive) content analysis was used to analyze responses to the portion of the interview focused on firearm assessment and disclosure.

RESULTS

Thirty-seven patients in Washington State ages 20-95 completed the qualitative interview by phone. Organizing themes included apprehensions about disclosing access to firearms related to privacy, autonomy, and firearm ownership rights; perceptions regarding relevance of the firearm question, informed by experiences with suicidality and common beliefs and misconceptions about the inevitability of suicide; and suggestions for connecting questions about firearms and other lethal means to suicide risk.

CONCLUSIONS

Clarifying the purpose and use of routine firearm access assessment, contextualizing firearm questions within injury prevention broadly, and addressing misconceptions about suicide prevention may help encourage disclosure of firearm access and increase the patient centeredness of this practice.

Hospital Emergency Department Lethal Means Counseling for Suicidal Patients

INTRODUCTION

Lethal means counseling of suicidal individuals in emergency departments has the potential to reduce suicide. This study examines the provision of lethal means counseling and the presence of written protocols in a region with high rates of both firearm ownership and suicide.

METHODS

In 2015-2016, emergency department nurse managers in hospital-based emergency departments throughout eight states were surveyed using an 80-item survey developed through qualitative interviews and pilot testing. Questions focused on discharge counseling with suicidal patients and the presence of written protocols. Using survey weights to adjust for nonresponse, relationships of protocols with counseling practices were examined.

RESULTS

Data were obtained from 52.3% of all 363 eligible hospital emergency departments in the region. Among facilities that discharge suicidal patients, 79.7% (95% CI=75.0%, 84.4%) reported asking about access to firearms and 68.9% (95% CI=62.9%, 74.8%) counsel about safe storage when patients reported access. Forty-four percent of emergency departments reported having written protocols for lethal means counseling. Presence of written protocols was associated with a higher rate of counseling for all suicidal patients even if they were not planning to use a gun (45.0% [95% CI=33.4%, 56.7%] in hospitals with protocols vs 21.5% [95% CI=14.9%, 29.0%] in facilities without protocols).

CONCLUSIONS

There are significant gaps in attention to lethal means counseling in emergency departments. This signals an opportunity to increase consistency and thoroughness of care for suicidal patients in the emergency department and for leadership from key professional organizations to advocate for protocols.

Guns in Intimate Partner Violence: Comparing Incidents by Type of Weapon

Objective: The goal of this study was to assess the frequency, nature, and outcome of weapon use in intimate partner violence (IPV) and to assess compliance with related gun policies.

Methods: Data were drawn from forms police are mandated to complete at the scene of IPV in the fifth largest U.S. city during 2013. Proportions were calculated and odds ratios were adjusted for demographic and contextual characteristics and a Bonferroni correction for multiple statistical tests was applied.

Results: Of the 35,413 incidents, 6,573 involved hands, fists, or feet, and 1,866 involved external weapons of which 576 were guns. Most incidents were male-on-female: 63.4% (no weapon), 77.4% (bodily weapon), 50.2% (nongun external weapon), and 79.5% (gun). Guns were used most often to threaten the partner (69.1%). When a gun (vs. bodily or nongun external weapon) was used, IPV victims were less likely to have visible injuries (adjusted odds ratio [AOR] = 0.64 and 0.23, respectively)—offenders were less likely to have pushed or shoved, grabbed, punched, or kicked the victim—but (victims) were more likely to be frightened (AOR = 3.13 and 1.49, respectively).

Conclusions: Weapon use of any type by an intimate partner is associated with a wide range of violent offender behavior and multiple negative outcomes for victims. The use of a gun has implications that include, but go beyond, physical injury of the victim. Documentation of the enforcement of state law regarding gun removal merits improvement, which has important implications for the evaluation of policies designed to keep guns out of the hands of abusers.

A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes

OBJECTIVES

Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes.

METHODS

This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering.

RESULTS

There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters.

CONCLUSIONS

Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence.