Determining who healthcare providers screen for firearm access in the United States

Suicide is the twelfth leading cause of death in the US (WISQARS (Web-based Injury Statistics Query and Reporting System)|Injury Center|CDC, n.d.). Firearms account for over 50% of these deaths and are the most lethal modality (WISQARS (Web-based Injury Statistics Query and Reporting System)|Injury Center|CDC, n.d.). In addition to suicide, firearm access increases risk for unintentional shootings (Levine and McKnight, 2017) and homicides (Studdert et al., 2022). In 2020, there were an average of 124 daily gun-related deaths, a single year increase of 13.9% (WISQARS (Web-based Injury Statistics Query and Reporting System)|Injury Center|CDC, n.d.). Thus, this public health concern demands continued attention.

Research has not definitively demonstrated that increasing safe firearm storage reduces firearm injuries and deaths; however, evidence supports the potential of this approach. Safe firearm storage education, distribution of cable locks, and lethal means counseling have been shown to positively change storage behaviors (Anestis et al., 2021; Bandealy et al., 2020; Barber et al., 2022; Khazem et al., 2015). Lethal means counseling involves screening for firearm access, and discussing ways to increase secure storage that meet individual client needs and preferences. More work is needed, however, to identify additional intervention points that may prompt population change in firearm storage practices.

Healthcare providers are well-positioned to screen for environmental risk. Mental health providers frequently treat patients contemplating suicide (McAdams, 2000) and, if trained to do so, are significantly more likely to provide firearm counseling to these patients. However, it is unclear how consistently mental health providers screen patients for firearm access and if screening is reserved for patients considered to be at high risk of self-harm (Roszko et al., 2016). One recent study indicated safe firearm storage counseling may be lacking specifically among mental health patients (Horn et al., 2021).

The American Academy of Pediatrics (AAP) was the first major organization to recommend routine screening for firearm access for parents during well-child visits (Dowd and Sege, 2012). The literature, however, suggests pediatricians avoid discussing firearm safety during well-child visits due to discomfort with the topic (Hinnant et al., 2021), lack of time, and insufficient training (Bandealy et al., 2020). Pediatricians are more consistent in discussing firearm safety with families of adolescent patients who are depressed and/or suicidal in both primary care and emergency settings (Bandealy et al., 2020; Hinnant et al., 2021; Webb et al., 2022).

Like pediatricians, adult primary and emergency healthcare providers have not routinely screened patients for firearm access. Instead, they often reserve firearm screening and safe storage discussions for patients experiencing a mental health crisis and/or identified as being at risk for suicide, though even in these circumstances implementation is inconsistent (Roszko et al., 2016). One large retrospective study revealed that only 18% of adult emergency patients identified as exhibiting elevated suicide risk were screened for firearm access or provided with lethal means counseling (Betz et al., 2018). Explanations for hesitancy among emergency department providers include lack of confidence delivering the intervention, lack of training, and not feeling convinced that restricting access to firearms will prevent suicide (Betz et al., 2013; Diurba et al., 2020).

Recently, physician and public health professional organizations have called for firearm screening and lethal means counseling to extend to the primary care setting (McLean et al., 2019). This is important because very few firearm owners contemplating suicide utilize mental services before they die (Bond et al., 2022). However, people experiencing suicidal thoughts often utilize primary and emergency care leading up to a suicide attempt. One large-scale study revealed that 90% of people who died by suicide had contact with a primary or emergency physician within one year of their death and over 50% were in contact within the prior month (Ahmedani et al., 2019).

Data on the frequency or efficacy of universal firearm screening among adults in outpatient healthcare settings is limited. One study examined firearm screening in the Veteran's Health Administration (VHA), with a sample of over 760,000 Post-9/11 Veterans in their first year of VHA care. Researchers reviewed charts from primary, urgent, or emergent care clinics and found that <10% of the sample had a documented firearm screening (Brandt et al., 2021). Within the VHA sample, women had the lowest number of documented firearm screenings and Veterans who identified as Black or Hispanic had less documented screenings for firearm access than Veterans who identified as White. Further, Veterans aged 30–49 were less likely to have a documented firearm screening than Veterans <30 years and older than 50 years (Brandt et al., 2021). The VHA study highlights the need for further investigations to understand if similar gaps in screening are present within civilian populations and to identify how consistently firearm screening occurs.

The present study broadens the VHA inquiry to a representative primarily civilian sample (n = 3510) across five states within the U.S – Colorado, Minnesota, Mississippi, New Jersey, and Texas – that vary widely in their geographic location, culture, demographic composition, and firearm access and gun violence rates, with data collected between April 29 and May 15, 2022. We sought to determine to what extent healthcare providers screen adults for firearm access and to identify who is being screened. This study examines healthcare provider firearm screening by demographics such as race/ethnicity, sex, income, age, and education level. Given the dearth of prior research on this issue, we did not put forth a priori hypotheses and instead conceptualize these results as exploratory and descriptive. By highlighting the frequency with which certain communities have been asked about firearm access within a healthcare setting, we hope to call attention to areas in which increased frequency of clinical conversations might yield meaningful changes in firearm storage behaviors.

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