Search

Among women Veterans, firearms are the leading suicide means. This has prompted efforts to elucidate factors associated with women Veterans' firearm ownership. This cross-sectional study examined if deployment experiences were associated with firearm ownership among women Veterans and if safety-related beliefs mediated these associations.492 previously deployed post-9/11 women Veterans participated in a national survey that included the Deployment Risk and Resilience Inventory-2, subscales of the Posttraumatic Cognitions Inventory and Posttraumatic Maladaptive Beliefs Scale, and firearm ownership questions. Path analysis was used.Perceived threat during deployment was associated with firearm ownership, irrespective of safety-related beliefs. Indirect effects did not support that safety-related beliefs mediated relations between deployment experiences and firearm ownership. The other deployment experiences (sexual harassment, sexual assault, general harassment, combat experiences) were not indirectly associated with firearm ownership, nor were safety-related beliefs (negative cognitions about the world, threat of harm, beliefs about others' reliability and trustworthiness) directly associated with firearm ownership. In an exploratory serial mediation analysis, perceived threat during deployment mediated the association between combat experiences and firearm ownership. In a sensitivity analysis examining firearm acquisition following military service, results were similar, except the indirect effect of combat experiences upon firearm acquisition through perceived threat was not significant.Post-9/11 women Veterans' firearm acquisition and ownership may relate to specific deployment experiences, such as perceived threat; however, longitudinal studies are needed to fully ascertain this. Efforts to address firearm access among post-9/11 women Veterans may benefit from assessing heightened sense of danger during deployment.

Firearm injury, particularly self-directed, is a major source of preventable morbidity and mortality among older adults. Older adults are at elevated risk of serious illness, cognitive impairment, and depression-all known risk factors for suicide and/or unintentional injury. Healthcare providers are often the first to identify these conditions and, although they commonly deliver safety guidance to such patients, little is known about how they approach firearm safety conversations with older adults.We conducted semi-structured interviews with healthcare providers who care for older adults (November 2020-May 2021). We used inductive and deductive thematic analyses to develop themes. We present themes and representative quotes from our analysis.We interviewed 13 healthcare providers who regularly care for older adult firearm owners. Emergent themes were: circumstances that prompt firearm safety conversations; strategies for addressing firearm safety in routine and acute circumstances; barriers to addressing firearm safety; and available or desired resources.Planning for firearm safety should occur "early and often" as part of a longitudinal relationship with older adult patients. Age-related safety issues such as driving are regularly addressed with older adult patients, likely because there are standard processes and established pathways. Establishing processes and provider/ patient resources would help improve provider efficacy to address firearm safety and relinquishment for older adult firearm owners. Integrating firearm safety conversations into routine encounters (e.g., Medicare Annual Wellness Visit, problem-focused visits) templates could be a promising initial step but resources for follow-up to the firearm screening must be available to both provider and patient.

Safety planning to reduce suicide or other-directed violence risk involves efforts toward "making the environment safe," including working collaboratively with at-risk patients to encourage voluntary changes in their firearm storage decisions [ie, lethal means safety (LMS) counseling]. This column provides a conceptual framework and real-world evidence to support the delivery of LMS counseling to at-risk patients, as well as guidance on asking about firearm access and making individualized safety recommendations. It also reviews important elements related to documenting LMS discussions and legal considerations related to these conversations.

Suicides by firearm have increased over the past decade among United States service members and veterans. As firearm access is a suicide risk factor, firearm-related lethal means safety is critical to suicide prevention. However, identity, occupational, and cultural barriers may deter efforts to promote lethal means safety with service members and veterans. The current manuscript describes a collaborative framework to guide mental health providers' in conducting firearm-related lethal means safety with service members and veterans, including within the context of Safety Planning. In approaching firearm lethal means safety conversations with patients, clinicians must work to overcome their own reticence, address patient concerns directly, and remain culturally sensitive to the values of the military and veteran communities. This approach is illustrated using case vignettes that encompass addressing firearm-related lethal means safety with service members and veterans.

Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care. Describe veterans’ perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide. Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans. Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender. The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach. There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans’ knowledge of firearms. Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

Seventy percent of suicides among U.S. veterans are due to firearm injury. Because discussions about firearm access are an important component of evidence-based suicide prevention programs, we sought to quantify the proportion of U.S. veterans who have discussed firearm safety with a healthcare provider.Data come from a probability-based, nationally representative online survey of U.S. adults living in households with firearms in 2019 (response 65%). In this study, we include only self-identified veteran firearm owners. Respondents were asked, "Has a physician or other healthcare practitioner ever spoken to you about firearm safety?" Analyses were stratified by self-reported use of Veterans Health Administration (VHA) healthcare services.Overall, 31.5% (95% CI 27.5-35.8) reported using VHA services and 9.2% (95% CI 6.8-12.3) reported that a clinician had ever spoken with them about firearm safety (14.3% among VHA users, 6.8% among non-users). Of those who reported a discussion, nearly three quarters reported it was with an outpatient primary care physician or medical specialist.A large majority of veteran firearm owners have not had, or do not recall having had, a firearm safety discussion with a clinician, suggesting that additional efforts to facilitate such discussions in the VHA and elsewhere are needed.

Firearm injury is the leading mechanism of suicide among US women, and lethal means counseling (LMC) is an evidence-based suicide prevention intervention. We describe current knowledge and research gaps in tailoring LMC to meet the needs of US women.Available LMC and firearm suicide prevention literature has not fully considered how LMC interventions should be tailored for women. This is especially important as firearm ownership and firearm-related suicides among women are increasing. Additional research is needed to better understand firearm characteristics, behaviors, and beliefs of US women, particularly related to perceptions of personal safety and history of trauma. Research is also needed to identify optimal components of LMC interventions (e.g., messengers, messages, settings) and how best to facilitate safety practices among women with firearm access who are not themselves firearm owners but who reside in households with firearms. Finally, it will be important to examine contextual and individual factors (e.g., rurality, veteran status, intimate partner violence) which may impact LMC preferences and recommendations.This commentary offers considerations for applying existing knowledge in LMC and firearm suicide prevention to clinical practice and research among US women, among whom the burden of firearm suicide is increasing.

Extreme risk protection orders (ERPOs) represent a potential mechanism to facilitate firearm-related lethal means safety. ERPOs are a legal mechanism that enables law enforcement to temporarily remove firearms from, and prevent firearm purchase by, an individual who presents a significant danger to self or others, as determined by a court of law. While few jurisdictions currently allow mental health professionals to initiate ERPO petitions, it nonetheless seems important that clinicians be familiar with ERPOs, as clinicians may still serve an important role in disseminating information and facilitating judicious petitions. However, ERPO laws remain quite new, and the implications for mental health professionals when participating (directly or indirectly) in ERPOs remain unclear. This column introduces readers to ERPOs and offers resources to learn more about how ERPOs work across various jurisdictions.

Objectives Although firearms are the leading suicide means among female veterans, firearm research in this population remains limited. This study explored female veterans' firearm-related experiences and perspectives. Method Sixteen cisgender female veterans (ages 27-69) participated in qualitative interviews. Results Participants gained initial firearm knowledge and exposure in childhood and adolescence through older male family members. Military service led to broader exposure to firearms, which were perceived as important for survival and protection in a male-dominated environment, predominantly due to the risk for sexual violence. Following military service, the desire for self-protection motivated firearm ownership and storage practices. Participants perceived trust as essential to firearm discussions, preferring for family members to initiate such conversations. Conclusions This study provides insight into the context in which female veterans' firearm-related beliefs and practices develop. Interpersonal factors and various lifespan experiences appear to play a vital role in female veterans' firearm access, ownership, and storage practices.

BACKGROUND: Premature mortality observed among the mentally ill is largely attributable to chronic illnesses. Veterans seen within Veterans Affairs (VA) have a higher prevalence of mental illness than the general population but there is limited investigation into the common causes of death of Veterans with mental illnesses. OBJECTIVE: To characterize the life expectancy of mentally ill Veterans seen in VA primary care, and to determine the most death rates of combinations of mental illnesses. DESIGN: Retrospective cohort study of decedents. SETTING/PARTICIPANTS: Veterans seen in VA primary care clinics between 2000 and 2011 were included. Records from the VA Corporate Data Warehouse (CDW) were merged with death information from the National Death Index. MAIN MEASURES: Mental illnesses were determined using ICD9 codes. Direct standardization methods were used to calculate age-adjusted gender and cause-specific death rates per 1000 deaths for patients with and without depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), serious mental illness (SMI), and combinations of those diagnoses. KEY RESULTS: Of the 1,763,982 death records for Veterans with 1 + primary care visit, 556,489 had at least one mental illness. Heart disease and cancer were the two leading causes of death among Veterans with or without a mental illness, accounting for approximately 1 in 4 deaths. Those with SUD (n = 204,950) had the lowest mean age at time of death (64 ± 12 years). Among men, the death rates were as follows: SUD (55.9/1000); anxiety (49.1/1000); depression (45.1/1000); SMI (40.3/1000); and PTSD (26.2/1000). Among women, death rates were as follows: SUD (55.8/1000); anxiety (36.7/1000); depression (45.1/1000); SMI (32.6/1000); and PTSD (23.1/1000 deaths). Compared to men (10.8/1000) and women (8.7/1000) without a mental illness, these rates were multiple-fold higher in men and in women with a mental illness. A greater number of mental illness diagnoses was associated with higher death rates among men and women (p < 0.0001). CONCLUSIONS: Veterans with mental illnesses, particularly those with SUD, and those with multiple diagnoses, had shorter life expectancy than those without a mental illness. Future studies should examine both patient and systemic sources of disparities in providing chronic illness care to Veterans with a mental illness. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05307-w) contains supplementary material, which is available to authorized users.

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 (non-partner) 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.

This Viewpoint discusses lethal means safety (LMS), an approach to reducing suicide risk by reducing access to firearms by at-risk individuals; highlights challenges in implementing LMS interventions in clinical settings; and provides examples of programs and resources for preventing firearm suicide at the individual, patient group, and population level.

Objectives Electronic consultations, or e-consults, between primary care providers and specialists have been shown to improve access to specialty care, shorten wait times, and reduce outpatient visits. The objective of this study was to evaluate differences in health care costs between patients who received an electronic specialty consultation and patients who received a face-to-face specialty consultation. Study design Retrospective cohort evaluation of patients who received a specialty consultation in the Veterans Health Administration during 2016. Methods Patients who received an e-consult were matched 1:1 to patients who received a face-to-face consultation using propensity scores. Total, outpatient, and inpatient health care costs over 3 and 6 months following the specialty consultation were compared using a generalized linear model with a gamma distribution and log link. Results e-Consults accounted for 1.8% (urology) to 9.6% (hematology) of specialty consultations, on average. Across 11 specialties, patients receiving an e-consult had significantly lower health care costs compared with patients receiving a face-to-face consultation, ranging from 3.6% (cardiology) to 30.7% (hematology) lower. This was largely driven by differences in outpatient costs. Patients receiving an e-consult had significantly lower outpatient costs for all specialties except cardiology, ranging from 6.9% (endocrinology) to 31.2% (hematology) lower. Three-month inpatient costs among those who received an e-consult were significantly lower only in cardiology (5.2%), nephrology (9.3%), pulmonary (13.0%), and gastroenterology (14.3%). Conclusions Electronic specialty consultations are a potential mechanism to reduce health care costs and promote the efficient use of health care resources.

Objective To describe VHA primary care clinician and staff perspectives on conducting firearms storage safety (FSS) discussions in primary care, and to identify key approaches for primary care teams to facilitate FSS conversations. Method Qualitative analysis of transcripts and notes from focus groups with VA primary care staff and individual semi-structured interviews with primary care clinicians. One hundred-seven VHA primary care team members participated in one of four focus groups or individual semi-structured interviews (n = 5). Results FSS discussions are perceived as within the purview of primary care. Primary care staff also outlined five tools and processes needed to meaningfully implement FSS discussions in primary care: training on firearms and firearms culture; examining personal attitudes toward firearms; developing supplemental materials to normalize and support FSS discussions; increasing knowledge of firearms laws and regulations; and providing scripts to facilitate conversations. Conclusions Conducting FSS discussions in primary care settings is perceived as an acceptable practice, yet care teams identified barriers and suggestions for overcoming implementation challenges.

Introduction: A study of 42,000 cardiology consults within the Veterans Health Administration (VHA) in 2016 found that patients who received electronic consultation (e-consults) had similar healthcare costs at 6 months compared to those who received face-to-face (F2F) consults. However, results may have been confounded if patients with less costly conditions received e-consults. Our aim was to compare costs between those receiving F2F vs. e-consults for a similar indication. Hypothesis: Electronic rather than F2F consultation for atrial fibrillation (AF) management will be associated with lower total healthcare costs. Methods: We conducted a retrospective cohort study of a national sample of VHA patients who received cardiology consultation in 2016. We used a natural language processing script to identify consults for AF management. Primary outcomes were total healthcare costs at 3 and 6 months. Secondary outcomes included inpatient and outpatient costs. We compared costs between groups using a generalized linear model with a gamma distribution and log link. We adjusted for community wage and Charlson comorbidity indices, distance to nearest facility, age, and gender. Standard errors were clustered at the facility level. Results: We sampled 176 F2F and 136 e-consults from 43 facilities. Mean total 6-month costs were $12,928 (95% confidence interval [CI]: 1,377; 40,644) and $8,286 (95% CI: 959; 31,320) among e-consult and F2F groups, respectively. The e-consult group had 12.3% higher 3-month (p Conclusions: Use of e-consults for AF management is associated with reduced inpatient costs at 3 months, but higher total costs, which were largely driven by outpatient costs. Improving our understanding of healthcare utilization after initial consultation, or in differences in reasons for consultation within AF management may help explain these differences.

Objective Few studies have assessed the suicide-specific perceptions and awareness of school-based nurses and counselors. This project assessed the self-reported training, beliefs, and professional experiences of school counselors and nurses towards suicide prevention, and identified areas for enhancing efforts to respond to student suicidality. Methods A self-report needs assessment survey was conducted with school-based nurses and counselors in King County, Washington. Group comparisons and descriptive statistics were calculated to characterize providers' perceptions and experiences. Results Most training experiences reported by counselors and nurses corresponded with greater perceptions of comfort in applying suicide prevention knowledge and skills. Fewer respondents endorsed means safety and safety planning as regularly implemented interventions for at-risk students compared to other interventions. Conclusion Means safety and safety planning appeared to be areas for enhancing existing suicide prevention efforts.

Background: Discussing safe storage of firearms, including access, during times of crisis with veterans in primary care settings may enhance suicide prevention efforts. However, veteran attitudes toward such discussions are not well understood. The goal of this study is to understand the perspectives of veterans on discussing firearms storage safety with staff during primary care visits. Methods: Individual semistructured interviews with veterans were conducted by telephone, qualitatively coded, and analyzed for themes. The sample was composed of veterans (n = 27) who had positive depression or post-traumatic stress disorder screens and who received care from Veterans Health Administration primary care team members trained to discuss firearms storage safety with patients. Results: Citing the urgent need to prevent veteran suicide, most veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Veterans identified the need for providers to be transparent in their purposes for asking about firearms and to respect veterans9 unique relationships with firearms. Discussion: Conducting firearms safety discussions in a primary care setting with veterans who are at elevated risk for suicide is acceptable to veterans when a respectful, veteran-centered, and transparent approach is used.

Accurate estimates of burnout prevalence are critical for workforce planning. We assessed survey nonresponse bias and its impact on burnout estimates by linking 27,226 primary care employees to administrative data, categorized by whether they responded to a 2016 workforce survey (19.2% response). We adjusted burnout prevalence by response propensity using mixed-effects logistic regression. Thirty-six percent of respondents screened positive for burnout. There were significant differences between respondents and non-respondents (e.g.,gender, tenure), but no difference between unadjusted (i.e., respondents only) and propensity-adjusted estimates of burnout among the workforce. This provides support that workforce surveys may yield valid burnout estimates despite low response.

In 2017, half of the 47,173 suicides in the United States were firearm related. Health care systems have an important role in promoting firearm-related lethal-means safety, a key component of suicide prevention programs. To effectively do so, health care systems will face challenges, including training staff, developing interventions, navigating patients' risk perceptions, and managing sensitive firearm-related patient information. These challenges can be addressed by developing evidence-driven and provider-specific training, prioritizing research that informs evidence-based clinical interventions (in part through improving understanding of risk perceptions), clarifying data management practices, partnering with stakeholders from the firearm community, and leveraging the health care systems' roles within the public health system.

Only 7.5% of United States (U.S.) adults report ever having spoken with a clinician about firearm safety. One reason that clinicians may infrequently counsel patients about firearm safety is that they are unsure whether patients are open to these discussions. The aim of this study was to assess public opinion about whether clinicians should provide firearm safety counseling for patients in specific clinical contexts. We conducted a cross-sectional analysis of online survey data collected in 2019 from a nationally representative sample of U.S. adults residing in households with firearms (n = 4030, response 65%). Participants were asked "As part of routine care, should physicians and/or other health care professionals talk with their patients about firearms and firearm safety if their patient or their patient's family member (is at risk of suicide; has mental health or behavioral problems; is abusing or addicted to alcohol or drugs; is a victim of domestic violence; has Alzheimer's disease or another dementia; is going through a hard time)?" Across the six contexts, 76-89% of adults reported that clinicians should "sometimes" or "always" discuss firearm safety with patients. These findings demonstrate that a large majority of U.S. adults who live in households with firearms believe that clinicians should discuss firearm safety when patients or their family members are experiencing specific clinical scenarios. Clinicians' and healthcare systems' concerns that patients might object to discussing firearm safety in these contexts should not impede efforts to integrate such interventions into routine care.

Despite the disproportionate use of firearms in Veteran suicides and the well-established link between firearm access and suicide, little is known about how Veterans store their firearms or what they think about the relationship between firearm access and suicide risk. Using data from 2015 nationally representative online survey (response rate 60.9%), we compare characteristics of Veteran firearm owners with and without self-harm risk factors with respect to how they store their firearms and their beliefs about suicide risk related to firearms. Overall, one in three U.S. Veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members. Storage practices and risk perceptions are similar among those with and without self-reported suicide risk factors. Affecting risk perceptions may be a critical aspect of interventions addressing lethal means safety among U.S. Veterans.

Purpose Safe firearm storage practices are associated with a lower risk of self-inflicted injury and death. Whether such practices and relevant beliefs differ between households of adolescents with and without mental illness is unknown. Methods We used survey and administrative data to perform a two-stage cross-sectional study of parents/guardians of adolescents who were 11–17 years, enrolled in a managed care plan in 2004 and living in a household with a firearm. Multivariable Poisson models compared the prevalence of three firearm storage practices between households of adolescents with (depression or bipolar disorder) and without mental illness (no psychiatric or substance use disorder), including whether all firearms were locked, any firearms were loaded, and all firearms were locked and unloaded. We used chi-square tests to compare responses to Likert items assessing beliefs relevant to storage practices between households. Results Adolescents with mental illness were present in 141 (50.5%) of 279 study households. Their mean age was 14.5 years, and 54.8% were male. The mean age of parent/guardian respondents was 47.0 years, and 17.9% were male. Respondents from nearly 70% of households reported that all household firearms were stored locked and unloaded. In unadjusted and adjusted analyses, there were no significant differences in the prevalence of three firearm storage practices or in beliefs relevant to those practices between households of adolescents with and without mental illness. Conclusions These findings add to a growing body of evidence suggesting that firearm storage practices do not differ based on household mental health risk factors for self-harm.

BackgroundSafe firearm storage practices are associated with a lower risk of unintentional and self-inflicted firearm injuries among household members, though many firearms remain unlocked and/or loaded.ObjectivesConduct a preliminary evaluation of a community-based firearm safety intervention and assess participants’ preferences for firearm locking devices and their comfort with potential firearm safety counsellors.Design/MethodsBaseline event and follow-up surveys among adult participants to assess changes in firearm storage practices, including whether all household firearms were stored locked, all were unloaded, all ammunition was locked, and a composite measure assessing whether all firearms were locked and unloaded and all ammunition was stored locked.ResultsA total of 206 out of 415 participants completed both surveys and were included. Nearly 9 in 10 respondents preferred the firearm lock box rather than a trigger lock. At follow-up, a significantly greater proportion reported that all household firearms were locked (+13.7%) and unloaded (+8.5%) and a non-significantly greater proportion reported that all ammunition was locked (+6.3%). A significantly greater proportion reported practising all three safe firearm and ammunition storage practices at follow-up (+12.6%). A majority reported they would becomfortableorvery comfortablediscussing firearm safety with various safety counsellors, though women were less likely to do so than men.ConclusionThis intervention that included distribution of a free, participant-selected locking device improved safe firearm storage practices among participants. Differences in participant preferences for devices and safety counsellors suggest that a ‘one size fits all’ approach may be inadequate in affecting population-level storage practices.

Background/Objective Male veterans ages 55–74 comprise a disproportionate number of suicide deaths among United States veterans, for whom a majority of suicides are firearm-related. Little is known about the firearm-related experiences and beliefs of veterans, which could be informative for firearm-related lethal means safety interventions. The aim of this qualitative study was to identify themes relevant to developing such interventions among older male veterans. Methods We conducted semi-structured qualitative interviews with seventeen United States male veterans, ages 50–70, who were eligible to receive Veterans Health Administration services, and were current or former firearm owners or users. Transcripts were analyzed via thematic analysis using an inductive approach. Results Six themes were identified: 1) Firearm experiences were usually facilitated by male family members and occurred at an early age; 2) Safety lessons during early firearm encounters focused on preventing unintentional injuries through safe firearm handling and using “common sense;” 3) Firearms serve an important social function across veterans’ lifespans (e.g., hunting with friends); 4) Veterans perceive firearms as useful for protection; 5) Veterans believe that not everyone should have access to firearms, and some described scenarios in which they acted to limit others’ access during unsafe situations; and 6) Veterans have preferences for who is involved in firearm safety discussions. Conclusions We identified themes relevant to developing firearm-specific lethal means safety interventions among older male veterans. Findings suggest potential obstacles (e.g., sociocultural value of firearms) to affecting changes in firearm behaviors, and factors that could potentially facilitate interventions (e.g., family involvement). Consideration of these findings may be important for developing personalized, effective interventions for this population.

In the United States, suicide rates are increasing among nearly all age groups. Primary care is a critical setting for suicide prevention, where interventions often rely on identifying mental health conditions as indicators of elevated suicide risk. Quantify the proportion of suicide decedents within primary care who had no antecedent mental health or substance use diagnosis. Retrospective cohort study. Veterans who received Veterans Health Administration (VHA) primary care any time from 2000 to 2014 and died by suicide before 2015 (n = 27,741). We categorized decedents by whether they had any mental health or substance use diagnosis (yes/no) using ICD-9 codes available from VHA records. We compared sociodemographic, clinical, and suicide mechanism characteristics between groups using chi-square, Student’s T, or Wilcoxon tests. Forty-five percent of decedents had no mental health or substance use diagnosis. Decedents without such a diagnosis were older (68 vs. 57 years, p

Author(s): Simonetti, Joseph A.; Simeona, Cassie; Gallagher, Chelsie; Bennett, Elizabeth; Rivara, Frederick; Rowhani-Rahbar, Ali | Abstract: Introduction: Safe firearm storage is associated with a lower risk of firearm-related injury and death. Although providing firearm locking devices is a key component of firearm safety interventions, little is known about the types and characteristics of devices preferred by firearm users or others who make decisions about firearm storage. The aim of this study was to describe preferences for firearm locking devices and device features among firearm safety event participants.Methods: We conducted a cross-sectional survey in the State of Washington in 2016 that assessed participants’ preferences for five firearm locking devices (eg, trigger lock) and seven device features (eg, quick access). We categorized respondents (n=401) as adults in households with 1) all firearms locked, 2) at least one unlocked firearm, and 3) no firearms. We analyzed data in 2017.Results: Device ownership and feature preferences varied substantially but were similar across the three household categories. Of those residing with unlocked firearms, 84% reported they would consider using or definitely use a lock box, whereas 11% reported they would never use a trigger lock. Additionally, of those residing with unlocked firearms, 80% and 89% reported that the ability to lock a firearm while loaded and unlock it quickly were, respectively, “very important” or “absolutely essential.”Conclusion: Participants had differing preferences for firearm locking devices and device features, although preferences were largely similar across households with locked, unlocked, or no firearms. At least eight in ten participants reported “great importance” regarding the ability to lock a firearm while loaded and unlock it quickly, which is likely related to perceptions about the utility of safely stored firearms for household protection. Designing firearm safety interventions to match the needs and preferences of those who make firearm storage decisions may improve their effectiveness.

Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians.To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams.We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014.Primary care personnel at VA clinics responding to a national survey.Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity).There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition.Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.

Key Points Question What are primary care clinicians’ perceptions regarding electronic consultation and their clinical workload? Findings In this qualitative study including 34 primary care clinicians in the US Veterans Health Administration health care system, 3 themes regarding electronic consultation and workload were identified. The clinicians viewed electronic consultations as an added time burden, as shifting responsibilities from specialists to themselves, and even with the increased workload, as improving timeliness and quality of care. Meaning The findings of this study suggest that further research is warranted to assess whether the increased workload is objective or perceived., Importance Electronic consultation (e-consultation) is increasingly being adopted to expand access to specialty care and reduce health care costs. Little is known about clinicians’ perceptions of using e-consultations, which may be associated with program adoption. Objective To identify perceptions of primary care clinicians in the US Veterans Health Administration (VHA) system about e-consultation and workload. Design, Setting, and Participants A qualitative study using semistructured interviews was conducted from September 2017 through March 2018 in a national sample of VHA primary care clinics in the US. Participants were primary care clinicians who had at least 300 total patient encounters from July 2016 to June 2017, including at least 1 e-consultation request. A convenience sample of participants was recruited using email invitations. Deductive and inductive content analysis were used to identify themes. Data were analyzed from October 2017 to April 2018. Exposures Use of e-consultation. Main Outcomes and Measures Primary care clinician perspectives regarding e-consultation and their workload. Results A total of 34 primary care clinicians enrolled working across 27 VHA clinical sites were included; 9 (26%) were between ages 40-49 years; 23 (68%) were female. Three themes were identified. First, the process of entering, tracking, and following up on e-consultations added a time burden to primary care clinicians. Second, e-consultation was perceived to shift diagnostic and follow-up responsibilities from specialists to primary care clinicians. Third, e-consultations were thought to improve the timeliness and quality of care provided despite a perceived increase in workload. Conclusions and Relevance In this study, participants perceived e-consultation as valuable for patient care but also as an increase in their workload. Further work is warranted to quantify the workload increase on clinician burnout, job satisfaction, and turnover., This qualitative study examines perceptions of the workload burden associated with electronic consultations among a national sample of Veterans Health Administration (VHA) primary care clinicians.

Objectives. We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries. Methods. We estimated discharge rates for hospitalized and emergency department–treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates. Results. We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3–36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department–treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries. Conclusions. There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.

More than 500,000 children sustain a traumatic brain injury (TBI) each year. Previous studies have described significant variation in inhospital mortality after pediatric TBI. The aim of this study was to identify facility-level characteristics independently associated with 30-day inhospital mortality after pediatric severe TBI. We hypothesized that, even after accounting for patient-level characteristics associated with mortality, the characteristics of facilities where patients received care would be associated with inhospital mortality. Using data from the National Trauma Data Bank from 2009-2012, we identified a cohort of 6707 pediatric patients hospitalized with severe TBI in 391 facilities and investigated their risk of 30-day inhospital mortality. Pre-specified facility-level characteristics (trauma certification level, teaching status, census region, facility size, nonprofit status, and responsibility for pediatric trauma care) were added to a Poisson regression model that accounted for patient-level characteristics associated with mortality. In multivariable analyses, patients treated in facilities located in the Midwest (risk ratio [RR]=1.42; 95% confidence interval [CI] 1.12-1.81) and South (RR=1.39; 95% CI: 1.12-1.72) regions had higher likelihoods of 30-day inhospital mortality compared with patients treated in the Northeast. Other facility-level characteristics were not found to be significant. To our knowledge, this is one of the largest investigations to identify regional variation in inhospital mortality after pediatric severe TBI in a national sample after accounting for individual and other facility-level characteristics. Further investigations to help explain this variation are needed to inform evidence-based decision-making for pediatric severe TBI care across different settings.

Introduction Interventions that reduce access to highly lethal and commonly used methods of suicide (e.g., limiting firearm access) are considered essential elements of effective suicide prevention programs. Scant epidemiologic data are available to inform such efforts among Veterans. The aim of this study is to describe firearm storage practices and correlates of those practices among a nationally representative sample of U.S. Veteran firearm owners. Methods The authors used a probability-based online survey of Veteran firearm owners in 2015 (data analyzed in 2017; 54.6% response rate). The primary outcome was firearm storage practices. Additional items assessed individual and household-level sociodemographic characteristics, firearm-related characteristics, and risk perceptions related to firearm ownership. Results One in three (33.3%, 95% CI=28.6%, 38.4%) Veteran firearm owners stores at least one firearm loaded and unlocked. The prevalence of this practice ranges substantially (9%–65%) across individual, household, and firearm ownership characteristics, and is strongly related to other firearm-related behaviors (e.g., carrying handguns); reasons for firearm ownership (e.g., protection versus other); number of firearms owned; and perceptions about the utility of guns stored safely and whether guns make homes safer. Conclusions Storing a firearm loaded and unlocked is common among Veterans. Storage practices are strongly related to reasons for ownership and potentially malleable perceptions including beliefs about firearm-related risks. Suicide prevention initiatives among Veterans should incorporate communication strategies that address common misperceptions about household firearm risk and whether safe storage practices may better align with reasons most Veterans own firearms (i.e., safety)—especially when someone in their home is at increased risk for suicide.

Objectives. To determine the frequency of loaded handgun carrying among US adult handgun owners, characterize those who carry, and examine concealed carrying by state concealed carry laws. Methods. Using a nationally representative survey of US adults in 2015, we asked handgun owners (n = 1444) about their past-30-day carrying behavior. Results. Among surveyed handgun owners, 24% (95% confidence interval[CI] = 21%, 26%) carried loaded handguns monthly, of whom 35% (95% CI = 29%, 41%) did so daily; 82% (95% CI = 77%, 86%) carried primarily for protection. The proportion of handgun owners who carried concealed loaded handguns in the past 30 days was 21% (95% CI = 12%, 35%) in unrestricted states, 25% (95% CI = 21%, 29%) in shall issue—no discretion states, 20% (95% CI = 16%, 24%) in shall issue—limited discretion states, and 9% (95% CI = 6%, 15%) in may-issue states. Conclusions. We estimate that 9 million US adult handgun owners carry loaded handguns monthly, 3 million do so every day, and most report protection as the main carrying reason. Proportionally fewer handgun owners carry concealed loaded handguns in states that allow issuing authorities substantial discretion in granting carrying permits.

Background While the majority of veteran suicides involve firearms, no contemporary data describing firearm ownership among US veterans are available. This study uses survey data to describe the prevalence of firearm ownership among a nationally representative sample of veterans, as well as veterans’ reasons for firearm ownership. Methods A cross-sectional, nationally representative web-based survey conducted in 2015. Results Nearly half of all veterans own one or more firearms (44.9%, 95% CI 41.3–48.6%), with male veterans more commonly owning firearms than do female veterans (47.2%, 95% CI 43.4–51.0% versus 24.4%, 95%CI 15.6–36.1%). Most veteran firearm owners own both handguns and long guns (56.5%, 95% CI 51.1–61.8%); a majority cite protection as a primary reason for firearm ownership (63.1%, 95% CI 58.2–67.8%). Conclusions The current study is the first to provide detailed, nationally representative information about firearm ownership among U.S. veterans. Better understanding firearm ownership among veterans can usefully inform ongoing suicide prevention efforts aiming to facilitate lethal means safety among vulnerable veterans during at-risk periods. Electronic supplementary material The online version of this article (10.1186/s40621-017-0130-y) contains supplementary material, which is available to authorized users.

Statement of Purpose Little is known about why, how frequently, or in what manner US adults carry loaded handguns. We sought to describe these characteristics of firearm carrying, and examine to what extent carrying behaviour is related to state laws regulating concealed carry permits (Unrestricted, Shall-Issue/No-Discretion; Shall-Issue/Limited-Discretion, May-Issue). Approach We conducted a probability-based, nationally-representative, online survey of US adults aged ≥18 years in 2015. Handgun owners were asked if they had carried a loaded handgun in the past 30 days, the number of days they had carried, whether they had carried openly or concealed, and their primary reason for carrying. Results 24% (95% CI: 21%–26%) of the 38 million US handgun owners carried a loaded handgun in the past 30 days; among those, 35% (95% CI: 29%–41%) did so every day. Most carried primarily for protection (81%; 95% CI: 76%–86%) and had a concealed carry permit (79%; 95% CI: 73%–84%). Of those who carried, two-thirds always carried concealed (66%; 95% CI: 60%–72%) and 11% (95% CI: 7%–15%) always carried openly. The proportion of those who carried concealed was 21% (95% CI: 12%–35%) in Unrestricted, 25% (95% CI: 21%–29%) in Shall-Issue/No-Discretion, 20% (95% CI: 16%–24%) in Shall-Issue/Limited-Discretion, and 9% (95% CI: 6%–15%) in May-Issue states. Conclusion 1 in 4 adult handgun owners in the US carry a loaded handgun and most do so for personal protection. Of those, about 1 in 3 carry every day. Proportionally fewer handgun owners carried concealed loaded handguns at any time in the past month if they lived in states with laws that allow law enforcement to exercise notable discretion in issuing carrying permits. Significance Findings provide empiric evidence for the frequent occurrence of loaded handgun carrying among adult handgun owners, especially in states with less stringent firearm carrying statues.

Safe firearm storage is associated with lower risk of unintentional and intentionally self-inflicted firearm injuries among children and adolescents. Ten community-based firearm safety events were conducted across Washington state from 2015 to 2018. We sought to describe characteristics of event participants and assess whether presence and age of children in the household were associated with household firearm locking practices. We assessed demographic characteristics and baseline firearm storage behaviors of participants using a 13-item survey. Multivariable Poisson regression models were used to estimate prevalence ratios (PR) and corresponding confidence intervals (CI) for the association of presence and age of children in households with prevalence of storing a household firearm unlocked. Of 2956 participants, 58.3% were male and 57.9% lived with an individual under 18 years. Among the 89.8% participants living with firearms, 40.1% stored at least one firearm unlocked and 39.1% stored at least one firearm loaded. In adjusted analyses, there was no statistically significant difference in prevalence of storing a household firearm unlocked between those living with no children (reference group) and those living with a child11 years (PR = 0.91; 95% CI: 0.80,1.04), or a child aged 11-18 years (PR = 0.94; 95% CI: 0.81,1.09). A high proportion of participants stored a firearm unlocked or loaded at home and neither living with young children nor adolescents was associated with safe locking practices. In comparison with firearm safety interventions conducted in clinic settings, a majority of the participants in these community-based interventions were male and owned firearms.

Key Points Question To what extent do firearm ownership, use, accessibility, and storage practices increase suicide risk among US Army soldiers? Findings In this case-control, psychological autopsy study of 135 soldiers who died by suicide, firearm accessibility was associated with a significant increase in the risk of suicide. Next-of-kin reported that soldiers who died by suicide were more likely to own firearms, have home access to firearms, and have home storage of ammunition compared with propensity-matched controls. Meaning This study suggests that identifying possible targets for intervention, such as promoting the separate storage of guns and ammunition as well as discouraging public carrying of firearms when not required for military duties, has important implications for suicide prevention., Importance Since 2004, the suicide rate among US Army soldiers has exceeded the rate of death from combat injury. It is critical to establish factors that increase the risk of acting on suicidal thoughts to guide early intervention and suicide prevention. Objective To assess whether firearm ownership, use, storage practices, and accessibility are associated with increased risk of suicide. Design, Setting, and Participants In this case-control study, suicide cases (n = 135) were defined as US Army soldiers who died by suicide while on active duty between August 1, 2011, and November 1, 2013. Next-of-kin and Army supervisors of soldiers who died by suicide (n = 168) were compared with propensity-matched controls (n = 137); those soldiers with a suicidal ideation in the past year (n = 118) provided structured interview data. Data were analyzed from April 5, 2018, to April 2, 2019. Main Outcomes and Measures Firearm ownership, storage, and accessibility were assessed by using items from the World Health Organization Composite International Diagnostic Interview screening scales along with items created for the purpose of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) study. Results Among the 135 suicide decedents, next-of-kin reported that they had greater accessibility to firearms compared with propensity-matched controls. Specifically, suicide decedents were more likely to own 1 or more handguns compared with propensity-matched controls (odds ratio [OR], 1.9; 95% CI, 1.0-3.7; χ21 = 4.2; false discovery rate [FDR] P = .08), store a loaded gun at home (OR, 4.1; 95% CI, 1.9-9.1; χ21 = 12.2; FDR P = .003), and publicly carry a gun when not required for military duty (OR, 3.2; 95% CI, 1.4-7.3; χ21 = 7.4; FDR P = .02). The combination of these 3 items was associated with a 3-fold increase in the odds of suicide death (OR, 3.4; 95% CI, 1.2-9.4; χ21 = 5.4; FDR P = .05). Storing a loaded gun with ammunition at home or publicly carrying a gun when not on duty was associated with a 4-fold increase in the odds of suicide death (OR, 3.9; 95% CI, 1.9-7.9; χ21 = 14.1; FDR P = .002). Conclusions and Relevance In this study, in addition to gun ownership, ease and immediacy of firearm access were associated with increased suicide risk. Discussion with family members and supervisors about limiting firearm accessibility should be evaluated for potential intervention., This case-control study uses data from the Soldier Health Outcomes Study conducted as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) to evaluate whether increased accessibility to firearms is associated with an increased risk of suicide among US Army soldiers.

OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL 9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL 9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34–0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57–0.99]) or to achieve an LDL CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.