Firearm Safety Discussions Between Clinicians and U.S. Adults Living in Households With Firearms: Results From a 2019 National Survey
Authors: Andrew Conner, Deborah Azrael, Matthew Miller
Journal: Annals of Internal Medicine (2020)

LettersMay 2021Firearm Safety Discussions Between Clinicians and U.S. Adults Living in Households With Firearms: Results From a 2019 National SurveyFREEAndrew Conner, BS, Deborah Azrael, PhD, and Matthew Miller, MD, MPH, ScDAndrew Conner, BSFrank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut , Deborah Azrael, PhDHarvard Injury Control Research Center, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, and Matthew Miller, MD, MPH, ScDBouvé College of Health Sciences, Northeastern University, Boston, MassachusettsAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-6314 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Several U.S. medical organizations urge clinicians to counsel patients about firearm risk (1). How often these conversations occur and what topics are covered are unknown.Objective: To estimate the proportion of adults in gun-owning households who have discussed firearm safety with a clinician and to characterize these encounters.Methods: Data were obtained from the second National Firearms Survey, conducted online 30 July 2019 to 11 August 2019 by the survey firm Ipsos. The study sample comprised adults living in homes with firearms, regardless of whether they were gun owners themselves. Participants were sampled from Ipsos KnowledgePanel, a probability-based web panel of approximately 55 000 noninstitutionalized, English-speaking adults that was designed to represent the U.S. population, excluding active military service personnel. Weighting commands in Stata, version 16.1 (StataCorp), were used to generate descriptive statistics using weights provided by Ipsos. Poststratification weights adjusted for nonresponse and under- or overcoverage from the study-specific sample design relative to expected demographic distributions from the U.S. Census Current Population Survey and the American Community Survey. These weights also adjusted for characteristics not available from national surveys, such as gun ownership, from weighted KnowledgePanel data. Harvard University's Institutional Review Board approved the study.Respondents were asked, "Has a physician or other health care practitioner ever spoken to you about firearm safety?" Those answering affirmatively were asked where discussions occurred (outpatient medical visit, outpatient mental health visit, emergency department, or other setting); who the patient was (the respondent, another adult, or a child); and, for each patient–setting combination affirmed, what was discussed in the most recent such encounter. Participant characteristics included sociodemographics, presence of children in the home, and personal firearm ownership status.Findings: The National Firearms Survey included 4030 adult respondents, all of whom lived in homes with firearms (completion rate, 65%); 4011 answered all firearm safety questions. Of all respondents, 7.5% (95% CI, 6.6% to 8.6%) had ever discussed firearm safety with a provider (12.0% [CI, 9.9% to 14.6%] of those living with children vs. 5.3% [CI, 4.4% to 6.3%] in homes without children) (Table 1). Most encounters involved an outpatient medical visit (not shown). Of respondents spoken to about firearms, 48.0% (CI, 41.1% to 54.9%) said that locking all firearms was discussed at their most recent visit, 31.8% (CI, 23.6% to 38.7%) that storing ammunition separately from firearms was discussed, and 15.9% (CI, 11.3% to 21.9%) that removing firearms from the home was covered (Table 2). Removing firearms was rarely discussed when the patient was a child (4.1% [CI, 1.1% to 9.4%]); when the patient was the respondent or another adult, however, conversations about removal were reported by one quarter or half of respondents, respectively.Table 1. Proportion of U.S. Adults Living in Households With Firearms Who Have Been Spoken to by a Physician or Other Health Care Provider About Firearm Safety (n = 4011)*Table 2. Advice Given by Physician or Other Health Care Provider During Discussion With Respondent Regarding Firearm Safety, Stratified by Respondent's Relationship to the Patient, During the Clinical Encounter (n = 244)Discussion: Fewer than 10% of adults who currently live in homes with firearms report having ever discussed firearm safety with a clinician. When firearm discussions occurred, the most common advice across all clinical settings was to lock all household firearms. Whether additional safety advice was offered varied by context. In pediatric settings, removing firearms from the home was rarely discussed. By contrast, and consistent with empirical evidence favoring removal over in-home storage for adults (2), when an adult other than the respondent was the patient, removal was discussed in more than half of encounters in which firearm safety was discussed (and in one quarter of such encounters when the respondent was the patient). To our knowledge, this is the first study to address the frequency and content of firearm safety conversations in a national sample.Our study has limitations, perhaps the most consequential being that we focused exclusively on adults currently living in homes with firearms. On the basis of a prior study that found that few former gun owners gave up their firearms because of safety concerns (3), we do not expect that expanding the denominator to adults who had ever lived in a home with firearms would appreciably alter our main findings. Recall bias may have led to underestimates. If so, our findings nevertheless reflect a clinically relevant outcome: encounters salient enough to be recalled.Our study suggests that efforts to date have not adequately promoted firearm safety discussions in clinical settings. Addressing clinician concerns that these discussions will negatively affect the physician–patient relationship (4) in light of recent evidence that patients are usually open to such conversations (5) may be a good place to start.References1. Weinberger SE, Hoyt DB, Lawrence HC, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6. doi:10.7326/M15-0337 LinkGoogle Scholar2. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327:467-72. [PMID: 1308093] CrossrefMedlineGoogle Scholar3. Wertz J, Azrael D, Hemenway D, et al. Differences between new and long-standing US gun owners: results from a national survey. Am J Public Health. 2018;108:871-877. [PMID: 29771618] doi:10.2105/AJPH.2018.304412 CrossrefMedlineGoogle Scholar4. Pallin R, Spitzer SA, Ranney ML, et al. Preventing firearm-related death and injury. Ann Intern Med. 2019;170:ITC81-ITC96. doi:10.7326/AITC201906040 LinkGoogle Scholar5. Valenstein M, Walters H, Pfeiffer PN, et al. Acceptability of potential interventions to increase firearm safety among patients in VA mental health treatment. Gen Hosp Psychiatry. 2018;55:77-83. [PMID: 30447477] doi:10.1016/j.genhosppsych.2018.10.010 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Alan R. Ertle, MD, MPH, MBAEmeritus Enterprises, LLC21 December 2020 Give physicians the tools they need to have firearm safety conversations. I enjoyed the brief article by Conners, et.al., regarding finding from the National Firearms Survey. With about 40% of households with firearms, firearm safety should be an important inclusion in preventive healthcare measures, but unfortunately this is rare occurrence. There have been numerous articles and opinion pieces indicating that physicians should discuss these issues with their patients. However, the first step in helping these conversations to occur might be to understand why physicians do not have them. The article points out that physicians are worried that having these conversations will negatively impact the physician-patient relationship, despite patients indicating that they are open to these discussions. Having physicians blindly attempt these potentially hot-button conversations with no knowledge or training is just as foolish as having an untrained physician attempt neurosurgery. Why don't the ACP, the AAFP, and the AAP get together with the NRA and others to develop an online CME course that teaches the basic knowledge necessary to have a reasonable conversation with patients? This would include: 1. This is not taking a position regarding gun ownership; 2. Access to firearms is associated with suicide, accidents, and firearm-related violence; 3. State laws regarding safe firearm storage; 4. Principles of safe storage; 5. Principle of separate ammunition storage; 5. Concept of removing firearms to another location (e.g., a relative) when children are small. This CME could be required much as pain management CME's have become required. Give them the tools. James Webster MD, MS, MACPFeinberg School of Medicine of Northwestern University22 December 2020 Physicians and Guns Colleagues, we can and must do better. We did it with seatbelts. It's not that hard to ask the question or put into your intake questionaire; Is there a gun in the house? and if yes is the answer, follow-up. Considering the surge in gun ownership during the pandemic it's essential to add this for your patient's health and even survival. Author, Article, and Disclosure InformationAffiliations: Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut Harvard Injury Control Research Center, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MassachusettsBouvé College of Health Sciences, Northeastern University, Boston, MassachusettsFinancial Support: By Fund for a Safer Future, the Joyce Foundation, the National Collaborative on Gun Violence Research, and a Frank H. Netter MD School of Medicine Summer Research Fellowship.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6314.Reproducible Research Statement: Study protocol: Survey questions are in the Supplement. Statistical code: Available from Dr. Miller (e-mail, ma.[email protected]edu). Data set: Not available.Corresponding Author: Matthew Miller, MD, MPH, ScD, Professor of Health Sciences and Epidemiology, Northeastern University, Bouvé College of Health Sciences, Department of Health Sciences, Room 316 Robinson Hall, 360 Huntington Avenue, Boston, MA 02115-5000; e-mail, ma.[email protected]edu.This article was published at Annals.org on 22 December 2020. 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