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Firearm Access Documentation in High Risk Clinical Situations: Missed Opportunities

      Purpose

      The American Academy of Pediatrics, among other groups, strongly encourages screening for firearm access in pediatric patients, as there is significant morbidity and mortality related to having access to firearms, particularly among youth at risk for suicide. The current study was designed to determine whether health care providers (HCPs) miss opportunities to detect youth access to firearms in particularly high risk situations such as the presence of depression or violence risk.

      Methods

      Adolescents ages 12-17 scheduled for a routine physical exam in an urban, adolescent medicine clinic between Oct 2010-December 2011 were eligible. Assent from adolescents and consent from parents (both by phone) was obtained to participate in a study assessing violence risk. As part of usual care, youth had the opportunity to answer a standardized health assessment, including whether there were guns in their home. Chart review was completed one month after the appointment. Data collected included youth self-report of violence risk, depression (PHQ-9) and access to firearms in the home and provider documentation of violence risk, mental health diagnosis and the presence of firearms in the home. Rates of each were calculated. Bivariate analysis determined whether there were associations between provider documentation of mental health issues or violence risk and documentation of firearms in the home.

      Results

      549/784 (70%) of eligible youth consented), and 85% of those (n= 466) actually completed their appointment. Mean age was 14.5 (sd 1.6); 65% female, 45 % Hispanic, 38% Black, 17% White. 300/466 (64%) completed the health screening questionnaire. Providers documented a mental health diagnosis in 22% of all patients, including 14% with Depression, 4% with ADHD, and 4% all others. Providers only documented either the presence or absence of a firearm in just 15.9% of these patients, with 2% documentation of the presence of a firearm. Youth who were diagnosed with a mental health issue reported having firearm access 13.8% of the time- only 20% of the time did providers recognize this. For the 14.6% of youth who were positive for moderate-severe depression on the PHQ-9 -in only 8.1% was there documentation of access to firearms. Similarly, 14.6% were positive for future violence risk, and in only 17% was there documentation by providers of firearm access. No demographic characteristics, including age, race/ethnicity, gender or SES were associated with whether a provider documented the presence of a firearm in the home for these high risk youth.

      Conclusions

      Despite the prevalence of mental health diagnosis and violence risk in this adolescent population, providers are largely not documenting youth access to firearms. Missed opportunities to counsel parents and youth about the risk of firearms in high risk situations can lead to potentially devastating consequences. Ways to document access to firearms needs to be improved.

      Sources of Support

      Colorado Injury Control Research Center, Children's Hospital Colorado Research Institute, Deans Academic Enrichment Fund.