Joseph A. Simonetti

Psychiatric Comorbidity, Suicidality, and In-Home Firearm Access Among a Nationally Representative Sample of Adolescents

IMPORTANCE Suicide is the second leading cause of death among US adolescents, and in-home firearm access is an independent risk factor for suicide. Given recommendations to limit firearm access by those with mental health risk factors for suicide, we hypothesized that adolescents with such risk factors would be less likely to report in-home firearm access. OBJECTIVES To estimate the prevalence of self-reported in-home firearm access among US adolescents, to quantify the lifetime prevalence of mental illness and suicidality (ie, suicidal ideation, planning, or attempt) among adolescents living with a firearm in the home, and to compare the prevalence of in-home firearm access between adolescents with and without specific mental health risk factors for suicide. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of data from the National Comorbidity Survey-Adolescent Supplement, a nationally representative survey of 10,123 US adolescents (age range, 13-18 years) who were interviewed between February 2001 and January 2004 (response rate 82.9%). EXPOSURES Risk factors for suicide, including a history of any mental health disorder, suicidality, or any combination of the 2. MAIN OUTCOMES AND MEASURES Self-reported access to a firearm in the home. RESULTS One in three respondents (2778 [29.1%]) of the weighted survey sample reported living in a home with a firearm and responded to a question about firearm access; 1089 (40.9%) of those adolescents reported easy access to and the ability to shoot that firearm. Among adolescents with a firearm in home, those with access were significantly more likely to be older (15.6 vs 15.1 years), male (70.1% vs 50.9%), of non-Hispanic white race/ethnicity (86.6% vs 78.3%), and living in high-income households (40.0% vs 31.8%), and in rural areas (28.1% vs 22.6%) (P < .05 for all). Adolescents with firearm access also had a higher lifetime prevalence of alcohol abuse (10.1% vs 3.8%, P < .001) and drug abuse (11.4% vs 6.9%, P < .01) compared with those without firearm access. In multivariable analyses, adolescents with a history of mental illness without a history of suicidality (prevalence ratio [PR], 1.13; 95% CI, 0.98-1.29) and adolescents with a history of suicidality with or without a history of mental illness (PR, 1.20; 95% CI, 0.96-1.51) were as likely to report in-home firearm access as those without such histories. CONCLUSIONS AND RELEVANCE Adolescents with risk factors for suicide were just as likely to report in-home firearm access as those without such risk factors. Given that firearms are the second most common means of suicide among adolescents, further attention to developing and implementing evidence-based strategies to decrease firearm access in this age group is warranted.

Effectiveness of Interventions to Promote Safe Firearm Storage

Despite supportive evidence for an association between safe firearm storage and lower risk of firearm injury, the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, we conducted a systematic review of randomized and quasi-experimental controlled studies of safe firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language, year, or location from inception through May 27, 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Collaborations domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000-2012 using counseling with or without safety device provision met the inclusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices, while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies precluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recommendations for conducting future studies. Although additional studies are needed, the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely.

Racial Comparisons of Diabetes Care and Intermediate Outcomes in a Patient-Centered Medical Home

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 <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >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 <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >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 <100 mg/dL (OR 0.74 [95% CI 0.55–0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49–0.84]). 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.

State Firearm Legislation and Nonfatal Firearm Injuries.

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.

The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members

BackgroundWork-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.ObjectiveTo 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.DesignWe conducted an individual-level cross-sectional analysis of survey and administrative data in 2014.ParticipantsPrimary care personnel at VA clinics responding to a national survey.Main MeasuresBurnout 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).Key ResultsThere 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.ConclusionsComplete 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.

Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

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.

Evaluation of a community-based safe firearm and ammunition storage intervention

Background Safe 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. Objectives Conduct 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/Methods Baseline 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. Results A 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 be comfortable or very comfortable discussing firearm safety with various safety counsellors, though women were less likely to do so than men. Conclusion This 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.

Patient-centered Medical Home Implementation and Burnout Among Va Primary Care Employees

Burnout is widespread throughout primary care and is associated with negative consequences for providers and patients. The relationship between the patient-centered medical home model and burnout remains unclear. Using survey data from 8135 and 7510 VA primary care employees in 2012 and 2013, respectively, we assessed whether clinic-level medical home implementation was independently associated with burnout prevalence and estimated whether burnout changed among this workforce from 2012 to 2013. Adjusting for differences in respondent and clinic characteristics, we found that burnout was common among primary care employees, increased by 3.9% from 2012 to 2013, and was not associated with the extent of medical home implementation.

Violence perpetration among patients hospitalized for unintentional and assault-related firearm injury: a case-control study and a cohort study

An estimated 41024 persons aged 15 years or older were hospitalized because of nonfatal firearm injuries in 2014 in the United States (1). About 79% of those injuries were intentional and resulted from interpersonal violence (assault), and 11% were unintentional (accidental). The remaining 10% were self-inflicted, were due to legal interventions, or had an undetermined intent. Regardless of intent, many patients with nonfatal firearm injuries have short-term, long-term, or permanent physical and psychological sequelae (2). Illness associated with such trauma translates to a notable loss of healthy life-years and considerable societal costs (3, 4). Effective primary, secondary, and tertiary prevention strategies are critically needed to reduce the heavy burden of firearm injuries. Such strategies should preferably integrate pertinent elements of clinical care, public health, and/or the criminal justice systems. Previous investigations have highlighted overlapping risks between becoming a victim and perpetrator of violence (511). Population-based research to specifically examine violence perpetration before and after firearm injury can inform interventions in both community and health care settings. Because only about half of all violence victimizations (that is, becoming a victim of violence) are reported to police (12), hospital admission is an important sentinel event that could present a valuable opportunity for violence risk reduction. In 2009, the National Network of Hospital-based Violence Intervention Programs was formally established (13). These programs consider the in-hospital recovery period as a valuable opportunity or teachable moment during which patients can be connected with principal community services to help reduce retaliation and recidivism. Programs typically focus on patients whose injury was assault-related because of their presumed involvement in a cycle of interpersonal violence. Whether patients without assault-related injuries would also benefit from such programs is unclear. Of note, empirical evidence is lacking on prior involvement in, and subsequent risk for, violence perpetration among patients with unintentional injuries. We conducted 2 statewide studies to examine violent crime perpetration both before and after hospitalization for a firearm injury among patients aged 15 years or older. Injury and crime were studied together to add to the existing body of knowledge on gun violence by using data from both clinical and criminal justice system encounters. Injury intent was a central theme of both studies and was separated into 2 categories (assault vs. unintentional) to examine the association between intent-specific firearm injury and violence perpetration. We focused on these categories because they constitute most firearm injuries requiring hospitalization. Most patients with self-inflicted firearm injuries die before presenting to the hospital, and the number of patients in other injury intent categories (for example, legal interventions) is also relatively small within the hospitalized population. Methods Design, Setting, and Participants We conducted a casecontrol study and a retrospective cohort study. In the casecontrol study, we compared the odds of violence-related arrest before hospitalization between persons hospitalized for firearm injuries and those hospitalized for other reasons. In the cohort study, we compared rates of violence-related arrest after hospitalization between persons hospitalized for firearm injuries and those hospitalized for other reasons. We used data previously assembled in a larger investigation for both of these studies (14). In that investigation, we first identified all patients hospitalized for an injury by any mechanism from 2006 to 2007 in Washington by using International Classification of Diseases, Ninth Revision, codes. Then we chose a random sample of patients hospitalized for a noninjury reason (that is, the no injury group) and frequency-matched them with those in the injury group on age and year of hospitalization in a 2:1 ratio. For the analyses presented here, we separated the injury group into 2 mutually exclusive subgroups: patients hospitalized for a firearm injury (firearm injury group), and those hospitalized for an injury not caused by a firearm (other injury group), resulting in 3 groupsfirearm injury, other injury, and no injury. Figure 1 depicts the design of the 2 studies. In the casecontrol study, the firearm injury group served as the case population and the other injury and no injury groups served as 2 separate control populations. The exposure of interest was arrest for a violent crime before hospitalization. In the cohort study, the firearm injury group served as the exposed population and the other injury and no injury groups served as 2 separate unexposed populations. The outcome of interest was time to first arrest for a violent crime after hospital discharge. Figure 1. Design of the 2 studies. Information on hospitalizations was obtained from the Washington State Department of Health Comprehensive Hospital Abstract Reporting System (15). This system contains coded discharge information and is used to collect various data, such as age, sex, payer status, and diagnosis and procedure codes. Consistent with the literature, an injury-related hospitalization was defined as a discharge with a primary diagnosis of an acute injury (International Classification of Diseases, Ninth Revision, codes 800 to 959). Records containing injuries from medical and surgical misadventures (E870 to E879), late effects of injury (E929 or E999), and adverse effects of substances in therapeutic use (E930 to E949) were excluded (16). Codes for external causes of injury (that is, E codes) were used to determine the mechanism and intent of an injury. The Centers for Disease Control and Prevention recommended this framework of E-code groupings for presenting injury mortality and morbidity data (17). We used E codes to categorize hospitalizations by injury intent: assault, unintentional, self-inflicted, or undetermined. In these studies, we restricted intent-specific analyses to assault-related and unintentional injuries because of the small number of self-inflicted injuries and those with an undetermined intent; however, overall analyses included all injuries regardless of intent. Information on arrests was obtained from Washington State Patrol records. This database provided full arrest history, including juvenile criminal records, and contained information for persons as young as 10 years. We used specific codes in the Revised Code of Washington to identify violent crimes, including homicide, rape, robbery, and assault, according to the Uniform Crime Reporting program of the Federal Bureau of Investigation (18). All patients were aged 15 years or older at the time of hospital discharge. We excluded records for persons younger than 15 years at the time of discharge because they would not have had any criminal records before age 10. Probabilistic algorithms were used to link each patients hospitalization record to his or her arrest record from 2001 through 2011. A subset of identifiers, including the first 2 letters of the first name, first 2 letters of the last name, date of birth, sex, and first 3 digits of the ZIP code, was used for the linkage. Detailed information about data linkage procedures can be found elsewhere (14). The Human Subjects Division of the Washington State Department of Health approved the study protocol and procedures. Statistical Analysis In the casecontrol study, odds of prior violence-related arrest were compared between case and control patients. Odds ratios (ORs) and their corresponding 95% CIs were determined by using multivariable logistic regression models that included covariates for age; sex; payer status; hospital county; and history of diagnosis of a psychiatric disorder, including substance use disorders. In the cohort study, only patients who survived their hospitalization were included. Follow-up began on the day of discharge and ended on the day of the first violence-related arrest, death, or 31 December 2011whichever occurred first. The unadjusted absolute risk for violence-related arrest was estimated by using the cumulative incidence function, with death treated as a competing event. In regression analyses, we used the methods described by Fine and Gray (19) to model violence-related arrest with the subdistribution hazards regression. Subhazard ratios and their corresponding 95% CIs were determined by multivariable models that included the same set of covariates used in the casecontrol study plus history of violence-related arrest. Additional analyses were conducted to compare the firearm injury group with a subset of patients in the other injury group who had sustained injuries through cut or pierce mechanisms (for example, stab wounds) or struck-by or struck-against mechanisms. In terms of the social context in which the injury occurred, these individuals may have been more comparable with the firearm injury group than those who sustained injuries by such mechanisms as motor vehicle crashes or falls. In all analyses, an of 0.05 was used to denote statistical significance. All tests were 2-sided and conducted using SAS, version 10 (SAS Institute), and Stata, version 13 (StataCorp), with the stcrreg and stcurve package for Fine and Gray modeling. Role of the Funding Source This research was funded by the City of Seattle and the University of Washington Royalty Research Fund. The funding sources had no role in the design, conduct, and reporting of this research or the decision to submit the manuscript for publication. Results A total of 245343 hospitalized patients were included in this investigation. Of these, 658, 71855, and 172830 were in the firearm injury, other injury, and no injury groups, respectively. A greater proportion of patients in the firearm injury group than those in the other 2 groups

Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self-Harm Risk Factors

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.