Proceedings from the Medical Summit on Firearm Injury Prevention: A Public Health Approach to Reduce Death and Disability in the US

An historic meeting of 44 major medical and injury prevention organizations and the American Bar Association was hosted by the American College of Surgeons (ACS) February 10-11, 2019. Leaders of these professional organizations met with the goal of building consensus around opportunities to work together to address the growing problem of firearm injury and death in the US. A multidisciplinary planning committee invited speakers who are leading experts and researchers in this field to review the epidemiology of firearm injury, discuss structural violence and the social determinants of health, review the public health approach to the problem, and discuss opportunities for injury prevention interventions. The goal was to be maximally inclusive and include organizations that represent physicians, nurses, public health professionals, and emergency medical services providers who are both on the front lines in caring for injured patients and also manage the long-term consequences of violence in the community. All invited organizations were encouraged to submit digital materials related to their organization’s firearm injury prevention initiatives and these were shared before the Medical Summit. A list of the organizations that have agreed to support the consensus statements from this conference can be found in Appendix 1.

For the past 30 years, many medical organizations have led efforts to address firearm injury and firearm violence, but most (if not all) of these efforts have become mired in a debate about personal liberty and the Second Amendment to the US Constitution. Some of this controversy has been internal to professional organizations, and some has been external. In general, this debate has not been productive—while death rates from other medical conditions such as traffic injury, heart disease, cancer, and HIV have decreased, firearm death rates in the US are increasing. The ACS Committee on Trauma has worked steadily to move beyond this debate, and to move from published statements to constructive action. The keys to this approach center on addressing firearm injury as a medical and public health problem, not a political problem; developing research agendas to understand and address root causes of violence; and committing to a professional and civil dialogue centered on how best to reduce and prevent firearm injury, death, and disability. This mirrors the public health model that has been so effective in improving outcomes in traffic-related injury.

The following were the objectives of this Summit:

1. Identify opportunities for the medical community to reach a consensus-based, non-partisan approach to firearm injury prevention
2. Discuss the key components of a public health approach and define interventions this group will support
3. Develop consensus on actionable items for firearm injury prevention using the public health framework

We also sought to learn about the current independent efforts of all participating organizations to identify gaps and collaborative opportunities (Appendix 2).

These objectives focus on injury prevention, which is integrated into a healthcare and trauma system framework that also functions to turn bystanders into immediate responders, and ensures the delivery of optimal prehospital, hospital/trauma center, and rehabilitative care. This system also serves as a framework for disaster and mass casualty response. This systematic approach requires engagement, stakeholder partnerships, data collection, research, education, advocacy, communication, and cooperation.

The public health approach to firearm injury prevention is identical to other highly successful injury prevention initiatives. The underlying philosophy is grounded in an ethical framework centered on the principles of beneficence, autonomy, and honesty. Although not speaking specifically about injury prevention, Dr Richard Moulton sums up the philosophic approach well about the rationale for professionals leading in this sphere. He states, “We dedicate ourselves to the service of humanity, and most importantly we place the needs of the patient above those of the doctor…” And, “We will base our knowledge and actions on objective scientific truth as best we can determine it.” This ethical framework is the foundation of why professional societies are engaged in injury prevention programs. Firearm injury is a significant health problem for our patients and the communities we serve; therefore, it is important that we develop effective injury prevention strategies. Coming together as a professional community and approaching this epidemic as a disease and a public health problem promises to make our neighborhoods and our country safer, stronger, and more resilient. We believe that this can be done in a manner that preserves (or even enhances) freedom. This professional approach requires freedom with responsibility.

The group reviewed survey data from the ACS that, on the surface, are consistent with a philosophic divide concerning the general benefit of firearms and views of firearms and freedom. In previous surveys of surgeons, a majority in the US adheres to 1 of 2 contrasting and conflicting narratives about firearm ownership.¹ The visual abstract in Figure 1 graphically depicts this polarized debate and an inclusive alternative.² This philosophic divide is most evident on the extremes, but these competing philosophies lead to polarized personal narratives and create the perception of a large chasm between 2 groups. One of 2 dominant narratives asserts that firearms are beneficial, necessary, and a protected right. The strongest adherents of this philosophic view very tightly link freedom and firearms; so for them, the term gun control is synonymous with freedom control. The second narrative asserts that firearms are harmful, generally unnecessary in civil life, and decrease personal liberty because of increased risk of harm (in homes and in communities). Strong adherents of this philosophic view very tightly link guns with violence, so for them gun control is synonymous with violence control.

Figure 1.: Visual abstract describing the American College of Surgeons Committee on Trauma Consensus–based approach to the dialog related to firearm injury prevention.

When faced with a perceived stress or crisis, those who view firearms as critical for personal freedom and protection push for greater availability and tend to purchase more firearms. Those who view firearms as emblematic of violence and harm push for increased restriction on access to firearms, and protest the violence. Both sides appear convinced they are absolutely correct, and both often react to each other by reinforcing their own position, while simultaneously villainizing the other. When searching for constructive solutions that realistically could positively impact hundreds of thousands of American lives annually, this gap can initially appear uncrossable.

However, the chasm is not as wide as it might seem. In surveys of both medical professionals and the lay public there are many areas of agreement about firearm injury prevention. In a recent survey of ACS members, most respondents believe that firearms are both beneficial and harmful. When questioned about the role of firearms in protecting or restricting freedom, the most common response was that firearms neither protect nor limit personal freedom (unpublished data, ACS membership survey). The view of 2 conflicting narratives creates a false dichotomy. As Figure 1 depicts, there is a common narrative, inclusive of both philosophic views: firearm ownership is a constitutionally protected right and we also have a major firearm violence problem. The way to address the epidemic of firearm violence is to work together to fully understand and address the underlying causes of violence, while simultaneously working to make firearm ownership as safe as possible (for those who own firearms and for those who do not).

The emergency healthcare community has led the implementation of a systematic approach to developing emergency medical services, trauma, disaster, and emergency healthcare systems. Through the development of these systems, important lessons have been learned that are relevant to addressing complex health problems. The general approach to implementation of these systems is based on the following 5 key principles: be maximally inclusive with engagement of stakeholders, create a dialogue and develop a consensus plan centered on what is the right thing to do for the patient or the population being served, establish systems that ensure timely and structured cooperation and communication, develop data systems with strong support for research and quality improvement, and cultivate a bias for action with a focus on implementing and hardwiring system improvements. This inclusive, consensus, action-oriented approach requires professional freedom with responsibility to the patient and the community. This approach generates trust and leads to productive teams and durable solutions. These professional principles are generalizable to solving or effectively managing other complex problems—such as firearm injury prevention.

This systems approach, based on the public health model, requires engagement, responsibility and partnership across disciplines, geographic regions, and philosophic differences. It requires commitment to values of civility, professionalism, humility, and mutual respect. When applied to firearm injury prevention, this approach requires engaging firearm owners as a part of the solution rather than as a part of the problem; engaging underserved community members as a part of the solution rather than as a part of the problem; a commitment to addressing structural factors and social determinants of health that lead to and potentiate the cycle of violence; and a commitment to develop investigators and adequately fund research at a level commensurate with the burden of the health problem. These proceedings will summarize the presentations at the conference and conclude with a consensus-based approach to this issue that all of the professional organizations listed in Appendix 1 have agreed to support.

EPIDEMIOLOGY OF FIREARM INJURY

In 2017, there were 39,773 firearm-related deaths in the US, of which 60% were suicides, 37% were homicides, 1% were unintentional injuries, and approximately 1% were related to legal intervention (2017 data from CDC WISQARS [Web-Based Injury Statistics Query and Reporting System; https://www.cdc.gov/injury/wisqars/nvdrs.html]). Although mass shootings have garnered recent attention and are increasing in frequency, they represent <1% of homicide deaths. As shown in Figure 2, the death rate peaked in the early 1990s, but has been increasing during the past 3 years. We do not have adequate data systems to accurately define the rate of non-fatal firearm injuries in the US. Although firearm injuries represent only 4% of injuries seen at major trauma centers, based on analysis from the National Trauma Databank, due to the high case fatality rate, the deaths attributed to firearms in the population are equivalent to motor vehicle crashes and falls (Fig. 3). Figure 4 shows the varying population-based mortality rates by state. Among those with serious injury, the case fatality rate for motor vehicle crashes has declined in the past 10 years, while there has been no similar improvement for firearm injuries.³ In addition, for patients hospitalized as a result of a firearm injury, the injury severity has increased steadily over time.⁴ Suicide by firearm carries an 85% fatality rate, which is significantly higher than all other mechanisms.^5-7 Firearm suicide disproportionately involves older, white males in rural environments, and firearm homicide disproportionally affects young men of color in urban environments. Unintentional injury disproportionally impacts children with access to firearms. Ninety-one percent of children killed by guns in high-income countries are in the US. Worldwide it is estimated that 251,000 people died from firearm injury in 2016.

Figure 2.: Mortality rates from firearm injury in the US over time based on data from CDC WISQARS (Web-Based Injury Statistics Query and Reporting System, https://www.cdc.gov/injury/wisqars/nvdrs.html).

Figure 3.: (A) The percentage of patients seen at trauma centers in the US based on mechanism of injury, data from the National Trauma Databank, 2014. (B) Population-based mortality for the top 3 mechanisms of injury in the US, data from CDC.

Figure 4.: Firearm Mortality by State, 2017. Age-adjusted firearm death rates per 100,000 population from the US Centers for Disease Control: https://www.cdc.gov/nchs/pressroom/sosmap/firearm_mortality/firearm.htm.

SOCIAL DETERMINANTS OF HEALTH AND STRUCTURAL VIOLENCE

The social determinants of health are the conditions in which people are born, grow, live, work, and age, and are shaped by the distribution of money, power, and resources at global, national, and local levels. They are the major drivers of health and disparate health outcomes across communities and populations. The lack of opportunities to thrive and be successful in life contributes to shorter lives, particularly for people of color. Entire neighborhoods across the US can be seen suffering from a host of chronic diseases, including gun violence, as a result of inequity in the social determinants of health. Creation of heat maps across the US of diseases such as early heart ailments, certain cancers, environmental disorders, COPD, obesity, diabetes, and gun violence illustrate the clear inequity of our ethnic minority populations; our poor; and our populations with poor access to equitable education, housing, and employment. Turning this equation around, addressing socioeconomic factors appropriately has the largest potential impact of any intervention on the health of our population.

The US spends >17% of its gross domestic product on healthcare, a proportion much higher than any other high-income country. Despite this statistic, the US life expectancy, infant mortality, and age of the population that is older than 65 years old are lower than our economic counterparts. The number of comorbidities and the obesity rates are also relatively higher than other high-income countries (OECD [Organisation for Economic Co-operation and Development] Health Statistics database; http://www.oecd.org/els/health-systems/health-data.htm). Understanding the factors responsible for population health requires that we examine the daily realities that affect the lives and the health of our people and fund the needed research to better understand the complexities. In the US and around the world, there are extensive data linking socioeconomics to health. Gradients of wealth parallel gradients of health. Low life expectancy is clearly related to living below the federal poverty level and to poor levels of education.

Structural violence is a term coined by Johan Galtung and colleagues⁸ that describes social structures—economic, political, legal, religious, and cultural—that keep individuals, groups, and societies from reaching their full potential. As a fish cannot see water, these structures are mostly invisible to most of us, but they put individuals and populations in harm’s way.⁹ One example of this is the practice of “red-lining,” which is the practice of refusing loans (such as mortgages) to people who live in a neighborhood deemed a poor financial risk. Social arrangements creating structural violence result in profound disparities in access to education, income, opportunities for wealth building, and housing. It is in these neighborhoods that we find interpersonal violence exceedingly prevalent. These inequities are a key underlying factor in interpersonal firearm violence. These neighborhoods represent the places where young African Americans and Latinos experience gun violence at epidemic rates. Homicide is the leading cause of death in young African Americans, and the second leading cause of death among young Latinos. Homicide is a downstream consequence of profound inequities upstream. A paradigm shift for treatment and interventions for victims of violence should begin there.

THE DISEASE MODEL AND THE PUBLIC HEALTH APPROACH

Firearm violence can be viewed as a complex biopsychosocial disease.¹⁰ The biology of this disease is treated acutely every day in emergency departments (EDs) and trauma centers across the US. Increasingly, the care of the patients and their families (and communities) are being informed and strengthened by behavioral health and social interventions that reduce subsequent risk, such as post-traumatic stress disorder, and can inform at-risk assessments for youth and other vulnerable populations. Furthermore, by framing gun violence as a complex disease, the public health approach to preventing these deaths rests on a scientific basis that provides structure to healthcare systems, public health agencies, and other organizations that wish to reduce this burden in our communities. Framing gun violence as a complex disease also provides a basis for systematic research that improves our understanding of these deaths and non-fatal events, similar to approaches for other diseases, such as HIV/AIDS.

Among the key goals of the summit was to define “the public health approach” to firearm injury prevention. The public health approach to any issue is a comprehensive, multidisciplinary approach that includes population level screening and multiple interventions spanning the disciplines of health, education, culture, law, and policy. This approach involves 4 stages including understanding the epidemiology, program development, research to evaluate program outcomes, and dissemination of successful programs. Each injury prevention program that is developed should undergo this rigorous process. However, research funding has been lacking to adequately develop and assess efforts in this systematic way, underscoring the need for significant federal funding directed at injury prevention and firearm violence research. As a deliverable from this summit, we sought to evaluate the current firearm injury prevention programs provided by the participating organizations, to understand where organizations are overlapping in their approach and where there might be gaps. These are summarized in Appendix 2.

To evaluate existing programs, we elected to use a tool that forms the basis of many public health injury prevention initiatives: the Haddon Matrix.¹¹ Developed by William Haddon in 1970, this matrix forms a 3 × 4 box of intersecting cells. On one side are 3 rows representing primary, secondary, and tertiary prevention. Primary prevention occurs before the event, secondary prevention involves decreasing magnitude of the impact on the individual at the time of the event, and tertiary prevention is about lessening the effect of the event on the individual’s life moving forward, or, more simply, to help in recovery. There are 4 columns that describe the 4 opportunities for intervention: the host, vector, social environment, and physical environment. In the case of firearm injury, these 4 opportunities are clear: the host is the individual who is injured by firearm, the vector/agent is the firearm, and the social and physical environment encompass the communities where people live, work, and play, and the laws, regulations, and cultures of those communities. This approach led to a dramatic decrease in motor vehicle deaths per miles driven in the latter half of the 20th century. Given the variability in epidemiology and risk factors, we elected to complete a Haddon matrix for each of the 3 main types of firearm injury: suicide, unintentional injury, and intentional interpersonal violence. Intentional interpersonal violence encompasses homicide, mass shootings, and intimate partner violence (Figs. 5–7).

Figure 5.: Haddon’s Matrix describing potential injury prevention initiatives for firearm suicide prevention.

Figure 6.: Haddon’s Matrix describing potential injury prevention initiatives for intentional interpersonal injury by firearms.

Figure 7.: Haddon’s Matrix describing potential injury prevention initiatives for unintentional firearm injury.

For suicide, primary prevention involves addressing underlying mental health problems and social stressors, secondary prevention involves reducing the risk of death from attempted suicide, and tertiary prevention is lessening the effect of a suicide attempt on the individual’s life. Similarly, if we consider violence as an affliction or disease, primary prevention is about preventing violence, secondary prevention is about lessening the effects of violence or the severity of injury, and tertiary prevention involves helping an individual recover from violence. Prevention of unintentional injury focuses largely on safety training to avoid mishandling of firearms and limiting access to children, and strengthening the safety features of firearms. The Haddon Matrices provided in this document represent a summary of the work currently being done by the medical community and areas in need of further development. Although these provide a summary of potential interventions, we did not seek to reach consensus on all of the items in the Haddon’s matrices, but rather offer them as a strategy to develop a comprehensive approach to this complex problem.

FIREARM INJURY PREVENTION RESEARCH: GAPS AND OPPORTUNITIES

The science of injury prevention—a systematic strategy for reducing the public health burden of firearm epidemics—was established in the 1960s in the face of an epidemic of motor vehicle crash injuries. Healthcare providers and researchers can reduce the incidence and health consequences of firearm injuries in precisely the same manner as was done with motor vehicle crashes: through a rigorous, coordinated strategy for research and the application of research evidence to medical and public health practice. However, healthcare providers have been limited in their ability to use this standard approach to firearm injury prevention because of lack of funding.¹²

We can track the effect of funding restrictions on both the science and the burden of injury. In 1996, the Dickey Amendment was passed, stating “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote gun control.”¹³ Although the Dickey amendment did not technically prevent firearm research from being conducted, since that time, Congress and CDC have failed to appropriate any designated support for firearm injury research. The level of NIH funding for this disease process is only 1.6% of the amount predicted for conditions with similar mortality burdens.¹⁴

Commensurate with the level of funding, publications and number of active researchers addressing firearm injury had also decreased,¹⁵ although there has been a recent increase in articles in the medical literature on firearms. A recent systematic review demonstrated that only 72 articles addressed clinically relevant firearm injury prevention; of these, only 12 assessed patient-level interventions and only 6 were randomized controlled trials.¹⁶ Although these studies provide preliminary evidence for the value of provider-level interventions in increasing safe storage and decreasing weapon carriage and fights, injury-specific outcomes are lacking.^17-21

Reflecting the current lack of rigorous research on firearm injury prevention, multiple organizations have developed high-quality research agendas.^22,23 But these agendas remain unanswered. Without adequate funding, the medical and public health community will not be able to address key unanswered questions around the epidemiology of firearm injury; effective primary, secondary, and tertiary prevention interventions; and how best to disseminate and implement effective programs. Answering these questions will require significant public and private investment. It is essential for the medical community to continue its advocacy for adequate research funding at the federal level (eg NIH, CDC, and National Institute of Justice). While continuing this advocacy, we also have a responsibility to our patients and communities to expedite lifesaving, high-quality research through alternate means of funding. The American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) is a non-profit organization recently founded by several medical organizations to provide an opportunity for private individuals, foundations, and corporations to invest in the research that will lead to solutions to our firearm injury epidemic, and to directly support professionals who will design, implement, and evaluate the necessary public health approaches.

THE AMERICAN COLLEGE OF SURGEONS’ EXPERIENCE: ENGAGING FIREARM OWNERS IN THE SOLUTION

After the Sandy Hook shooting in 2012, the ACS revised its statement on firearm injuries and the response of members to this revised statement revealed that many surgeons hold very polar views on personal firearm ownership. In early 2015, the ACS joined 7 other health professional organizations and the American Bar Association in a call to action to address firearm-related injury and death in the US.²⁴ With the support of the ACS Board of Regents, the ACS Committee on Trauma embarked on a public health approach to decrease firearm injuries and deaths, leveraging our network of more than 500 ACS-verified trauma centers throughout the US, which routinely treat those injured by firearms. The experience of the ACS in developing this approach can provide insight for other professional organizations that seek to address this issue without polarizing their membership.

The first step was to survey the membership of the ACS Committee on Trauma and the ACS Board of Governors to better understand their views on firearm ownership and advocacy issues.²⁵ Members agreed that the ACS should give high priority to reducing firearm injuries, as well as preserving healthcare professionals’ rights to counsel patients (or parents of patients) about prevention of firearm injuries and the importance of providing federal funds for research on firearm injury. Significant consensus on a broad range of advocacy initiatives informed the ACS strategy of “Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death and Disability from Firearm Violence”² (Fig. 1).

Subsequently, the ACS leadership approved a 9-point strategic action plan to address firearm violence, including support trauma system development and promulgation of the Stop the Bleed program; create a Firearm Strategy Team group of firearm-owning surgeons to inform injury prevention and advocacy; survey all US ACS members (n = 50,000); develop collaborative partnerships with other organizations; implement firearm injury prevention initiatives; develop a research agenda and advocate for federal and private research funding; promote responsible gun ownership and non-violent conflict resolution; advocate for mental health funding; and support expanded background checks.

One of the most important components of this plan was the formation of the Firearm Strategy Team group, which includes surgeons who own firearms for hunting, sport shooting, self-defense, law enforcement, and military service. Analogous to engaging bicyclists to help develop an action plan to decrease bicycle injuries, the ACS engaged members who own firearms to help develop durable and informed injury prevention and advocacy strategies. Although their recommendations do not represent all firearm-owning ACS members, this group’s initial recommendations address ownership, registration, licensure, education and training, ownership responsibilities, mandatory reporting and risk mitigation, safety innovation and technology, research, culture of violence, social isolations, and behavioral health.²⁶

Additional injury prevention initiatives included development of a brochure on firearm safety that healthcare professionals can use to talk with their patients, as well as a primer on how to establish a hospital-based violence intervention program. These are available at: https://www.facs.org/quality-programs/trauma/advocacy/ipc/firearm-injury.

The ACS is also actively advocating for federal and private research funding of firearm injury prevention research and expanded background check legislation. This Medical Summit was convened to further develop collaborative relationships across the medical community to support this public health approach.

INTERVENTIONS FOR FIREARM INJURY PREVENTION

Safe storage: counseling patients and families

It is important for clinicians to appreciate that injury is the leading cause of death for American children and adolescents, and that firearm injuries are the second most common cause of injury-related death after motor vehicle crashes. Every year, nearly 1,300 children (0 to 19 years) are killed and another 5,790 are injured by firearms in the US.²⁷ Survey studies of American households have shown that more than one-third (35%) have at least 1 firearm, which means approximately 22 million American children live in a home where at least 1 firearm is present. Of those households with guns, 43% keep at least 1 firearm unlocked, and nearly 1 in 10 (9%) have firearms that are stored unlocked and loaded.²⁸ Many parents fail to appreciate the limitations of their children’s developmental stages, and erroneously believe younger children can distinguish between real and toy guns, and loaded and unloaded firearms, when they are unable to do so.^29-31

Safe storage (and related counseling) is also important for prevention of suicide and in the context of dementia or other cognitive impairment. The association between firearms and increased incidence and death from firearms has been known for more than 40 years, and well-designed epidemiologic studies have repeatedly demonstrated a strong association between the presence of household firearms and an increased risk of firearm-related homicide, suicide, and unintentional shooting.^32,33 The public health significance of firearms in the home is a function of both their relative risk of exposure and the prevalence of firearms where children and adolescents live.³⁴ The 4 practices of keeping a gun locked, storing a gun unloaded, keeping ammunition locked, and storing ammunition and guns separately are associated with incremental decreases in firearm-related injury.³³

There is broad support from major American medical organizations encouraging physicians to provide counseling on safe firearm ownership and to incorporate primary prevention of firearm-related injury into clinical practice, and no legal barriers to doing so, but developing effective ways to incorporate this into clinical practice has proven challenging.^24,35-38 A recent survey showed that most gun owners (81%) did not think that physicians would be good or excellent messengers to teach them about safe firearm storage.³⁹ These data illustrate the importance of engaging firearm owners in this work because some clinicians and medical organizations frame their message about firearm safety in a way that can be off-putting to families who keep guns for hunting or personal protection. It is important for physicians to recognize that the public health message about the importance of storing firearms safely is very similar to the safe storage message promoted by gun rights and shooting sports groups, and should be consistent with other injury prevention strategies for parents, such as the safe storage of medicines and other harmful products.

Many firearm injury prevention programs are developed by well-meaning groups concerned about this issue, and they focus on behavioral interventions. Unfortunately, these programs are rarely based on theoretical models or preliminary effectiveness data (eg Scared Straight, Eddie Eagle, and Straight Talk about Risks). Based on these shortcomings, the National Research Council Committee to Improve Research Information and Data on Firearms recommends that firearm prevention programs be based on general prevention theory and research, and that they incorporate rigorous evaluation into the design and implementation of these programs. There is an extreme paucity of data to support the best approach to counseling children and adults for child access prevention; however, there have been 2 recent studies that have shown that the counseling of the parents of young children about safe storage is effective, when they are provided with free or low-cost safety devices.^17,40 Broad, multidimensional measures using a public health approach will be required to lower the incidence of firearm injury in the US, and should engage gun owners and non-gun owners alike in devising scientifically sound public health interventions that can be applied broadly to clinical practice.

Lethal means safety for suicide prevention

Suicide accounted for 60% of firearm deaths in the US in 2017, with particularly high firearm suicide rates among middle-aged and older white males (2017 data, CDC WISQARS database) “Lethal means safety” is an evidence-based approach to suicide based on the concept that reducing access to highly lethal means of suicide during a time of vulnerability can prevent suicide by reducing the lethality of attempts.^41-44 These research findings demonstrate that there is often a short period of final deliberation before an attempt; means substitution (choosing a different method if the first preferred method is unavailable), if it occurs, reduces the risk of fatal outcomes; and only a small minority of individuals with nonfatal attempts die by suicide later.⁷ Firearms are a key focus of lethal means safety because of their high case fatality rate—approximately 90%—which is higher than other methods of suicide. Counseling by healthcare providers about reducing access to lethal means (lethal means counseling) is recommended as part of standard care for individuals at risk of suicide. Counseling typically includes messages about voluntarily, and often temporarily, reducing access by moving firearms out of the home (for storage with trusted others, at law enforcement, gun ranges/retailers, pawn shops, armories, or storage facilities), or by securing them in the home (with a locking device and/or by removing ammunition) so the person at risk cannot access them.

Lethal means counseling is often not routine, in part because of clinician ignorance or discomfort discussing firearms.^45,46 Yet, research suggests many patients are open to respectful, nonjudgmental education from clinicians, including in the context of suicide risk assessment.^41,47,48 Close attention to messaging can enhance patient receptivity to counseling.^49-51 For example, emphasizing firearm safety and personal responsibility—both core tenets of responsible gun ownership—and engaging trusted family or friends can reduce suspicion or resistance.⁵² Partnerships between suicide prevention professionals and firearm retailers offer promising new opportunities for collaborative development of interventions and for dissemination of lethal means messages to firearm owners.^53,54 Examples include the partnership between the American Foundation for Suicide Prevention and the National Shooting Sports Foundation (http://www.nssfblog.com/nssf-afsp-suicide-prevention-partnership/) and the Utah Suicide Prevention Coalition’s “Is Your Safety On?” campaign (https://vimeo.com/175761640). Future research examining the effectiveness of messaging and other interventions should engage diverse stakeholders from varied geographic areas (including urban and rural and different areas of the US) to optimize generalizability of findings. Materials and training for healthcare providers about when and how to discuss firearm safety should continue to include suicide as a key point of intervention, given the high proportion of firearm deaths due to suicide. Similarly, suicide prevention will require comprehensive, multi-pronged approaches, but should include lethal means safety as a core component.

Hospital-based violence intervention programs

The public health approach applied to violence intervention focuses attention on modifiable risk factors and on protective factors. Within that framework, the social determinants of health allow us to outline the root causes of interpersonal violence. Since the inception of hospital-based violence intervention programming more than 20 years ago, more than 35 programs with fidelity in the public health model currently exist.⁵⁵

Hospital-based violence intervention (HVIP) is deeply rooted in the communities these programs serve. The programs have 3 core principles:

1. There is a teachable moment shortly after an individual is injured from interpersonal violence, when he/she is actively feeling a sense of a “second chance,” looking for a way to safety and a way to thrive.
2. A culturally competent case manager/intervention specialist sees the injured person at the bedside, during this critical time alongside the provider team. This begins the opportunity to form a mentoring relationship with victim and case manager. A risk assessment and needs assessment is developed through this partnership.
3. A long-term plan for case management and shepherding victims to risk reduction resources in the community is set in motion. There is a strong understanding in these programs of the trauma informed approach. This approach recognizes that long-standing psychological wounds in our victims of interpersonal violence are critical to address up front. Many of the programs have mental health professionals embedded on staff. Others have close working relationships with mental health providers.

Hospital-based violence interventions exemplify a paradigm shift in treating trauma victims by practicing a more comprehensive approach to reduce the risk factors of violent injury. Although the hospital is the critical portal of entry, case managers build essential partnerships with services in the community that provide for employment opportunities, tattoo removal, immigration services, educational pathways, and housing services. Case managers stay with clients for months and sometimes years as clients navigate these services. Case managers often provide essential court advocacy for clients. There are data to support the value of HVIPs. Programs have been successful in addressing the risk factors associated with violent injury.⁵⁶ Studies have demonstrated reductions in injury recidivism and in cost-effectiveness.⁵⁷ It is also essential to track the qualitative value of HVIPs. Preliminary work supports this value through the voices of clients themselves. Programs are currently sustained financially in a number of pathways. There is legislation being developed that would allow billing for fee-for-service for case management. Programmatic development, working group opportunities, and technical assistance are supported by the National Network of Hospital-Based Violence Intervention (www.NNHVIP.org).

Screening for patients at risk for firearm injury or death

Routine screening for the risk of domestic violence and suicide have been implemented in many EDs, primary care offices, and mental health visits. Screening of all patients should be considered where comprehensive resources are available and interventions have been developed that support this screening and support patients and families identified as high risk for injury, with specific interventions for those who have access to a firearm. In some states, Extreme Risk Protection orders can be issued, which allow the temporary removal of firearms from the homes of those at risk. Restraining orders can also restrict an abusers access to purchase firearms. Patients identified as at-risk for domestic violence or suicide need to be asked routinely about the access to firearms in the home and be advised, along with family members, on the steps to take to mitigate this risk.

Interpersonal firearm violence among youth and young adults 14 to 24 years is a substantial public health problem, and physicians require a clinical screening tool to identify high-risk youth to guide resource allocation. The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence in urban settings.⁵⁸ The SaFETy screen shows potential to guide resource allocation for prevention of firearm violence. The specific questions are “In the past 6 months, including today, how often did you get into a serious physical fight?” “How many of your friends have carried a knife, razor, or gun?” “In the past 6 months, how often have you heard guns being shot?” “How often, in the past 6 months, including today, has someone pulled a gun on you?” The SaFETy instrument, which can be administered in 1 to 2 minutes, defines a gradient of future firearm violence risk that can be adapted to a variety of settings.

SafERteens (https://saferteens.org) is an evidence-based brief intervention to prevent youth violence that has been translated into routine ED clinical practice.^59-61 This 30-minute single therapy session one-on-one with the teen during the ED visit uses motivational interviewing techniques to change behavior in a respectful, non-confrontational, and non-judgmental manner. The program has been shown to be efficacious to decrease peer fighting (aggression and victimization) and dating victimization in multiple randomized controlled trials, with number needed to treat = 8 for decreasing peer aggression/fights with sustained effects at 1 year post session. In cost analysis, SafErteens was found to cost approximately $17/event averted.⁶² Additional trials have demonstrated efficacy when provided to youth living in high-risk communities without individual screening.⁶³ It has not been evaluated for firearm violence outcomes but instead works to interrupt the cycle of violence among youth earlier in a spectrum of violent behaviors.

Another patient population deserving attention is older adults with dementia, a population that will grow to an estimated 13.8 million by 2050. Among older adults aged 65 years and older, approximately 45% personally own a gun or live with someone who does.⁶⁴ The few available studies suggest that firearm prevalence among those with dementia might be similar or even higher (60% in one small study⁶⁵). For individuals with dementia, suicide is the primary risk for firearm injury or death, with 91% of all older adult firearm deaths due to suicide.⁶⁶ However, the mood and behavioral changes that often accompany dementia (such as agitation, anxiety, and paranoia) can lead to potentially deadly situations if firearms are accessible. Advance planning, counseling, and materials for family members and other caregivers can be useful in helping navigate the sensitive topic of when a person with dementia is no longer safe to have firearm access.^67,68 Additional research is needed on when and how to screen and intervene with patients with dementia, while still supporting their independence and rights. Widespread education of healthcare providers who will encounter patients at risk for firearm injury or death is needed to optimize screening and intervention.

Mental health and firearm injury

The overwhelming majority of individuals diagnosed with mental illnesses are not violent, and the majority of people who are violent do not have an identifiable mental illness.⁶⁹ Researchers have estimated that only 4% of criminal violence can be attributed to mentally ill individuals.^70,71 In addition, individuals with mental illnesses are 3 times more likely to be targets than perpetrators of violence.⁷² In one recent study, researchers did not find significant temporal associations between mental health symptoms and gun violence (ie gun carrying and threatening someone with a gun).⁷³ Another study demonstrated that gun violence committed by individuals with severe mental illness occurs in <2% of patients in the year after discharge from inpatient facilities.⁷⁴ In fact, people with mental illnesses are far more likely to hurt themselves than others.⁷⁵ Research has consistently demonstrated that individuals with mental disorders (eg schizophrenia, bipolar disorder, depression) have a significantly increased risk of suicide.⁷⁶ However, in a study conducted by CDC examining data from the National Violent Death Reporting System, 54% of individuals who died by suicide did not have a known mental health condition.⁷⁷ In addition, the odds of having a mental disorder have been found to be lower among cases of firearm suicide compared with suicide involving other methods.⁷⁸

Research findings suggest that only 18% of suicidal patients in EDs were assessed for lethal means access and <8% had someone discuss an action plan to reduce access.⁷⁹ Similarly, in a study evaluating practices in hospital-based EDs across 8 states, fewer than one-third of them had discussed firearm storage with suicidal patients at discharge.⁴⁶ Although mental illness does confer some risk for suicide and violence, there are other stronger predictors, namely access to firearms, which need to be considered as targets of intervention. Health professionals play a critical role in assessing their patients for suicide and violence risk; counseling about firearm safety; and incorporating education on suicide, violence, and firearm injury prevention into medical/graduate schools, residency programs, and continuing medical education, creating rational and evidence-based public policy to reduce firearm injuries and deaths without unnecessarily stigmatizing people with mental illness.⁸⁰

A PUBLIC POLICY APPROACH

Tackling this complex health problem necessitates a multifaceted approach to decrease firearm-related injury and death in our communities across the US, and policy is one facet of the public health approach. It is important to recognize that most governing in the US happens at the local and state level. Therefore, it is critical to ensure that policies created are being adapted to the needs and are culturally relevant on both the local/state and federal levels.

Although there are some differences about where we should begin from a policy perspective, there are multiple areas that have significant support from the medical community. Examples of this are providing federal dollars for firearm injury prevention research at a level that is proportional to the burden of disease, expansion of background checks to all firearm sales, and ensuring access to behavioral health services.

Policy happens in the public sector but can also be institutional. Some healthcare systems, such as Kaiser Permanente, have committed to providing financial support for firearm injury research. Other healthcare systems have partnered with the local community to address the social determinants of health and improve the physical environment in urban setting with high rates of violence. At the hospital level, institutional/organizational level policies can be developed at all trauma centers to have a clinical psychologist and social service practitioner as part of the inpatient team caring for the injured patient, or to develop a formal hospital-based violence intervention program. The house of medicine, along with other healthcare disciplines, has an opportunity to help inform our policy and decision makers as we work toward implementing data-driven solutions to reduce firearm-related injury and death.

CONSENSUS STATEMENT

The following represent a consensus-based approach to the issue of firearm injury prevention supported by all of the organizations listed in Appendix 1.

1. Firearm injury in the US is a public health crisis.
2. A comprehensive public health and medical approach is required to reduce death and disability from firearm injury.
3. Research is needed to better understand the root causes of violence, identify people at risk, and determine the most effective strategies for firearm injury prevention.
4. Federal and philanthropic research funding must be provided to match the burden of disease.
5. Engaging firearm owners and populations at risk is critical in developing programs and policies for firearm injury prevention.
6. Healthcare providers should be encouraged to counsel patients and families about firearm safety and safe storage. Educational and research efforts are needed to support appropriate culturally competent messaging.
7. Screening for the risk of depression, suicide, intimate partner violence, and interpersonal violence should be conducted across all healthcare settings and in certain high-risk populations (such as those with dementia). Comprehensive resources and interventions are needed to support patients and families identified as high risk for firearm injury and who have access to a firearm.
8. Hospitals and healthcare systems must genuinely engage the community in addressing the social determinants of disease, which contribute to structural violence in underserved communities.
9. Our professional organizations commit to working together and continuing to meet to ensure these statements lead to constructive actions that improve the health and well-being of our fellow Americans.

Author Contributions

Acquisition of data: Bulger, Kuhls, Campbell, Bonne, Cunningham, Betz, Dicker, Ranney, Barsotti, Hargarten, Sakran, Rivara, James, Lamis, Timmerman, Rogers, Choucair, Stewart

Analysis and interpretation of data: Bulger, Kuhls, Campbell, Bonne, Cunningham, Betz, Dicker, Ranney, Barsotti, Hargarten, Sakran, Rivara, James, Lamis, Timmerman, Rogers, Choucair, Stewart

Drafting of manuscript: Bulger, Kuhls, Campbell, Bonne, Cunningham, Betz, Dicker, Ranney, Barsotti, Hargarten, Sakran, James, Lamis, Stewart

Critical revision: Bulger, Kuhls, Campbell, Bonne, Cunningham, Betz, Dicker, Ranney, Barsotti, Hargarten, Sakran, Rivara, James, Lamis, Timmerman, Rogers, Choucair, Stewart