Clinical Approaches to the Prevention of Firearm-Related Injury

Abstract

F irearm-related injuries are an urgent health crisis in the United States, with firearm-related deaths surpassing deaths from motor vehicle crashes in 2017. 1 In contrast to other conditions for which clinicians have evidence-based solutions to reduce harm, the 25-year gap in federal research funding 2,3 halted substantial advances in the science of firearm-related injury prevention. Yet renewed funding and emerging science continue to highlight the critical role clinicians have in prevention efforts. 2,3 Similar to other complex health issues, firearm-related injury is heterogeneous, with multiple causes (Fig. 1). Each of these causes has entry points within clinical encounters that represent opportunities to interact, interrupt, and prevent negative outcomes. The lack of research has resulted in a generation of clinicians currently lacking the training necessary to implement the solutions generated by recent science. As a result, despite clinicians recognizing the need for prevention and agreeing that prevention of firearm-related injury is within their scope of practice, 13 few deliver evidence-based interventions even though their patients find such measures acceptable within the context of clinical care. 14 This lack of training is compounded by a shortage of adequate health care infrastructure necessary to support the integration of useful approaches into practice. Clinicians note multiple barriers, including a lack of knowledge, guidelines, time, clinical support, and reimbursement , as well as a fear of offending patients or encountering legal trouble. 15-17 Clinicians routinely provide harm-reduction measures and anticipatory guidance for a range of complex health issues (e.g., substance use and vaccination), capitalizing on available evidence, their relationships with patients, and their community standing to promote health and safety. Although gaps exist, there remain opportunities to improve the current standard of care for the prevention of firearm-related injury. In this article, we review clinical approaches to prevention, ranging from ones implemented within individual clinical encounters to ones advanced by health care leaders within the systems and communities they serve. Pr e v ention Fr a me wor k Similar to other behavioral-health issues, the primary clinical approach to patients at an increased risk for firearm-related injury is prevention counseling to increase safety behaviors. This approach may take the form of universal counseling for all patients regardless of their individual risk, selective counseling that is tailored to populations known to be at heightened risk (e.g., older adults), or indicated approaches that assess a patient's risk (i.e., screening) and provide tailored counseling. 18 In the absence of guidelines from health authorities, researchers 14,19-22 have advocated for pragmatic approaches that embed anticipatory guidance regarding secure storage and safety practices within routine primary care encounters (e.g., wellness examinations)