O3242: Prevalence and Correlates of Firearm Screening and Safety Counseling in Pediatric Primary Care at a Large, Midwestern Academic Institution

Background: Firearm-related injuries are the leading cause of death amongst children in the United States. Current American Academy of Pediatrics (AAP) guidelines state that pediatricians should screen for firearm access and provide appropriate anticipatory guidance related to safety as part of a broad, multilevel strategy focused on harm reduction, particularly for those at risk for self-harm. However, it is unclear how often clinicians perform screening and counseling in practice. At our institution, a large tertiary academic center in the Midwest, we reviewed well child exam (WCE) documentation to determine how often clinicians perform firearm access screening and safety counseling and correlated these with patient and provider characteristics to assess the influence of high-risk features such as psychiatric disorder.

Methods: We conducted a retrospective cross-sectional analysis of all WCEs for patients ≤21 years old across 18 primary care sites within Michigan Medicine from September 1, 2021, to February 28, 2022. Primary outcomes included documentation of firearm access screening and safety counseling in the setting of documented screening. Secondary outcomes included screening responses and counseling in the absence of screening or in the setting of different screening responses. We used multinomial logistic regression to estimate associations of primary outcomes with patient characteristics and clinician level and specialty, using multilevel modeling to account for patients nested within clinics.

Results: We reviewed progress notes for 32,582 WCE encounters. Table 1 shows sample characteristics and outcomes. Figure 1 shows multinomial logistic regression analysis results; given that Family Medicine and Internal Medicine-Pediatrics clinicians had screening in nearly all encounters, we focused analysis for this outcome on Pediatrics only. Age range of 0–1 years, decreased Pediatric Comorbidity Index score, patients classified as non-Hispanic Black or Other, and resident/fellow physicians were associated with decreased likelihood of screening, with 82.8% of outcome variability attributable to inter-clinic variability. In the setting of documented screening, age ranges of 2–5 years and 6–11 years and resident/fellow physicians were associated with increased likelihood of counseling, while age range of 12–21 years, non-Hispanic Asian patients, and Internal Medicine-Pediatrics clinicians were associated with decreased likelihood, with 20.4% of outcome variability attributable to inter-clinic variability.

Conclusion: Despite AAP recommendations, categorical Pediatric clinicians did not uniformly perform firearm access screening during WCEs (unlike Family Medicine and Internal Medicine-Pediatrics clinicians) with high inter-clinic variability, yet categorical Pediatricians more often documented counseling, which was much less common than screening overall. Patient sociodemographic and clinician characteristics, rather than high-risk features such as psychiatric and substance use history, appeared to influence screening and counseling. Findings suggest the need for clinician education on appropriate policies and clinical guidelines and related quality improvement efforts to operationalize best practices in firearm screening and safety counseling, avoid possible biases during practice, and ensure uniform implementation.