Patient-Reported Firearm Access Prior to Suicide Death

Firearms are the most common means of suicide death in the US.¹ Major medical associations recommend health care providers counsel at-risk patients to limit firearm access.² However, no national practice recommendations exist for implementing standardized firearm access screening.³ Health care systems more commonly rely on clinicians to ask patients about firearm access and ownership at their discretion.³ In 2015, Kaiser Permanente Washington added the question, “Do you have access to guns? (yes/no),” to a standard mental health (MH) monitoring questionnaire to support suicide risk identification and safety planning.⁴ Our objective was to evaluate whether and how suicide decedents who received ambulatory care answered the question about firearm access in the year prior to death.

This population-based case series utilized Washington State death records and electronic health record data to identify Kaiser Permanente Washington patients who received outpatient care within the year prior to suicide death. Cause-of-death indicators for firearm vs other suicide means were defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for intentional self-harm by firearm; sociodemographic and clinical characteristics were extracted from electronic health data (eMethods in the Supplement). Between January 1, 2016, and December 31, 2019, the MH monitoring questionnaire was routinely used and recorded in the electronic health record for all MH specialty encounters, urgent care encounters per provider discretion, and primary care encounters following MH integration for all patients with an active MH or substance use disorder (SUD) diagnosis.⁵ We report the proportions of patients who (1) had MH or SUD diagnoses, (2) received the firearm question, (3) answered the question, and (4) reported access. We stratified findings by firearm and other suicide methods, because opportunities for suicide prevention may differ between these groups. The Kaiser Permanente institutional review board approved this study and waived the need for patient informed consent, because use of this protected health information involved no more than a minimal risk to the privacy of individuals. This study followed the reporting guideline for case series.

During the observation period, 236 ambulatory care patients died by suicide, including 114 (48%) who died by firearm (98 men [86%] and 16 women [14%]; 3 Asian [3%], 3 Black [3%], 1 Hawaiian or Pacific Islander [1%], 3 Hispanic or Latino/a/x [3%], 97 White [85%], and 7 of unknown race or ethnicity [6%]; 57% younger than 65 years), of whom 104 (91%) had utilized care in 1 or more clinics using the MH questionnaire with the firearm question (93 for primary care [82%], 30 for MH specialty care [26%], and 41 for urgent care [36%]) (Table). Sixty-seven firearm suicide decedents (59%) had MH or SUD diagnoses (the target patient-population for the MH questionnaire), 41 (36%) received the firearm question, 38 (33%) answered, and 17 (15%) reported access (Figure). Eighty-four of 122 other suicide decedents (69%) had MH or SUD diagnoses, 51 (42%) received the firearm question, 44 (36%) answered, and 2 (2%) reported access.

Our findings have important implications for health care systems that are considering firearm access screening to support suicide prevention. First, this study underscored the potential reach of standardized firearm access questions in primary care clinics, which implemented routine use of this question during the study and where the highest proportion of firearm suicide decedents were seen prior to death. Second, the decision to only ask primary care patients with a MH or SUD diagnosis about firearm access likely resulted in missed opportunities, as many firearm suicide decedents did not have these diagnoses.

This study also highlighted the need to improve how health care systems ask standardized questions. Most patients who died by firearm suicide answered the firearm access question when they received it, confirming our prior finding that patients will answer this standardized firearm access question.⁵ However, more than half of those who answered the question and who subsequently died by firearm suicide reported no firearm access. A study limitation is that we cannot determine whether these individuals acquired access after answering the question or answered no despite having access. Nevertheless, prior qualitative findings suggest that transparency about how firearm access information will be used and building clinician competency and clinician–patient trust may encourage honest reporting, open dialogue, and improved patient-centeredness of this practice.⁶ Assessing patients’ plans to acquire firearms may also be useful. Future work is needed to test language and strategies designed to encourage patient-reported firearm access.

Accepted for Publication: November 11, 2021.

Published: January 10, 2022. doi:10.1001/jamanetworkopen.2021.42204

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Richards JE et al. JAMA Network Open.

Corresponding Author: Julie E. Richards, PhD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101 (julie.e.richards@kp.org).

Author Contributions: Dr Richards had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Richards, Boggs, Rowhani-Rahbar, Kuo, Bobb.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Richards, Kuo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Richards, Kuo, Bobb.

Obtained funding: Richards.

Supervision: Rowhani-Rahbar, Kuo.

Conflict of Interest Disclosures: Dr Boggs reported receiving grants from Kaiser Permanente’s Office of Community Health during the conduct of the study. No other disclosures were reported.

Funding/Support: This research study was funded by Kaiser Permanente’s Office of Community Health as part of its Firearm Injury Prevention Program.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; or decision to submit the manuscript for publication. The funder reviewed the manuscript prior to submission for awareness purposes.

Disclaimer: The views and opinions expressed in this article are the responsibility of the authors and do not necessarily represent the official views of Kaiser Permanente.

Additional Contributions: We thank Rebecca Parrish, LICSW (Administrator of Mental Health & Wellness Clinical Operations at Kaiser Permanente Washington, Seattle) for assistance planning the analyses and reviewing the findings, Christine Stewart, PhD (Programmer Analyst, Kaiser Permanente Washington Health Research Institute, Seattle) for assistance with preparing the analytic data set used for this analysis, and Ursula Whiteside, PhD (Clinical Psychologist and Founder of NowMattersNow.org) for assistance reviewing and interpreting study findings. Ms Parrish and Dr Stewart performed this work as part of their positions and did not receive additional compensation. Dr Whiteside received an honorarium for her contributions to this project. We also acknowledge that this research would not be possible without the people who receive health care from Kaiser Permanente Washington and all of the clinicians and staff who support the organization.