Data were evaluated for 3 study periods: from the start of the study (January 3, 2017) to the mass shooting in Las Vegas, Nevada (October 1, 2017); from the Las Vegas shooting to the mass shooting in Parkland, Florida (February 14, 2018); and from the Parkland shooting to the end of the study (June 30, 2018). Each point represents the proportion of WCVs in which queries were documented per week (orange, smoke alarm queries; blue, gun queries). A and B, Statistical process control p-charts for residents and faculty. In each chart and study period, the upper and lower control lines (black solid lines) are 3 SDs greater than and less than the mean control line (black dotted line). The red points indicate special cause variation, defined in statistical process control as a data point 3 or more SDs greater than or less than the mean control line. Between 1 and 2 months after the Las Vegas and Parkland shootings, there were a total of 3 weeks with smoke alarm queries 3 or more SDs greater than the mean for faculty but not residents (weeks of November 6, 2017, November 13, 2017, and March 26, 2018). Between 2 and 4 months after the Las Vegas and Parkland shootings, there were a total of 2 weeks with gun queries 3 or more SDs less than the mean for residents but not faculty (weeks of December 26, 2017, and June 4, 2018). C and D, Interrupted time series for smoke alarm and gun queries for residents and faculty. The interrupted time series regression line (trend line) from the start to end of each study period is quantified and reported as slope (95% CI) for smoke alarm queries (orange) and gun queries (blue). The trend line interruption associated with an event that defines the start of a new study period is the difference between the y-axis values of the trend lines of the new and previous period, determined at the time of the first measurement after the event. The smoke alarm trend line interruption was increased for faculty with the Las Vegas shooting by 7.5% (95% CI, 0.5%-14.4%; P = .04) and with the Parkland shooting by 7.2% (95% CI, 1.4%-13.0%; P = .02). The gun query trend line interruption was increased for residents with the Parkland shooting by 15.9% (95% CI, 2.3%-29.5%; P = .02).
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Stipelman CH, Stoddard G, Bata K, Muniyappa B, Trepman E, Smith E. Home Gun Safety Queries in Well-Child Visits. JAMA Pediatr. 2019;173(12):1205–1208. doi:10.1001/jamapediatrics.2019.3845
Firearms are a leading cause of death in US children, and the rate of suicide by firearms in people aged 10 to 19 years has increased since 2008.1 In the United States, 4.6 million children (approximately 7%) live in households with at least 1 gun that is stored loaded and unlocked.2
Safe storage of guns and ammunition may decrease the occurrence of self-inflicted or unintentional firearm injury to children, and interventions by pediatricians may increase safe firearm storage.3 Although several states have introduced legislation to restrict physicians from discussing guns,4 pediatric and adult physician organizations encourage physician discussion with patients about firearm risk.5 However, most physicians do not ask patients whether they have guns in their households.6
We added questions about gun storage and smoke alarm safety in patient households to an electronic health record (EHR) well-child visit (WCV) encounter form. We evaluated the association of these questions and recent mass shootings with pediatric primary care physician documentation of gun storage and smoke alarm safety in patient households over time.
In a university health care system EHR, we programmed discrete entry elements into a structured documentation template in the safety section of WCV encounters. The EHR cues for gun and smoke alarm queries were activated simultaneously on January 11, 2016, and included buttons for guns in the home (yes or no) and safety for any guns in the home(s) (gun safe, locked cabinet, trigger lock) adjacent to buttons for working smoke alarms (yes, no, or do not know). Encounter form use was mandatory, but no training was provided about queries; answering individual questions was voluntary and measured as the outcome. The University of Utah Institutional Review Board determined that the study was exempt from oversight and waived the need for informed consent because the study was a quality improvement project evaluating EHR use.
Data were collected about query documentation from January 2017 to June 2018 at an academic pediatric primary care clinic with 77 residents and 26 faculty for a total of 16 576 WCVs. Data about mass shootings were obtained from Gun Violence Archive (http://www.gunviolencearchive.org/reports). Data analyses were performed with Stata statistical software version 15.1 (StataCorp). Time series data were analyzed with statistical process control (SPC) and interrupted time series (ITS). Risk ratios for gun queries (reference, smoke alarm queries) were determined by mixed-effects Poisson regression and adjusted for gun and smoke alarm queries, nested within visit and physician. Associations of physician and patient demographic factors were evaluated with multivariable mixed-effects Poisson regression, with visits nested within physician and using regression model Wald tests for significance testing. All reported P values represented 2-sided comparisons with significance set at P ≤ .05. For gun safety, analysis was limited to the query of guns in the home.
Residents and faculty were less likely to document data about guns than smoke alarms (Table). With smoke alarm queries as the reference, the risk ratio for gun queries for residents was 0.71 (95% CI, 0.68-0.75; P < .001) and for faculty was 0.68 (95% CI, 0.66-0.70; P < .001). Smoke alarm query SPC weekly average was within 3 SDs of the mean for residents but was more than 3 SDs greater than the mean for faculty after the mass shooting in Las Vegas, Nevada (October 1, 2017), and the mass shooting in Parkland, Florida (February 14, 2018), for a total of 3 weeks (Figure). Between the Las Vegas and Parkland shootings, the smoke alarm ITS slope was increasing for residents and decreasing for faculty. The smoke alarm trend line interruption was increased for faculty with the Las Vegas and Parkland shootings.
The weekly SPC proportion of gun queries was within 3 SDs of the mean for faculty but was more than 3 SDs less than the mean for residents after the Las Vegas and Parkland shootings for a total of 2 weeks (Figure). The gun query ITS slope was negative between the Las Vegas and Parkland shootings and between the Parkland shooting and study end for residents but not faculty (Figure). The gun query trend line interruption was increased for residents with the Parkland shooting.
Faculty but not residents had an increased likelihood of documenting queries in WCVs for older patients than infants for smoke alarms (preschool to adolescent patients) and guns (preschool and adolescent patients) (Table). Patient ethnicity or race, physician clinical experience, and physician sex had no association with documentation.
Despite EHR cues, queries were less likely for guns than smoke alarms. Resident gun queries had a negative slope after mass shootings. Further work is needed to identify and overcome barriers that prevent physicians from discussing gun safety with patients.6
Accepted for Publication: June 8, 2019.
Corresponding Author: Carole H. Stipelman, MD, MPH, Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 (email@example.com).
Published Online: October 28, 2019. doi:10.1001/jamapediatrics.2019.3845
Author Contributions: Dr Stipelman and Mr Stoddard had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Stipelman, Muniyappa, Smith.
Acquisition, analysis, or interpretation of data: Stipelman, Stoddard, Bata, Trepman.
Drafting of the manuscript: Stipelman, Stoddard, Trepman.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Stipelman, Stoddard.
Administrative, technical, or material support: Stipelman, Bata, Trepman.
Study supervision: Stipelman.
Conflict of Interest Disclosures: None reported.
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