Firearm injury prevention counseling: are We missing the mark?

OBJECTIVE: To determine whether pediatricians accurately estimate the likelihood of gun ownership among their patients' families. Design. Self-administered, written surveys completed simultaneously by pediatricians and their patients' parents. SETTING: A total of 23 pediatric practices and hospital-based clinics in three cities in the United States. SUBJECTS: A total of 66 pediatricians paired with 169 of their patients' parents. MAIN OUTCOME MEASURES: Parent survey: ownership and storage of guns, willingness to admit gun ownership, and previous counseling by pediatrician. Pediatrician survey: estimated prevalence of gun ownership, likelihood of gun ownership by each participant family, and beliefs about firearm injury prevention counseling. RESULTS: All parents who owned guns indicated they would acknowledge owning a gun if asked by their pediatricians. Of the participating families, 28% owned at least one gun; 39% of the homes with guns contained a gun that was unlocked, loaded, or both. Of the parents, 11% reported that their pediatrician had discussed firearm safety with them. Pediatricians' average estimate of the overall prevalence of gun ownership in their patient populations was 25%. When asked to predict the likelihood of gun ownership by the specific families in the study, pediatricians predicted a 0% likelihood of gun ownership for 33% of the families. Of those families, 30% reported owning at least one gun. Considering physician predictions of any likelihood of gun ownership >0% (1%-100%) to be a positive prediction and using parent reports as the gold standard, physician estimates of gun ownership were only 65% sensitive. Approximately half (55%) of the participating pediatricians believed that pediatricians should discuss gun safety with all families, and 98% believed that pediatricians should discuss gun safety with all gun-owning families. CONCLUSIONS: Pediatricians believe that all families with guns should receive firearm safety counseling. However, pediatricians significantly underestimate the likelihood of gun ownership by specific families. Parents who own guns indicate that they would acknowledge gun ownership if their pediatrician asked about guns in the home. Therefore, rather than relying on assumptions about whether particular patients seem likely to be gun owners, pediatricians should ask all families whether they own guns.

Improving quality, minimizing error: making it happen.

Medical errors and the quality problems to which they lead harm millions of Americans each year. If we are to reduce errors and improve quality substantially, we must create systems and care processes that anticipate inevitable human errors and either prevent them or compensate for them before they cause harm. Formidable barriers now stand in the way of progress. Success will require a multifaceted strategy, including public education, government investment and regulation, payment system restructuring, and leadership from within the delivery system.

Improving the quality of health care: who will lead?

National interest in the quality of American health care increased dramatically in 1999. The press, the Institute of Medicine, legislators, physicians, and hospitals joined in a vigorous policy discussion. But a similar debate occurred in 1988, following reports from four public agencies that detailed their concerns about health care quality. In the intervening decade, research has not documented much improvement. In this paper we outline the quality problems in U.S. health care, review some of their most prominent causes, consider the biggest obstacles to bringing about major improvement, and discuss the vital role of leadership in achieving this goal.

What are Medicare managed care plans doing to measure and improve quality of care?

To explore managed care plans' efforts to assess and improve quality of care for Medicare beneficiaries, the authors surveyed managed care plans with risk contracts for Medicare beneficiaries in 20 large metropolitan areas in January 1998. The survey inquired about: (1) the health plans' efforts to assess and improve quality of care for specific underuse, overuse, and misuse problems; (2) how the health plans assessed functional status of enrollees, and (3) the quality improvement program they believed had the greatest impact on the health of enrollees. The managed care plans reported a heterogeneous mix of quality improvement activities ranging from poorly developed to very sophisticated. The vast majority of the more sophisticated programs addressed problems with underuse of services rather than overuse or misuse.

Physician firearm ownership as a predictor of firearm injury prevention practice.

OBJECTIVES: This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention. METHODS: Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable. RESULTS: Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling. CONCLUSIONS: Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.