Understanding the response of mammography facilities to breast density notification.

BACKGROUND: State-specific breast density notification legislation requires that women undergoing mammography be informed about breast density, with variation among states. Because mammography facilities are among the main points of contact for women undergoing mammography, research is needed to understand how facilities communicate information on breast density, cancer risk, and supplemental screening to women. METHODS: A cross-sectional, 50-item, mailed survey of 156 American College of Radiology-certified mammography facilities in North Carolina was conducted in 2017 via the Tailored Design Method. Breast density notification practices, supplemental screening services, and patient educational materials were compared by supplemental screening availability via t tests and chi-square tests. RESULTS: All responding facilities (n = 94; 60.3% response rate) notified women of their breast density in the mammography results letter. Breast cancer risk assessments were performed by 36.2% of the facilities, with risk information communicated in the final radiology report for the referring provider to discuss with the woman (79.4%) or in the results letter (58.8%). Supplemental breast cancer screening was offered by 63.8% of the facilities, with use based on multiple factors, including recommendations from the referring physician (63.3%) or reading radiologist (63.3%), breast density (48.3%), other risk factors (48.3%), and patient request (40.0%). Although 75.0% of the facilities offered breast density educational materials, only 36.6% offered educational materials on supplemental screening. CONCLUSIONS: In a state with a breast density notification law, mammography facilities communicate breast density, cancer risk, and supplemental screening information to women through various approaches. When supplemental screening is offered, facilities use multiple decision-making criteria rather than breast density alone.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents.

INTRODUCTION: The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts. METHODS: Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints. RESULTS: The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers. CONCLUSION: Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking. IMPLICATIONS: Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

Public Knowledge and Credibility Perceptions of the FDA as a Tobacco Regulator.

Introduction: Since the U.S. Food and Drug Administration (FDA) was granted regulatory authority over tobacco products in 2009, few studies have examined perceived credibility of the FDA in this role. The current study assessed knowledge and credibility of the FDA as a regulator of tobacco products. Methods: In a nationally representative survey of U.S. adults (N = 4758), we assessed knowledge that the FDA regulates the manufacture, distribution, and marketing of cigarettes, and credibility of the FDA as a tobacco regulator. We examined demographic differences in knowledge and credibility, and associations of knowledge and trust in government with credibility perceptions. Results: Less than half of respondents reported knowing the FDA regulates how cigarettes are sold (46.8%) and advertised (49.7%), and only 36.0% knew the FDA regulates how cigarettes are made, with few demographic differences. Respondents reported that the FDA was moderately credible in regulating tobacco. Knowledge of the FDA as a tobacco regulator and trust in government were the strongest predictors of credibility. Being of younger age, being White (compared to African American), and being male were associated with higher credibility ratings of the FDA. Conclusions: Much of the public still does not know that the FDA regulates tobacco products, and credibility perceptions are moderate. Greater knowledge of the FDA's regulatory role was associated with higher credibility; efforts that increase the public's understanding of the FDA's role as a tobacco regulator may positively impact views of the agency's credibility. This may in turn improve public reception to the FDA's messages and regulations. Implications: This study is the first to show nationally representative estimates of both knowledge and credibility of the FDA as a tobacco regulator. Our research shows further that knowledge of the FDA's tobacco regulatory roles is likely to be an important factor related to perceived credibility of the FDA. Increasing the public's knowledge of the FDA's roles may enhance the agency's credibility, which can improve public reception to messages and regulations.

Law Enforcement and Gun Retailers as Partners for Safely Storing Guns to Prevent Suicide: A Study in 8 Mountain West States.

OBJECTIVES: To examine the extent to which law enforcement agencies (LEAs) and gun retailers are willing to offer voluntary, temporary storage as a part of an overall suicide prevention effort. METHODS: We invited all LEAs and gun retailers in 8 US states to respond to questionnaires asking about their willingness to offer temporary gun storage and their recommendations to gun owners about safe storage. RESULTS: We collected data in 2016 from 448 LEAs and 95 retailers (response rates of 53% and 25%, respectively). Three quarters of LEAs (74.8%; 95% confidence interval [CI] = 72.1, 77.5) indicated they already provided temporary storage compared with 47.6% (95% CI = 39.2, 56.0) of retailers. LEAs were most willing to provide storage when a gun owner was concerned about the mental health of a family member. Retailers were more receptive than were LEAs to providing storage when visitors were coming or for people wanting storage while traveling. Both groups recommended locking devices within the home, but LEAs were slightly more favorable to storing guns away from the home. CONCLUSIONS: Law enforcement agencies and gun retailers are important resources for families concerned about suicide.

Measuring Black men's police-based discrimination experiences: Development and validation of the Police and Law Enforcement (PLE) Scale.

OBJECTIVES: Although social science research has examined police and law enforcement-perpetrated discrimination against Black men using policing statistics and implicit bias studies, there is little quantitative evidence detailing this phenomenon from the perspective of Black men. Consequently, there is a dearth of research detailing how Black men's perspectives on police and law enforcement-related stress predict negative physiological and psychological health outcomes. This study addresses these gaps with the qualitative development and quantitative test of the Police and Law Enforcement (PLE) Scale. METHOD: In Study 1, we used thematic analysis on transcripts of individual qualitative interviews with 90 Black men to assess key themes and concepts and develop quantitative items. In Study 2, we used 2 focus groups comprised of 5 Black men each (n = 10), intensive cognitive interviewing with a separate sample of Black men (n = 15), and piloting with another sample of Black men (n = 13) to assess the ecological validity of the quantitative items. For Study 3, we analyzed data from a sample of 633 Black men between the ages of 18 and 65 to test the factor structure of the PLE, as we all as its concurrent validity and convergent/discriminant validity. RESULTS: Qualitative analyses and confirmatory factor analyses suggested that a 5-item, 1-factor measure appropriately represented respondents' experiences of police/law enforcement discrimination. As hypothesized, the PLE was positively associated with measures of racial discrimination and depressive symptoms. CONCLUSIONS: Preliminary evidence suggests that the PLE is a reliable and valid measure of Black men's experiences of discrimination with police/law enforcement. (PsycINFO Database Record

Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer.

Importance: Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects. Objective: To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance. Design, Setting, and Participants: Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015. Exposures: Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance. Main Outcomes and Measures: Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point. Results: Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains. Conclusions and Relevance: In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

Public understanding of cigarette smoke constituents: three US surveys.

INTRODUCTION: The Tobacco Control Act requires public disclosure of information about toxic constituents in cigarette smoke. To inform these efforts, we studied public understanding of cigarette smoke constituents. METHODS: We conducted phone surveys with national probability samples of adolescents (n=1125) and adults (n=5014) and an internet survey with a convenience sample of adults (n=4137), all in the USA. We assessed understanding of cigarette smoke constituents in general and of 24 specific constituents. RESULTS: Respondents commonly and incorrectly believed that harmful chemicals in cigarette smoke mostly originate in additives introduced by cigarette manufacturers (43-72%). Almost all participants had heard that nicotine is in cigarette smoke, and many had also heard about carbon monoxide, ammonia, arsenic and formaldehyde. Less than one-quarter had heard of most other listed constituents being in cigarette smoke. Constituents most likely to discourage respondents from wanting to smoke were ammonia, arsenic, formaldehyde, hydrogen cyanide, lead and uranium. Respondents more often reported being discouraged by constituents that they had heard are in cigarette smoke (all p<0.05). Constituents with names that started with a number or ended in 'ene' or 'ine' were less likely to discourage people from wanting to smoke (all p<0.05). DISCUSSION: Many people were unaware that burning the cigarette is the primary source of toxic constituents in cigarette smoke. Constituents that may most discourage cigarette smoking have familiar names, like arsenic and formaldehyde and do not start with a number or end in ene/ine. Our findings may help campaign designers develop constituent messages that discourage smoking.

Understanding how perceptions of tobacco constituents and the FDA relate to effective and credible tobacco risk messaging: A national phone survey of U.S. adults, 2014-2015.

BACKGROUND: The passage of the 2009 Family Smoking Prevention and Tobacco Control Act has necessitated the execution of timely, innovative, and policy-relevant tobacco control research to inform Food and Drug Administration (FDA) regulatory and messaging efforts. With recent dramatic changes to tobacco product availability and patterns of use, nationally representative data on tobacco-related perceptions and behaviors are vital, especially for vulnerable populations. METHODS: The UNC Center for Regulatory Research on Tobacco Communication conducted a telephone survey with a national sample of adults ages 18 and older living in the United States (U.S.). The survey assessed regulatory relevant factors such as tobacco product use, tobacco constituent perceptions, and tobacco regulatory agency credibility. The study oversampled high smoking/low income areas as well as cell phone numbers to ensure adequate representation among smokers and young adults, respectively. Coverage extended to approximately 98 % of U.S. households. RESULTS: The final dataset (N = 5,014) generated weighted estimates that were largely comparable to other national demographic and tobacco use estimates. Results revealed that over one quarter of U.S. adults, and over one third of smokers, reported having looked for information about tobacco constituents in cigarette smoke; however, the vast majority was unaware of what constituents might actually be present. Although only a minority of people reported trust in the federal government, two thirds felt that the FDA can effectively regulate tobacco products. CONCLUSIONS: As the FDA continues their regulatory and messaging activities, they should expand both the breadth and availability of constituent-related information, targeting these efforts to reach all segments of the U.S. population, especially those disproportionately vulnerable to tobacco product use and its associated negative health outcomes.

Predictors of smoke-free policies in affordable multiunit housing, North Carolina, 2013.

INTRODUCTION: Smoke-free policies can effectively protect nonsmokers from secondhand smoke (SHS) exposure in multiunit housing. We surveyed all affordable multiunit housing properties in North Carolina to determine the statewide prevalence of smoke-free policies and to identify predictors of smoke-free policies. METHODS: Representatives of affordable housing properties in North Carolina completed a mailed or online survey during June through October 2013. The primary outcome measure was presence of a smoke-free policy, defined as prohibiting smoking in all residential units. We used χ(2) analysis and multivariate logistic regression to identify correlates of smoke-free policies. RESULTS: Of 1,865 eligible properties, responses were received for 1,063 (57%). A total of 16.5% of properties had policies that prohibited smoking in all residential units, while 69.6% prohibited smoking in indoor common areas. In multivariate analysis, an increase in the number of children per unit was associated with a decrease in the odds of having a smoke-free policy at most properties. Newer properties across all company sizes were more likely to have smoke-free policies. Accessing units from interior hallways predicted smoke-free policies among medium-sized companies. CONCLUSION: More smoke-free policies in affordable multiunit housing are needed to protect vulnerable populations, particularly children, from SHS exposure. Public health professionals should continue to educate housing operators about SHS and the benefits of smoke-free policies at all properties, including older ones and ones where units are accessed from outside rather than from an interior hallway.

Protocol of a mixed method research design to study medical respite programs for persons experiencing homelessness.

Medical Respite Programs (MRPs) characterize a care model that has been developed to address the health care and social needs of persons experiencing homelessness by providing post-acute hospital care in a safe environment. Although this model has been shown to reduce hospitalizations, improve health outcomes and increase access to health services, prior studies of MRP programs and outcomes have been limited to individual sites and may not generalize to the population of individuals receiving MRP care. This study protocol describes a mixed method design to collect organizational, provider, and patient-level data from a sample of MRPs.

Consideration of patient preferences and challenges in storage and access of pharmacogenetic test results.

PURPOSE: Pharmacogenetic testing is one of the primary drivers of personalized medicine. The use of pharmacogenetic testing may provide a lifetime of benefits through tailoring drug dosing and selection of multiple medications to improve therapeutic outcomes and reduce adverse responses. We aimed to assess public interest and concerns regarding sharing and storage of pharmacogenetic test results that would facilitate the reuse of pharmacogenetic data across a lifetime of care. METHODS: We conducted a random-digit-dial phone survey of a sample of the US public. RESULTS: We achieved an overall response rate of 42% (n = 1139). Most respondents indicated that they were extremely or somewhat comfortable allowing their pharmacogenetic test results to be shared with other doctors involved in their care management (90% ± 2.18%); significantly fewer respondents (74% ± 3.27%) indicated that they were extremely or somewhat comfortable sharing results with their pharmacist (P < 0.0001). CONCLUSION: Patients, pharmacists, and physicians will all be critical players in the pharmacotherapy process. Patients are supportive of sharing pharmacogenetic test results with physicians and pharmacists and personally maintaining their test results. However, further study is needed to understand which options are needed for sharing, appropriate storage, and patient education about the relevance of pharmacogenetic test results to promote consideration of this information by other prescribing practitioners.

Public attitudes toward ancillary information revealed by pharmacogenetic testing under limited information conditions.

PURPOSE: Pharmacogenetic testing can inform drug dosing and selection by aiding in estimating a patient's genetic risk of adverse response and/or failure to respond. Some pharmacogenetic tests may generate ancillary clinical information unrelated to the drug treatment question for which testing is done-an informational "side effect." We aimed to assess public interest and concerns about pharmacogenetic tests and ancillary information. METHODS: We conducted a random-digit-dial phone survey of a sample of the US public. RESULTS: We achieved an overall response rate of 42% (n = 1139). When the potential for ancillary information was presented, 85% (±2.82%) of respondents expressed interest in pharmacogenetic testing, compared with 82% (±3.02%) before discussion of ancillary information. Most respondents (89% ± 2.27%) indicated that physicians should inform patients that a pharmacogenetic test may reveal ancillary risk information before testing is ordered. Respondents' interest in actually learning of the ancillary risk finding significantly differed based on disease severity, availability of an intervention, and test validity, even after adjusting for age, gender, education, and race. CONCLUSION: Under the limited information conditions presented in the survey, the potential of ancillary information does not negatively impact public interest in pharmacogenetic testing. Interest in learning ancillary information is well aligned with the public's desire to be informed about potential benefits and risks before testing, promoting patient autonomy.

Systemic treatment of pediatric atopic dermatitis with azathioprine and mycophenolate mofetil.

Severe forms of atopic dermatitis (AD) cause significant morbidity in vulnerable pediatric populations and necessitate treatment with systemic therapy. The existing literature concerning the treatment of severe pediatric AD with azathioprine (AZ) and mycophenolate mofetil (MM) is sparse. The purpose of this case series is to examine the use of these two drugs in the treatment of severe pediatric AD. Medical records of 28 pediatric patients with AD from the University of North Carolina at Chapel Hill pediatric dermatology clinic treated using these two drugs were analyzed for laboratory values, thiopurine methyltransferase (TPMT) levels, symptoms, infections, and other relevant data. Patients were also contacted via the telephone to ascertain outcomes and any missing data. Treatment outcomes were scored into three categories: significant improvement, some improvement, and no improvement. AZ dosing was correlated to TPMT levels successfully, with comparable levels of improvement in the heterozygous and homozygous wild-type groups. Absolute eosinophil count corresponded to AD activity and treatment response across both treatment modalities in 18 of 26 (69%) patients. Seventeen of 28 (61%) patients treated with AZ and eight of 12 (66%) treated with MM reported significant improvement. We had lower rates of laboratory abnormalities and side effects with MM than with AZ but similar rates of cutaneous infections. Treatment outcomes did not appear to differ with race, sex, or TPMT level. We experienced success with AZ and MM in the treatment of severe pediatric AD. Coordinating treatment to each patient's unique morbidities is the best way to choose systemic treatments.

Availability Versus Utilization of Supplemental Breast Cancer Screening Post Passage of Breast Density Legislation.

Objective: Despite the lack of evidence that supplemental screening in women with dense breasts reduces breast cancer mortality, 38 states have passed breast density legislation, with some including recommendations for supplemental screening. The objective of this study is to compare the availability versus use of supplemental breast cancer screening modalities and determine factors driving use of supplemental screening in rural versus urban settings. Methods: A 50-item mailed survey using the Tailored Design Method was sent to American College of Radiology mammography-accredited facilities in North Carolina in 2017. Respondents included 94 facilities (48 rural and 46 urban locations). Survey questions focused on breast cancer and supplemental screening services, breast density, risk factors/assessment, and facility demographics. Results: The survey response rate was 60.3% (94/156). Among the 94 respondents, 64.0% (n = 60) reported availability of any type of supplemental screening (digital breast tomosynthesis [DBT], ultrasound, or magnetic resonance imaging [MRI]). In facilities where supplemental screening modalities were available, the most commonly utilized supplemental screening modality was DBT (96.4%), compared with ultrasound (35.7%) and MRI (46.7%). Facilities reported using supplemental screening based on patient breast density (48.3%), referring physician recommendation (63.3%), reading radiologist recommendation (63.3%), breast cancer risk factors (48.3%), and patient request (40.0%). Urban facilities were more likely than rural facilities to base supplemental screening on breast cancer risk factors (62.5% vs. 32.1%; p-value = 0.019), referring physician (75.0% vs. 50.0%; p-value = 0.045), and reading radiologist (78.1% vs. 46.4%; p-value = 0.011). Conclusion: In our study, supplemental screening modalities were widely available, with facilities more likely to use DBT for supplemental screening compared to other modalities.

On Examining the Quality of Spanish Translation in Telephone Surveys: A Novel Test-Retest Approach.

Past research has shown that commonly reported cultural group disparities in health-related indices may be attributable to culturally mediated differences in the interpretation of translated survey questions and response scales. This problem may be exacerbated when administering single-item survey questions, which typically lack the reliability seen in multi-item scales. We adapt the test-retest approach for single-item survey questions that have been translated from English into Spanish and demonstrate how to use this approach as a quick and efficient pilot test before fielding a major survey. Three retest conditions were implemented (English-Spanish, Spanish-English, and English-English) on a convenience sample (n = 109) of Latinos and non-Latinos where translated items were compared against an English-English condition that served as our control. Several items were flagged for investigation using this approach. Discussion centers on the utility of this approach for evaluating the Spanish translation of single-item questions in population-based surveys.

Survey of the US Surgeon Workforce: Practice Characteristics, Job Satisfaction, and Reasons for Leaving Surgery.

BACKGROUND: An impending surgeon shortage looms in the US due to increasing demand and a stagnant number of surgeons entering practice. We sought to evaluate the state of our surgical workforce by exploring current practice patterns, job satisfaction, and reasons why surgeons consider leaving surgery. STUDY DESIGN: In 2018, a link to a detailed survey was distributed by email to Fellows of the American College of Surgeons (ACS) who actively practice in the US and have completed a general surgery residency or integrated cardiothoracic, vascular, or plastic surgery fellowship. Detailed questions regarding practice attributes, surgical training, professional choices, and career satisfaction were included. Nonresponse weights were adjusted for respondent sex, age, and presence of subspecialty training between respondents and the total surveyed ACS population. All estimates and analyses were weighted to account for potential nonresponse bias. RESULTS: There were 3,807 surgeons who responded (15% response rate). Overall, 81% reported career satisfaction and 80% would choose surgery over again. Twenty-six percent were considering leaving surgery within the next 2 years. Stratified by age groups 40 to 49, 50 to 59, and 60 to 69 years, the survey found that 9%, 17%, and 45% of respondents were considering leaving surgery within the next 2 years, respectively. Thirteen percent of surgeons less than 60 years old were considering leaving surgery, and only 49% of these surgeons reported career satisfaction. Among surgeons less than 60 years old who were considering leaving surgery, the top 3 reasons rated as very important were overall stress (79%), work time demands (77%), and personal time requirements (73%). CONCLUSIONS: Reported surgeon job satisfaction was high, but a surprising number of surgeons reported that they were considering leaving surgery. Work time requirements and lack of personal time are leading factors contributing to surgeons leaving practice.

Hospital Emergency Department Lethal Means Counseling for Suicidal Patients.

INTRODUCTION: Lethal means counseling of suicidal individuals in emergency departments has the potential to reduce suicide. This study examines the provision of lethal means counseling and the presence of written protocols in a region with high rates of both firearm ownership and suicide. METHODS: In 2015-2016, emergency department nurse managers in hospital-based emergency departments throughout eight states were surveyed using an 80-item survey developed through qualitative interviews and pilot testing. Questions focused on discharge counseling with suicidal patients and the presence of written protocols. Using survey weights to adjust for nonresponse, relationships of protocols with counseling practices were examined. RESULTS: Data were obtained from 52.3% of all 363 eligible hospital emergency departments in the region. Among facilities that discharge suicidal patients, 79.7% (95% CI=75.0%, 84.4%) reported asking about access to firearms and 68.9% (95% CI=62.9%, 74.8%) counsel about safe storage when patients reported access. Forty-four percent of emergency departments reported having written protocols for lethal means counseling. Presence of written protocols was associated with a higher rate of counseling for all suicidal patients even if they were not planning to use a gun (45.0% [95% CI=33.4%, 56.7%] in hospitals with protocols vs 21.5% [95% CI=14.9%, 29.0%] in facilities without protocols). CONCLUSIONS: There are significant gaps in attention to lethal means counseling in emergency departments. This signals an opportunity to increase consistency and thoroughness of care for suicidal patients in the emergency department and for leadership from key professional organizations to advocate for protocols.