A Systematic Review of Lethal Means Safety Counseling Interventions: Impacts on Safety Behaviors and Self-Directed Violence.

For lethal means safety counseling interventions (LMSC) to reduce population-level suicide rates, interventions must be deployed across many settings and populations. We conducted a systematic search in six databases to review the current state of LMSC interventions across study designs, settings, messengers, populations, and injury prevention levels (e.g., universal). Eligibility criteria were: any individual or group receiving a LMSC intervention involving a human-to-human component aiming to influence adult behaviors related to lethal suicide methods, and outcome assessment of storage behaviors and/or suicidal self-directed violence (SDV). Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A descriptive synthesis approach was used for analysis. Twenty-two studies were included that reported medication and/or firearm storage behaviors and/or SDV following LMSC. Fourteen of the 19 studies assessing behavioral change reported a significant improvement in safe storage behaviors, and all studies measuring acceptability reported that participants found the interventions favorable. Quality of evidence was limited. No studies were rated low risk of bias, and 77% were rated high risk of bias. There was substantial heterogeneity in the settings, populations, injury prevention levels, delivery methods, and intervention elements. Many included studies focused on caregivers of pediatric populations, and few studies assessed SDV outcomes. Higher quality trials conducted across a variety of settings, particularly those focusing on adults at risk of suicide, are needed. There was no funding for this review, and it was preregistered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42021230668).

Longitudinal Influence of Prescribed Antidepressants on Fecal and Oral Microbiomes Among Veterans With Major Depressive Disorder.

OBJECTIVE: The purpose of this study was to evaluate the influence of a new course of antidepressant monotherapy on gut and oral microbiomes and the relationship to depressive symptoms. METHODS: Longitudinal microbiome samples obtained from 10 U.S. veterans were analyzed. Baseline samples were taken before a new course of antidepressant monotherapy (either switching from a previous treatment or starting a new treatment). Targeted genomic sequencing of the microbiome samples was used to analyze changes in taxonomy and diversity across participants, medications, and medication class. Associations between these changes and Patient Health Questionnaire-9 (PHQ-9) scores were analyzed. RESULTS: Taxonomic variability was observed across participants, with the individual being the main microbial community driver. In terms of the fecal microbiome, antidepressants were associated with shifts toward Bacteroides being less abundant and Blautia, Pseudomonas, or Faecalibacterium being more abundant. Likewise, the composition of the oral microbiome was variable, with individual participants being the primary drivers of community composition. In the oral samples, the relative abundance of Haemophilus decreased after antidepressants were started. Increases in Blautia and decreases in Bacteroides were associated with lower PHQ-9 scores. CONCLUSIONS: Antidepressants were found to influence fecal and oral microbiomes such that a new course of antidepressant monotherapy was associated with taxonomic alterations toward healthier states in both fecal and oral microbiomes, which were associated with decreases in depressive symptoms. Additional longitudinal research is required to increase understanding of microbiomes and symptom-based changes, with a particular focus on potential differences between medication classes and underlying mechanisms.

Financial barriers and facilitators to secure firearm and medication storage among veterans with elevated suicide risk: a qualitative study.

OBJECTIVE: To explore financial barriers and facilitators to promoting secure firearm and medication storage among patients at risk for suicide. METHODS: Veterans seeking care in Veterans Affairs emergency care settings (N=28) participated in qualitative interviews on barriers and facilitators to adopting secure firearm and medication storage behaviours. Thematic analysis with inductive and iterative coding was used to identify themes pertaining to financial barriers and facilitators. Interviews were double-coded for reliability. RESULTS: We identified four themes-two related to financial barriers and two to financial facilitators. Barrier-related themes included: (1) the high cost of firearms and medications made owners less likely to dispose of medications, relinquish ownership of firearms or pursue out-of-home storage for firearms; (2) the high cost of out-of-home storage and preferred locking devices were barriers to secure storage. Facilitator-related themes included: (1) no-cost services or locking devices may help motivate secure firearm and medication storage and (2) preferences varied for no-cost locking devices versus coupons for devices. CONCLUSIONS: Addressing financial barriers and leveraging financial facilitators may motivate secure storage of lethal means, which could enhance suicide prevention efforts.

Perspectives on clinician-delivered firearm safety counseling during routine care: Results of a national survey.

Only 7.5% of United States (U.S.) adults report ever having spoken with a clinician about firearm safety. One reason that clinicians may infrequently counsel patients about firearm safety is that they are unsure whether patients are open to these discussions. The aim of this study was to assess public opinion about whether clinicians should provide firearm safety counseling for patients in specific clinical contexts. We conducted a cross-sectional analysis of online survey data collected in 2019 from a nationally representative sample of U.S. adults residing in households with firearms (n = 4030, response 65%). Participants were asked "As part of routine care, should physicians and/or other health care professionals talk with their patients about firearms and firearm safety if their patient or their patient's family member (is at risk of suicide; has mental health or behavioral problems; is abusing or addicted to alcohol or drugs; is a victim of domestic violence; has Alzheimer's disease or another dementia; is going through a hard time)?" Across the six contexts, 76-89% of adults reported that clinicians should "sometimes" or "always" discuss firearm safety with patients. These findings demonstrate that a large majority of U.S. adults who live in households with firearms believe that clinicians should discuss firearm safety when patients or their family members are experiencing specific clinical scenarios. Clinicians' and healthcare systems' concerns that patients might object to discussing firearm safety in these contexts should not impede efforts to integrate such interventions into routine care.

Effect of Pharmacogenomic Testing for Drug-Gene Interactions on Medication Selection and Remission of Symptoms in Major Depressive Disorder: The PRIME Care Randomized Clinical Trial.

Importance: Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment. Objective: To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications. Interventions: Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978). Main Outcomes and Measures: The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters. Results: Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45). Conclusions and Relevance: Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission. Trial Registration: ClinicalTrials.gov Identifier: NCT03170362.

Strategies for Discussing Firearms Storage Safety in Primary Care: Veteran Perspectives.

BACKGROUND: Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care. OBJECTIVE: Describe veterans' perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide. DESIGN: Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans. PARTICIPANTS: Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender. APPROACH: The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach. KEY RESULTS: There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans' knowledge of firearms. CONCLUSIONS: Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

Firearm Lethal Means Safety with Military Personnel and Veterans: Overcoming Barriers using a Collaborative Approach.

Suicides by firearm have increased over the past decade among United States service members and veterans. As firearm access is a suicide risk factor, firearm-related lethal means safety is critical to suicide prevention. However, identity, occupational, and cultural barriers may deter efforts to promote lethal means safety with service members and veterans. The current manuscript describes a collaborative framework to guide mental health providers' in conducting firearm-related lethal means safety with service members and veterans, including within the context of Safety Planning. In approaching firearm lethal means safety conversations with patients, clinicians must work to overcome their own reticence, address patient concerns directly, and remain culturally sensitive to the values of the military and veteran communities. This approach is illustrated using case vignettes that encompass addressing firearm-related lethal means safety with service members and veterans.

Characteristics and Injury Mechanisms of Veteran Primary Care Suicide Decedents with and without Diagnosed Mental Illness.

BACKGROUND: In the United States, suicide rates are increasing among nearly all age groups. Primary care is a critical setting for suicide prevention, where interventions often rely on identifying mental health conditions as indicators of elevated suicide risk. OBJECTIVE: Quantify the proportion of suicide decedents within primary care who had no antecedent mental health or substance use diagnosis. DESIGN: Retrospective cohort study. PARTICIPANTS: Veterans who received Veterans Health Administration (VHA) primary care any time from 2000 to 2014 and died by suicide before 2015 (n = 27,741). MAIN MEASURES: We categorized decedents by whether they had any mental health or substance use diagnosis (yes/no) using ICD-9 codes available from VHA records. We compared sociodemographic, clinical, and suicide mechanism characteristics between groups using chi-square, Student's T, or Wilcoxon tests. RESULTS: Forty-five percent of decedents had no mental health or substance use diagnosis. Decedents without such a diagnosis were older (68 vs. 57 years, p < 0.001), and more likely to be male (98.3% vs. 95.8%, p < 0.001), non-Hispanic White (90.6% vs. 87.9%, p < 0.001), married/partnered (50.4% vs. 36.6%, p < 0.001), and without military service-connected disability benefits (72.6% vs. 56.9%, p < 0.001). They were also more likely to die from firearm injury (78.9% vs. 60.7%, p < 0.001). There were statistically significant differences in physical health between groups, but the magnitudes of those differences were small. Decedents without a mental health or substance use diagnosis had significantly shorter durations of enrollment in VHA healthcare, less healthcare utilization in their last year of life, and had little utilization aside from primary care visits. CONCLUSIONS AND RELEVANCE: From 2000 to 2014, of nearly thirty thousand VHA primary care patients who died by suicide, almost half had no antecedent mental health or substance use diagnosis. Within VHA primary care settings, suicide risk screening for those with and without such a diagnosis is indicated.

Understanding female veterans' experiences and perspectives of firearms.

OBJECTIVES: Although firearms are the leading suicide means among female veterans, firearm research in this population remains limited. This study explored female veterans' firearm-related experiences and perspectives. METHOD: Sixteen cisgender female veterans (ages 27-69) participated in qualitative interviews. RESULTS: Participants gained initial firearm knowledge and exposure in childhood and adolescence through older male family members. Military service led to broader exposure to firearms, which were perceived as important for survival and protection in a male-dominated environment, predominantly due to the risk for sexual violence. Following military service, the desire for self-protection motivated firearm ownership and storage practices. Participants perceived trust as essential to firearm discussions, preferring for family members to initiate such conversations. CONCLUSIONS: This study provides insight into the context in which female veterans' firearm-related beliefs and practices develop. Interpersonal factors and various lifespan experiences appear to play a vital role in female veterans' firearm access, ownership, and storage practices.

Formal firearm training among adults in the USA: results of a national survey.

Despite broad support for policies requiring that prospective firearm owners receive training before acquiring a firearm, little is known about the scope and content of firearm training in the USA. Nationally representative surveys conducted in 1994 estimated that 56%-58% of the US firearm owners had received formal firearm training. We conducted a nationally representative survey in 2015 (n=3932; completion proportion=55%) to update those estimates and characterise training contents. 61% of firearm owners and 14% of non-owners living with a firearm owner reported having received formal firearm training. The most commonly reported combination of training topics was safe handling, safe storage and preventing accidents. 15% of firearm owners reported that their training included information about suicide prevention. The proportion of the US firearm owners with formal firearm training has not meaningfully changed since two decades ago. Training programme contents vary widely. Efforts to standardise and evaluate the effectiveness of firearm training are warranted.

Evaluation of a community-based safe firearm and ammunition storage intervention.

BACKGROUND: Safe firearm storage practices are associated with a lower risk of unintentional and self-inflicted firearm injuries among household members, though many firearms remain unlocked and/or loaded. OBJECTIVES: Conduct a preliminary evaluation of a community-based firearm safety intervention and assess participants' preferences for firearm locking devices and their comfort with potential firearm safety counsellors. DESIGN/METHODS: Baseline event and follow-up surveys among adult participants to assess changes in firearm storage practices, including whether all household firearms were stored locked, all were unloaded, all ammunition was locked, and a composite measure assessing whether all firearms were locked and unloaded and all ammunition was stored locked. RESULTS: A total of 206 out of 415 participants completed both surveys and were included. Nearly 9 in 10 respondents preferred the firearm lock box rather than a trigger lock. At follow-up, a significantly greater proportion reported that all household firearms were locked (+13.7%) and unloaded (+8.5%) and a non-significantly greater proportion reported that all ammunition was locked (+6.3%). A significantly greater proportion reported practising all three safe firearm and ammunition storage practices at follow-up (+12.6%). A majority reported they would be comfortable or very comfortable discussing firearm safety with various safety counsellors, though women were less likely to do so than men. CONCLUSION: This intervention that included distribution of a free, participant-selected locking device improved safe firearm storage practices among participants. Differences in participant preferences for devices and safety counsellors suggest that a 'one size fits all' approach may be inadequate in affecting population-level storage practices.

The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members.

BACKGROUND: Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians. OBJECTIVE: To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams. DESIGN: We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014. PARTICIPANTS: Primary care personnel at VA clinics responding to a national survey. MAIN MEASURES: Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity). KEY RESULTS: There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition. CONCLUSIONS: Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.

Loaded Handgun Carrying Among US Adults, 2015.

OBJECTIVES: To determine the frequency of loaded handgun carrying among US adult handgun owners, characterize those who carry, and examine concealed carrying by state concealed carry laws. METHODS: Using a nationally representative survey of US adults in 2015, we asked handgun owners (n = 1444) about their past-30-day carrying behavior. RESULTS: Among surveyed handgun owners, 24% (95% confidence interval[CI] = 21%, 26%) carried loaded handguns monthly, of whom 35% (95% CI = 29%, 41%) did so daily; 82% (95% CI = 77%, 86%) carried primarily for protection. The proportion of handgun owners who carried concealed loaded handguns in the past 30 days was 21% (95% CI = 12%, 35%) in unrestricted states, 25% (95% CI = 21%, 29%) in shall issue-no discretion states, 20% (95% CI = 16%, 24%) in shall issue-limited discretion states, and 9% (95% CI = 6%, 15%) in may-issue states. CONCLUSIONS: We estimate that 9 million US adult handgun owners carry loaded handguns monthly, 3 million do so every day, and most report protection as the main carrying reason. Proportionally fewer handgun owners carry concealed loaded handguns in states that allow issuing authorities substantial discretion in granting carrying permits.

Violence Perpetration Among Patients Hospitalized for Unintentional and Assault-Related Firearm Injury: A Case-Control Study and a Cohort Study.

BACKGROUND: Hospital-based violence intervention programs typically focus on patients whose firearm injury occurred through interpersonal violence (assault). Knowledge of violence perpetration by victims of unintentional (accidental) firearm injury is limited. OBJECTIVE: To examine violence perpetration before and after a patient becomes hospitalized for firearm injury according to injury intent (intentional [assault] or unintentional [accidental]). DESIGN: A case-control study and a retrospective cohort study. SETTING: Hospitals in Washington. PATIENTS: Persons aged 15 years or older hospitalized for a firearm injury, other injuries, or a noninjury reason from 2006 to 2007. MEASUREMENTS: In the case-control study, the odds of violence-related arrest from 2001 through hospitalization by injury intent among 3 groups were compared. In the cohort study, the rates of violence-related arrest from hospitalization through 2011 by injury intent among 3 groups were compared. RESULTS: Patients with unintentional firearm injuries (n = 180) were more likely than those with other unintentional injuries (n = 62 795; odds ratio [OR], 2.01 [95% CI, 1.31 to 3.09]) and no injuries (n = 172 830; OR, 3.43 [CI, 2.22 to 5.32]) to have been arrested for a violent crime before hospitalization. Prior violence-related arrest did not differ between patients with assault-related firearm injuries (n = 339) and those with other assault-related injuries (n = 2342; OR, 1.10 [CI, 0.84 to 1.46]). During follow-up, the cumulative incidence of violence-related arrest for patients with unintentional and assault-related firearm injuries was 10% and 15% (subhazard ratio, 1.88 [CI, 1.11 to 3.17] and 1.61 [CI, 1.08 to 2.44]), respectively, compared with 1% for those without injuries. LIMITATION: Exclusion of self-inflicted injuries, misclassification of intent, and ascertainment bias. CONCLUSION: Some firearm injuries classified as accidental may indicate involvement in the cycle of violence and present an opportunity for intervention. PRIMARY FUNDING SOURCE: City of Seattle and the University of Washington Royalty Research Fund.

Effectiveness of Interventions to Promote Safe Firearm Storage.

Despite supportive evidence for an association between safe firearm storage and lower risk of firearm injury, the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, we conducted a systematic review of randomized and quasi-experimental controlled studies of safe firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language, year, or location from inception through May 27, 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Collaboration's domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000-2012 using counseling with or without safety device provision met the inclusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices, while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies precluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recommendations for conducting future studies. Although additional studies are needed, the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely.

Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study.

BACKGROUND: Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions. OBJECTIVE: To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population. DESIGN: Retrospective cohort study. SETTING: All hospitals in Washington. PATIENTS: Patients with an FRH and a random sample of those with a non-injury-related hospitalization in 2006 to 2007 (index hospitalization). MEASUREMENTS: Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011. RESULTS: Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non-injury-related index hospitalization. LIMITATION: Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification. CONCLUSION: Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted. PRIMARY FUNDING SOURCE: Seattle City Council and University of Washington Royalty Research Fund.

Association Between Receipt of Brief Alcohol Intervention and Quality of Care among Veteran Outpatients with Unhealthy Alcohol Use.

BACKGROUND: Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships. OBJECTIVE: The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use. DESIGN: Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP). PARTICIPANTS: The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009-2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care. MAIN MEASURES: We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care--patient ratings of their VA provider and of overall VA healthcare (range 0-10, dichotomized as ≥ 9 indicating high quality)--for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year. KEY RESULTS: Among 10,612 eligible veterans, 43.8% reported having received brief intervention, and 84.2% and 79.1% rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9% vs. 82.0%, p < 0.01) and the VA overall (82.7% vs. 75.9%, p < 0.01) as high. CONCLUSIONS: In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients' perceptions of care.

State Firearm Legislation and Nonfatal Firearm Injuries.

OBJECTIVES: We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries. METHODS: We estimated discharge rates for hospitalized and emergency department-treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates. RESULTS: We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3-36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department-treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries. CONCLUSIONS: There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.