Health Systems Interventions to Prevent Firearm Injuries and Death Proceedings of a Workshop (2019) / Chapter Skim
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7 Programs and Research
7 Programs and Research
Pages 55-74
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From page 55... ...
consortium, the director of the enters for Disease Control and Prevention (CDC) -funded University C of Michigan njury Prevention Center, a professor of emergency medicine at I the University of Michigan School of Medicine, and a professor of health behavior and health education at the University of Michigan School of Public Health; Rinad Beidas, an associate professor of psychiatry, medical ethics, and health policy and the director of implementation research at the University of Pennsylvania Perelman School of Medicine; and Kyle Fischer, an adjunct assistant professor of health policy and the leadership fellowship director at the University of Maryland School of Medicine.
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From page 56... ...
PROJECT UJIMA Addressing youth violence, Levas said, requires recognizing that there are four major components to account for the youth victims, the communities they come from, the health care system that for the most part has taken a patch-up-and-send-back-out-to-the-community response, and law enforcement and the legal system. Project Ujima was designed to work at the intersection of these four components.
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From page 57... ...
Another 178 children came into the program after being seen in the emergency department, and 34 children were victims of domestic violence. To test Project Ujima's effectiveness at curbing youth violence, Levas and his colleagues have been using validated patient-reported outcomes.
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After recording baseline scores from patient-reported outcomes, adverse childhood event scores, and measures of posttraumatic stress disorder, the researchers follow up on these children every 3 months in an attempt to find out which children are being helped most by the program's interventions. "Traditionally we had a blanket approach with Project Ujima, where every kid would get just about every intervention," Levas said, "but we realized that we could be smarter and more targeted if we look at the kids, look at their scores, look at the interventions that are being done, and really try to find out which kids might really benefit from camp and which kids do not, which kids need the behavioral specialist early before any other programing is going to really affect them." Levas acknowledged that Project Ujima is reactionary, not prevention oriented, in part because its funding comes from Victims of Crime Act dollars.
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From page 59... ...
"It is the right thing to do, and the hospital recognizes that, matching every Victims of Crime Act dollar the program receives," he said. At the same time, the Children's Hospital has been an early adopter of other violence prevention and intervention initiatives, including one that looks at how the hospital system interacts with law enforcement and police to tackle youth violence.
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From page 60... ...
The intervention they are testing has three components: a motivational interview done at the bedside or in the emergency department; a critical time intervention (CTI) ; and attention from a multidisciplinary team comprising colleagues from community services, law enforcement, mental health, employment, education, and housing.
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From page 61... ...
. We need to do enhanced communication among those involved in the implementation and evaluation of these programs -- I can say that the more advocacy, the better -- to get additional resources for this type of work." SAFERTEENS: AN EVIDENCE-BASED YOUTH VIOLENCE PREVENTION PROGRAM In 2009, Cunningham and several colleagues authored a paper that presented some of their thinking about what the trauma community should be doing before and after a patient reaches the trauma bay (Cunningham et al., 2009)
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. Cunningham and m her colleagues concluded that while many emergency departments are trying to do something to prevent youth violence, many others were not even doing risk assessment.
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From page 63... ...
Another study that Cunningham discussed followed a cohort of youths who had come to the emergency department with any assault-related injury and a matched cohort of youths who came to the emergency department without an assault-related injury. Assaulted youth had twice the risk for a later violent injury than those who had not been assaulted, and 59 percent of the assaulted youth reported experiencing some form of firearm violence during the 2 years of the study, with 8 percent sustaining a fatal or non fatal firearm injury and 77 percent reporting that firearm violence was not limited to a single episode (Carter et al., 2015)
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From page 64... ...
"This is how a health system partners with a community to make it work," Cunningham said. This multifaceted approach, she added, produced a significant decrease in assault offenses and violent injury presentations to the emergency department in youth ages 10 to 24 in the intervention neighborhood as compared with a control neighborhood (Heinze et al., 2016)
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From page 65... ...
SOURCE: As presented by Rebecca Cunningham at the workshop on Health Systems Interventions to Prevent Firearm Injuries and Death on 65 O ctober 18, 2018.
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The consortium will define a pediatric-specific firearm injury research agenda, conduct core studies to provide preliminary data which will then inform large-scale studies and fill early data needs, establish a Web-based, searchable data archive for childhood firearm injury, and build a cadre of national research scholars that will serve as an emerging pipeline for future research. FACTS makes available a series of counseling videos created by investigators that demonstrate and model for young pediatricians how they can have a conversation with parents about safe firearm storage in a nonjudgmental way.
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From page 67... ...
Analysis of the qualitative interviews with gun owners, who were individuals in law enforcement and from firearm advocacy groups as well as firearm safety course instructors and firearm retailers, one finding was that there was a concern among gun owners that screening would lead to documentation in the EHR and inclusion in a national registry. There was the sense that screening was not necessary to do the other parts of the inter ention and also a lack of trust and a feeling among gun owners that v
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From page 68... ...
Our gun owner constituents suggested that it would be critical for health systems to think about partnering with firearm safety experts, such as safety course instructors, who are more credible and knowledgeable to firearm owners." As part of this work, Beidas and her collaborators generated a list of implementation strategies that they hope to test in a future trial: • Creating a plan for who on the medical team will be responsible for implementing each component of the Firearm Safety Check. • Changing the clinic or health system policies to encourage the implementation of the Firearm Safety Check.
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From page 69... ...
Effectiveness trials with rigorous endpoints are needed, she said, as are large implementation trials testing different implementation strategies to see which ones result in the best uptake. STATE OF THE SCIENCE FOR HOSPITAL-BASED VIOLENCE: RESEARCH AND POLICY IMPLICATIONS HVIPs, Fischer explained, combine a brief in-hospital intervention with intensive, community-based case management and provide targeted services to high-risk populations to reduce the risk factors for re-injury and retaliation while cultivating protective factors.
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From page 70... ...
He noted that one common problem with doing randomized, controlled trials involving violence is that many institutional review boards consider them unethical and will not approve trials that do not provide the intervention to all participants. For adults, there have been two randomized controlled trials showing a marked reduction in re-injury for individuals treated by an HVIP, with one trial showing a reduction in violent re-injury from 36 percent to 5 percent (Cooper et al., 2006)
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In the policy realm, Fischer said, perhaps the most important change related to violence prevention programs has been the Patient Protection and Affordable Care Act's (ACA's) Medicaid expansion.
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Levas replied that AAP has a council on injury and violence prevention that is working on recommendations, such as for car seat injuries, and is paying more attention to gun violence. "I think that the American Academy of Pediatrics has a large and important voice in recommending screening," he said, "and right now they are talking about having screening in primary care clinics." AAP has also supported large effectiveness trials, Beidas added.
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From page 73... ...
Woodie Kessel from the Koop Institute at Dartmouth asked the panelists where the best opportunities for intervention are in terms of return on investment and where the best opportunities for scale-up exist. Regarding the first question, Cunningham said it is important to invest in a number of programs simultaneously, including resiliency-building components in communities or Project Ujima's summer camps, in order to have the best chance of interrupting some of the early events that occur before guns become involved.
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From page 74... ...
Meredith Wadman from Science magazine asked Beidas if she could explain why only 2 percent of the doctors in her study were routinely handing out gun locks, given that doing so does prevent suicides. Beidas replied that the reasons the physicians gave were mostly about operational concerns -- who would pay for the gun locks, where would they be stored, how would they be distributed, who would teach people how to use the gun locks -- rather than worries that they would offend parents by suggesting they lock their guns.
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