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Health consequences and public
health impact of firearm deaths
and injuries
11
Bindu Kalesan, PhD, MPH
Boston University
Email: [email protected] ; [email protected]
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization trends.
5. Vascular injury at presentation.
6. Vascular injury outcomes.
2
TOPICS
3
TOPICS
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization trends.
5. Vascular injury at presentation.
6. Vascular injury outcomes.
Constitution of United States of America 1789 (rev. 1992)
Amendment II
A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.
4
The looming constitutional debate
55
Every gun that is made, every warship launched, every rocket fired, signifies in the final sense a theft from those who hunger and are not fed, those who are cold and are not clothed.
- Dwight Eisenhower
6
America is a country founded on guns. It's in our DNA. It's very strange but I feel better having a gun. I really do. I don't feel safe, I don't feel the house is completely safe, if I don't have one hidden somewhere. That's my thinking, right or wrong.
- Brad Pitt7
8http://www.motherjones.com/mojo/2015/10/mental-health-gun-laws-washington-post-poll
Firearm ownership
survey, 2013
Current Gun ownership rates
29% of the country owns as many guns to arm every person in the US
Gun ownership and social gun culture. Inj Prev 2015. 8
9Kalesan B, Weinberg J, Galea S. Gun violence in Americans’ social network during their lifetime. Preventive Medicine. 2016;93:53-56. PMID: 27667339. http://dx.doi.org/10.1016/j.ypmed.2016.09.025
Nearly all Americans are likely to know a victim of gun violence within their social networks during their lifetime, indicating that citizens are “closer to gun violence than they perceive,”
10
Motor vehicle deaths vs. Firearm deaths
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Ra
te p
er
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0,0
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MVA Firearm
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
National Crime rates versus Firearm Deaths, 1981 -2015
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Firearm Violent crime
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates. FBI crime rates 11
12http://www.cnn.com/2015/12/04/us/gun-violence-graphics/index.html
13
TOPICS
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization trends.
5. Vascular injury at presentation.
6. Vascular injury outcomes.
14
fatal, 440,095,
30%
treated and released, 432,010,
30%
transferred or hospitalized,
547,689, 38%
held for observation/
unknown, 22,948, 2%
Non-fatal
National Fatal and Non -fatal Firearm Injuries, 2001 -2013
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
15
Mass and school shootings are 2% of annual gun deaths,
<1/10% of all firearm injuries
National Firearm Deaths and Injuries
30% of all who are shot, die at the acute event
30% admitted to ER will be treated and discharged
40% of admitted to ER will be hospitalized
Prepared by: Bindu Kalesan, Boston University
1616
Fatal and non -fatal firearm injuries
17
Intent -specific Firearm deaths
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Undetermined 1.1 0.8 0.8 0.8 0.8 0.8 0.7 0.7 0.9 0.9 0.7 0.8 0.8 0.8 0.8 0.8 0.8 0.8
Untentional 2.9 2.7 2.7 2.5 2.4 2.2 2.6 2.1 2.0 1.9 1.8 1.9 1.8 1.6 1.5 1.7 1.3 1.3
Assault 38.5 38.6 39.5 40.1 40.7 40.4 41.3 42.6 41.6 39.6 37.7 36.1 35.6 36.0 34.7 34.0 37.1 38.6
Suicide 57.5 57.9 57.0 56.6 56.1 56.6 55.4 54.6 55.6 57.7 59.8 61.2 61.8 61.6 63.0 63.5 60.7 59.3
0.0
20.0
40.0
60.0
80.0
100.0
120.0
18
Intent-specific non-fatal firearm injuries
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Undetermined 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Untentional 28.1 29.9 28.8 25.7 22.0 20.6 22.5 21.9 27.9 19.3 19.9 21.3 20.0 19.7 20.6 18.6
Assault 66.7 64.5 65.6 69.1 73.5 75.0 71.4 73.3 67.6 74.4 75.8 73.6 75.2 76.2 74.8 77.6
Suicide 5.2 5.6 5.6 5.2 4.4 4.5 6.1 4.8 4.5 6.3 4.4 5.0 4.7 4.1 4.6 3.8
0.0
20.0
40.0
60.0
80.0
100.0
120.0
State - specific firearm death rates
1999 -2016
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
19
State -specific potential life years lost rates per 100,000 - 1999 -2016
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
20
Fatal firearm - Temporal trends by Race
Whites: Annual rate change= 0.006 per 100,000, P-tr end=0.71Blacks: Annual rate change= -0.114 per 100,000, P-trend=0.22Other race: Annual rate change= -0.12 per 100,000, P-trend<0.0001
0
5
10
15
20
25
White Black Other race
Data source: CDC, WISQARS. NCHS Vital Statistics Sy stem for numbers of deaths. Bureau of Census for population estimates.
21
Firearm deaths 2007 -2016
22
Firearm nonfatal injuries 2007 -2016
23
Temporal trends of fatal and non - fatal firearm injuries by race/ethnicity,
2001 -2013 Rate per
100,000
Annual
2001 2013 change p-trend p-inter
0.001*
White 16.9 20.4 0.28 <0.0001 0.92
Fatal 9.44 11.0 0.15 <0.0001
Non-fatal 7.47 9.33 0.13 <0.0001
Black 92.6 86.8 -0.48 0.059 0.14
Fatal 19.1 17.8 -0.20 <0.0001
Non-fatal 73.4 68.9 -0.28 0.279
Hispanic 31.6 30.3 0.27 0.23 <0.0001
Fatal 8.54 5.60 -0.28 <0.0001
Non-fatal 23.1 24.7 0.55 0.014
Other 17.9 12.7 -0.46 0.006 0.20
Fatal 4.20 3.68 -0.08 <0.0001
Non-fatal 13.7 9.03 -0.38 0.024
The hidden firearm epidemic: increasing firearm inj ury rates 2001 - 2013 . Am J of Epidem In press.
24
Fatal and non-fatal firearm trends by intent
The hidden firearm epidemic: increasing firearm inj ury rates 2001-2013 . Am J of Epidem In press. 25
26
TOPICS
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization trends.
5. Vascular injury at presentation.
6. Vascular injury outcomes.
School shootings during 2013 –2015 in the USA
27
• 154 incidents of school shootings.
• Events increased from 35 to 55 to 64
• Indicating increasing incidence of school shooting episodes
• The majority of the school shootings were intentional, committed by males.
• States with background check laws, spend more on mental health and K -12 education, and more urban population had lower school shooting incidents.
School shootings during 2013 –2015 in the USA
28
School shootings 2013 -2015 - Public interest
[search term - School shooting]
29
Red dots are school shooting incidents
School shootings 1/1/2013 to 12/31/2017 Public interest [search
term - School shooting]
30
Red dots are school shooting incidents. Total of 270 school shootings. 34 (12.6%) of received high attention, 93 (34.4%) received moderate attention, and 143 (53.0%) low.
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization trends .
5. Vascular injury at presentation.
6. Vascular injury outcomes.
31
TOPICS
Patterns of injury severity in firearm hospitalizations from 1993 to
2014: A repeated cross -sectional study
• Non-fatal firearm injuries constitute approximately 70% of all firearm trauma injuries in the United States.
• Young adults -> by assault;
• Older adults -> self-inflicted.
• Are there temporal patterns in severity of these injuries (overall, age-, sex-, and intent-specific).
32
• Nationwide Inpatient Sample (NIS) data -1993-2014
• Firearm hospitalization -> assault (E965x), unintentional (E922x), intentional self-harm (E955x), legal (E970) and undetermined (E985x)
• Injury severity using the computed New Injury Severity Score (NISS).
• Survey weighted means, SE, Joinpointregression -> to analyze temporal trends annual percent change (APC).
33
Patterns of injury severity
Injury severity Trends, Overall
Patterns of injury severity
Injury severity Trends, By age
Patterns of injury severity
Injury severity Trends, By sex
Patterns of injury severity
Injury severity Trends, By intent
Patterns of injury severity
Patterns of injury severity
• In conclusion :
• Growing injury severity among firearm hospitalizations over time.
• Suggests an increasing health care burden related to firearm violence survivorship.
• This increasing challenge is primarily driven by assaultive intent particularly among young adults.
• Shift towards hospitalization of more serious injuries, and outpatient management of less serious injuries across the board.
38
Readmission after firearm injury hospitalization
• Nationwide Readmission Database 2013
• Claims-based, retrospective cohort study
• Patients who survived an index hospitalization of firearm injury, pedestrian and occupant motor vehicle accidents.
• Injury severity score (ISS), Computed New Injury Severity score (NISS)
• Risk of re-hospitalization at 90-days
39
Readmission after firearm injury hospitalization
40
Firearm Pedestrian MVC Occupant MVC
n 31,610 36,164 262,906
Age, mean (SE) 30.3 (0.2) 40.8 (0.4) 42.0 (0.2)
Men, n (%)28,068 (88.8)
24,133 (66.7)169,646 (64.5)
Residence: Central Metro (>1m), n (%)
13,005 (41.4)
15,275 (42.9)58,083 (22.2)
Insurance: Medicaid/Self/ No charge/other, n (%)
23,420 (74.3)
15,177 (42.1)90,560 (34.6)
Hospital size: Large, n (%)23,031 (72.9)
26,954 (74.5)199,160 (75.8)
Urban hospital, n (%)20,600 (65.2)
24,680 (68.2)130,543 (49.7)
NISS, mean (SE) 13.8 (0.2) 12.9 (0.2) 13.5 (0.1)
ISS: Extremities or pelvic girdle 11984 (37.9) 18497 (51.1)102462 (39.0)
Elixhauser comorbidity score,mean (SE)
1.18 (0.01) 1.22 (0.02) 0.94 (0.02)
Readmission after firearm injury hospitalization
41
Risk of readmission at 30-days, 60-days and 90-days after surviving the injury
Multivariable
n (%) HR (95% CI) P
At 30-days
Firearm 1917 (6.1)
vs. Pedestrian 2009 (5.6) 1.26 (1.12-1.43) <0.0001
vs. Occupant 14481 (5.5) 1.34 (1.22-1.47) <0.0001
At 60-days
Firearm 2804 (8.9)
vs. Pedestrian 3110 (8.6) 1.23 (1.10-1.37) <0.0001
vs. Occupant 20665 (7.9) 1.36 (1.25-1.47) <0.0001
At 90-days
Firearm 3334 (10.5)
vs. Pedestrian 3818 (10.6) 1.20 (1.09-1.32) <0.0001
vs. Occupant 24672 (9.4) 1.34 (1.26-1.44) <0.0001
Firearm injury survivorship
• Nationwide Readmission Database 2013
• Claims -based, retrospective cohort study
• Patients who survived an index hospitalization of firearm injury, pedestrian and occupant motor vehicle accidents.
• Injury severity score (ISS), Computed New Injury Severity score (NISS)
42
Readmission after firearm injury hospitalization
Readmission after firearm injury hospitalization
43
Stratified analysis of 90-day readmission
Readmission after firearm injury hospitalization
44
1. In conclusion :
2. Firearm injury patients have an increased risk of readmission within 90-days compared to pedestrians and occupants.
3. Children have the greatest risk of readmission.
4. Head or neck, facial, chest and abdominal injuries also carry a higher risk of readmission.
5. There was no difference in risk of readmission among those who had Medicaid as compared to private insurance.
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization.
5. Profiles of those hospitalized.
6. Vascular injury at presentation.
7. Vascular injury outcomes.45
TOPICS
1. Firearm injuries affect various organ systems including the vasculature.
2. Traumatic vascular injury - associated with high morbidity and mortality.
3. Unlike with blunt trauma, which is increasingly being treated with endovascular techniques, penetrating vascular trauma is still often treated with open surgery.
4. Our goal - to assess the pattern and incidence of vascular injuries from firearms in the United States and associated in-hospital mortality and morbidity. 46
Vascular Repair after Firearm Injury is Associated with Increased Morbidity and
Mortality
1. Nationwide Inpatient Sample from 1993-2014 for all firearm injury .
2. Patients who underwent a vascular repair for those firearm injuries were then identified using the following ICD-9 procedure codes.
3. Exposure groups: treated with vascular repair and those without a vascular repair.
4. Primary outcome: in-hospital mortality.
5. Secondary outcomes: Any complication-acute renal failure, venous thromboembolism, pulmonary complications, cardiac complications, neurological
47
Vascular Repair after Firearm Injury is Associated with Increased in-hospital
mortality and complications
48
Vascular Repair after Firearm Injury is Associated with Increased in-hospital
mortality and complicationsChange in new computed injury severity score by vas cular repair across time
49
OverallN = 648,662
Vascular RepairN = 63,973
No Vascular RepairN = 584,689
P-Value
Year <.0001
1993-1996 152,442 (23.5) 13,646 (21.3) 138,796 (23.7)
1997-2002 167,900 (25.9) 15,955 (24.9) 151,945 (26.0)
2003-2007 144,942 (22.3) 14,522 (22.7) 130,420 (22.3)
2008-2014 183,378 (28.3) 19,851 (31.0) 163,527 (27.9)
Age (years) <.0001
0-15 36,031 (5.6) 2,571 (4.0) 33,460 (5.7)
16-45 534,140 (82.3) 54,874 (85.8) 479,266 (82)
≥46 78,491 (12.1) 6,528 (10.2) 71,963 (12.3)
Race/Ethnicity <.0001
White 146,805 (22.6) 12,825 (20.1) 133,980 (22.9)
Black 260,478 (40.2) 27,730 (43.3) 232,748 (39.8)
Hispanic 94,519 (14.6) 9,902 (15.5) 84,617 (14.5)
Other race 26,378 (4.1) 2,817 (4.4) 23,561 (4.0)
Missing 120,480 (18.6) 10,698 (16.7) 109,782 (18.8)
Sex <.0001
Male 575,604 (88.7) 58,399 (91.4) 517,205 (88.7)
Female 71,162 (11) 5,531 (8.6) 65,631 (11.3)
Insurance <.0001
Private 178,774 (27.6) 15,871 (25.1) 162,903 (28.2)
Self-pay/None 202,409 (31.2) 19,695 (31.1) 182,714 (31.6)
Medicaid 260,902 (40.2) 27,767 (43.8) 233,135 (40.3)
Household income .003
$1-$24,000 275,760 (42.5) 28,106 (46.9) 247,654 (45.0)
$25,000-$34,999 172,802 (26.6) 16,441 (27.5) 156,361 (28.4)
$35,000-$44,999 104,319 (16.1) 10,055 (16.8) 94,264 (17.1)
≥$45,000 56,906 (8.8) 5,280 (8.8) 51,626 (9.4)
Vascular Repair after Firearm Injury is Associated with Increased in-hospital
mortality and complications
50
OverallN = 648,662
Vascular Repair
N = 63,973
No Vascular Repair
N = 584,689
P-Value
Trauma DetailsIntent <.0001
Assault/Legal 389,506 (60) 42,604 (66.6)
34,6902 (59.3)
Unintentional 157,225 (24.2)
13,845 (21.6)
143,380 (24.5)
Suicide 55,601(8.6) 2,880 (4.5) 52,721 (9.0)
Undetermined 46,331 (7.1) 4,644 (7.3) 41,687 (7.1)
NISS <.00011-3 137,110
(21.1)2,680 (4.2) 134,430
(23.0)4-9 177,381
(27.3)9,364 (14.6) 168,017
(28.7)10-18 150,795
(23.2)20,955 (32.8)
129,840 (22.2)
19-75 172,478 (26.6)
30,886 (48.3)
141,592 (24.2)
Location of injury <.0001Head/neck 74,491
(11.5)4,249 (6.7) 70,242
(12.5)Face 24,044 (3.7) 758 (1.2) 23,286 (4.2)
Chest 78,597 (12.1)
6,387 (10.1) 73,210 (13.1)
Abdomen/pelvis 150,479 (23.2)
21,183 (33.6)
129,296 (23.1)
Vascular Repair after Firearm Injury is Associated with Increased in-hospital
mortality and complications
51
Vascular Repair after Firearm Injury is Associated with Increased in-hospital
mortality and complicationsRisk factors associated with in-hospital mortality and complications related to vascular repair, multivari able
analysis
n (%) Adjusted OR (95% CI) p
In-hospital mortality
<0.0001
No 45551 (7.8) Reference
Yes 8274 (12.9) 2.68 (2.43-2.95)
Complications<0.000
1
No 11502 (2.0) Reference
Yes 3621 (5.7) 2.12 (1.98-2.28)
1. Background
2. Mortality and morbidity burden
3. School shootings
4. Firearm related hospitalization.
5. Vascular injury trends.
6. Vascular injury outcomes.
52
TOPICS
1. Historically, trauma and vascular surgery patients are at higher risk for readmissions.
2. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury.
53
Readmissions after Firearm Injury Requiring Vascular Repair
1. National Readmission Database from 2011-2014 –an inpatient database by the Agency for Healthcare Research and Quality (AHRQ) as part of the Healthcare Cost and Utilization Project to help reduce hospital readmissions
2. Patients who underwent a vascular repair for those firearm injuries were then identified using the following ICD-9 procedure codes.
3. Exposure groups: treated with vascular repair and those without a vascular repair.
4. Primary outcome: readmission at 180-days.
5. Secondary outcomes: readmission at 30 and
54
Readmissions after Firearm Injury Requiring Vascular Repair
55
Readmissions after Firearm Injury Requiring Vascular Repair
Kaplan Meier curves for all-cause readmission by vascular repair at baseline
56
Readmissions after Firearm Injury Requiring Vascular Repair
Risk of all-cause Readmissions
OutcomesVascular Repair
No Vascular Repair
HR (95% CI) P-Value
30 day Readmission
251 (8.9) 2176 (5.5)1.26 (.92-1.72)
0.14
90 day Readmission
511 (18.1)
3744 (9.5)1.38 (1.14-1.68)
0.001
180 day Readmission
631 (22.3)
5123 (13.0)1.24 (1.06-1.45)
0.009
1. # of guns>citizens.
2. Non-fatal injuries > fatal injuries -> continued health consequences.
3. School shootings are increasing along with an interest among the public.
4. Injury severity among those hospitalized after firearm injury - increasing-driven by young adults.
5. Potential clinical phenotypes by intent.
6. Vascular injury increases the risk of in-hospital mortality and complications at presentation and increases the risk of readmissions.
57
SUMMARY
1. Policies for treatment of gun violence survivors.
2. Longer term clinical and social consequences of all types of survivors. [www.everesearch.org]
3. Suggested classification of gun violence survivorship:
1. Direct: who were shot and survived
2. Indirect: parents, children and spouses of those who were shot (killed or survived)
3. Event: present during the shooting without being shot
4. Gun ownership – attitudes, knowledge and characteristics [SOUL study]
58
NEXT STEPS
Thank you• Dr. Sandro Galea
• Dr. Jeffrey Fagan
• Dr. Michael Siegel
• Dr. Ziming Xuan
• Sowmya Vasan
• Marcos Villarreal
• Matt Mobily
• Patrick Hlavacek
• Stefan Debaic
• Yi Zuo
• Elizabeth Pino
• Kinan Lagast
• Max Rosenthal
• Meghan Smith
• Langdon Kessner
59