Health Consequences of Firearm Injury Weds 3 30 · Readmission after firearm injury hospitalization...

Health consequences and public

health impact of firearm deaths

and injuries

Bindu Kalesan, PhD, MPH

Boston University

Email: kalesan@bu.edu ; gvir@bu.edu

1. Background

2. Mortality and morbidity burden

3. School shootings

4. Firearm related hospitalization trends.

5. Vascular injury at presentation.

6. Vascular injury outcomes.

TOPICS

1. Background

3. School shootings

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.

The looming constitutional debate

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

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,”

Motor vehicle deaths vs. Firearm deaths

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

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

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

TOPICS

1. Background

3. School shootings

fatal, 440,095,

treated and released, 432,010,

transferred or hospitalized,

547,689, 38%

held for observation/

unknown, 22,948, 2%

Non-fatal

National Fatal and Non -fatal Firearm Injuries, 2001 -2013

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

Fatal and non -fatal firearm injuries

Intent -specific Firearm deaths

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

Intent-specific non-fatal firearm injuries

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

State - specific firearm death rates

1999 -2016

State -specific potential life years lost rates per 100,000 - 1999 -2016

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

White Black Other race

Firearm deaths 2007 -2016

Firearm nonfatal injuries 2007 -2016

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.

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

TOPICS

1. Background

3. School shootings

School shootings during 2013 –2015 in the USA

• 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

School shootings 2013 -2015 - Public interest

[search term - School shooting]

Red dots are school shooting incidents

School shootings 1/1/2013 to 12/31/2017 Public interest [search

term - School shooting]

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

3. School shootings

4. Firearm related hospitalization trends .

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).

• 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).

Patterns of injury severity

Injury severity Trends, Overall

Injury severity Trends, By age

Injury severity Trends, By sex

Injury severity Trends, By intent

• 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.

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

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)

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)

Stratified analysis of 90-day readmission

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

3. School shootings

4. Firearm related hospitalization.

5. Profiles of those hospitalized.

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

Vascular Repair after Firearm Injury is Associated with Increased in-hospital

mortality and complications

mortality and complicationsChange in new computed injury severity score by vas cular repair across time

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)

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)

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

No 11502 (2.0) Reference

Yes 3621 (5.7) 2.12 (1.98-2.28)

1. Background

3. School shootings

4. Firearm related hospitalization.

5. Vascular injury trends.

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.

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

Kaplan Meier curves for all-cause readmission by vascular repair at baseline

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)

90 day Readmission

511 (18.1)

3744 (9.5)1.38 (1.14-1.68)

180 day Readmission

631 (22.3)

5123 (13.0)1.24 (1.06-1.45)

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.

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]

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

Health Consequences of Firearm Injury Weds 3 30 · Readmission after firearm injury hospitalization...

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