Hospital-based violence intervention programs work

Evaluation of Injury Recidivism Using the Electronic Medical Record

BACKGROUND

Traumatic injuries remain one of the leading causes of death in the United States. Patients who survive traumatic injuries but return to the emergency department with repeat injuries are said to suffer from injury recidivism. Numerous studies have described trends in injury recidivism using trauma registry and survey data. To our knowledge, no prior study has leveraged electronic medical record (EMR) data to characterize injury recidivism. The EMR is potentially more comprehensive as it contains details of patients who visited the emergency department after injury but did not meet the criteria for inclusion in the trauma registry. Such injuries could be predictive of future recidivism. We therefore aimed to describe patterns of injury recidivism seen at a Level 1 trauma center using the EMR.

METHODS

A retrospective review was conducted of all injury-related encounters between January 2016 and December 2019. Manual review was conducted of all recidivistic encounters with < 11 months between encounters to ensure the recidivistic encounter was not a sequela of the index visit. A general estimating equation logistic regression adjusted for age, race, sex, and insurance payor, estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between injury mechanism and odds of recidivistic encounter.

RESULTS

A total of 20,566 index encounters was included during the study period. Of the 20,566 encounters, 7.6% (n = 1570) had a recidivistic encounter during the study period, half of which (n = 781) occurred within the first year of the index encounter. An over two-fold increased odds of recidivism was observed for blunt assault encounters (OR 2.53, 95% CI 2.03-3.15) and unintentional falls (OR 2.10, 95% CI 1.76-2.52). For both mechanisms, this increase was observed across the three years following the index encounter.

CONCLUSIONS

Our study found that patients with assault injuries have the highest odds of injury recidivism and assault-related recidivistic encounters. These results demonstrate the feasibility and utility of incorporating EMR data, and suggest that the development of targeted interventions focused on mitigating assault injuries, such as hospital-based violence intervention programs, should be considered in our region.

Gun Violence and Firearm Injuries in West Michigan: Targeting Prevention

INTRODUCTION

Firearm-related deaths and injuries are ongoing public health issues in the United States. We reviewed a series of gun violence- and firearm-related injuries treated at a multi-campus community healthcare system in West Michigan to better understand the demographic and clinical characteristics of these injuries. We also studied hospital charges, and payers responsible, in an effort to identify stakeholders and opportunities for community- and hospital-based prevention.

METHODS

We performed a retrospective review of firearm injuries treated at Mercy Health Muskegon (MHM) between May 1, 2015 and June 30, 2019. Demographic data, injury type, Injury Severity Score (ISS), anatomic location and organ systems involved, length of stay (LOS), mortality, time of year, and ZIP code in which the injury occurred were reviewed, as were hospital charges and payers responsible.

RESULTS

Of those reviewed, 307 firearm-related injuries met inclusion criteria for the study. In 69.4% of cases the injury type was attempted murder or intent to do bodily harm. Accidental and self-inflicted injuries accounted for 25% of cases. There was a statistically significant difference in the mechanism of injury between Black and White patients with a higher proportion of Black men injured due to gun violence (P < 0.001). Median ISS was 8 and the most commonly injured organ system was musculoskeletal. Median LOS was one day. Self-inflicted firearm injuries had the highest rate of mortality (50%) followed by attempted murder (7%) and accidental discharge (3.1%; P < 0.001). Median hospital charge was $8,008. In 68% of cases, Medicaid was the payer. MHM received $4.98 million dollars in reimbursement from Medicaid; however, when direct and indirect costs were taken into account, a loss of $12,648 was observed.

CONCLUSION

Findings from this study reveal that young, Black men are the primary victims of gun violence-related injuries in our West Michigan service area. Hospital care of firearm-related injuries at MHM was predominantly paid for by Medicaid. Multiple stakeholders stand to benefit from funding and supporting community- and hospital-based prevention programs designed to reduce gun violence and firearm-related injuries in our service area.

Perceptions of violence in justice-involved youth

Background

Youth are tragically affected by violence. Justice-involved youth are at elevated risk for the effects of violence, as incarceration serves as a risk factor. The objective of this study is to explore the risks and needs of justice-involved youth and identify channels for future hospital-based programming.

Methods

Four weekly focus groups were conducted by a credible messenger at the Douglas County Youth Center with former participants of Dusk 2 Dawn, a youth violence prevention program delivered at the Douglas County Youth Center. Eight participants were prompted with preset interview questions. All focus groups were recorded and transcribed by a professional transcription service. A thematic analysis was performed by 2 independent coders to identify themes using Dedoose software.

Results

The 3 most frequently occurring themes involved topics on protection, identified 40 times; family, identified 36 times; and the challenge of overcoming violence, identified 31 times. These themes often overlapped with one another, demonstrating the complexity of youth violence.

Conclusion

Providing a safe and judgement-free space for the youth to discuss issues of violence was beneficial for 3 reasons: (1) inclusion of youth perspectives allows violence prevention programs to be tailored to specific needs, (2) participants were able to deeply reflect on violence in their own lives and consider steps toward positive change, and (3) open communication encourages trust building and collaborative prevention efforts between the hospital and community.

Medical Treatment Following Violence Exposure in a National Sample of Children and Youth

IMPORTANCE

Children and youth experience high rates of exposure to violence, which is associated with later poor physical and mental health outcomes. The immediate injuries and impacts from these exposures are often treated in emergency departments and medical offices.

OBJECTIVE

To characterize, using nationally representative data, the size and characteristics of the child and youth population being seen by medical authorities in the wake of violence exposure.

DESIGN, SETTING, AND PARTICIPANTS

The survey study used a representative sample of children and youth aged 2 to 17 years, from 2 waves (2011 and 2014) of the National Survey of Children Exposed to Violence, drawn from a mix of random digit dialing and address-based sampling. Interviews were conducted (1) over the phone with caregivers of young children or (2) directly with the youth aged 10 to 17 years. Data analysis was performed from September to December 2020.

MAIN OUTCOMES AND MEASURES

Violence exposures were assessed with the 53-item Juvenile Victimization Questionnaire, which had follow-up questions that asked about injury and going "to the hospital, a doctor's office, or some kind of health clinic because of what happened." Additional questions were asked about lifetime and past-year childhood adversities and current trauma symptoms using the Trauma Symptom Checklist and the Trauma Symptom Checklist for Young Children.

RESULTS

The combined 2-survey sample had 5187 children and youth who reported a lifetime violence exposure, of whom 45.6% (95% CI, 43.1%-48.2%) were aged 2 to 9 years, and 54.4% (95% CI, 51.8%-56.9%) were aged 10 to 17 years; 53.6% (95% CI, 51.0%-56.2%) were male. Based on the full sample of 8503 children and youth, 3.4% (95% CI, 2.6%-4.4%) had a violence-related medical visit at some time in their lives. The rate of past-year medical visits due to a violence exposure was 1.9% (95% CI, 1.2%-2.7%), equivalent to a point estimate of approximately 1.4 million children and youth. Of those with medical visits, 33.3% (95% CI, 23.1%-45.4%) were aged 2 to 9 years. Those with a past-year visit had higher levels of trauma symptoms (risk ratio, 1.71; 95% CI, 1.44-2.03) adverse childhood experiences (risk ratio, 2.55; 95% CI, 2.34-2.78) and multiple violence exposures (risk ratio, 3.91; 95% CI, 3.22-4.76) compared with the general sample of children and youth.

CONCLUSIONS AND RELEVANCE

The estimated large number of violence-related visits with medical professionals offers an opportunity to address a source of frequent injury, and provide counseling and referral for a high-risk segment of the population to treat and prevent further physical and mental health and social consequences.

Annual Research Review: Youth firearm violence disparities in the United States and implications for prevention

OBJECTIVE

Research has identified the United States (U.S.) as a global outlier in its firearm ownership rates, with a correspondingly higher risk of youth firearm violence compared to other countries. The relative extent of disparities in youth firearm violence within the U.S. has been less clear. Little is known about factors in the social ecology driving these disparities and whether current firearm violence prevention approaches sufficiently address them.

METHOD

Applying a health disparities framework, we synthesized epidemiological, sociological, and prevention science literatures, emphasizing structural inequalities in youth sociocultural positionality in life course developmental context. We also highlighted findings from national injury data and other studies regarding the magnitude and impacts of youth firearm violence disparities.

RESULTS

The burden of firearm violence varied markedly at intersections of gender, race, place, developmental stage, and homicidal or suicidal intent. Firearm homicide among Black boys and young men (ages 15-24) was at outlier levels - many times greater than the rates of any other demographic group, developmental stage, or violence intent, particularly in urban settings. Recent research has operationalized structural racism and implicated historically racialized spaces as a root cause of this disparity. In contrast, elevated firearm suicide rates were found among Native and White boys and young men in rural settings; firearm-related cultural attitudes and gender socialization were points of consideration to explain these disparities. We highlighted research-based youth firearm violence preventive interventions, and emphasized gaps in efforts focused on structural and sociocultural factors.

CONCLUSIONS

More explicit attention to reducing firearm homicide among Black boys and young men and firearm suicide among Native and rural White boys and young men is urgently needed and has potential to substantially lower overall rates of firearm violence in the U.S.

Generating a Core Set of Outcomes for Hospital-Based Violence Intervention Programs

Hospital-based violence intervention programs (HVIPs) engage individuals who have experienced violent victimization in postmedical care programming, with the goal of reducing the incidence and impact of future injuries. Although there is some empirical support for HVIPs' impact on violence and crime-related outcomes, proper impact assessment is limited by a lack of systematized research on outcomes that relate to the proximal goals and activities of the programs themselves. To address this critical gap, we conducted a two-stage Delphi method to elicit and prioritize these outcomes using the wisdom and experience of those who are engaged in service delivery (i.e., HVIP community-based practitioners, program coordinators, and embedded researchers; N = 79). Through this process, respondents prioritized outcomes related to posttraumatic stress symptoms, beliefs about aggression, coping strategies, and emotional regulation, which have not been consistently measured using validated or standardized tools. Results suggest that, rather than limiting program outcomes to those related to repeat violent injury or criminality, hospital- and community-based violence prevention programs seek to improve and measure mental health and socioemotional outcomes as a benchmark for healing and recovery after a violent injury. Prioritization of these outcomes broadens the definition of recovery to include psychosocial health and well-being. In addition, inclusion of these outcomes in effectiveness studies will serve to bolster the relevance of findings, and provide support for continued development and refinement of HVIP practice.

Factors associated with pediatric firearm injury and enrollment in a violence intervention program

PURPOSE

To identify factors associated with firearm injury (FI) and willingness to enroll in a violence intervention program amongst pediatric victims of violence.

METHODS

Cross-sectional study of victims of violence age 6-19 years presenting to a children's hospital emergency department from 2014 to 2017. Participants were interviewed by social workers prior to being offered enrollment in a violence intervention program. We used multivariate logistic regression analyses to identify factors associated with FI and enrollment in the violence intervention program.

RESULTS

Four hundred seven patients were analyzed, 156 (38%) of which were victims of FI and 251 (62%) were victims of non-firearm-related physical assaults (PA). Multiple factors were associated with FI including older adolescent age, male sex, separated/divorced parents, losses in family/social network due to violence, being on probation, illicit substance use, gang affiliation, and lack of school enrollment. One hundred four patients (26%) enrolled in the violence intervention program. There was no difference in enrollment between FI and PA. However, older adolescent age, illicit substance use and probation were associated with significantly decreased odds of enrolling in the program.

CONCLUSIONS

Multiple identifiable and potentially actionable risk factors exist amongst pediatric victims of acute FI. More specific targeting of at-risk groups may improve enrollment in violence interventions programs.

LEVEL OF EVIDENCE

This is a prognostic study, investigating the natural history of pediatric firearm injuries, factors associated with firearm injuries as well as those associated with patient propensity to enroll in a violence intervention program. This study is observational in nature and utilizes patients with non-firearm-related physical assaults as a control group, making this study Level III evidence.

The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

Helping individuals with firearm injuries: A cluster randomized trial

BACKGROUND

Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries.

METHODS

We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization.

RESULTS

Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury.

CONCLUSIONS

This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program.

LEVEL OF EVIDENCE

Care management, level II.

Characterising mental health and addictions and assault-related health care use in the year prior to death: a population-based linked cohort study of homicide victims

INTRODUCTION

Homicide is an important cause of death for older youth and adult Canadians; however, little is known about health care use prior to death among this population.

OBJECTIVES

To characterise health care use for mental health and addictions (MHA) and serious assault (herein referred to assault) one year prior to death among individuals who died by homicide in Ontario, Canada using linked mortality and health care utilisation data.

METHODS

We report rates of health care use for MHA and assault in the year prior to death among all individuals 16 years and older in Ontario, Canada, who died by homicide from April 2003 to December 2012 (N = 1,541). Health care use for MHA included inpatient stays, emergency department (ED) visits and outpatient visits, whereas health care use for assault included only hospital-based care (ED visits and inpatient stays). Sociodemographic characteristics and health care utilisation were examined across homicide deaths, stratified by sex.

RESULTS

Overall, 28.5% and 5.9% of homicide victims sought MHA and assault care in the year prior to death, respectively. A greater proportion of females accessed care for MHA, whereas a greater proportion of males accessed assault-related health care. Males were more likely to be hospitalised following an ED visit for a MHA or assault related reason, in comparison to females. The most common reason for a MHA hospital visit was for substance-related disorders. We found an increase over time for hospital-based visits for assault prior to death, a trend that was not observed for MHA-related visits.

CONCLUSIONS

A large proportion of homicide victims interacted with the health care system for MHA or assault in the year prior to death. An increase in hospital-based visits for assault-related reasons prior to death was observed. These trends may offer insight into avenues for support and prevention for victims of homicide.

The Challenges and Strategies of Affordable Care Act Navigators and In-Person Assisters with Enrolling Uninsured, Violently Injured Young Black Men into Healthcare Insurance Coverage

Low-income young Black men experience a disproportionate burden of violent injury in the United States. These men face significant disparities in healthcare insurance coverage and access to care. The Affordable Care Act (ACA) created a new healthcare workforce, Navigators and In-Person Assisters (IPAs), to support low-income minority populations with insurance enrollment. Using a longitudinal qualitative case study approach with Navigators and IPAs at the two busiest urban trauma centers in Maryland, this study identifies the culturally and structurally responsive enrollment strategies used by three Navigators/IPAs as they enrolled violently injured young Black men in healthcare insurance coverage. These approaches included gaining their trust and building rapport and engaging female caregivers during enrollment. Navigators and IPAs faced significant barriers, including identity verification, health literacy, privacy and confidentiality, and technological issues. These findings offer novel insight into the vital work performed by Navigators and IPAs, as they attempt to decrease health disparities for young Black male survivors of violence. Despite high rates of victimization due to violent firearm injury, little is known about how this population gains access to healthcare insurance. Although the generalizability of this research may be limited due to the small sample size of participants, the qualitative case study approach offers critical exploratory data suggesting the importance of trauma-informed care in insurance enrollment by Navigators and IPAs. They also emphasize the need to further address structural issues, which affect insurance enrollment and thus undermine the well-being of young Black men who have survived violent injury.

Boston Violence Intervention Advocacy Program: Challenges and Opportunities for Client Engagement and Goal Achievement

OBJECTIVES

A better understanding of the factors affecting client engagement in hospital-based violence intervention programs (HVIPs), and which types of client needs prove most challenging to achieve, may be of key importance in developing novel, targeted strategies to violence intervention. In this study, we examined the demographics and injury characteristics of violently injured patients by their level of engagement with the Boston Violence Intervention Advocacy Program (VIAP) and determined the degree of client goal achievement through VIAP client services.

METHODS

This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury due to community violence between 2013 and 2018. Data on client demographics, injury characteristics, and client needs were collected from the VIAP data repository. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals to assess the difference in hazards of client goal achievement by need type.

RESULTS

Of the 2,243 victims of violent injury, 839 (37.4%) patients engaged with VIAP. Significant predictors of client engagement include younger age, Black race, permanent home, existing mental health diagnosis, gunshot wound, and more severe injuries. Conversely, older age, homelessness, substance use, stab wound, and less severe injuries predicted refusal of VIAP services. For clients who chose to engage with VIAP, needs related to education (HR = 0.47, 95% CI = 0.38 to 0.58), employment (HR = 0.66, 95% CI = 0.57 to 0.77), and housing (HR = 0.76, 95% CI = 0.68 to 0.86) were significantly less likely to be achieved compared to basic needs.

CONCLUSIONS

This study demonstrates that VIAP is effectively engaging the client population that HVIPs have been designed to support. HVIPs should consider novel strategies to engage vulnerable populations not typically targeted by intervention programs. These results speak to the difficulties of program attrition and the complexities of altering the life course for victims of violence.

Young victims of youth violence: using youth workers in the emergency department to facilitate 'teachable moments' and to improve access to services

There have been rising concerns in the UK about the levels of serious violence between young people, especially serious physical violence and knife crime. Interactions with young people in the emergency department (ED) at the time of injury provide an opportunity for screening and intervention in order to reduce the risk of repeat attendances. However, paediatricians and other healthcare workers can feel unsure about the best way to intervene. Embedding youth workers in EDs has started in some UK hospitals, making use of a potential 'teachable moment' in the immediate aftermath of an event to help change behaviour. Based on a rapid review of the literature, we summarise the evidence for these types of interventions and present two practice examples. Finally, we discuss how EDs could approach the embedding of youth workers within their department and considerations required for this.

Utilization of mental health services in pediatric patients surviving penetrating trauma resulting from interpersonal violence

BACKGROUND

Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma.

METHODS

Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization.

RESULTS

There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation.

CONCLUSION

Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.

Testing the efficacy of a hospital-based violence intervention programme: protocol and design

INTRODUCTION

Hospital-based violence intervention programmes (HBVIPs) are a promising strategy to reduce trauma recidivism and promote safety among victims of violent injury. While previous studies have demonstrated cost-effectiveness and positive impact on the lives of victims, there are a number of key limitations in the study designs of this evidence base. This study seeks to address the methodological shortcomings of previous research, determine the efficacy of HBVIPs using a randomised control study design, and provide a better understanding of successful service allocation within an HBVIP.

METHODS AND ANALYSIS

The current study is 1 of 12 demonstration projects being implemented around the country with the purpose of bolstering the ability to provide effective, culturally appropriate and trauma-informed services for boys and men harmed by violence. We propose a randomised control trial in which male victims of violence receive one of two interventions: treatment as usual versus enhanced services. The purpose is to determine which intervention leads to reductions in trauma recidivism over the period of 1 year from contact with the programme. Differences will also be monitored on measures of mental health, quality of life and attitudes towards violence. Analyses employed will include Kaplan-Meier analysis and Cox proportional hazards regression with death and recidivism being the outcomes of interest.

ETHICS AND DISSEMINATION

Study procedures have been approved by the Institutional Review Boards of the University at Buffalo and four hospitals. Results will be submitted for publication in peer-reviewed journals.

Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database

BACKGROUND

Recidivism is a key outcome measure for injury prevention programs. Firearm injury recidivism rates are difficult to determine because of poor longitudinal follow-up and incomplete, disparate databases. Reported recidivism rates from trauma registries are 2% to 3%. We created a collaborative database merging law enforcement, emergency department, and inpatient trauma registry data to more accurately determine rates of recidivism in patients presenting to our trauma center following firearm injury.

METHODS

A collaborative database for Jefferson County, Kentucky, was constructed to include violent firearm injuries encountered by the trauma center or law enforcement from 2008 to 2019. Iterative deterministic data linkage was used to create the database and eliminate redundancies. From patients with at least one hospital encounter, raw recidivism rates were calculated by dividing the number of patients injured at least twice by the total number of patients. Cox proportional hazard models were used to evaluate risk factors for recidivism. The cumulative incidence of recidivism over time was estimated using a Kaplan-Meier survival model.

RESULTS

There were 2, 363 assault-type firearm injuries with at least 1 hospital encounter, approximately 9% of which did not survive their initial encounter. The collaborative database demonstrated raw recidivism rates for assault-type firearm injuries of 9.5% compared with 2.5% from the trauma registry alone. Risk factors were young age, male sex, and African American race. The predicted incidence of recidivism was 3.6%, 5.6%, 11.4%, and 15.8% at 1, 2, 5, and 10 years, respectively.

CONCLUSION

Both hospital and law enforcement data are critical for determining reinjury rates in patients treated at trauma centers. Recidivism rates following violent firearm injury are four times higher using a collaborative database compared with the inpatient trauma registry alone. Predicted incidence of recidivism at 10 years was at least 16% for all patients, with high-risk subgroups experiencing rates as high as 26%.

LEVEL OF EVIDENCE

Epidemiological, level III.

A Case for Risk Stratification in Survivors of Firearm and Interpersonal Violence in the Urban Environment

The emergency department (ED) serves as the main source of care for patients who are victims of interpersonal violence. As a result, emergency physicians across the nation are at the forefront of delivering care and determining dispositions for many at-risk patients in a dynamic healthcare environment. In the majority of cases, survivors of interpersonal violence are treated and discharged based on the physical implications of the injury without consideration for risk of reinjury and the structural drivers that may be at play. Some exceptions may exist at institutions with hospital-based violence intervention programs (HVIPs). At these institutions, disposition decisions often include consideration of a patient’s risk for repeat exposure to violence. Ideally, HVIP services would be available to all survivors of interpersonal violence, but a variety of current constraints limit availability. Here we offer a scoping review of HVIPs and our perspective on how risk-stratification could help emergency physicians determine which patients will benefit most from HVIP services and potentially reduce re-injury secondary to interpersonal violence.

Staying Out of the Way: Perceptions of Digital Non-Emergency Medical Transportation Services, Barriers, and Access to Care Among Young Black Male Survivors of Firearm Violence

With a reduction in primary barriers to healthcare access as a result of the Affordable Care Act, there is an increased need to address secondary barriers faced by low-income young Black male survivors of violent injury. While transportation is often characterized as a barrier for individuals with chronic disease and disability, it also acts as a significant barrier in accessing cognitive behavioral therapy and mentoring services through hospital-based violence intervention programs (HVIPs). These services address the traumatic stress associated with surviving gun violence. Although there are many challenges associated with the current practices of non-emergency medical transportation, participants in HVIPs face additional risk factors. We highlight the application of a digital transportation intervention to increase the use of psychosocial services among low-income young Black male survivors of violent injury participating in an HVIP. Digital non-emergency medical transportation services (DNEMT) address issues concerning financial barriers, personal safety, program credibility, and program participation. We conducted qualitative interviews and a focus group with this population to assess the impact of Uber Health, a DNEMT service, on their participation in an HVIP located in a suburban Maryland hospital immediately outside of Washington, D.C. Survivors identified the use of Uber Health as essential to addressing the multifaceted and interconnected barriers to treatment. These barriers included reluctance to use alternative forms of transportation services (i.e., bus or subway) due to potential encounters with rivals, increased risk of repeat violent victimization, the need to carry a weapon for protection, stigmatization, and symptoms associated with traumatic stress. We found that integrating digital transportation services into the standard practices of HVIPs, as a part of a patient-centered outcomes framework, contributes to a reduction in violent injury and re-traumatization by addressing the multi-layered risks experienced by survivors of gun violence.

Identifying participants for inclusion in hospital-based violence intervention: An analysis of 18 years of urban firearm recidivism

BACKGROUND

Identifying individuals at highest risk maximizes efficacy of prevention programs in decreasing recidivist gunshot wound (GSW) injury. Characteristics of GSW recidivists may identify this population. Hospital-based violence intervention programs (HVIPs) are one effective strategy; however, programs are expensive, therefore, when possible, epidemiologic data should guide inclusion criteria.

METHODS

Seventeen years of all GSW patients presenting to an urban Level I trauma center were reviewed. Countywide murders were reviewed from the same timeframe. Recidivists were any patient presenting twice, either to the hospital or once to the hospital and subsequently dying by firearm. Demographics and characteristics of future recidivists were compared with nonfuture recidivists.

RESULTS

There were 9,699 unique intentional, GSW cases reviewed and 1,426 died, leaving 8,273 at risk of recidivism. Five hundred fourteen (6.2%) became recidivists. Most recidivists were African-American men and were younger at first GSW. Median time between incidents was 2.5 years, with a range of 0 days to 16 years. Nearly half were treated and released from the emergency department at their first episode of GSW. For recidivists who died, 128 died at the second incident, 29 at later incidents. Mortality from a second incident of firearm injury is 10% higher than first injuries, second hospitalizations are US $5,000 more expensive, and loss of life has a societal cost of US $167 billion in this community alone.

CONCLUSION

The most appropriate population for inclusion in HVIPs at our hospital are young black men. The HVIP services are needed in the emergency department to address those treated and released at first GSW. Recidivists have higher mortality, and hospitalizations are significantly more expensive at the second injury. The investment in prevention is justified and may lead to a decrease in recidivism.

LEVEL OF EVIDENCE

Therapeutic/Care Management level III.

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

BACKGROUND

Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression.  OBJECTIVES: To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.

DATA COLLECTION AND ANALYSIS

Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included nine studies-four CRCTs, three RCTs, and two CBAs-with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden. All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains. Effects on aggression Short-term follow-up The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence). Long-term follow-up Education may not reduce aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 CRCT; low-certainty evidence). Effects on knowledge, attitudes, skills, and adverse outcomes Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD 0.59, 95% CI 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not have an effect on skills related to workplace aggression (SMD 0.21, 95% CI -0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD -0.31, 95% CI -1.02 to 0.40, 1 RCT; very low-certainty evidence). Measurements of these concepts showed high heterogeneity.

AUTHORS' CONCLUSIONS

Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

"You don't want anyone who hasn't been through anything telling you what to do, because how do they know?": Qualitative analysis of case managers in a hospital-based violence intervention program

STATEMENT OF PURPOSE

Intentional violent injury is a leading cause of disability and death among young adults in the United States. Hospital-based violence intervention programs (HVIPs), which strive to prevent re-injury through intensive case management, have emerged as a successful and cost-effective strategy to address this issue. Despite the importance of strong therapeutic relationships between clients and their case managers, specific case manager behaviors and attributes that drive the formation of these relationships have not been elucidated.

METHODS

A qualitative analysis with a modified grounded theory approach was conducted to gain insight into what clients perceive to be crucial to the formation of a strong client-case manager relationship. Twenty-four semi-structured interviews were conducted with prior clients of our hospital's HVIP. The interviews were analyzed using constant comparison method for recurrent themes.

RESULTS

Several key themes emerged from the interviews. Clients emphasized that their case managers must: 1) understand and relate to their sociocultural contexts, 2) navigate the initial in-hospital meeting to successfully create connection, 3) exhibit true compassion and care, 4) serve as role models, 5) act as portals of opportunity, and 6) engender mutual respect and pride.

CONCLUSIONS

This study identifies key behaviors of case managers that facilitate the formation of strong therapeutic relationships at the different stages of client recovery. This study's findings emphasize the importance of case managers being culturally aligned with and embedded in their clients' communities. This work can provide a roadmap for case managers to form optimally effective relationships with clients.

Are ED-based violence intervention programmes effective in reducing revictimisation and perpetration in victims of violence? A systematic review

OBJECTIVES

Community violence bears significant human and economic costs. Furthermore, victims requiring ED treatment are at a greater risk of violent reinjury, arrest due to perpetration and violent death. We aimed to evaluate the effectiveness of ED-based violence intervention programmes (EVIPs), which aim to reduce future violence involvement in these individuals.

METHODS

We performed a systematic literature review searching MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, The Cochrane Library and Web of Science, in addition to hand-searching. Randomised controlled trials (RCTs) were included if they enrolled victims of community violence requiring ED treatment, evaluated interventions taking place in the ED and used violent revictimisation, arrests or intermediate outcome measures as endpoints. We included trials that had a Jadad score of 2 or above.

RESULTS

297 records were identified, and 13 articles were included in our final qualitative analysis, representing 10 RCTs and 9 different EVIPs. The risk of selection bias was low; the risk of performance, detection and attrition bias was moderate. 9 out of 13 papers reported statistically significant improvements in one or more outcome measures related to violence, including violent reinjury and arrests due to violence perpetration.

CONCLUSION

The results of this literature review show that EVIPs may be capable of reducing violent reinjury and arrests due to violence perpetration. Larger RCTs, taking place in different regions, in different age groups and using different techniques, are justified to determine which conditions may be required for success and whether EVIPs are generalisable.

How can adolescent aggression be reduced? A multi-level meta-analysis

Aggressive behaviour among adolescents has significant social and economic costs. Numerous attempts have been made to intervene to reduce aggression in adolescents. However, little is known about what factors enhance or diminish intervention effectiveness. The present systematic review and meta-analysis, therefore, seeks to quantify the effectiveness of interventions to reduce aggressive behaviour in adolescents and to identify when and for whom such interventions work best. Sixteen databases were searched for randomised controlled trials that assessed interventions to reduce aggression among adolescents. After screening 9795 records, 95 studies were included. A multi-level meta-analysis found a significant overall small-to-medium effect size (d = 0.28; 95% CI [0.17, 0.39]). More effective interventions were of shorter duration, were conducted in the Middle East, were targeted at adolescents with higher levels of risk, and were facilitated by intervention professionals. Potentially active ingredients were classified using the Behaviour Change Technique Taxonomy. Behavioural practice and problem solving were components of more effective interventions targeted at the general population. Overall the findings indicate that psychosocial interventions are effective in reducing adolescent aggression. Future trials need to assess the effect of individual techniques and their combination to identify the key components that can reduce aggression in adolescents.

Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma

BACKGROUND

Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals.

METHODS

The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury.

RESULTS

There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05).

CONCLUSIONS

This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.

Rates and correlates of risky firearm behaviors among adolescents and young adults treated in an urban emergency department

Firearm violence is a leading cause of death for urban adolescents and young adults (A/YAs). Little is known about patterns of risky firearm behaviors (RFBs) that may increase firearm-related fatality and non-fatal injury risk. To inform prevention efforts, we examined the rates and correlates of RFBs, including firearm carriage in risky situations (e.g., while drunk/high), discharge in risky situations (e.g., fleeing police), and firearm aggression (e.g., firearm threats/use against a partner/non-partner), among a sample of A/YAs (age-16-29) seeking medical or injury related care (7/2017-6/2018) at a Level-1 urban Emergency Department (ED). In total, 1312 A/YAs completed the survey (mean-age 23.2; 29.6%-male; 50.5%-Black; 56.3%-public assistance), with 102 (7.8%) engaging in RFBs. Among those engaging in RFBs, 42% reported firearm ownership, 68.6% firearm carriage in high-risk situations, 39.2% firearm discharge in risky situations, and 41.2% reported partner/non-partner firearm aggression. Regression identified RFBs correlates, including older age (AOR = 1.09), male sex (AOR = 1.63), Black race/ethnicity (AOR = 2.01), substance misuse (AOR = 2.75), attitudes favoring firearm use/retaliation (AOR = 1.38), peer firearm ownership/carriage (AOR = 3.26), higher levels of community violence exposure (AOR = 1.05), and active parole/probation (AOR 2.38). Higher coping skills were protective for RFBs (AOR = 0.83). Overall, we found that A/YAs seeking urban ED treatment reported elevated RFB rates, emphasizing the need for novel prevention initiatives, especially those incorporating tailored content addressing substance use, retaliatory violence, and peer delinquency/norms, while enhancing self-efficacy for avoiding RFBs and providing access to external resources within a resiliency-based framework. Such prevention approaches may be a critical step towards addressing the public health problem of firearm violence. Primary Funding Sources: NIH/NIDA K23DA039341; NIH/NCATS UL1TR000433.

"We Are Our Own Counselor": Resilience, Risk Behaviors, and Mental Health Service Utilization among Young African American Men

Despite risk for trauma, subsequent mental health concerns, and poor health outcomes, young Black/African American men (YBM) are less likely to receive mental health services than other racial/ethnic groups. Despite the growing literature on resilience, there is less information on relationships between resilience, risk behaviors, and use of mental health services. This study sought to examine resilience, trauma-related risk behaviors, and receipt of mental health services among a sample of YBM who experienced trauma. Focus groups and a brief survey were conducted with YBM (N = 55) who had been exposed to at least one traumatic event (e.g., witnessing violence, experienced serious injury or illness) and were recruited from urban community settings (e.g., colleges/universities, barbershops, churches). Participants were an average age of 23 years (SD = 3.9; range 18-30) and experienced an average of 2 to 3 traumatic events (SD = 2.2). Trauma exposure was a significant predictor of risk factors (β = .513, p < .01). However, resilience did not significantly moderate this relationship. Resilience also did not predict receipt of mental health services. Culturally relevant qualitative themes found to be related to resilience included maintaining resilience autonomously, preferred coping methods (e.g., friends, music), and habituating to adversity. This study has potential to inform the development of culturally tailored, relevant interventions to promote engagement in mental health services among YBM who've experienced trauma.

A System Dynamics Model of Violent Trauma and the Role of Violence Intervention Programs

BACKGROUND

Violence intervention programs (VIPs) can reduce interpersonal violence (IPV); however, optimizing the implementation of VIPs is challenging, given the complex dynamics of IPV. System dynamics models (SDMs) provide a means of visualizing dynamic and causal relationships in such complex systems. We use the IPVSDM to characterize and examine the relationship between IPV, VIPs, and the social determinants of health (SDH).

MATERIALS AND METHODS

The simulation model was created from a diagram that links putative causal relationships between VIPs, SDH, and IPV events. Simulation rules are then used to calculate a risk of violence parameter based on the SDH, which drives the transition from low-risk to high-risk populations and in turn influences IPV event rates. A qualitative relational approach was used to evaluate long-term effects of VIP on IPV events.

RESULTS

The model produced qualitatively plausible behavior with respect to IPV events, population transitions, and relative overall VIP effect. Simulation runs converged to stable steady states with an exponential benefit of VIP on reducing IPV that is best appreciated after 1-2 y. The VIP functioned in a recognizable fashion by slowing the shift from low-risk to high-risk populations.

CONCLUSIONS

This initial implementation of the IPVSDM produced recognizable baseline behavior while incorporating the possible effects of a VIP. The model allows causality and counterfactual testing, which is impractical in vivo. Community-level VIP efforts should show benefit particularly after a couple years. Future work will emphasize adding complexity to the IPVSDM and identifying real-world metrics to aid in testing, validation, and prediction of the model.

Acceptability of Adolescent Social and Behavioral Health Screening in the Emergency Department

PURPOSE

The American Academy of Pediatrics recommends routine screening for social and behavioral health risks (SBHR) in adolescents. Because adolescents who seek care in emergency departments (EDs) may have riskier behaviors than adolescents who access primary care, the ED may be a strategic additional setting for screening. We sought to identify acceptable domains for comprehensive SBHR screening in a pediatric ED.

METHODS

We conducted a cross-sectional survey to assess adolescent and caregiver acceptance of ED-based SBHR screening across multiple domains. Logistic regression was performed to identify factors associated with screening acceptance. McNemar's test was used to assess agreement within patient/caregiver dyads across domains.

RESULTS

Among our 516 study participants (347 adolescents and 169 caregivers), those who indicated that they "agree" or "strongly agree" that ED-based screening should be conducted were classified as finding screening acceptable. Acceptability rates ranged from 45.0% (firearm access) to 77.5% (suicidality) among adolescents and 61.5% (firearm access) to 84.0% (substance use) among caregivers. After adjusting for gender, race/ethnicity, and insurance status, adolescents were less accepting than caregivers of screening for: substance use (adjusted odds ratio [aOR]: .51; .31, .83; p < .01); violence (aOR: .63; .41, .97; p = .04); depression (aOR: .65; .42, .99; p = .04); human trafficking (aOR: .58; .39, .86; p < .01); and access to firearms (aOR: .47; .32, .70; p < .01). Shared agreement within adolescent/caregiver dyads ranged from 25.2% to 67.1%.

CONCLUSIONS

A majority of adolescents and caregivers agree that ED-based SBHR screening should be conducted across most domains. Caregivers generally had higher rates of screening acceptance than adolescents.

Reducing gunshot victimization in high-risk social networks through direct and spillover effects

More than 60,000 people are victimized by gun violence each year in the United States. A large share of victims cluster in bounded and identifiable social networks. Despite a growing number of violence reduction programmes that leverage networks to broaden programmatic effects, there is little evidence that reductions in victimization are achieved through spillover effects on the peers of participants. This study estimates the direct and spillover effects of a gun violence field intervention in Chicago. Using a quasi-experimental design, we test whether a desistance-based programme reduced gunshot victimization among 2,349 participants. The study uses co-arrest network data to further test spillover effects on 6,132 non-participants. Direct effects were associated with a 3.2-percentage point reduction in victimization among seeds over two years, while potential spillover was associated with a 1.5-percentage point reduction among peers. Findings suggest that peer influence and the structure of networks might be leveraged to amplify gun violence reduction efforts.

An Integrated Public Health Approach to Interpersonal Violence and Suicide Prevention and Response

Violence is a leading source of morbidity and mortality in the United States. In this article, we suggest a public health framework for preventing community violence, intimate partner violence and sexual violence, and suicide as key forms of interpersonal and self-directed violence. These types of violence often co-occur and share common risk and protective factors. The gender, racial/ethnic, and age-related disparities in violence risk can be understood through an intersectionality framework that considers the multiple simultaneous identities of people at risk. Important opportunities for cross-cutting interventions exist, and intervention strategies should be examined for potential effectiveness on multiple forms of violence through rigorous evaluation. Existing evidence-based approaches should be taken to scale for maximum impact. By seeking to influence the policy and normative context of violence as much as individual behavior, public health can work with the education system, criminal justice system, and other sectors to address the public health burden of interpersonal violence and suicide.

A Content Analysis of Hospitals' Community Health Needs Assessments in the Most Violent U.S. Cities

The emergence of evidence-supported interventions allows hospitals the opportunity to reduce future reinjury among patients who are violently injured. However, hospital knowledge of these interventions and their perceived role in violence prevention is unknown. The Patient Protection and Affordable Care Act created new legal requirements for non-profit hospitals to conduct community health needs assessments (CHNA) every three years to maintain not-for-profit status. In turn, this allows an empiric evaluation of hospital recognition and response to community violence. To do so, this study performed a content analysis of hospital CHNAs from the 20 U.S. cities with the highest violent crime rates. A total of 77 CHNAs were examined for specific violence-related keywords as well as whether violence prevention was listed as a priority community need. Overall, 74% of CHNAs mentioned violence-related terms and only 32% designated violence prevention as a priority need. When discussed, 88% of CHNAs referenced community violence, 42% intimate partner or sexual violence, and 22% child abuse. This study suggests that hospitals may lack awareness of violence as an actionable, preventable public health issue. Further, evidence-based program models are available to hospitals that can reduce the recurrence of assaultive injuries.

Nationwide risk factors for hospital readmission for subsequent injury after motor vehicle crashes

OBJECTIVE

Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital.

METHODS

The Nationwide Readmissions Database for 2010-2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash-related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates.

RESULTS

During the study period, 1,008,991 patients were admitted for motor vehicle-related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.20-1.45; P < .01) and a higher ISS (OR = 1.38; 95% CI, 1.27-1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR = 1.39; 95% CI, 1.32-1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR = 2.49; 95% CI, 1.73-3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR = 1.12; 95% CI, 1.07-1.18; P < .01).

CONCLUSIONS

Nearly a third of patients suffering subsequent motor vehicle crash-related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements.

Arrests Among High-Risk Youth Following Emergency Department Treatment for an Assault Injury

INTRODUCTION

Violence is a leading cause of morbidity and mortality for youth, with more than 600,000 emergency department visits annually for assault-related injuries. Risk for criminal justice involvement among this population is poorly understood. The objective of this study was to characterize arrests among high-risk, assault-injured, drug-using youth following emergency department treatment.

METHODS

Youth (aged 18-24 years) with past 6-month drug use who were seeking emergency department treatment for either an assault or for non-violence reasons were enrolled (December 2009-September 2011) in a 2-year longitudinal study. Arrests in the 24 months following the emergency department visit were analyzed in 2016-2017 using survival analysis of objective Law Enforcement Information Network data. Hazard ratios quantifying the association between risk factors for arrest were estimated using Cox regression.

RESULTS

In the longitudinal cohort, 511 youth seeking emergency department care (assault injury group n=299, comparison group n=212) were aged ≥18 years and were included for analysis. Youth in the assault injury group cohort had a 47% higher risk of arrest than the comparison group (38.1% vs 25.9%, RR=1.47, p<0.05). In unadjusted analyses, male sex, assault injury, binge drinking, drug use disorder, and community violence exposure were all associated with increased risk of arrest during the follow-up period. Cox regression identified that male sex (hazard ratio=2.57), drug use disorder diagnosis (hazard ratio=1.42), assault injury at baseline (hazard ratio=1.63), and community violence exposure (hazard ratio=1.35) increased risk for arrest.

CONCLUSIONS

Drug-using assault-injured youth have high rates of arrest. Emergency department and community interventions addressing substance use and violence involvement may aid in decreasing negative violence and criminal justice outcomes among high-risk youth.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01152970.

Tracking Assault-injured, Drug-using Youth in Longitudinal Research: Follow-up Methods

OBJECTIVES

Violence is one of the leading causes of death among youth ages 14 to 24. Hospital- and emergency department (ED)-based violence prevention programs are increasingly becoming a critical part of public health efforts; however, evaluation of prevention efforts is needed to create evidence-based best practices. Retention of study participants is key to evaluations, although little literature exists regarding optimizing follow-up methods for violently injured youth. This study aims to describe the methods for retention in youth violence studies and the characteristics of hard-to-reach participants.

METHODS

The Flint Youth Injury (FYI) Study is a prospective study following a cohort of assault-injured, drug-using youth recruited in an urban ED, and a comparison population of drug-using youth seeking medical or non-violence-related injury care. Validated survey instruments were administered at baseline and four follow-up time points (6, 12, 18, and 24 months). Follow-up contacts used a variety of strategies and all attempts were coded by type and level of success. Regression analysis was used to predict contact difficulty and follow-up interview completion at 24 months.

RESULTS

A total of 599 patients (ages 14-24) were recruited from the ED (mean ± SD age = 20.1 ± 2.4 years, 41.2% female, 58.2% African American), with follow-up rates at 6, 12, 18, and 24 months of 85.3%, 83.7% 84.2%, and 85.3%, respectively. Participant contact efforts ranged from two to 53 times per follow-up time frame to complete a follow-up appointment, and more than 20% of appointments were completed off site at community locations (e.g., participants' homes, jail/prison). Participants who were younger (p < 0.05) and female (p < 0.01) were more likely to complete their 24-month follow-up interview. Participants who sought care in the ED for assault injury (p < 0.05) and had a substance use disorder (p < 0.01) at baseline required fewer contact attempts to complete their 24-month follow-up, while participants reporting a fight within the immediate 3 months before their 24-month follow-up (p < 0.01) required more intensive contact efforts.

CONCLUSIONS

The FYI study demonstrated that achieving high follow-up rates for a difficult-to-track, violently-injured ED population is feasible through the use of established contact strategies and a variety of interview locations. Results have implications for follow-up strategies planned as part of other violence prevention studies.

Methodological Considerations for Research With Black Male Victims of Violent Injury in an Urban Trauma Unit

There is a body of research over the last three decades that has focused on the etiology of violence among victims of violent injury. This body of literature indicates that Black men are disproportionately represented among victims of violent injury seen in emergency departments and trauma centers across the country. Despite the disproportionate number of low-income young Black men treated for violent injury in urban trauma units and the growing body of literature accompanying it, little is known about the unique methodological challenges violent injury researchers face when conducting research on this vulnerable population in a clinical setting. This article describes the unique and often nuanced methodological difficulties a research team encountered while conducting a longitudinal qualitative study on risk factors for repeat violent injury among low-income young Black male victims of violent injury treated at a Level II trauma center in the Eastern United States. Four methodological challenges are identified: (a) the identification and screening of participants, (b) recruitment and interviewing, (c) understanding hospital culture, policies, and procedures, and (d) retention and attrition of sample. Recommendations to overcome these challenges are offered.

Motivational Interviewing for Victims of Armed Community Violence: A Nonexperimental Pilot Feasibility Study

OBJECTIVE

The present study aimed to develop a novel, hospital-based motivational interviewing (MI) intervention for victims of armed community violence (MI-VoV) targeting patient-specific risk factors for future violence or violent victimization.

METHOD

This uncontrolled pilot feasibility study examined a sample of patients (n = 71) hospitalized due to violent injury at a Level 1 Trauma Center in [Location Redacted for Masked Review] between January 2013 and May 2014. Patients first participated in a brief assessment to identify risk factors for violence/violent injury. A single MI session then targeted risk behaviors identified for each patient. Proximal outcomes, including motivation for change and behaviors to reduce risk, were examined at 2 weeks and 6-12 weeks post-discharge. Distal outcomes, including fighting, weapon-carrying, and gun-carrying, and other violence risk factors were examined at 6-12 week follow-up.

RESULTS

Ninety-five patients were offered participation, 79 (83.2%) agreed to participate, and 73 (76.8%) completed the risk assessment. Of these, 71 had at least one violence/violent injury risk factor. Behaviors to reduce risk were significantly greater at two-week and 6-12 week follow-up (ps < .05). Fighting, weapon-carrying, gun-carrying were significantly reduced at 6-12 week follow-up (p < .05).

CONCLUSIONS

This intervention appears to be feasible to implement and acceptable to patients. A randomized controlled trial evaluating efficacy appears warranted.

Long-term evaluation of a hospital-based violence intervention program using a regional health information exchange

BACKGROUND

Hospital-based violence intervention programs (HVIP) aim to reduce violent-injury recidivism by providing intensive case management services to high-risk patients who were violently injured. Although HVIP have been found effective at reducing recidivism, few studies have sought to identity how long their effects last. Additionally, prior studies have been limited by the fact that HVIP typically rely on self-report or data within their own healthcare system to identify new injuries. Our aim was to quantify the long-term recidivism rate of participants in an HVIP program using more objective and comprehensive data from a regional health information exchange.

METHODS

The study included 328 patients enrolled in Prescription for Hope (RxH), an HVIP, between January 2009 and August 2016. We obtained RxH participants' emergency department (ED) encounter data from a regional health information exchange database from the date of hospital discharge to February 2017. Our primary outcome was violent-injury recidivism rate of the RxH program. We also examined reasons for ED visits that were unrelated to violent injury.

RESULTS

We calculated a 4.4% recidivism rate based on 8 years of statewide data, containing 1,575 unique encounters. More than 96% of participants were matched in the state database. Of the 15 patients who recidivated, only five were admitted for their injury. More than half of new violence-related injuries were treated outside of the HVIP-affiliated trauma center. The most common reasons for ED visits were pain (718 encounters), followed by suspected complications or needing additional postoperative care (181 encounters). Substance abuse, unintentional injuries, and suicidal ideation were also frequent reasons for ED visits.

CONCLUSION

The low, long-term recidivism rate for RxH indicates that HVIPs have enduring positive effects on the majority of participants. Our results suggest that HVIP may further benefit patients by partnering with organizations that work to prevent suicide, substance use disorders, and other unintentional injuries.

LEVEL OF EVIDENCE

Therapeutic study, level III.

A decade of hospital-based violence intervention: Benefits and shortcomings

INTRODUCTION

Initial analyses of hospital-based violence intervention programs (VIPs) have demonstrated decreased violent injury recidivism. Long-term VIP performance has not been assessed. Violence intervention program quality improvement requires evaluation to identify shortcomings and client subpopulations warranting additional resources. We evaluated our case manager-based VIPs to identify modifiable risk factors that most impact violent injury recidivism and determine subpopulations that need modification of targeted services.

METHODS

Data on demographic variables, socioeconomic factors, needs, and injury recidivism from 2005 to 2014 were collected through our VIP database. Possible client needs included housing, education, employment, court advocacy, driver's license obtainment, and "other." Case managers assessed needs as "not needed," "identified (unmet)," and "met." χ And nonparametric tests were used to identify factors associated with recidivism reduction.

RESULTS

Over the 10-year period, 466 clients were enrolled in VIP. During the program period, the violent reinjury rate was 4%, as compared with a historical control of 8% from 2000 to 2004. Women had lower rates of reinjury than men (3% vs 13%, respectively, p = 0.023). Blacks had the lowest recidivism (2%, p < 0.0001), whereas a higher rate (11%) was observed among Latinos. Although a minority of clients (5%), 100% of white clients were reinjured. Mental health services (51%), victim-of-crime compensation (48%), employment (36%), and housing (30%) were the most frequently identified needs. Expressing the need for education was significantly associated with likelihood of reinjury, an effect that was completely reversed when the need was met.

CONCLUSION

This evaluation of a VIP demonstrates sustained recidivism reduction and success in addressing client needs from a traditionally underserved population. Efforts to identify and address root causes of Latino and white client reinjury should be increased. Violence intervention program prioritization of housing needs may reduce future reinjury. This study demonstrating sustainable success underscores the importance of increased integration of VIP into trauma centers nationally.

LEVEL OF EVIDENCE

Therapeutic study, level III.

The effects of health care-based violence intervention programs on injury recidivism and costs: A systematic review

BACKGROUND

Youth violence affects thousands annually, with homicide being the third leading cause of death for those aged 10 to 24 years. This systematic review aims to evaluate the published evidence for the effects of health care-based violence intervention programs (VIPs), which focus on reducing recurrent presentations for injury due to youth violence ("recidivism").

METHODS

Health literature databases were searched. Studies were retained if peer reviewed and if programs were health care based, focused on intentional injury, addressed secondary or tertiary prevention (i.e., preventing recidivism and reducing complications), included participants aged 14 to 25 years, had greater than 1-month follow-up, and evaluated outcomes. Studies of child and sexual abuse and workplace, intimate partner, and self-inflicted violence were excluded. Extracted data subject to qualitative analysis included enrollment and retention, duration of follow-up, services provided, statistical analysis, and primary and intermediate outcomes.

RESULTS

Of the 2,144 citations identified, 22 studies were included in the final sample. Twelve studies were randomized controlled trials representing eight VIPs. Injury recidivism was assessed in six (75%) of eight programs with a significant reduction in one (17%) of six programs. Of the randomized controlled trials showing no difference in recidivism, all were either underpowered or did not include a power analysis. Two observational studies also showed significant reduction in recidivism. Significant intermediate outcomes included increased service use, attitude change, and decreases in violence-related behavior. Reductions in injury recidivism led to reductions in health care and criminal justice system costs.

CONCLUSIONS

Three studies showing reduced injury recidivism and several studies showing positive intermediate outcomes identify VIPs as a promising practice. Many studies were limited by poor methodological quality, including high losses to follow-up.

LEVEL OF EVIDENCE

Systematic review, level III.

A prospective randomized study of the efficacy of "Turning Point," an inpatient violence intervention program

BACKGROUND

From 2002 to 2011, there were more than 17,000 shootings in Philadelphia. "Turning Point," Temple University Hospital's inpatient violence intervention program, takes advantage of the teachable moment that occurs after violent injury. In addition to receiving traditional social work services, Turning Point patients watch their trauma bay resuscitation video and a movie about violence, meet with a gunshot wound survivor and an outpatient case manager, and also undergo psychiatric assessment. The purpose of this study was to determine the efficacy of Turning Point in changing attitudes toward guns and violence among victims of penetrating trauma.

METHODS

This prospective randomized study was conducted from January 2012 to January 2014. Patients who sustained a gunshot or stab wound were randomized to standard of care, which involved traditional social work services only, or Turning Point. The Attitudes Toward Guns and Violence Questionnaire was administered to assess attitude change. Analysis was performed with repeated-measures analysis of variance. A p < 0.05 was significant.

RESULTS

A total of 80 of a potential 829 patients completed the study (40 standard of care, 40 Turning Point). The most common reason for exclusion was anticipated length of stay being less than 48 hours. The two groups were similar with respect to most demographics. Unlike the standard-of-care group, the Turning Point group demonstrated a 50% reduction in aggressive response to shame, a 29% reduction in comfort with aggression, and a 19% reduction in overall proclivity toward violence.

CONCLUSIONS

Turning Point is effective in changing attitudes toward guns and violence among victims of penetrating trauma. Longer follow-up is necessary to determine if this program can truly be a turning point in patients' lives.

LEVEL OF EVIDENCE

Therapeutic/care management study, level II.

Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk

BACKGROUND

Interpersonal firearm violence among youth is a substantial public health problem, and emergency department (ED) physicians require a clinical screening tool to identify high-risk youth.

OBJECTIVE

To derive a clinically feasible risk index for firearm violence.

DESIGN

24-month prospective cohort study.

SETTING

Urban, level 1 ED.

PARTICIPANTS

Substance-using youths, aged 14 to 24 years, seeking ED care for an assault-related injury and a proportionately sampled group of non-assault-injured youth enrolled from September 2009 through December 2011.

MEASUREMENTS

Firearm violence (victimization/perpetration) and validated questionnaire items.

RESULTS

A total of 599 youths were enrolled, and presence/absence of future firearm violence during follow-up could be ascertained in 483 (52.2% were positive). The sample was randomly split into training (75%) and post-score-construction validation (25%) sets. Using elastic-net penalized logistic regression, 118 baseline predictors were jointly analyzed; the most predictive variables fell predominantly into 4 domains: violence victimization, community exposure, peer influences, and fighting. By selection of 1 item from each domain, the 10-point SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score was derived. SaFETy was associated with firearm violence in the validation set (odds ratio [OR], 1.47 [95% CI, 1.23 to 1.79]); this association remained (OR, 1.44 [CI, 1.20 to 1.76]) after adjustment for reason for ED visit. In 5 risk strata observed in the training data, firearm violence rates in the validation set were 18.2% (2 of 11), 40.0% (18 of 45), 55.8% (24 of 43), 81.3% (13 of 16), and 100.0% (6 of 6), respectively.

LIMITATIONS

The study was conducted in a single ED and involved substance-using youths. SaFETy was not externally validated.

CONCLUSION

The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse R01024646.

Violent reinjury risk assessment instrument (VRRAI) for hospital-based violence intervention programs

BACKGROUND

Violent injury is the second most common cause of death among 15- to 24-year olds in the US. Up to 58% of violently injured youth return to the hospital with a second violent injury. Hospital-based violence intervention programs (HVIPs) have been shown to reduce injury recidivism through intensive case management. However, no validated guidelines for risk assessment strategies in the HVIP setting have been reported. We aimed to use qualitative methods to investigate the key components of risk assessments employed by HVIP case managers and to propose a risk assessment model based on this qualitative analysis.

MATERIALS AND METHODS

An established academic hospital-affiliated HVIP served as the nexus for this research. Thematic saturation was reached with 11 semi-structured interviews and two focus groups conducted with HVIP case managers and key informants identified through snowball sampling. Interactions were analyzed by a four-member team using Nvivo 10, employing the constant comparison method. Risk factors identified were used to create a set of models presented in two follow-up HVIP case managers and leadership focus groups.

RESULTS

Eighteen key themes within seven domains (environment, identity, mental health, behavior, conflict, indicators of lower risk, and case management) and 141 potential risk factors for use in the risk assessment framework were identified. The most salient factors were incorporated into eight models that were presented to the HVIP case managers. A 29-item algorithmic structured professional judgment model was chosen.

CONCLUSIONS

We identified four tiers of risk factors for violent reinjury that were incorporated into a proposed risk assessment instrument, VRRAI.

Trauma Center Youth Violence Screening and Brief Interventions: A Multisite Pilot Feasibility Study

Every day, 16 American youths between the ages of 10 and 24 years are murdered; 84% of these fatalities involve a firearm. Nearly half of traumatic youth deaths result from violence-related injuries. In 2013, 580,250 youth suffered nonfatal, assault-related injuries, necessitating emergency department treatment. The aim of this multisite pilot study was to examine the process, feasibility, and challenges of violence brief interventions (VBIs). The participants were youth between 15 and 25 years of age, at 2 major Level 1 trauma centers (TCs; TC1, TC2) in the Southeastern United States. Eligible participants (N = 38; TC1: n = 20, TC2: n = 18) received at least 1 VBI during their hospital stay, which provided information about individual screening results and elicited patients' perspectives on violent and risky behaviors. More participants at TC2 than at TC1 completed 2 VBI sessions. Barriers to and support of implementation were identified at both sites, and factors for improving implementation were identified, including the need for staff support through clinical guidelines and coordinated prevention and outreach programs. Further research is needed to identify factors for successful implementation of VBIs in TCs.

Marijuana use trajectories among drug-using youth presenting to an urban emergency department: Violence and social influences

AIMS

This paper examined longitudinal marijuana use trajectories among drug-using youth presenting to the ED to inform intervention development.

METHODS

Given interest in substance use and violence, this study oversampled those presenting with assault injuries. Assault-injured youth (ages 14-24) endorsing past 6-month drug use (n=349), and a sex and age proportionally-sampled comparison group (n=250) endorsing drug use, completed a baseline assessment and follow-ups at 6, 12, 18, and 24 months. Latent class trajectory analyses examined days of marijuana use over 2 years. Multinomial regression analyses examined baseline, 12-month and 24-month factors associated with substance use trajectory groups.

RESULTS

Trajectory analyses identified 5 groups: Low (Low; 28.2%; n=169); Intermittent (INT; 16.2%; n=97); Moderate Decline (MD; 12.0%; n=72); High decline (HD, 13.2%; n=79) and Chronic (C; 30.4%; n=182). At baseline, as compared to the Low group, the other trajectory groups were more likely to be male and have greater levels of physical aggression. At 12- and 24-months, negative and positive peer influences, incarceration and community violence were additional characteristics associated with the greater marijuana use trajectories (as compared to the Low group).

CONCLUSIONS

Interventions for drug-using youth presenting to the urban ED should address peer influences, physical aggression and community violence exposure, given the association between these characteristics and greater marijuana use trajectories.

Trauma Center Based Youth Violence Prevention Programs: An Integrative Review

OBJECTIVE

Youth violence recidivism remains a significant public health crisis in the United States. Violence prevention is a requirement of all trauma centers, yet little is known about the effectiveness of these programs. Therefore, this systematic review summarizes the effectiveness of trauma center-based youth violence prevention programs.

METHODS

A systematic review of articles from MEDLINE, CINAHL, and PsychINFO databases was performed to identify eligible control trials or observational studies. Included studies were from 1970 to 2013, describing and evaluating an intervention, were trauma center based, and targeted youth injured by violence (tertiary prevention). The social ecological model provided the guiding framework, and findings are summarized qualitatively.

RESULTS

Ten studies met eligibility requirements. Case management and brief intervention were the primary strategies, and 90% of the studies showed some improvement in one or more outcome measures. These results held across both social ecological level and setting: both emergency department and inpatient unit settings.

CONCLUSIONS

Brief intervention and case management are frequent and potentially effective trauma center-based violence prevention interventions. Case management initiated as an inpatient and continued beyond discharge was the most frequently used intervention and was associated with reduced rearrest or reinjury rates. Further research is needed, specifically longitudinal studies using experimental designs with high program fidelity incorporating uniform direct outcome measures. However, this review provides initial evidence that trauma centers can intervene with the highest of risk patients and break the youth violence recidivism cycle.