Association of Legal Intervention Injuries With Race and Ethnicity Among Patients Treated in Emergency Departments in California

Emergency department documentation of legal intervention injuries at a Washington, DC, hospital

BACKGROUND

The U.S. Centers for Disease Control and Prevention (CDC) defines legal intervention injuries as injuries caused by law enforcement agents in the course of official duties. Public health databases utilize International Classification of Diseases, 10th Revision (ICD-10), coding to collect these data through the "Y35" family ICD-10 code. Prior studies report deficiencies in public health recording of fatal legal intervention injuries. Few studies have characterized nonfatal injuries. This study investigates emergency department (ED) capture of legal intervention injury diagnostic coding.

METHODS

A retrospective chart review was performed on ED encounter data from January 1, 2017, to June 30, 2019, at an academic hospital in Washington, DC. Charts were identified using a keyword search program for "police." Chart abstracters reviewed the flagged charts and abstracted those that met injury definition. Primary outcomes included injury severity, patient demographics, and documented ICD-10 codes. One sample proportion testing was performed comparing sample census ED data.

RESULTS

A total of 340 encounters had sufficient descriptions of legal intervention injuries. A total of 259 had descriptions consistent with the patient specifier of "suspect." Hospital coders recorded 74 charts (28.6%) with the Y35 family legal intervention injury code. A total of 212 involved a Black patient. A total of 122 patients had Medicaid and 94 were uninsured. Black patients made up a higher proportion of individuals in the "suspect identified legal intervention injury" group than the total population (0.819 vs. 0.609, p < 0.01, 95% CI 0.772-0.866). Patients with Medicaid or who were uninsured made up substantial proportions as well (0.471 vs. 0.175, p < 0.01, 95% CI 0.410-0.532 for Medicaid patients and 0.363 vs. 0.155, p < 0.01, 95% CI 0.304-0.424 for the uninsured patients).

CONCLUSION

A large proportion of nonfatal legal intervention injuries remain unreported. Black and low-income patients are disproportionately affected. More research is needed but benefits from interprofessional data sharing, injury pattern awareness, and diagnostic coding guidance may improve reporting.

Fatal and non-fatal civilian injuries sustained during law enforcement-reported encounters in California, 2016-2021

BACKGROUND

In 2015, California passed AB 71 to create a state-wide Use of Force Incident Reporting Database (URSUS) to tabulate law enforcement-reported encounters that resulted in serious bodily injury, death or discharge of a firearm. We use these data to analyse encounters that resulted in fatal and non-fatal civilian injuries in California between 2016 and 2021.

METHODS

We performed a retrospective review of URSUS from January 2016 to December 2021. The main outcomes were the number of law enforcement encounters that involved civilian serious bodily injury or death and encounter-level characteristics.

RESULTS

URSUS recorded 3677 incidents between 2016 and 2021 resulting in 942 civilian fatalities and 2735 instances of serious civilian injuries. Injury rates were highest for civilians who identified as Hispanic (1.80 injuries per 100 000 population) or black (5.17 injuries per 100 000 population). Injuries involving a firearm were usually fatal (58.9% fatality rate; 1471 injuries), while non-firearm incidents were more likely to result in serious injuries (4.2% fatality rate; 2929 injuries). We did not find statistically significant trends in rates of civilian injuries per 100 000 population.

CONCLUSION

Rates of law enforcement-related injuries were highest for Hispanic and black civilians in California between 2016 and 2021 and firearm-related injuries were overwhelmingly fatal. The URSUS database represents an important effort by law enforcement agencies to collect information on injuries and fatalities resulting from law enforcement encounters. Given similar databases exist in fewer than half of states, additional legislative efforts are needed to improve systematic national data collection on these encounters.

Relationship between Civilian Injuries Caused during Contact with Law Enforcement and Community-Level Sociodemographic Characteristics

Civilian injuries caused during contact with law enforcement personnel erode community trust in policing, impact individual well-being, and exacerbate existing health inequities. We assessed the relationship between ZIP code-level rates of civilian injuries caused during legal interventions and community-level sociodemographic characteristics using Illinois hospital data from 2016 to 2022. We developed multivariable Poisson regression models to examine whether legal intervention injury rates differed by race-ethnicity and community economic disadvantage across three geographic regions of Illinois representing different levels of urbanization. Over the study period, 4976 civilian injuries were treated in Illinois hospitals (rate of 5.6 per 100,000 residents). Compared to non-Hispanic white residents, non-Hispanic Black residents demonstrated 5.5-10.5 times higher injury rates across the three geographic regions, and Hispanic-Latino residents demonstrated higher rates in Chicago and suburban Cook County, but lower rates in the rest of the state. In most regions, models showed that as the percent of minority residents in a ZIP code increased, injury rates among non-Hispanic Black and Hispanic-Latino residents decreased. As community economic disadvantage increased at the ZIP code level, civilian injury rates increased. Communities with the highest injury rates involving non-Hispanic white residents were significantly more economically unequal and disadvantaged. While the injury rates were consistently and substantially higher among non-Hispanic Black residents throughout the state, the findings illustrate that the association between overall civilian injuries caused during contact with law enforcement and community sociodemographic characteristics varied across regions. Data on local law enforcement agency policies and procedures are needed to better identify appropriate interventions.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Reducing Firearm Injury and Death in the United States

Firearms injury is a major cause of American morbidity and mortality. Although the firearm is a common vector, the intentions with which it is used represent a wide array of social ills-suicide, community violence, domestic violence, mass shootings, legal intervention, and unintended injury. The political and social underpinnings of this epidemic are inseparable from its prevention measures. Surgeons have an important role in firearm policy, research, prehospital and hospital advances, trauma survivor networks, and hospital-based violence prevention programs. It is only through interdisciplinary, multilevel, evidence-based prevention measures that the tides will turn on American firearm injury.

Association of Residential Racial and Ethnic Segregation With Legal Intervention Injuries in California

IMPORTANCE

The continued harm of Black individuals in the US by law enforcement officers calls for reform of both law enforcement officers and structural racism embedded in communities.

OBJECTIVE

To examine the association between county characteristics and racial and ethnic disparities in legal intervention injuries.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional study was conducted among 27 671 patients presenting to California hospitals from January 1, 2016, to December 31, 2019, with legal intervention injuries (defined as any injury sustained as a result of an encounter with any law enforcement officer) as identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

MAIN OUTCOMES AND MEASURES

Legal intervention injuries were classified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision external cause of injury code Y35. Expected injury counts were calculated for each county by multiplying statewide median rates of injury per capita for each age-racial and ethnic group, and then observed to expected injury ratios were measured. The association between county injury ratio, percentage of Black individuals, and residential segregation (measured using an index of dissimilarity) was modeled, stratifying by race and ethnicity.

RESULTS

A total of 27 671 patients (24 159 male patients [87.3%]; 1734 Asian and Pacific Islander [6.3%], 5049 Black [18.2%], 11 250 Hispanic [40.7%], and 9638 White [34.8%]; mean [SD] age, 34.2 [12.5] years) presented with legal intervention injuries in California from 2016 to 2019. Observed to expected injury ratios ranged from 0 to 7 for Black residents and from 0 to 5 for White residents. High observed to expected injury ratios for Black residents (408 observed vs 60 expected; ratio = 7) were clustered around San Francisco Bay Area counties and corresponded with a higher proportion of Black residents. High observed to expected injury ratios for White residents (57 observed vs 11 expected; ratio = 5) clustered around rural northern California counties and corresponded with higher mean percentage of residents with income below the federal poverty level and fewer urban areas.

CONCLUSIONS AND RELEVANCE

This study suggests that residential segregation may be associated with increased legal intervention injury rates for Black residents of California counties with a large percentage of Black residents. Reform efforts to address racial and ethnic disparities in these injuries should carefully consider and address the legacy of discriminatory policies that has led to segregated communities in California and the United States.

Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury

Purpose of Review

Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care.

Recent Findings

Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential.

Summary

A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.

Firearm injuries during legal interventions Nationwide analysis

INTRODUCTION

There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action.

METHODS

Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims.

RESULTS

A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]).

CONCLUSION

Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials.

LEVEL OF EVIDENCE

Epidemiologic, level IV.

Occurrence of fatal police violence during pregnancy and hazard of preterm birth in California

BACKGROUND

Exposure to fatal police violence may play a role in population-level inequities in risk for preterm delivery.

OBJECTIVE

To evaluate whether exposure to fatal police violence during pregnancy affects the hazard of preterm delivery and whether associations differ by race/ethnicity and fetal sex.

METHODS

We leveraged temporal variation in incidents of fatal police violence within census tracts to assess whether occurrence of fatal police violence in a person's tract during pregnancy was associated with increased hazard of extremely (20-27 weeks), early (28-31 weeks), moderate (32-33 weeks), and late (32-36 weeks) preterm delivery in California from 2007 to 2015. We used both death records and the Fatal Encounters database to identify incidents of fatal police violence. We estimated hazard ratios (HR) using time-varying Cox proportional hazard models stratified by census tract, controlling for age, race/ethnicity, educational attainment, health insurance type, parity, and the year and season of conception. We further stratified by race/ethnicity and infant sex to evaluate whether there were differential effects by these characteristics.

RESULTS

Exposure to an incident of fatal police violence was associated with a small increase in the hazard of late preterm birth using both the death records (N = 376,029; hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.00, 1.10) and the Fatal Encounters data (N = 938,814; HR 1.03, 95% CI 1.00, 1.06). We also observed an association for moderate preterm birth in the Fatal Encounters data (HR 1.06, 95% CI 0.98, 1.15). We did not observe associations for early or extremely preterm birth in either data source. Larger relative hazards of moderate (HR 1.25, 95% CI 0.93, 1.68) and late preterm delivery (HR 1.18, 95% CI 1.05, 1.33) were observed among Black birth parents with female births in the Fatal Encounters data.

CONCLUSIONS

Preventing police use of lethal force may reduce preterm delivery in communities where such violence occurs.

Diversity, equity, and inclusion interventions to support admissions have had little benefit to Black students over past 20 years

The United States has a history of systemic racism and violence toward minority communities. Unfortunately, the last year has demonstrated that systemic racism, and its consequences, persist. The dental profession has also failed to adequately resolve known issues of racial inequity and systemic racism, with persistent disparities in oral health outcomes for Black Americans compared to all other Americans, underrepresentation of minorities in the profession, and barriers to entry. However, dental education has the opportunity to address these issues. Current accreditation standards do not specifically address racial diversity among the student body, yet it is clear that representation of a population matters and the lack of representation may exacerbate race and racism as public health issues in dentistry. To explore the issue, we curated American Dental Education Association (ADEA) data on the race of students admitted and enrolled into dental programs across the United States. We used data visualization techniques to present the data and study trends. While the number of Black and African American (BAA) enrollees in dental schools has increased between 2000 and 2019, this population continues to make up a disproportionately small percentage of all enrollees, relative to the BAA percentage in the U.S. population. Much of the increase in BAA enrollment is attributable to increased places (due to the opening of new schools and increased class size in established schools) and the rate of acceptance of BAA students has had limited improvement. Very little progress has been accomplished in growing the enrollment of BAA applicants to dental school in 20 years. As a profession, we also fail to grow interest among our graduates in careers that may support historically underrepresented and marginalized racial groups-public health, rural practice, population research, academia, and health policy. This may be a contributing factor to the oral health disparities faced by Black Americans and have implications for dental education.

Racial Differences in Hospital Evaluation After the Use of Force by Police: a Tale of Two Cities

OBJECTIVE

To determine whether racial or sex bias or the number of officers influences the chances of reported injury or hospital evaluation after the use of less than lethal force by law enforcement.

METHODS

Retrospective cohort study of 12,326 incidents of less than lethal force in Indianapolis, Indiana (2014-2018), and Wichita, Kansas (2008-2018).

RESULTS

Injuries to non-White persons are under-reported (Indianapolis Pr ≤ 0.003; Wichita Pr ≤ 0.000) and non-White persons are less likely to be referred for hospital evaluation after the use of force (Indianapolis OR 0.57, CI 0.45-0.72, Wichita OR 0.66, CI 0.48-0.92). In Indianapolis, the presence of more than one officer significantly reduced the odds of hospitalization after both injury and serious injury (OR 0.48, CI 0.36-0.64 for injury, OR 0.22, CI 0.12-0.39 for serious injury). For both cities, an estimated 25% more non-White persons who were subject to the use of force should have been evaluated in a hospital than actually were.

CONCLUSIONS

Significant racial disparities exist in the reporting of injuries and in the access to care after the use of force by law enforcement.

IMPLICATIONS

Policies, procedures, and training need to be amended to correct the disparities in access to care after the use of force. Access to sequestered law enforcement data is imperative to assess the extent of these disparities nationwide.

Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex

We use data on police-involved deaths to estimate how the risk of being killed by police use of force in the United States varies across social groups. We estimate the lifetime and age-specific risks of being killed by police by race and sex. We also provide estimates of the proportion of all deaths accounted for by police use of force. We find that African American men and women, American Indian/Alaska Native men and women, and Latino men face higher lifetime risk of being killed by police than do their white peers. We find that Latina women and Asian/Pacific Islander men and women face lower risk of being killed by police than do their white peers. Risk is highest for black men, who (at current levels of risk) face about a 1 in 1,000 chance of being killed by police over the life course. The average lifetime odds of being killed by police are about 1 in 2,000 for men and about 1 in 33,000 for women. Risk peaks between the ages of 20 y and 35 y for all groups. For young men of color, police use of force is among the leading causes of death.