Morbidity and injury recurrence in victims of firearm injuries

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.

Readmission risk and costs of firearm injuries in the United States, 2010-2015

BACKGROUND

In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms.

METHODS

We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs.

RESULTS

Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%.

CONCLUSIONS

From 2010-2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this.

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.

Teenage Trauma Patients Are at Increased Risk for Readmission for Mental Diseases and Disorders

BACKGROUND

Most studies of readmission after trauma are limited to single institutions or single states. The purpose of this study was to determine the risk factors for readmission after trauma for mental illness including readmissions to different hospitals across the United States.

MATERIALS AND METHODS

The Nationwide Readmission Database for 2013 and 2014 was queried for all patients aged 13 to 64 y with a nonelective admission for trauma and a nonelective readmission within 30 d. Multivariable logistic regression was performed for readmission for mental diseases and disorders.

RESULTS

During the study period, 53,402 patients were readmitted within 30 d after trauma. The most common major diagnostic category on readmission was mental diseases and disorders (12.1%). The age group with the highest percentage of readmissions for mental diseases and disorders was 13 to 17 y (38%). On multivariable regression, the teenage group was also the most likely to be readmitted for mental diseases and disorders compared to 18-44 y (odds ratio [OR] 0.45, P < 0.01) and 45-64 y (OR 0.24, P < 0.01). Other high-risk comorbidities included HIV infection (OR 2.4, P < 0.01), psychosis (OR 2.2, P < 0.01), drug (OR 2.0, P < 0.01), and alcohol (OR 1.4, P < 0.01) abuse.

CONCLUSIONS

Teenage trauma patients are at increased risk for hospital readmission for mental illness. Efforts to reduce these admissions should be targeted toward individuals with high-risk comorbidities such as HIV infection, psychosis, and substance abuse.

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.

Prevalence and predictors of mental disorders in intentionally and unintentionally injured emergency center patients

Little is known about the prevalence and predictors of mental disorders among injured emergency center (EC) patients in low- and middle-income countries (LMICs). Patients presenting with either an intentional or unintentional injury were recruited (N = 200). Mental health, injury, and psychological trauma histories were assessed. Descriptive statistics and logistic regressions were conducted, and predictors of current mental disorder were identified. Diagnostic criteria for a current mental disorder, including substance use disorders, were met by 59.5% of the participants. Compared with those with an unintentional injury, the intentionally injured participants were more likely to be diagnosed with a current mental disorder (66.9% vs. 48.8%, p = .01). High frequencies of previous intentional injuries predicted for current mental disorder (OR = 1.46, 95% CI 1.08-1.98), whereas male gender and witnessed community violence predicted substance use disorder diagnoses. The findings indicate that injured EC patients, particularly those with intentional injuries, are at risk for mental disorders. Psychosocial interventions in the EC context can potentially make an important contribution in reducing the burden of mental disorders and injuries in LMICs.

Late death after multiple severe trauma: when does it occur and what are the causes?

INTRODUCTION

The information about the long-term mortality and causes of death after multiple injuries is sparse. In general, most follow-up studies report on 1 year to 3 years maximum follow up. The current literature focuses on causes of death immediately after trauma or during the initial in-hospital stay. We report on long-term mortality and causes of death in patients with multiple injures up to 30 years after the initial injury.

METHODS AND MATERIAL

We analyzed the causes of death using patient files, inquiries of patients' relatives, and death certificates. Inclusion criteria are (1) polytrauma (PT) (Injury Severity Score > or = 16) between 1973 and 1990; (2) age 3 years to 60 years at injury; (3) admission to the hospital alive; and (4) death during the study period. Patients were separated into two groups: patients deceased during the initial hospital stay (in-hospital deaths, n = 408) and patients deceased after discharge (postdischarge deaths, n = 103). The survival of the PT victims was compared descriptively with age- and gender-matched data from the general population (GP).

RESULTS

Causes of death in in-hospital deaths are head injury (37%), adult respiratory distress syndrome (14%), sepsis (11%), hemorrhagic shock (10%), pneumonia (9%), multiple organ failure (9%), and others (10%). Causes of death after discharge included cardiovascular diseases (23%), second major trauma (19%), neurologic diseases (16%), suicide (10%), malignancies (6%), and others (26%). The analysis of survival showed a higher mortality for PT compared with the GP group during the first year after the event (p < 0.05). Between 2 years and 10 years after the event, the annual mortality of the PT-group approximates the GP group.

CONCLUSION

PT patients who die after discharge from the initial hospitalization show other causes of death than age-matched controls of the general population. Among these are second major trauma and suicide. Future studies should investigate whether certain social or psychologic factors might play a role.

A psychiatric and social matched case series comparison of victims of criminal homicide and homicide perpetrators in Sweden

The aim of the present study was to compare the psychosocial profiles of criminal homicide victims with those of a matched sample of perpetrators. The hypothesis was that chance determines whether someone becomes a victim or a perpetrator. In a retrospective examination of forensic psychiatric records as well as hospital records, the following variables were studied: nationality, education, substance abuse and psychiatric diagnoses. A comparative study was performed of 88 perpetrators and 83 victims in Sweden during a time period of 17 years (1978-1994). All subjects had been treated as psychiatric inpatients before the homicide. The results support the hypothesis that perpetrators and victims of homicide are similar with regard to psychiatric morbidity and social functioning. The majority were born in Sweden, and the educational level was low in both groups. Substance abuse was common in both groups: 96.7% of male and 65.3% of female victims compared with 76.6% of male and 75% of female perpetrators. Many in both of the groups had criminal records. The only major difference between the groups was recorded for psychotic disorder diagnoses, with a higher rate among perpetrators as well as a lower rate of substance abuse in this group.

Trends in hospitalization for firearm-related injury in Finland from 1990 to 2003

BACKGROUND

The firearm-related mortality in Finland is one of the highest in Europe. The study objective was to describe the incidence trends and nature of firearm-related injury hospitalizations in Finland between 1990 and 2003.

METHODS

We included all firearm-related injury hospitalizations between 1990 and 2003. The data were obtained from the Finnish National Hospital Discharge Register. Only events with traumatic physical injuries were included.

RESULTS

The overall incidence of firearm-related injury hospitalization was 5.1 (95% confidence interval [CI]: 34.5-5.7) per 100,000 person-years in 1990 and 2.6 (95% CI: 2.1-3.0) in 2003. The absolute numbers were 254 and 133, respectively. Unintentional injuries accounted for 44% of injuries during the study period. Hospitalization incidence resulting from intentional firearm-related injuries (self-inflicted and assault) remained unaltered over the study period. Men's injury incidence was 10.0 times (95% CI: 8.8-11.4) that of women's. Young men aged 15 to 34 years displayed the highest incidence figures. The most common types of the firearm-related injuries were open wounds (52%) and fractures (17%). Anatomically they involved the head and the neck (35%), the lower limb (28%), and the trunk (19%).

CONCLUSIONS

Although the total incidence of firearm-related injuries decreased in Finland during the 14-year study period, the incidence of intentional firearm-related injuries remained at the same level. Finding information on the risk factors of firearm-related injuries and the reasons for the steady level of intentional injuries are the next steps toward preventive measures.

Outcome and Quality of Life 5 Years After Major Trauma

BACKGROUND

This study aimed to determine quality of life after injury and identify factors potentially associated with outcome.

METHODS

Five years after injury from blunt or penetrating trauma, patients received a questionnaire based on the SF-36 Health Survey.

RESULTS

Two hundred five patients (83%) replied. Most were men, median age 39 years, 93% injured by blunt energy, median Injury Severity Score 14 (range 9-57). Mean SF-36 scores were significantly lower than in a matched reference group. Poor outcome was associated with: in-hospital days, intensive care days, surgical procedures, in-hospital major complications, age, recurrent injury, and inadequate information. Subjects reported considerable physical (68%) and psychologic (41%) disabilities. Near half reported need of improved follow-up care. Injury severity did not predict poor health-related quality of life 5 years later.

CONCLUSION

Adequate information, sufficient pain management and follow-up by trauma specialist teams are needed. Certain factors can help identify patients in need of additional help and support.

Injury hospitalization and risks for subsequent self-injury and suicide: a national study from New Zealand

OBJECTIVES

Risks for suicide and nonfatal self-injury hospitalizations associated with previous injury hospitalizations were investigated in a nationwide retrospective cohort study conducted in New Zealand.

METHODS

Linked data from all New Zealand public hospitals were used to identify individuals with injury hospitalizations. Participants were followed for 12 months.

RESULTS

Significantly increased age- and sex-adjusted relative risks for suicide were associated with previous hospitalization for self-injury, injuries of undetermined causes, and assault. Also, elevated risks were associated with these causes of hospitalization in the case of subsequent self-injury hospitalizations.

CONCLUSIONS

Results indicate that identifiable subgroups of individuals hospitalized for injuries are at marked risk for serious suicidal behavior and suggest the potential of targeted suicide prevention for these individuals.

Fatal firearm injuries in Finland: a nationwide survey

BACKGROUND AND AIMS

Treatment of life-threatening firearm injuries represents major challenges to the involved medical staff. The aim of the study was to assess numbers, natures and injury patterns of fatal incidents by firearms in Finland over a 10-year period.

MATERIAL AND METHODS

Retrospective analysis of all firearm-related deaths during the 10-year period from January 1990 to December 1999. Death certificates were obtained and reviewed with detailed analysis of non-suicidal deaths.

RESULTS

Over the 10-year period 1990 to 1999, 452 individuals (equivalent to 1.8 cases per 100 000 person-years) died in Finland as a result of accidental or violent shooting. There were no significant changes in numbers of cases from year to year. The male-female ratio was 7:3. The mean age of the victims was 32 years. The shooting incident had been classified as an assault in 78% of cases. Its nature was unspecified in 13% of cases and clearly accidental in 9%. The predominant anatomical site of fatal injury following assault was the chest in 43%, the head in 42% and the abdomen in 8% of the cases. After accidental or unspecified nature shooting, the predominant site of injury was the head in 68%, followed by the chest in 16% and the abdomen in 10% of the cases. Most victims (86%) died at the scene of the shooting. Only 14% were alive at hospital admittance. Most hospitalised victims died within 24 hours of admission.

CONCLUSIONS

The annual incidence of fatal non-suicidal firearm injuries did not change significantly in Finland between 1990 and 1999. Victims of such injuries required only minimal hospital resources because in most cases they died at the scene of the shooting. The results of the study reported indicate that efforts to prevent fatal injuries from use of firearms or diminish their number should be focused mainly on prevention of firearm related assault.

Characteristics of the trauma recidivist: an exploratory descriptive study

INTRODUCTION

The purpose of this study was to identify characteristics and perceptions of trauma recidivists. Information obtained from this study will help health care professionals better understand trauma patients and design more effective trauma prevention programs.

METHODS

An exploratory descriptive, correlational design was used. A convenience sample of 100 trauma patients entering a midwestern university medical center were studied. A demographic chart review and a personal interview consisting of 29 questions were conducted for each subject. The interview questions sought information regarding high-risk behavior, risk-taking personality traits, safety precautions used, and social, psychological, and environmental factors surrounding the patient's traumatic event.

RESULTS

Thirty-six percent of trauma patients studied were recidivists. The recidivist was more likely to be male, younger than 45 years, a member of a racial minority, single, uninsured, and have less than 12 years of education. Behavioral characteristics common to most recidivists included a history of past arrests, illegal drug use, and having witnessed past violent injuries.

DISCUSSION

Trauma remains one of the most devastating diseases facing americans. Characteristics of trauma recidivists have been identified, and further research is needed to test possible interventions to curb the unnecessary trauma injuries that occur every day.

Women and injuries--factors influencing recovery

This study focuses on female patients of working age, hospitalized due to moderate, mostly orthopaedic injuries. The aim was to highlight the medical and non-medical factors affecting outcome. Two groups of women, those who 12 months after the injury reported disability within at least three out of five possible areas (work, family, household, social life and leisure-time; n = 34), were compared with women reporting disability within two areas or less (n = 59). Four factors were predictive of outcome according to the multivariate analysis: injury severity as measured by the Abbreviated Injury Scale (AIS), self-perceived injury-related mental and physical health measured by the Visual Analogue Scale (VAS) during hospitalization and a history of three or more previous injuries requiring medical care. Sociodemographic background factors did not affect the outcome. By integrating information from AIS and VAS with the number of previous injuries, three quarters of the women were correctly classified; i.e., it was possible to detect a majority of those reporting a poorer outcome one year after the injury already during hospitalization. Simple screening instruments like these seem to be useful in the early detection of vulnerable patients. This study further suggests that more attention should be paid to non-medical factors, the importance of which may have been underestimated regarding a poorer outcome among female patients hospitalized due to injuries. Thus, psychosocial support should not only be offered to patients with major trauma or an obvious psychiatric disorder, but to all injured patients and should be considered as an integral part of medical care.

A study of patient-related characteristics and outcome after moderate injury

The purpose of all injury care is to restore patients' pre-injury functioning and to facilitate the return to normal activities. The aim of this prospective study was to describe and analyse psychiatric factors and other patient-related characteristics which influence long-term results after moderate injuries. One hundred and sixty-nine injured patients were randomized to go through a comprehensive psychosocial research protocol and to participate in the 12 month follow up. The 49 patients lost to follow-up differed significantly from all other patients. They were more often single, blue-collar workers with a lower educational level and had a less favourable psychosocial background, including alcohol abuse. The 120 patients who completed the follow-up were divided in two groups: the non-recovered group (NR, N = 58), patients reporting limitations in performing their work and/or limitations in carrying out housework and/or in social life, and the recovered group (R, N = 62), patients reporting full recovery or only minor limitations in exercise or sports 12 months after the injury. The NR patients were older (P < 0.05), had a slightly higher injury Severity Score (P < 0.01) and showed signs of depression both during the acute post-injury period and at 1 year follow up (P < 0.001). The multivariate analysis showed that measurements of pain and depression during the acute post-injury period were associated with the functional outcome after 12 months. Co-operation between injury and psychiatric units should be developed to identify patients needing psychosocial or psychiatric support during the early phase of rehabilitation.