Beyond Band-Aids for Bullet Holes: Firearm Violence As a Public Health Priority

Bullet holes: A novel model to identify the most impactful gaps in the firearm homicide prevention laws of each state

BACKGROUND

Firearm homicides (FH) are a major cause of mortality in the United States. Firearm law implementation is variable across states, and legislative gaps may represent opportunities for FH prevention. For each state, we sought to identify which firearm law category would have been most effective if implemented and how effective it would have been.

METHODS

We conducted a retrospective cohort study examining the effects of firearm laws on FH rates in the 48 contiguous US states 2010 to 2019. Data were obtained from the CDC WONDER and FBI UCR databases, State Firearm Law Database, and US Census. Firearm laws were grouped into 14 categories. We assessed the association between the presence of each law category and FH rate as an incidence rate ratio (IRR) using a Poisson regression accounting for state population characteristics and laws of surrounding states. We estimated the IRR for each state that did not have a given law category present and determined which of these missing law categories would have been associated with the greatest reduction in FH rate.

RESULTS

FH rates varied widely across states and increased from a mean of 3.2 (SD = 1.7) to 4.2 (SD = 2.9) FH per 100,000. All law categories were significantly associated with decreased FH rate ( p < 0.05), with IRR ranging from 0.25 to 0.85. The most effective missing law category differed between states but was most commonly child access prevention (34.09% of states), assault weapons and large-capacity magazines (15.91%), preemption (15.91%), and concealed carry permitting (13.64%). In total across 2010 to 2019, we estimated that 129,599 fewer FH would have occurred with enactment of the most effective missing law category in each state.

CONCLUSION

Modeling firearm law prevention of FH with regard to state legislative and population characteristics can identify the highest impact missing law categories in each state. These results can be used to inform efforts to reduce FH.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Modification of Firearm Law-Firearm Injury Association by Economic Disadvantage

INTRODUCTION

Firearm-related injuries in the U.S. have risen 37% since 2015. Understanding how the association between firearm incidents and state-level firearm restrictiveness is modified by community-level distress and economic connectedness (EC) may inform upstream injury prevention efforts.

METHODS

A national cross-sectional study of firearm incidents (interpersonal and unintentional firearm events) occurring between 1/2015 and 12/2021 was performed using the Gun Violence Archive. The exposures were community distress (Distressed Communities Index, DCI), EC, and year-state-level firearm restrictiveness. The primary outcome was mean annual urban firearm incidence rate per ZIP Code Tabulation Area. Generalized linear mixed models were fit to evaluate the modification of the firearm law-firearm incident association by DCI and EC. Data analyses took place in 2022.

RESULTS

About 266,020 firearm incidents were included. The mean rate was higher with each DCI tertile, with a RR of 3.18 (95% CI: 3.06, 3.30) in high versus low distress communities. Low EC was associated with over 1.8 times greater rate of firearm-related injury. The least restrictive firearm laws were associated with 1.20 times higher risk of firearm incidents (95% CI: 1.12, 1.28). The association between restrictive laws and lower incidence rates was strongest in low and medium distress and high EC communities.

CONCLUSIONS

Stricter firearm laws are associated with lower rate of firearm incidents. The magnitude of this association is smallest for communities experiencing the greatest economic disadvantage.

How Americans encounter guns: Mixed methods content analysis of YouTube and internet search data

Firearm-related injury and death is a serious public health issue in the U.S. As more Americans consume news and media online, there is growing interest in using these channels to prevent firearm-related harms. Understanding the firearm-related narratives to which consumers are exposed is foundational to this work. This research used the browsing behavior of a representative sample of American adults to identify seven firearm-related content "ecosystems" (defined as naturally occurring networks of channels watched by the same users) on YouTube; we then described the demographics and internet search patterns of users affiliated with each ecosystem. Over the 9-month study period, 72,205 panelists had 16,803,075 person-video encounters with 7,274,093 videos. Among these, 282,419 were related to firearms. Using fast greedy clustering, we partitioned users and channel interactions into seven distinct channel-based content ecosystems that reached more than 1/1000 YouTube users per day. These ecosystems were diverse in reach, users, and content (e.g., guns for self-protection, guns for fun). On average, 0.5% of panelists performed a firearm-related internet search on a given day. The vast majority of searches were related to mass shootings or police-involved shootings (e.g., "active shooter"), and virtually none were about more common firearm harm such as suicide. Searches for firearm safety information were most common among panelists affiliated with the "Hunting & Fishing" and "Guns & Gear" ecosystems, which were watched primarily by older, white men. These findings identify an opportunity for analyzing firearm-related narratives and tailoring firearm safety messaging for users affiliated with specific online content ecosystems.

Global burden and trends of firearm violence in 204 countries/territories from 1990 to 2019

Background

Gaps remained in the updated information of the firearm violence (FV) burden from a global landscape. Understanding the global burden of FV could contribute to decision-making.

Methods

Data on the FV burden, including physical violence by firearm (PVF), self-harm by firearm (SHF), and unintentional firearm injuries (UFI), were extracted from the Global Burden of Disease 2019. The temporal trends of age-standardized rate (ASR) were estimated using estimated annual percentage change (EAPC).

Results

In 2019, PVF, SHF, and UFI reported 710.64 × 10³, 335.25 × 10³, and 2,133.88 × 10³, respectively, incident cases worldwide. Their ASR (/100,000 people-years) were 9.31, 4.05, and 28.07. During 1990-2019, the overall incident ASRs of PVF presented an increasing trend (EAPC = 0.61, 95% confidence interval [CI]: 0.48 to 0.75). Notably, pronounced increasing trends were observed in Tropical Latin America, and North Africa and Middle East. However, incident trends of SHF and UFI declined globally, with the respective EAPCs being -0.68 (95% CI: -0.83 to -0.54) and -0.98 (95% CI: -1.19 to -0.77). In 2019, the ASR of death due to PVF, SHF, and UFI were 2.23, 0.65, and 0.26, and that of DALYs were 127.56, 28.10, and 17.64, respectively. Decreasing trends in the ASRs of FV were observed in most regions and countries worldwide over the past three decades, particularly that of PVF in Estonia.

Conclusion

The FV burden was heterogeneous across regions and countries, which was deeply subjected to socioeconomic factors. The findings highlighted that specific prevention strategies and interventions were required, particularly in the high prevalent settings.

United States trends in healthcare charges for pediatric firearm injuries

BACKGROUND

From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups.

METHODS

In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time.

RESULTS

Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries.

CONCLUSIONS

Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.

Epidemiologic Trends in Fatal and Nonfatal Firearm Injuries in the US, 2009-2017

IMPORTANCE

Firearm injury research in the US has focused on fatal injuries. The incidence and epidemiologic factors associated with nonfatal firearm injuries are less understood.

OBJECTIVE

To evaluate estimates of incidence and trends over time of fatal and nonfatal firearm injuries.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, ecologic study was conducted using data throughout the US from 2009 to 2017. Data on fatal injuries from the Centers for Disease Control and Prevention were combined with national data on emergency department visits for nonfatal firearm injury from the Nationwide Emergency Department (ED) sample. Data analysis was conducted from August 2019 to September 2020.

EXPOSURES

Firearm injuries identified with International Classification of Diseases external cause of injury codes and categorized by intent of injury, age group, and urban-rural location.

MAIN OUTCOMES AND MEASURES

Incidence, case fatality rate, and trends over time of firearm injury according to intent, age group, and urban-rural location.

RESULTS

From 2009 to 2017, there was a mean of 85 694 ED visits for nonfatal firearm injury and 34 538 deaths each year. An annual mean of 26 445 deaths (76.6%) occurred outside of the hospital. Assault was the most common overall mechanism (38.9%), followed by unintentional injuries (36.9%) and intentional self-harm (19.6%). Self-harm, which accounted for 21 128 deaths (61.2%), had the highest case fatality rate (89.4%; 95% CI, 88.5%-90.4%), followed by assault (25.9%; 95% CI, 23.7%-28.6%) and legal intervention (23.4%; 95% CI, 21.6%-25.5%). Unintentional injuries were the most common nonfatal injuries (43 729 [51.0%]) and had the lowest case fatality rate (1.2%; 95% CI, 1.1%-1.3%). Self-harm deaths, 87.8% of which occurred outside the hospital, increased in all age groups in both rural and urban areas during the study period and were most common among people aged 55 years and older. The rate of fatal assault injuries was higher in urban than in rural areas (16.6 vs 9.0 per 100 000 per year) and highest among people aged 15 to 34 years (38.6 per 100 000 per year). Rates of unintentional injury were higher in rural than in urban areas (18.5 per 100 000 vs 12.4 per 100 000).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, suicide appears to be the most common cause of firearm injury death in the US, and most people who die from suicide never reach the hospital. These findings suggest that assaults and unintentional injuries account for most nonfatal and overall firearm injuries and for most of the injuries that are treated in hospitals.