Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review

Gun violence revictimization in New York State: What increases the risk of being shot again?

BACKGROUND

While gun injuries are more likely to occur in urban settings and affect people of color, factors associated with gun violence revictimization-suffering multiple incidents of gun violence-are unknown. We examined victim demographics and environmental factors associated with gun violence revictimization in New York State (NYS).

METHODS

The 2005 to 2020 NYS hospital discharge database was queried for patients aged 12 years to 65 years with firearm-related hospital encounters. Patient and environmental variables were extracted. Patient home zip code was used to determine the Social Deprivation Index (SDI) for each patient's area of residence. We conducted bivariate and multivariate analyses among patients who suffered a single incident of gun violence or gun violence revictimization.

RESULTS

We identified 38,974 gun violence victims among whom 2,243 (5.8%) suffered revictimization. The proportion of revictimization rose from 4% in 2008 to 8% in 2020 ( p < 0.01). The median [interquartile range] time from first to second incident among those who suffered revictimization was 359 days [81-1,167 days]. Revictimization was more common among Blacks (75.0% vs. 65.1%, p < 0.01), patients with Medicaid (54.9% vs. 43.2%, p < 0.01), and in areas of higher deprivation (84.8 percentile vs. 82.1 percentile, p < 0.01).

CONCLUSION

Gun violence revictimization is on the rise. People of color and those residing in areas with high social deprivation are more likely to be re-injured. Our findings emphasize the importance of community-level over individual-level interventions for prevention of gun violence revictimization.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Firearm Injuries Are on the Rise, the Results of a Pediatric Trauma Center

INTRODUCTION

Firearm injury is the leading cause of death in children. The recent rise has coincided with the COVID-19 pandemic. The purpose of this study was to evaluate the trends of pediatric firearm injury over a 6-y period, to include the COVID-19 pandemic, at our pediatric trauma center.

METHODS

A retrospective review of the trauma registry at a free-standing children's hospital from January 2018 to December 2023 was performed. The variables evaluated included year of injury, age of injury, race, gender, admission requirements, need for blood products, need for operation, mortality, insurance type, and reason for injury.

RESULTS

There were 397 firearm injury presentations identified over the 6-y period. The median age of injury was 13 y with an interquartile range of 6-15 y. Most were male (72.3%) and of Black race (74.6%). A majority of children who sustained a firearm injury had Medicaid (77.8%). During the years of 2018 and 2019, we evaluated 40 and 39 patients, respectively. Over the next 2 y, there was a dramatic increase in pediatric firearm injuries with an increase of 65% (N = 66) in 2020 and 102.5% (N = 81) in 2021. Although there was less of an increase above baseline in 2022, there was still an elevation of 82.5% (N = 73). By the end of 2023, there had been a 145% rise (N = 98) in pediatric firearm injuries above the baseline year of 2018. The mortality rate was 7.6% (N = 30), which is 2.5 times higher than the all-cause trauma mortality of 3.1% at our facility.

CONCLUSIONS

The number of firearm injuries dramatically increased during the COVID-19 pandemic and these increases have been sustained. Most of the victims have been male, of Black race, and publicly insured. While the state population of Alabama is 26.4% Black race, Black children account for 74.6% of all firearm-injured pediatric patients in our trauma registry. The reason for this disparity is not well-understood. Through ongoing research, we hope to gain insight into the reasons behind pediatric firearm injury and the best ways to mitigate them through both the medical and public health arenas.

The Impact of Area Deprivation Index, Geography, and Mechanism on Incidence of Ballistic Injury to the Upper Extremity

INTRODUCTION

This study investigates the intersection of ballistic injuries, geography, and Area Deprivation Index (ADI). We hypothesized that both ADI and geography are correlated with incidence of upper extremity ballistic injuries. Further, we characterize and compare 2 distinct upper extremity gunshot injury populations presenting to our institution: those sustaining violent ballistic injuries and those who suffer an accidental, self-inflicted injury. Our purpose is to evaluate the impact of geography and ADI on the pattern of upper extremity gunshot injuries in Illinois and Missouri.

MATERIALS AND METHODS

This was a retrospective review of adult patients sustaining ballistic injury to the upper extremity at a single urban level I trauma center over 10 years (n = 797). Seven hundred thirty patients had home addresses in Illinois or Missouri; these addresses were geocoded and included for analysis. Mechanism of injury was self-reported. ADI was measured from the 2019 Neighborhood Atlas, in which deprivation increases from 1 to 100. Comparisons between groups were conducted with unpaired t tests, Fisher exact test, or χ2 testing, where appropriate.

RESULTS

Addresses constituted 259 unique census tracts, and the average number of upper extremity gunshot wound incidents per tract was 3, with a maximum of 22; 15.4% of census block tracts made up almost half (48.4%) of the total ballistic injuries in the study period; 97.7% of violent injuries occurred in Urban areas, as compared with only 60% of accidental injuries (P < 0.05). ADI and incidence of upper extremity ballistic injury were positively correlated. ADI varied significantly between patients sustaining violent (median, 94; mean, 86.1) versus accidental self-inflicted (median, 79; mean, 70.9) injuries (P < 0.05). Fifty percent of violent injuries in our data set occurred in block groups from the 2 most deprived quintiles.

CONCLUSIONS

Upper extremity gunshot wounds in general are concentrated in census blocks with high ADI. Violent injuries in particular are more likely to occur in urban areas with high ADI, whereas patients with accidental, self-inflicted injuries are more geographically and socioeconomically diverse. These differing populations require unique approaches to reduce incidence and morbidity.

Pooled Analysis of Trauma Centers Better Predicts Risk Factors for Firearm Violence Reinjury

INTRODUCTION

Many trauma centers use the first firearm injury admission as a reachable moment to mitigate reinjury. Understanding repeat firearm violence can be difficult in metropolitan areas with multiple trauma centers and laws that prohibit sharing private health information across health systems. We hypothesized that risk factors for repeat firearm violence could be better understood using pooled data from two major metropolitan trauma centers.

METHODS

Two level I trauma center registries were queried (2007-2017) for firearm injury admissions using International Classification of Diseases, Ninth and Tenth Revision (ICD9/10) Ecodes. A pseudo encryption tool allowed sharing of deidentified firearm injury and repeat firearm injury data without disclosing private health information. Factors associated with firearm reinjury admissions including, age, sex, race, payor, injury severity, intent, and discharge, were assessed by multivariable logistic regression.

RESULTS

We identified 2145 patients with firearm injury admissions, 89 of whom had a subsequent repeat firearm injury admission. Majority of repeat firearm admissions were assaulted (91%), male (97.8%), and non-Hispanic Black (86.5%). 31.5% of repeat firearm injury admissions were admitted to a different trauma center from their initial admission. Independent predictors of repeat firearm injuries were age (adjusted odds ratio [aOR] 0.94, P < 0.001), male sex (aOR 6.18, P = 0.013), non-Hispanic Black race (aOR 5.14, P = 0.007), or discharge against medical advice (aOR 6.64, P=<0.001).

CONCLUSIONS

Nearly a third of repeat firearm injury admissions would have been missed in the current study without pooled metropolitan trauma center data. The incidence of repeat firearm violence is increasing and those at the highest risk for reinjury need to be targeted for mitigating interventions.

Racial Differences and Injury Pattern Variation: Impact of COVID-19 on a Bronx Trauma Center

BACKGROUND

New York City (NYC) became the epicenter of the COVID-19 pandemic in 2020. The Bronx, with the highest rates of poverty and violent crime of all NYC boroughs and a large Black and Hispanic population, was at increased risk of COVID-19 and its sequelae. We aimed to identify temporal associations among COVID-19 and trauma admission volume, demographics, and mechanism of injury (MOI).

METHODS

A retrospective review of prospectively collected data was conducted from a Level II trauma center in the Bronx. January 1st-September 30th for both 2019 (Pre-COVID) and 2020 (COVID) were compared. Pre-COVID and COVID cohorts were subdivided into EARLY (March-May) and LATE (June-September) subgroups. Demographics and trauma outcomes were compared.

RESULTS

Trauma admissions were similar between Pre-COVID and COVID. During COVID, there was an increased percentage of Black patients (Black Hispanic 20.1% vs 15.2% and Black Non-Hispanic 39.4% vs 34.1%, P < .05), younger patients (26-35 years old: 22.6% vs 17.6%, P < .05), and out-of-pocket payors (6.0% vs 1.6%, P < .05). Trauma severity outcomes were mixed-some measures supported increased severity; others showed no difference or decreased severity. During COVID, there was a rise in total penetrating injuries (27.4% vs 20.8%, P < .05), MVC (13.2% vs 7.1, P < .05), and firearm injuries (11.6% vs 6.0%, P < .05). Additionally, during LATE COVID, there was a resurgence of total penetrating, total blunt, MVC, falls, cyclists/pedestrians struck, and firearm injuries.

DISCUSSION

Our results emphasize MOI variations and racial differences of trauma admissions to a Level II trauma center in the Bronx during COVID-19. These findings may help trauma centers plan during pandemics and encourage outreach between trauma centers and community level organizations following future healthcare disasters.

The association between childhood opportunity index and pediatric hospitalization for firearm injury or motor vehicle crash

BACKGROUND

Community-level factors can profoundly impact children's health, including the risk of violent injury. This study's objective was to understand the relationship between the Childhood Opportunity Index and pediatric firearm injury owing to interpersonal violence compared with a motor vehicle crash.

METHODS

All pediatric patients (<18 years) who presented with an initial encounter with a firearm injury or motor vehicle crash between 2016 to 2021 were identified from 35 children's hospitals included in the Pediatric Health Information System database. The child-specific community-level vulnerability was determined by the Childhood Opportunity Index, a composite score of neighborhood opportunity level data specific to pediatric populations.

RESULTS

We identified 67,407 patients treated for injuries related to motor vehicle crashes (n = 61,527) or firearms (n = 5,880). The overall cohort had a mean age of 9.3 (standard deviation 5.4) years; 50.0% were male patients, 44.0% non-Hispanic Black, and were 60.8% publicly insured. Compared with motor vehicle crash injuries, patients with firearm-related injuries were older (12.2 vs 9.0 years), more likely to be male patients (77.7% vs 47.4%), non-Hispanic Black (63.5% vs 42.1%), and had public insurance (76.4 vs 59.3%; all P < .001). In multivariable analysis, children living in communities with lower Childhood Opportunity Index levels were more likely to present with firearm injury than those living in communities with a very high Childhood Opportunity Index. The odds increased as the Childhood Opportunity Index level decreased (odds ratio 1.33, 1.60, 1.73, 2.00 for high, moderate, low, and very low Childhood Opportunity Index, respectively; all P ≤ .001).

CONCLUSION

Children from lower-Childhood Opportunity Index communities are disproportionately impacted by firearm violence, and these findings have important implications for both clinical care and public health policy.

Firearm Injuries during Pregnancy in the USA

Trauma during pregnancy is the leading cause of non-pregnancy-related maternal deaths, with some due to injuries from firearms. It was the purpose of this study to characterize the patterns and presentations of firearm-associated injuries in pregnant women using a national emergency department visit database. Data from the Inter-University Consortium for Political and Social Research Firearm Injury Surveillance Study 1993-2020 were utilized. The data include age, sex, race, type of firearm, perpetrator of injury, intent of injury (unintentional, assault, suicide, or law enforcement), anatomic location of the injury, incident locale, disposition from the emergency department (ED), and whether the patient was shot or not with the firearm. Of the 3.36 million ED visits over this time span for firearm injuries, 4410 were pregnant women. The mean age of the pregnant cohort was 23.6 years, with more Hispanic and fewer White women in the pregnant group compared to the non-pregnant cohort. Pregnant women were more likely to experience an injury involving the lower trunk and had a higher percentage of fatalities and hospital admissions compared to the non-pregnant cohort. Fetal demise occurred in at least 70% of cases. Nearly one half of the assaults (44%) occurred on Saturdays and Sundays. As the cause of these injuries is complex, prevention will require input from multiple sources, including health care providers, social agencies, government agencies, elected officials, and law enforcement.

Changes in adult trauma at a level 1 trauma center before and during the COVID-19 pandemic

Background

Prior research has shown the COVID-19 pandemic is associated with changes in ED volumes, trauma caseloads and distribution of disease.

Objectives

We aim to characterize the impact of the COVID-19 pandemic at a diverse, high-volume Level 1 trauma center in the US.

Methods

We performed a retrospective review of our institutional trauma registry at our center from 2018 through 2021 to study changes before and after COVID-19. We established March 14 - December 31 as the study period of interest for each year. We analyzed the data with descriptive statistics and created Poisson regression models to determine the estimated percentage year-to-year changes.

Results

Total number of trauma cases increased with each subsequent year from 2018 (N ​= ​4605) to 2021 (N ​= ​7331) (total N ​= ​23,727). In general, the proportion of Black or African American patients increased over time (2018: 19.2%, 2021: 23.0%). The proportion of patients insured by Medicaid (8.0% vs 10.5%) and Medicare (26.5% vs 32.8%) increased from 2018 to 2021. Comparing 2019 to 2020, we found increases in violent traumas: GSW (+88.6%, 95% CI 63.8%-117.2%) and stabbings (+39.6%, 95% CI 8.1%-80.3%). Trauma patient ED LOS decreased from 300 ​min (67-400 IQR) in 2018 to 249 ​min in 2021 (104-510 IQR).

Conclusion

This analysis identified increased trauma volumes, especially violent trauma (GSW, stabbing, other penetrating). There was a greater proportion of Black/African American patients and those insured with Medicare or Medicaid during the pandemic. TED LOS decreased over time while ED mortality and hospital LOS remained stable.

Adolescent Gun Violence Shows an Age Group to Focus Trauma Prevention

INTRODUCTION

Gun violence continues to escalate in America's urban areas. Peer groups of gun wound victims are potential targets for violence prevention initiatives; identification of this cohort is pivotal to efficient deployment strategies. We hypothesize a specific age at which the incidence of penetrating trauma increases significantly in adolescence, below which should be the focus on future trauma prevention.

METHODS

Adolescent trauma patients with gunshot wounds seen from July 2011 through June 2021 at a well-established, urban, academic level 1 trauma center were reviewed retrospectively and grouped by age. A linear regression and repeated measured analysis of variance evaluated the change in gunshot wound victims over this time, grouped by age. Demographics were extrapolated, and standard statistical analysis was performed.

RESULTS

A total of 1304 adolescent trauma patients were included. Those aged 15 y and under had an unchanged incidence of gunshot wounds. However, those aged 16 y and more experienced the majority of increased gun violence; 92% were Black and 90% were male with a mortality of 12%. Adolescents aged 15 y and below were 95% Black and 84% male, with a mortality of 18%.

CONCLUSIONS

Primary prevention efforts to mitigate gun violence should be focused on adolescents below 16 y of age. Prevention of gun violence should include community outreach efforts directed toward middle school-aged children and younger, hoping to decrease the incidence of injury due to gun violence in older adolescents in the future.

Impact of COVID-related policies on gunshot wound assault hospitalizations in the United States: a statewide time series analysis

BACKGROUND

The CDC recently reported that firearm homicide rates in the United States increased in 2020, particularly among Black/African American individuals and men 25-44 years old. It is unclear whether firearm hospitalizations also increased, and more importantly, what impact the COVID-19 pandemic and COVID-related policies had. Using the North Carolina Trauma Registry, a statewide registry of trauma admissions to eighteen North Carolina hospitals, we calculated weekly GSW hospitalization rates from 1/2019 to 12/2020, overall and stratified by race-ethnicity, age, and sex. Interrupted time-series design and segmented linear regression were used to estimate changes in weekly hospitalization rates over time after (1) U.S. declaration of a public health emergency; (2) statewide Stay-at-Home order; (3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and (4) further lifting of restrictions (Phase 2.5: Safer-at-Home). Non-GSW assault hospitalizations were used as a control to assess whether trends were observed across all assault hospitalizations or if effects were specific to gun violence.

FINDINGS

Overall, 47.3% (n = 3223) of assault hospitalizations were GSW. Among GSW hospitalizations, median age was 27 years old (interquartile range [IQR] 21-25), 86.2% were male, and 49.5% occurred after the U.S. declared a public health emergency. After the Stay-at-Home order was implemented, weekly GSW hospitalization rates began increasing substantially among Black/African American residents (weekly trend change = 0.775, 95% CI = 0.254 to 1.296), peaking at an average 15.6 hospitalizations per 1,000,000 residents. Weekly hospitalization rates declined after restrictions were lifted but remained elevated compared to pre-COVID levels in this group (average weekly rate 10.6 per 1,000,000 at the end of 2020 vs. 8.9 per 1,000,000 pre-pandemic). The Stay-at-Home order was also associated with increasing GSW hospitalization rates among males 25-44 years old (weekly trend change = 1.202, 95% CI = 0.631 to 1.773); rates also remained elevated among 25-44-year-old males after restrictions were lifted in 2020 (average weekly rate 10.1 vs. 7.9 per 1,000,000). Non-GSW hospitalization rates were relatively stable in 2020.

CONCLUSIONS

The COVID-19 pandemic and statewide Stay-at-Home orders appeared to have placed Black/African American residents and men ages 25-44 at higher risk for GSW hospitalizations, exacerbating pre-existing disparities. Persistent gun violence disparities must be addressed.

Firearm-Related Injuries and Deaths in Children and Youth

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Gunshot casualties in Israel: A decade of violence

OBJECTIVE

The purpose of this study was to identify and characterize casualties hospitalized with assault (non-terror) related gunshot wounds (GSW) in Israel as a basis for determining the incidence, trends and at-risk population groups.

METHODS

This retrospective cohort study is based on data from the Israel National Trauma Registry. The data includes GSW casualties hospitalized between January 1, 2011 and December 31, 2020. Attempted suicide, unintentional injury, legal intervention, children (ages 0-9) and terror (Israeli-Arab conflict) related GSW were excluded. The remaining population was classified with an ICD-9-CM diagnosis code of 965.0-965.4.

RESULTS

The study population included 2,763 GSW admissions. A noticeable increase in GSW casualties was reported, from 206 hospitalization in 2011 to 456 in 2020. The proportion of Arab casualties increased from 73.3% of all GSW casualties in 2011 to 90.8% in 2020, far more than their proportion in the population (∼20%). The majority of the GSW casualties were males (95.8%) and between the ages of 20 and 29 (42.2%). Among severe/critical casualties, 19% of Arabs and 9.9% of Jews arrived by private car. Severe thoracic and abdominal injuries were the prominent injuries among fatal casualties (47.6 and 40.8, respectively). While the all-severity mortality rate was 5.6% (n = 147), 24.4% (n = 135) of severe/critical (ISS16+) casualties died, with no significant differences between Jews and Arabs. Forty percent of deaths occurred in the emergency department.

CONCLUSIONS

This study establishes that during the past decade in Israel, not only has there been a continuous increase in hospitalizations due to GSW, but also Arabs are at great risk of such related hospitalizations. Preventive strategies targeting at-risk groups are crucial for minimizing morbidity and mortality related to GSW in Israel.

A Closer Look at the Rising Epidemic of Mass Shootings in the United States and Its Association With Gun Legislation, Laws, and Sales

INTRODUCTION

Mass shootings pose a considerable threat to public safety and significantly cost the United States in terms of lives and expenses. The following are the specific aims of this study: (1) to assess US mass shootings, firearm-related sales, laws, and regional differences from 2015 to 2021 and (2) to investigate changes in mass shootings and firearm sales before and during the Coronavirus Disease 2019 pandemic.

METHODS

A retrospective review was conducted of mass shootings, gun sales, and laws regarding the minimum age required to purchase a firearm within the United States from 2015 to 2021. The 10 states/regions with the greatest mean mass shootings/capita from 2015 to 2021 were selected for further analysis.

RESULTS

Mass shootings correlated significantly with firearm sales from 2015 to 2021 nationwide (P < 0.02 for all). The growth in mass shootings, the number killed/injured, and gun sales were greater in 2020 and 2021 compared to the years prior. The 10 states with the highest mean mass shooting/capita over the study period were Alabama, Arkansas, the District of Columbia, Illinois, Louisiana, Maryland, Mississippi, Missouri, South Carolina, and Tennessee. No significant correlation was found between the number of mass shootings/capita and the minimum age to purchase a firearm.

CONCLUSIONS

Firearm sales correlated significantly with mass shootings from 2015 to 2021. Mass shootings and gun sales increased at greater rates during the Coronavirus Disease 2019 pandemic compared to the years before the pandemic. Mass shootings exhibited inconsistent trends with state gun laws regarding the minimum age to purchase a firearm. Future studies may consider investigating the methods by which firearms used in mass shootings are obtained to further identify targets for prevention.