Health system and law enforcement synergies for injury surveillance, control and prevention: a scoping review

Variable selection for latent class analysis in the presence of missing data with application to record linkage

The Fellegi-Sunter model is a latent class model widely used in probabilistic linkage to identify records that belong to the same entity. Record linkage practitioners typically employ all available matching fields in the model with the premise that more fields convey greater information about the true match status and hence result in improved match performance. In the context of model-based clustering, it is well known that such a premise is incorrect and the inclusion of noisy variables could compromise the clustering. Variable selection procedures have therefore been developed to remove noisy variables. Although these procedures have the potential to improve record matching, they cannot be applied directly due to the ubiquity of the missing data in record linkage applications. In this paper, we modify the stepwise variable selection procedure proposed by Fop, Smart, and Murphy and extend it to account for missing data common in record linkage. Through simulation studies, our proposed method is shown to select the correct set of matching fields across various settings, leading to better-performing algorithms. The improved match performance is also seen in a real-world application. We therefore recommend the use of our proposed selection procedure to identify informative matching fields for probabilistic record linkage algorithms.

Emergency department-based injury surveillance information system: a conceptual model

BACKGROUND

Injury data play a pivotal role in monitoring public health issues and Injury Surveillance Information Systems (ISIS) are useful for continuous data collection and analysis purposes. Since emergency department (ED) is usually the first place of referral for the injured people, the aim of this study was to develop a conceptual model for an ED-based ISIS.

METHODS

This study was completed in 2020 and the Delphi technique (three rounds) was used to determine the main components of an ED-based ISIS. The participants were selected using the purposive sampling method. A 5-point Likert scale questionnaire was used for data collection and data were analyzed using descriptive statistics.

RESULTS

In the first, second, and third rounds of the Delphi study, 60, 44, and 28 experts participated, respectively. In the first and second rounds, most of the items including the personal data, clinical data, data sources, and system functions were found important. In the third round of the Delphi study, 13 items which did not reach a consensus in the previous rounds were questioned again and five items were removed from the final model.

CONCLUSION

According to the findings, various data elements and functions could be considered for designing an ED-based ISIS and a number of data sources should be taken into count to be integrated with this system. Although the conceptual model presented in the present study can facilitate designing the actual system, the final system needs to be implemented and used in practice to determine how it can meet users' requirements.

Assault-related injuries reported to police and treated by healthcare providers in the United States

Research suggests that assault-related injuries known by the police significantly differ from those known by healthcare providers, but the magnitude and nature of these differences are poorly understood. To address this gap, our study examined the empirical differences between assault-related injuries reported to police and treated by healthcare providers. In June of 2021, we analyzed the National Crime Victimization Survey (1993-2019) to estimate the prevalence of police reporting and healthcare use among 5093 nonfatal victimizations that caused injury and were either reported to the police or treated by healthcare in the United States. Quasi-Poisson models identified the factors associated with whether people who sustained the injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare). Among victimizations that caused only minor injuries, 43% involved only a police report, 11% involved only healthcare, and 46% involved both services. Among victimizations that caused serious injuries, 14% involved only a police report, 13% involved only healthcare, and 73% involved both services. Whether people with violent injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare) was significantly associated with 13 different person- and incident-level factors. The number and nature of assault-related injuries reported to law enforcement significantly differ from those treated by healthcare providers. Therefore, public health efforts to link police and healthcare data are warranted and recommended.

Healthcare utilization and mental health outcomes among nonfatal shooting assault victims

Victims of nonfatal shooting (NFS) assaults suffer from emotional and physical trauma; however, little is understood about clinical care utilization patterns among victims. This study examines the healthcare utilization and mental health outcomes before and after an index NFS victimization. A longitudinal dataset of police and clinical data were linked at the individual level to define a cohort of NFS victims with one or more clinical encounter in the 24-months preceding an index NFS injury (N = 2,681) in Indianapolis, Indiana between 2005 and 2018. Mental health was defined using ICD diagnosis codes from any emergency department, inpatient, or outpatient encounter and clinical care utilization was the number of unique encounters within the 24-months preceding and following an index NFS injury. Multivariable logistic regression was conducted to examine factors associated with a mental health diagnosis in the post injury period. Analyses were conducted in October 2021-March 2022. Overall clinical care utilization (Mean: pre = 277.7 (SD 235.3) vs. post = 333.9 (SD 255.1), p < 0.001) and mental health prevalence (14.4% pre vs. 18.8% post, p < 0.001) increased in the 24-months following an index NFS compared to the prior 24-months. Preinjury mental health utilization increased the odds of receiving a mental health diagnosis in the 24-months following an index NFS injury - particularly for Black victims (Odds Ratio 1.69, 95% CI 1.01, 2.85). The findings indicate missed opportunities within the healthcare system to connect NFS victims with needed mental health services, as well as the importance of premorbid connection to mental health care.

Intersectoral violence prevention: the potential of public health-criminal justice partnerships

Building successful intersectoral partnerships to address health is critical to reaching health promotion goals. With the confluence of the COVID-19 pandemic, the increase in violence during the pandemic and the heightened demand for racial justice resulting from police killings of people of color, particularly young, black males, intersectoral public health-criminal justice partnerships must be more thoroughly examined. Violence prevention is both a public health and criminal justice issue, with public health systems emphasizing primary prevention and criminal justice systems addressing violence prevention at secondary and tertiary levels. Public health-criminal justice collaborations can provide an opportunity to seize upon unrealized violence reduction goals across the spectrum of prevention. At the same time, issues remain that are at odds across field boundaries as exemplified through community violence prevention. While there have been successful examples of such collaborations, past public health-criminal justice partnerships also demonstrate the challenges of working together. These challenges have yet to be systematically described and rooted in the larger literature on partnerships. In this paper, collaborative challenges are enumerated and evidence-informed strategies to overcome those barriers to achieve violence reduction goals are identified as a way to ground further intersectoral partnership work between public health and criminal justice.

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.

Mental illness concordance between hospital clinical records and mentions in domestic violence police narratives: Data linkage study (Preprint)

Background

To better understand domestic violence, data sources from multiple sectors such as police, justice, health, and welfare are needed. Linking police data to data collections from other agencies could provide unique insights and promote an all-of-government response to domestic violence. The New South Wales Police Force attends domestic violence events and records information in the form of both structured data and a free-text narrative, with the latter shown to be a rich source of information on the mental health status of persons of interest (POIs) and victims, abuse types, and sustained injuries.

Objective

This study aims to examine the concordance (ie, matching) between mental illness mentions extracted from the police’s event narratives and mental health diagnoses from hospital and emergency department records.

Methods

We applied a rule-based text mining method on 416,441 domestic violence police event narratives between December 2005 and January 2016 to identify mental illness mentions for POIs and victims. Using different window periods (1, 3, 6, and 12 months) before and after a domestic violence event, we linked the extracted mental illness mentions of victims and POIs to clinical records from the Emergency Department Data Collection and the Admitted Patient Data Collection in New South Wales, Australia using a unique identifier for each individual in the same cohort.

Results

Using a 2-year window period (ie, 12 months before and after the domestic violence event), less than 1% (3020/416,441, 0.73%) of events had a mental illness mention and also a corresponding hospital record. About 16% of domestic violence events for both POIs (382/2395, 15.95%) and victims (101/631, 16.01%) had an agreement between hospital records and police narrative mentions of mental illness. A total of 51,025/416,441 (12.25%) events for POIs and 14,802/416,441 (3.55%) events for victims had mental illness mentions in their narratives but no hospital record. Only 841 events for POIs and 919 events for victims had a documented hospital record within 48 hours of the domestic violence event.

Conclusions

Our findings suggest that current surveillance systems used to report on domestic violence may be enhanced by accessing rich information (ie, mental illness) contained in police text narratives, made available for both POIs and victims through the application of text mining. Additional insights can be gained by linkage to other health and welfare data collections.

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

Organisations spanning social services, public health and healthcare have increasingly experimented with collaboration as a tool for improving population health and reducing health disparities. While there has been progress, the results have fallen short of expectations. Reflecting on these shortcomings, the Robert Wood Johnson Foundation (RWJF) recently proposed a new framework for cross-sector alignment intended to move the field towards improved outcomes. A central idea in this framework is that collaboratives will be more effective and sustainable if they develop collaborative systems in four core areas: shared purpose, governance, finance and shared data. The goal of this paper is to provide a foundation for research on the four core areas of the cross-sector alignment framework. Accordingly, this study is based on two guiding questions: (1) how are collaboratives currently implementing systems in the four core areas identified in the framework, and (2) what strategies does the literature offer for creating sustainable systems in these four areas? Given the emergent nature of research on health-oriented cross-sector collaboration and the broad research questions, we conducted a systematic scoping review including 179 relevant research papers and reports published internationally from the years 2010-2020. We identified the main contributions and coded each based on its relevance to the cross-sector alignment framework. We found that most papers focused on programme evaluations rather than theory testing, and while many strategies were offered, they tended to reflect a focus on short-term collaboration. The results also demonstrate that starting points and resource levels vary widely across individuals and organisations involved in collaborations. Accordingly, identifying and comparing distinct pathways by which different parties might pursue cross-sector alignment is an imperative for future work. More broadly, the literature is ripe with observations that could be assessed systematically to produce a firm foundation for research and practice.

Implementation and initial analysis of Cardiff Model data collection procedures in a level I trauma adult emergency department

OBJECTIVES

Our understanding of community violence is limited by incomplete information, which can potentially be resolved by collecting violence-related injury information through healthcare systems in tandem with prior data streams. This study assessed the feasibility of implementing Cardiff Model data collection procedures in the emergency department (ED) setting to improve multisystem data sharing capabilities and create more representative datasets.

DESIGN

Information collection fields were incorporated into the ED electronic health record (EHR), which gathered additional information from patients reporting assaultive injuries. ED nurses were surveyed to evaluate implementation and feasibility of information collection. Logistic regression was performed to determine associations between missing location information and patient demographic data.

SETTING

60-bed academic level I trauma adult ED in a large Midwestern city.

PARTICIPANTS

2648 patients screened positive for assault injuries between 2017 and 2020. 198 patients were omitted due to age outside the range served by this ED. Unselected inclusion of 150 ED nurses was surveyed.

MAIN OUTCOME MEASURES

Main outcomes include nursing staff survey responses and ORs for providing complete injury information across various patient demographics.

RESULTS

Most ED nurses believed that information collection aligned with the hospital's mission (92%), wanted information collection to continue (88%), did not believe that information collection impacted their workflow (88%), and reported taking under 1 min to screen and document violence information (77%). 825 patients (31.2%) provided sufficient information for geospatial mapping. Likelihood of providing complete location information was significantly associated with patient gender, race, arrival means, accompaniment, trauma type and year.

CONCLUSIONS

It is feasible to implement information collection procedures about location-based, assault-related injuries through the EHR in the adult ED setting. Nurses reported being receptive to collecting information. Analyses suggest patient-level and time variables impact information collection completeness. The geospatial information collected can greatly improve preexisting law enforcement and emergency medical systems datasets.

Business and property types experiencing excess violent crime: a micro-spatial analysis

Background:

Beyond alcohol retail establishments, most business and property types receive limited attention in studies of violent crime. We sought to provide a comprehensive examination of which properties experience the most violent crime in a city and how that violence is distributed throughout a city.

Methods:

For a large urban city, we merged violent incident data from police reports with municipal tax assessor data from 2012-2017 and tabulated patterns of violent crime for 15 commercial and public property types. To describe outlier establishments, we calculated the proportion of individual parcels within each property-type that experienced more than 5 times the average number of crimes for that property-type and also mapped the 25 parcels with the highest number of violent incidents to explore what proportion of violent crime in these block groups were contributed by the outlier establishments.

Results:

While the hotel/lodging property-type experienced the highest number of violent crimes per parcel (2.72), each property-type had outlier establishments experiencing more than 5 times the average number of violent crimes per business. Twelve of 15 property-types (80%) had establishments with more than 10 times the mean number of violent incidents. The 25 parcels with the most violent crime comprised a wide variety of establishments, ranging from a shopping center, grocery store, gas station, motel, public park, vacant lot, public street, office building, transit station, hospital, pharmacy, school, community center, and movie theatre, and were distributed across the city. Eight of the 25 parcels with the highest amount of violent crime, accounted for 50% or more of the violent crime within a 400-meter buffer.

Conclusions:

All property-types had outlier establishments experiencing elevated counts of violent crimes. Furthermore, the 25 most violent properties in the city demonstrated remarkable diversity in property-type. Further studies assessing the risk of violent crime among additional property-types may aid in violence prevention.

Victims of Violence and Post-Discharge Adverse Events: A Prospective Modified Trauma Quality Improvement Program (TQIP) Study

Introduction

Trauma patients frequently return to an emergency department (ED) soon after discharge; often for non-urgent reasons. Social factors contribute to higher ED usage. At present, there is no standardized system for reporting of ED visits and readmissions among trauma care. We hypothesized that victims of violent crime suffer from many early post-discharge adverse events that has not been captured by current methods.

Methods

We prospectively consented and enrolled injured patients from January 1st, 2019 to December 31st, 2019. We documented 30-day post-discharge events using post-discharge phone calls and detailed chart abstraction. Patients were categorized as victims of violence (VV) or unintentional traumatic injury (UT).

Results

During the study period, 444 patients were enrolled. Fifty-one (11.5%) were victims of violence and 393 (88.5%) experienced unintentional injuries. The VV patients were younger (40.10 vs 60.36; p<0.0001), and more predominantly male (92.16% vs 57.51%; p<0.0001). Total injury severity score (ISS), critical care length of stay (LOS), and total LOS were similar. VV patients were more likely discharged home (70.59% vs 55.47%; p=0.0403). They were significantly more likely to return to an emergency department (47.06% vs 23.16%; p<0.0005) and had more total number of ED visits per patient. Readmission rates, however, were not different (21.57% vs 16.28%; p=NS). The VV patients more frequently were underinsured (72.5%, vs 20.6%, p<0.005).

Discussion

Victims of violence presented to the ED significantly more often, despite similar injury scores, LOS, and being of younger age. Of these patients, only 26.2% of ED presentations resulted in readmission, suggesting the majority of patient complaints may have been able to be managed in an office-based setting. VV had significantly more underinsured or subsidized patients. Victims of violence are vulnerable and may benefit from more resources provided in the early post-discharge period.

Identifying nonfatal firearm assault incidents through linking police data and clinical records: Cohort study in Indianapolis, Indiana, 2007-2016

Nonfatal firearm assault incidents are more prevalent than gun homicides, however, little is understood about nonfatal firearm assault incidents due to a lack of accurate data in the United States. This is a descriptive study of all nonfatal firearm assault incidents identified through police and clinical records from 2007 to 2016 in Indianapolis, Indiana. Records were linked at the incident level to demonstrate the overlap and non-overlap of nonfatal firearm assault incidents in police and clinical records and describe differences in demographic characteristics of the victims. Incidents were matched within a 24-h time window of the recorded date of the police incident. Data were analyzed in fall 2020. There were 3797 nonfatal firearm assault incidents identified in police reports and 3131 clinical encounters with an ICD 9/10 diagnosis-based nonfatal firearm-related injury. 62% (n = 2366) of nonfatal firearm assault incidents matched within 24 h to a clinical encounter, 81% (n = 1905) had a firearm related ICD code: 40% (n = 947) were coded as a firearm-related assault, 32% (n = 754) were coded as a firearm-related accident; and 8.6% (n = 198) were coded as undetermined, self-inflicted or law enforcement firearm-related. The other 20% (n = 461) did not have an ICD firearm related diagnosis code. Results indicate most nonfatal firearm assault incidents overlap between police and clinical records systems, however, discrepancies between the systems exist. These findings also demonstrate an undercounting of nonfatal firearm assault incidents when relying on clinical data systems alone and more efforts are needed to link administrative police and clinical data in the study of nonfatal firearm assaults.

Epidemiology of prehospital trauma deaths in Malawi: A retrospective cohort study

Introduction

Trauma is among the leading causes of death and disability in both adults and children worldwide. In Malawi, trauma patients are commonly brought in dead (BID). We aimed to describe the prevalence, sociodemographic, and injury-related characteristics of patients BID to Kamuzu Central Hospital (KCH), a referral hospital in Lilongwe, Malawi.

Methods

We retrospectively reviewed records of all patients BID in the trauma surveillance registry at KCH from February 2008 to September 2019. We excluded patients BID that did not present to the emergency centre, and were instead taken to the mortuary directly. We used descriptive statistics to evaluate the epidemiology of patients BID.

Results

We reviewed 106,198 trauma records and 1889 (1.8%) were BID patients. Most patients BID were male, in both adult (n = 1337/1528, 88.4%) and children (n = 231/360, 64.9%) cohorts. The mean age was 34.7 (SD 11.9) years in adults and 7.8 (SD 5.4) years in children. Among the adult BID patients, 33.2% were unemployed, 25.6% were construction workers, and 10.1% were small business owners or managers. The common injury mechanisms in adults were road traffic-related injuries (RTIs) (47.1%) and assaults (23.6%). In children, injuries resulted from RTIs (39.7%), with 74.4% of those were pedestrians hit by cars, drowning (22.9%), and burns (12.4%). In both groups, most injuries occurred on roads (60.2%) or at home (22.1%). Reported alcohol use at the time of trauma was present in 6.3%. The police (57.9%) and privately-owned vehicles (26.6%) transported most BID patients to KCH.

Conclusion

Efforts to reduce prehospital trauma mortality must focus on improving prehospital care, including training the police and community in basic life support and improving resources towards prehospital trauma care. Further efforts to reduce prehospital mortality must aim to decrease injuries on the roads and at home.

Firearm assault in Philadelphia, 2005-2014: a comparison of police and trauma registry data

Background

Firearm injury is a major public health burden in the USA. Absent a single, reliable data source, researchers have attempted to describe firearm injury epidemiology using trauma registry data. To understand the implications of this approach, we compared trends in firearm assault incidence and case-fatality in Philadelphia over 10 years from two sources: the Pennsylvania Trauma Outcomes Study (PTOS), Pennsylvania’s state-mandated trauma registry, and the Philadelphia Police Department database (PPD) of firearm assaults.

Methods

We included PTOS firearm assault patients treated in Philadelphia County and PPD database firearm assault victims from 2005 to 2014. We calculated counts of fatal and non-fatal incidents using PTOS and PPD data. We used generalized linear models adjusted for seasonality to estimate temporal trends in firearm assault rates and case-fatality for both data sources and compared patient demographics and injury characteristics between the two.

Results

A total of 6988 PTOS and 14 172 PPD subjects met the inclusion criteria. In both data sets, firearm assault rates decreased significantly during the study period (PTOS: 5.19 vs. 3.43 per 10 000 person-years, change/year: −0.21, 95% CI −0.26 to –0.16; PPD: 10.97 vs. 6.70 per 10 000 person-years, change/year: −0.53, 95% CI −0.62 to –0.44). PTOS mean case-fatality rate was 26.5% and decreased significantly (change/year: −0.41, 95% CI −0.78% to 0.04%). PPD mean case-fatality rate was 18.9% with no significant change over time (p=0.41).

Discussion

Relative to PPD data, PTOS data underestimated firearm assault incidence and overestimated mortality. Trends in case-fatality rates were disparate across the two data sources. A true understanding of firearm injury in the USA requires comprehensive data collection on the incidence, nature, and severity of these injuries. As trauma registry data are by definition incomplete, combining data sources is essential. Local law enforcement data are an important potential source for studying city-level firearm injury.

Level of evidence

Level III, epidemiological.

Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USA

OBJECTIVES

Violence is a major public health problem in the USA. In 2016, more than 1.6 million assault-related injuries were treated in US emergency departments (EDs). Unfortunately, information about the magnitude and patterns of violent incidents is often incomplete and underreported to law enforcement (LE). In an effort to identify more complete information on violence for the development of prevention programme, a cross-sectoral Cardiff Violence Prevention Programme (Cardiff Model) partnership was established at a large, urban ED with a level I trauma designation and local metropolitan LE agency in the Atlanta, Georgia metropolitan area. The Cardiff Model is a promising violence prevention approach that promotes combining injury data from hospitals and LE. The objective was to describe the Cardiff Model implementation and collaboration between hospital and LE partners.

METHODS

The Cardiff Model was replicated in the USA. A process evaluation was conducted by reviewing project materials, nurse surveys and interviews and ED-LE records.

RESULTS

Cardiff Model replication centred around four activities: (1) collaboration between the hospital and LE to form a community safety partnership locally called the US Injury Prevention Partnership; (2) building hospital capacity for data collection; (3) data aggregation and analysis and (4) developing and implementing violence prevention interventions based on the data.

CONCLUSIONS

The Cardiff Model can be implemented in the USA for sustainable violent injury data surveillance and sharing. Key components include building a strong ED-LE partnership, communicating with each other and hospital staff, engaging in capacity building and sustainability planning.

Clustered Arrivals of Firearm-Injured Patients in an Urban Trauma System: A Silent Epidemic

BACKGROUND

Recent attention has been paid to the role trauma centers play in responding to mass shootings. Although high-profile public events are the primary focus of media and policy makers, firearm-injured patients (FIPs) present in clusters to urban trauma centers every day. We examined the burden of FIP clusters from an urban trauma system perspective.

STUDY DESIGN

In this descriptive epidemiologic study, we used data from the Philadelphia Police Department registry of shootings from 2005 to 2015. Variables included patient demographics, injury date and time, receiving hospital, and mortality. We defined clustered FIPs as those arriving within 15 minutes of another FIP. We used rolling temporal windows to calculate the number of FIP clusters for each hospital, assessed patient demographic characteristics and mortality, and used linear regression models to evaluate trends in FIP cluster rates.

RESULTS

Of the 14,217 FIPs included, 22.1% were clustered. There were 54 events when 4 or more FIPs presented within 15 minutes and 92 events when 4 or more FIPs presented within 60 minutes. Clusters of FIP occurred most frequently during night shifts (7:00 pm to 7:00 am) (73.1%) at level I trauma centers (93.6%), with geographic clustering demonstrated at the hospital level. Compared with the overall FIP population, clustered FIPs were more likely to be female (p = 0.039), injured at night (p = 0.031), but less likely to die (p = 0.014). The rate of FIP clusters and mortality remained steady over the course of the study.

CONCLUSIONS

In the trauma system studied, FIP clusters are common and are likely to occur at similar rates in other urban centers. Therefore, the immediate burden on health care resources caused by multiple FIPs presenting within a short period of time is not limited to traditionally defined mass shootings.