We must do better science: addressing racism to improve health and safety for all people

Associations between nonfatal firearm injuries and risk of subsequent suicide among Veteran VA users: A retrospective cohort study

BACKGROUND

Suicide is a leading cause of death in the United States, particularly among Veterans. Nonfatal firearm injuries may indicate subsequent risk of suicide and, thus, provide important opportunities for prevention in emergency departments and other health care settings. We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used U.S. Department of Veterans Affairs (VA) health care, nationally, between 2010 and 2019.

METHODS

We linked VA health care and mortality data to identify VA users, nonfatal firearm injuries, and deaths. International Classification of Diseases (ICD)-10th Revision cause-of-death codes were used to identify suicides. Veterans' firearm injuries and their intent were categorized using cause-of-injury codes from the ICD Clinical Modification-9th and 10th Revisions systems. Using bivariable and multivariable regression, we estimated risk of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries. Among Veterans with nonfatal firearm injuries, we examined characteristics associated with subsequent suicide; electronic health record (chart) reviews explored documentation about firearm access among those who died.

RESULTS

Among 9,817,020 VA-using Veterans, 11,503 experienced nonfatal firearm injuries (64.9% unintentional, 12.3% intentional self-harm, 18.5% assault). Of these, 69 (0.6%) subsequently died by suicide (42 involving firearms). The odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were 2.4 (95% confidence interval 1.9-3.0); odds were only slightly attenuated in multivariable modeling. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without. Chart reviews identified small proportions of suicide decedents who were assessed for (21.7%), and/or counseled about (15.9%), firearm access.

CONCLUSIONS

Findings suggest that Veterans' nonfatal firearm injuries, regardless of injury intent, may be important but underutilized opportunities for suicide prevention. Future work should explore mechanisms to reduce risk among these patients.

An intersectional analysis of historical and contemporary structural racism on non-fatal shootings in Baltimore, Maryland

Introduction Non-fatal shooting rates vary tremendously within cities in the USA. Factors related to structural racism (both historical and contemporary) could help explain differences in non-fatal shooting rates at the neighbourhood level. Most research assessing the relationship between structural racism and firearm violence only includes one dimension of structural racism. Our study uses an intersectional approach to examine how the interaction of two forms of structural racism is associated with spatial non-fatal shooting disparities in Baltimore, Maryland. Methods We present three additive interaction measures to describe the relationship between historical redlining and contemporary racialized economic segregation on neighbourhood-level non-fatal shootings. Results Our findings revealed that sustained disadvantage census tracts (tracts that experience contemporary socioeconomic disadvantage and were historically redlined) have the highest burden of non-fatal shootings. Sustained disadvantage tracts had on average 24 more non-fatal shootings a year per 10 000 residents compared with similarly populated sustained advantage tracts (tracts that experience contemporary socioeconomic advantage and were not historically redlined). Moreover, we found that between 2015 and 2019, the interaction between redlining and racialized economic segregation explained over one-third of non-fatal shootings (approximately 650 shootings) in sustained disadvantage tracts. Conclusion These findings suggest that the intersection of historical and contemporary structural racism is a fundamental cause of firearm violence inequities in Baltimore. Intersectionality can advance injury prevention research and practice by (1) serving as an analytical tool to expose inequities in injury-related outcomes and (2) informing the development and implementation of injury prevention interventions and policies that prioritise health equity and racial justice.

Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veteran VA Users Nationwide With Traumatic Brain Injury, 2012-2020

OBJECTIVE

Many post-9/11 Veterans have received Department of Veterans Affairs (VA) healthcare for traumatic brain injury (TBI). Pain conditions are prevalent among these patients and are often managed with opioid analgesics. Opioids may impose unique risks to Veterans with a history of TBI, especially when combined with other psychotropic medications. We examined receipt of opioid and sedative-hypnotic prescriptions among post-9/11 Veterans with TBI who received VA care nationally between 2012 and 2020.

SETTING

Nationwide VA outpatient care.

PARTICIPANTS

Veterans with, versus without, clinician-confirmed TBI based on the VA's Comprehensive TBI Evaluation (CTBIE) were followed up for subsequent years in which they received VA care.

DESIGN

A historical cohort study.

MAIN MEASURES

Proportions of Veterans who received opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were compared by CTBIE outcome (TBI yes/no) and by year; overlaps between medication classes, long-term opioid therapy, and high-dose opioid therapy were also examined. Among those with confirmed TBI, logistic regression was used to examine associations between veteran characteristics and likelihood of these potentially high-risk opioid use outcomes.

RESULTS

Among 69 752 Veterans with clinician-confirmed TBI, 26.9% subsequently received opioids. The prevalence receiving opioids each year increased from 2012 (16.7%) to 2014 (17.7%), and then decreased each of the following years through 2020 (5.8%). Among Veterans with TBI who received opioids, large proportions also received benzodiazepine (30.1%) and nonbenzodiazepine (36.0%) sedative-hypnotic prescriptions; these proportions also decreased in recent years. In both bivariable and multivariable regression models, Veterans' demographic, TBI, and clinical characteristics were associated with likelihood of potentially high-risk opioid use.

CONCLUSIONS

VA opioid prescribing to Veterans with TBI has decreased in recent years but remains an important source of risk, particularly when considering coprescriptions of sedative-hypnotic medication. Understanding patterns of psychotropic prescription use among Veterans with TBI can highlight important healthcare and rehabilitation needs in this large patient cohort.

The time is now: why we must identify and address health disparities in sport and recreation injury

BACKGROUND

Social and structural determinants of health (SDOH) are the conditions in which individuals are born, live, learn, work, play, worship, and age. These drivers of health are integral in contextualizing the understanding and prevention of sport and recreation injury (SRI), and recognizing their impact is necessary to provide a complete and accurate picture of health and health outcomes related to injury. MAIN: Reducing disparities and achieving equity in sports and recreation is possible in part by improving data collection methodologies and utilization. Often, many SDOH have considerable effect on SRI. Although SRI epidemiology frequently examines differences by sex, there is limited inclusion of factors such as socioeconomic status, housing, gender, and food security, in sport specific data sources or in analysis of sport recreation and injury using other sources (e.g. administrative data). The ongoing dual epidemics in the United States - racism and COVID-19 - have emphasized the importance of having and utilizing SDOH data to reduce the burden of injury and disproportionate effects on our diverse population.

CONCLUSION

Moving forward, to address disparities in SRI, SDOH must be included as a part of research priorities, health related goals, and policies. This difference can be made in developing consistency in data collection and utilization. This will provide an accurate picture of the intersections and interdisciplinary changes required to design the best approach to problems to develop solutions. Future data collection and utilization should prioritize SDOH.