State Firearm Legislation and Nonfatal Firearm Injuries

Modeling the Relationship Between Firearm Restrictions, Medicaid Expansion, and Political Partisanship with Pediatric Firearm Mortality Costs

INTRODUCTION

Firearms are now the leading cause of pediatric mortality in the U.S., but few studies have investigated the economic impact of these deaths. Thus, this study determined whether multiple different gun-related measures, political partisanship and Medicaid expansion were related to the costs of pediatric gun deaths.

METHODS

Each states' medical costs, years of potential life lost (YPLL), and value of statistical life (VSL) lost due to pediatric gun deaths were extracted from the WISQARS database from 2015 to 2020. Seven firearm laws or restrictiveness measures (assault weapons bans, child access prevention laws, firearm registration and permit to purchase requirements, safe storage laws, Giffords Law Center ranking, and the number of firearm provisions), the Cook Partisan Voting Index (PVI), and Medicaid expansion status were determined across states. Unadjusted analyses compared each measure and (1) medical costs, (2) VSL, and (3) YPLL for each state. These were repeated using adjusted analyses, controlling for poverty, educational attainment, poor mental health, and race.

RESULTS

Of the 9 variables assessed, unadjusted analyses revealed that 8 variables were significantly associated with increased medical costs, all 9 were associated with higher VSL and 8 were associated with higher YPLL due to pediatric firearm-related mortality. Multivariable analyses revealed that 7 variables were associated with medical costs, 7 were associated with VSL and 6 were associated with YPLL.

CONCLUSION

States with fewer gun laws and those which have not adopted Medicaid expansion were more likely to experience a higher economic burden due to pediatric gun deaths. Quantifying the costs of these deaths can demonstrate the social toll of gun violence to policymakers and the general public.

LEVEL OF EVIDENCE

III.

Impact of Medicaid Expansion and Firearm Legislation on Cost of Firearm Injuries

INTRODUCTION

Firearm injury-related hospitalizations in the U.S. cost $900 million annually. Before the Affordable Care Act, government insurance programs covered 41% of the costs. This study describes the impact of Affordable Care Act Medicaid expansion and state-level firearm legislation on coverage and costs for firearm injuries.

METHODS

This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. The impact of the Affordable Care Act expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses.

RESULTS

The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted ($11,550; p=0.02) injuries; there were no state-level differences in assault or total per capita firearm-related hospitalization costs. Affordable Care Act expansion increased government coverage of costs by 15 percentage points (95% CI=3, 29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI=6, 21). In 2016, states with weak firearm legislation and no Affordable Care Act expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI=15, 34).

CONCLUSIONS

Affordable Care Act expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had the highest proportion of uninsured/self-pay patients.

Retrospective evidence for pediatric benefit of U.S. assault weapons ban as rationale for implementing an even more effective ban

BACKGROUND

With data available since 1981, firearm death rates in American children and adolescents can be evaluated for trends during the 13 years before, the decade of, and during 16 years since the United States (U.S.) 1994-2004 Federal Assault Weapons Ban (FAWB).

METHODS

National and regional firearm mortality trends in the U.S. during 1981-2020 were assessed with joinpoint regression applied to Centers for Disease Control and Prevention data.

RESULTS

After increasing exponentially before the FAWB, the national firearm death rate in 0-14 year-olds promptly reversed course and declined throughout the FAWB and then reversed again after the FAWB and resumed an exponential increase (all phases p<0.001). The reduction in firearm death rate occurred within 1-3 years of the start of the FAWB, in both sexes, in all four census regions of the U.S., and in all four major race/ethnicity subgroups, especially non-Hispanic blacks. No other form of violence in 0-14 year-olds had this temporal relationship with the FAWB. The firearm mortality reduction during the FAWB is strongly-highly correlated with the concomitant reduction in handgun manufacturing in 91 % of 24 sex, race/ethnicity and region subsets analyzed, These FAWB-related trends were also apparent in older adolescents and young adults and less so in older persons.

CONCLUSIONS

Firearm death rates in 0-14 year-olds before, during, and after the FAWB, and no other type of injury, implicate the FAWB as having had a beneficial effect. Legislation to mitigate firearm mortality and injury inclusive of a FAWB should be especially beneficial to children and young adolescents, and regardless of sex, race/ethnicity or region in the U.S.

Examining the Healthcare and Economic Burden of Gun Violence in a Major US Metropolitan City

INTRODUCTION

The highest rates of fatal and nonfatal injury due to firearms occur in the Southern United States. This study examined the epidemiology of gunshot wound (GSW) injuries and the association of injury severity with mortality.

METHODS

This is a retrospective cross-sectional analysis of 2016 to 2019 data from a mandatory reporting system for all licensed hospitals in Louisiana. Patients aged 18 years and older at the time of hospitalization for GSW were included. Injury severity was measured by the New Injury Severity Score (NISS). Primary outcomes assessed included mortality, length of stay, and total hospital charges.

RESULTS

There were 1,709 firearm injuries identified. The patient sample was 83.2% Black and 87.4% male, with a mean age of 34 years. Orthopaedics was the most frequently consulted surgical service. Total hospital visit charges for all GSW-associated care were $262.4 million. The multivariable adjusted odds ratio and 95% confidence interval for mortality associated with a high NISS was 16.32 (8.96, 29.72).

CONCLUSION

This study demonstrated the utility of NISS as a predictor of total hospital charges and length of stay, in addition to its well-established role as a predictor of mortality. Epidemiologic trends in GSW pathologies and associated procedures at a major urban trauma center were also reported.

LEVEL OF EVIDENCE

Level III, prognostic study.

Firearm assaults against US law enforcement officers in the line-of-duty: Associations with firearm ownership and state firearm laws

Law enforcement officers are disproportionately affected by occupational injury. Firearm violence is the second leading cause of occupational mortality for this group behind motor vehicle crashes. In the general population, greater firearm ownership and weaker firearm laws are associated with increased firearm violence incidence. It is plausible that a high prevalence of firearms could also be associated with a greater incidence of LEO assault with a firearm. Using data from the Federal Bureau of Investigation’s, Uniform Crime Reporting, Police Employee Data for 2006–2016, we conducted a panel analysis to estimate the association between state-level estimates of household firearm ownership and LEO assault with a firearm. We additionally examined if effect modification by universal background check law status was present. Higher state-level firearm ownership was associated with an increased odds of LEO assault with a firearm in multi-level models. This association was modified by universal background check law status. In states without a universal background check law, for every 1% increase in state-level firearm ownership per agency-year, there was a 12.4% increase in the odds of an LEO assault with a firearm when adjusting for confounders (OR:1.124; 95% CI:1.018,1.240). In states with a universal background check law, there was no association. Findings, though small in magnitude, suggest aggregate firearm ownership may contribute to LEO assault with a firearm in states without a universal background check law. Future research to prevent LEO assault with a firearm should combine measures to address high rates of firearm ownership with other evidence-based prevention strategies.

Reprint of "Using multiple imputation by super learning to assign intent to nonfatal firearm injuries"

The number of nonfatal firearm injuries in the US by intent (e.g., due to assault) is not reliably known: First, although the largest surveillance system for hospital-treated events, the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS), provides accurate data for the number of nonfatal firearm injuries, injury intent is not coded reliably. Second, the system that reliably codes intent, the CDC's National Electronic Injury Surveillance System - Firearm Injury Surveillance Study (NEISS-FISS), while large enough to produce stable estimates of the distribution of intent, is too small to produce stable estimates of the number of these events. Third, a large proportion of cases in NEISS-FISS, notably in early years of the system, are coded as of "undetermined intent." Trends in the proportion of nonfatal firearm injuries by intent in NEISS-FISS thus depend on whether these cases are treated as a distinct category, or, instead, can be re-classified through imputation. We contrast the distributions of nonfatal firearm injury by intent generated using multiple imputation with those generated using complete-case analyses and analyses that consider "undetermined intent" as a distinct category. We produce estimates of the annual number of firearm injuries by intent in a two-step process. First, we impute intent for cases coded as "undetermined" using Multiple Imputation by Super Learning (MISL). Second, we apply MISL-derived distributions to aggregate count data from HCUP-NEDS. The proportion of non-fatal firearm assaults appears to increase over time when injuries coded as undetermined are included as a category. By contrast, the proportion of assaults remains relatively constant over time in complete-case and multiply imputed analyses. Differences between complete-case and multiple imputation approaches become apparent in subgroup analyses. Trends in the number of nonfatal firearm injuries by intent, 2006-2016, derived in our two-step process, are relatively flat. Multiple imputation strategies recovered intent distribution trends that differed from trends derived using methods that are not designed to account for the multiple complex relationships of missingness present in NEISS - FISS data. When applied to NEISS - FISS, MISL imputation produces plausible distributional estimates of firearm injury by intent.

Using multiple imputation by super learning to assign intent to nonfatal firearm injuries

The number of nonfatal firearm injuries in the US by intent (e.g., due to assault) is not reliably known: First, although the largest surveillance system for hospital-treated events, the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS), provides accurate data for the number of nonfatal firearm injuries, injury intent is not coded reliably. Second, the system that reliably codes intent, the CDC's National Electronic Injury Surveillance System - Firearm Injury Surveillance Study (NEISS-FISS), while large enough to produce stable estimates of the distribution of intent, is too small to produce stable estimates of the number of these events. Third, a large proportion of cases in NEISS-FISS, notably in early years of the system, are coded as of "undetermined intent." Trends in the proportion of nonfatal firearm injuries by intent in NEISS-FISS thus depend on whether these cases are treated as a distinct category, or, instead, can be re-classified through imputation. We contrast the distributions of nonfatal firearm injury by intent generated using multiple imputation with those generated using complete-case analyses and analyses that consider "undetermined intent" as a distinct category. We produce estimates of the annual number of firearm injuries by intent in a two-step process. First, we impute intent for cases coded as "undetermined" using Multiple Imputation by Super Learning (MISL). Second, we apply MISL-derived distributions to aggregate count data from HCUP-NEDS. The proportion of non-fatal firearm assaults appears to increase over time when injuries coded as undetermined are included as a category. By contrast, the proportion of assaults remains relatively constant over time in complete-case and multiply imputed analyses. Differences between complete-case and multiple imputation approaches become apparent in subgroup analyses. Trends in the number of nonfatal firearm injuries by intent, 2006-2016, derived in our two-step process, are relatively flat. Multiple imputation strategies recovered intent distribution trends that differed from trends derived using methods that are not designed to account for the multiple complex relationships of missingness present in NEISS - FISS data. When applied to NEISS - FISS, MISL imputation produces plausible distributional estimates of firearm injury by intent.

Permissiveness of firearm laws, pro-gun culture, and suicides by firearm in the U.S., 2000–2016

Objectives

Stricter firearm policies correlate with lower suicides by firearm in the US. However, much work examines policies in isolation and does not investigate firearm policies as they relate to US pro-gun culture. We examine the relation between permissiveness of state firearm laws, gun culture, and suicides by firearm.

Study design

Panel longitudinal study.

Methods

The count of suicides by firearm for 50 US states from 2000 to 2016 served as the outcome. Permissiveness of multiple state firearm laws, based on ratings from the Traveler's Guide to the Firearm Laws of the Fifty States, served as the exposure. These ratings, measured at the state-year, capture not only the overall policy environment but also the extent to which the state exhibits a pro-gun culture. We applied a fixed effects negative binomial count model, which controls for the population-at-risk, to examine suicides overall and by race/ethnicity and gender.

Results

A 10-unit increase in permissiveness of state firearm laws corresponds with 2% greater suicides by firearm overall (Incidence rate ratio [IRR] = 1.02; 95% CI: 1.01–1.03) and among non-Hispanic white males ([IRR] = 1.02, 95% CI: 1.01–1.02).

Conclusions

Findings, if replicated, indicate that states enacting more restrictive firearm policies, and lessening a pro-gun culture, may lead to reductions in suicide by firearm.

•

Firearms persist as the most common method of suicide in the US.

•

Firearm policies and the broader pro-gun culture may correspond with suicides.

•

Permissiveness of state firearm laws precede increases in suicides by firearm.

•

A restrictive suite of firearm policies may reduce suicides by firearm.

Regional Differences in Pediatric Firearm-Related Emergency Department Visits and the Association With Firearm Legislation

OBJECTIVE

The objective of this study was to describe regional and temporal trends in pediatric firearm-related emergency department (ED) visits and investigate association with regional firearm legislation.

METHODS

We conducted a cross-sectional analysis using the Nationwide Emergency Department Sample from 2009 to 2013 for children aged 21 years or younger. We calculated national estimates of firearm-related visits using annual census data and measured trends. We used state-level gun law scores to derive regional scores to measure strictness of firearm legislation. We used multivariable logistic and linear regression to measure regional differences in visits and their association with regional gun law scores, respectively.

RESULTS

There were 111,839 (95% confidence interval, 101,248-122,431) ED visits for pediatric firearm-related injuries. Rates of visits varied by region, with the lowest rate in the Northeast and highest rate in the South (40.0 [34-45]; 70.8 [63.7-76.9] per 100,000 ED visits, respectively). Compared with the Northeast, odds of firearm-related ED visits were higher in the Midwest (adjusted odds ratio [aOR], 1.8; 1.4-2.3), West (aOR, 2.5; 2.0-3.2), and South (aOR, 1.9; 1.5-2.4). Firearm-related visits remained consistent over time. A higher (stricter) regional median Brady gun law score was associated with a lower rate of firearm-related visits (β = -0.8; R2 = 0.9; P = 0.03).

CONCLUSIONS

Rates of pediatric firearm-related ED visits vary by region. Stricter regional gun laws were associated with lower rates of ED visits for pediatric firearm-related injuries. Further study of the social and cultural regional differences in gun ownership and the role of legislation in the prevention of pediatric firearm-related morbidity and mortality is warranted.

Annual Incidence of Hospitalization for Nonfatal Firearm-Related Injuries in New York From 2005 to 2016

IMPORTANCE

In the US, approximately 40 000 people die due to firearm-related injuries annually. However, nonfatal firearm-related injuries are less precisely tracked.

OBJECTIVES

To assess the annual incidence of hospitalization for nonfatal firearm-related injuries in New York and to compare the annual incidence by sex, race/ethnicity, county of residence, and calendar years.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study used data from the New York Statewide Planning and Research Cooperative System for patients aged 15 years or older who presented to an emergency department in New York with nonfatal firearm-related injuries from January 1, 2005, to December 31, 2016. Data were analyzed from January 15, 2019, to April 21, 2021.

EXPOSURE

A nonfatal firearm-related injury, defined by International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

The annual incidence of nonfatal firearm-related injuries was calculated by determining the number of patients with a nonfatal firearm-related injury each year divided by the total population of New York.

RESULTS

The study included 31 060 unique patients with 35 059 hospital encounters for nonfatal firearm-related injuries. The mean (SD) age at admission was 28.5 (11.9) years; most patients were male (90.6%) and non-Hispanic Black individuals (62.0%). The overall annual incidence was 18.4 per 100 000 population. Although decreasing trends of annual incidence were observed across the state during the study period, this trend was not present in all 62 counties, with 32 counties (51.6%) having an increase in the incidence of injuries between 2005 and 2010 and 29 (46.8%) having an increase in the incidence of injuries between 2010 and 2015. In 19 of the 30 counties (63.3%) that had a decrease in incidence in earlier years, the incidence increased in later years.

CONCLUSIONS AND RELEVANCE

The annual incidence of hospitalization for nonfatal firearm-related injuries in New York during the study period was 18.4 per 100 000 population. Reliable tracking of nonfatal firearm-related injury data may be useful for policy makers, hospital systems, community organizers, and public health officials as they consider resource allocation for trauma systems and injury prevention programs.

State firearm laws, race and law enforcement-related deaths in 16 US states: 2010-2016

The aim of this study was to assess the association between state firearm legislation and law enforcement-related deaths (LEDs) and its modification by race. We used secondary data from an ecological cohort of 16 states (2010 to 2016), using the National Violent Death Reporting System (NVDRS), the State Firearm Law Database and additional public sources. Poisson regression with generalised estimating equations and inverse probability of exposure weights to account for time-varying confounding were used to quantify the association. LEDs were also disaggregated by race (Black vs non-Black). A total of 1593 LEDs took place during the 6-year study period. After adjusting for confounders, the IRR among non-Blacks was 0.48 (95% CI 0.26 to 0.89) and 1.53 (95% CI 0.93 to 2.54) among Blacks. Our findings highlight the fact that increased firearm provisions may decrease rates of LED among non-Black American individuals-an association not observed among Black Americans.

The Association of State Firearm Legislation With the Burden of Firearm-Related Surgery

BACKGROUND

United States state-level firearm legislation is linked to rates of firearm-related suicides, pediatric injuries, nonfatal injuries, hospital discharges, and mortality. Our objective was to evaluate the burden of firearm-related injuries requiring surgery for states with strict as opposed to nonstrict firearm legislation.

MATERIALS AND METHODS

The 2014 Healthcare Cost and Utilization Project State Inpatient Database was utilized to extract data for all available 28 states and the District of Columbia. States were dichotomized into strict and nonstrict legislative categories using the 2014 Brady and Gifford's scores (15 strict, 14 nonstrict). Patients with a firearm injury requiring surgery were identified and the incidence of surgery aggregated to the county level. Negative binomial regression with an offset for county-level residential population was used to estimate the incident rate ratio for surgical volume comparing counties in strict and nonstrict states. Models were stratified by injury intent and adjusted for county population characteristics.

RESULTS

A total of 11,939 patients were hospitalized with firearm-related injuries, with 65% (n = 7759) undergoing an operative procedure. The adjusted incidence rate of firearm-related surgery per 100,000 people was 1.29 (95% confidence interval; 1.13-1.46, P < 0.001) times higher and the adjusted cost of hospitalization per 100,000 people was $6028.69 ($3744.61-$8312.78, P = 0.001) greater for counties in nonstrict states than those for counties in strict states. The burden of health care for these injuries is invariably shifted to state- and county-level finances.

CONCLUSIONS

The rate of firearm-related surgical intervention was higher for states with nonstrict firearm legislation than that for states with strict legislation. States should reevaluate their firearm legislation to potentially reduce the burden of firearm-related surgery and health care costs.

The persistent southern disadvantage in US early life mortality, 1965-2014

BACKGROUND

Recent studies of US adult mortality demonstrate a growing disadvantage among southern states. Few studies have examined long-term trends and geographic patterns in US early life (ages 1 to 24) mortality, ages at which key risk factors and causes of death are quite different than among adults.

OBJECTIVE

This article examines trends and variations in early life mortality rates across US states and census divisions. We assess whether those variations have changed over a 50-year time period and which causes of death contribute to contemporary geographic disparities.

METHODS

We calculate all-cause and cause-specific death rates using death certificate data from the Multiple Cause of Death files, combining public-use files from 1965-2004 and restricted data with state geographic identifiers from 2005-2014. State population (denominator) data come from US decennial censuses or intercensal estimates.

RESULTS

Results demonstrate a persistent mortality disadvantage for young people (ages 1 to 24) living in southern states over the last 50 years, particularly those located in the East South Central and West South Central divisions. Motor vehicle accidents and homicide by firearm account for most of the contemporary southern disadvantage in US early life mortality.

CONTRIBUTION

Our results illustrate that US children and youth living in the southern United States have long suffered from higher levels of mortality than children and youth living in other parts of the country. Our findings also suggest the contemporary southern disadvantage in US early life mortality could potentially be reduced with state-level policies designed to prevent deaths involving motor vehicles and firearms.

Trends in US Emergency Department Visits for Pediatric Acute Ocular Injury

Importance

There is a lack of literature describing the incidence of pediatric acute ocular injury and associated likelihood of vision loss in the United States. Understanding national pediatric eye injury trends may inform future efforts to prevent ocular trauma.

Objective

To characterize pediatric acute ocular injury in the United States using data from a stratified, national sample of emergency department (ED) visits.

Design, Setting, and Participants

A retrospective cohort study was conducted. Study participants received care at EDs included in the 2006 to 2014 Nationwide Emergency Department Sample, comprising 376 040 children aged 0 to 17 years with acute traumatic ocular injuries. Data were analyzed from June 2016 to March 2018.

Exposures

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and external-cause-of-injury codes identified children with acute ocular injuries.

Main Outcomes and Measures

Demographic and clinical characteristics of children with acute traumatic ocular injuries were collected and temporal trends in the incidence of ocular injuries by age, risk of vision loss, and mechanism of injury were explored.

Results

In 2014, there were an estimated 163 431 (95% CI, 151 235-175 627) ED visits for pediatric acute ocular injury. Injured children were more often male (63.0%; 95% CI, 62.5-63.5) and in the youngest age category (birth to 4 years, 35.3%; 95% CI, 34.4-36.2; vs 10-14 years, 20.6%; 95% CI, 20.1-21.1). Injuries commonly resulted from a strike to the eye (22.5%; 95% CI, 21.3-23.8) and affected the adnexa (43.7%; 95% CI, 42.7-44.8). Most injuries had a low risk for vision loss (84.2%; 95% CI, 83.5-85.0), with only 1.3% (95% CI, 1.1-1.5) of injuries being high risk. Between 2006 and 2014, pediatric acute ocular injuries decreased by 26.1% (95% CI, -27.0 to -25.0). This decline existed across all patient demographic characteristics, injury patterns, and vision loss categories and for most mechanisms of injury. There were increases during the study in injuries related to sports (12.8%; 95% CI, 5.4-20.2) and household/domestic activities (20.7%; 95% CI, 16.2-25.2). The greatest decrease in high-risk injuries occurred with motor vehicle crashes (-79.8%; 95% CI, -85.8 to -74.9) and guns (-68.5%; 95% CI, -73.5 to -63.6).

Conclusions and Relevance

This study demonstrated a decline in pediatric acute ocular injuries in the United States between 2006 and 2014. However, pediatric acute ocular injuries continue to be prevalent, and understanding these trends can help establish future prevention strategies.

The association of firearm laws with firearm outcomes among children and adolescents: a scoping review

We conducted a scoping review to determine the current state of knowledge and areas for advancements in research on the association of firearm laws with child and adolescent firearm-related outcomes. We queried Scopus, EMBASE, Pubmed, and CJ Abstracts for English language original empirical research articles on policies affecting child and adolescent firearm-related outcomes published between January 1, 1985 and July 1, 2018. Data were abstracted, and methodologic quality assessed. Twenty articles met inclusion criteria. Among the policies studied were child access prevention laws (12 studies) and minimum age restrictions for firearm purchase and possession (4 studies). Outside of child access prevention laws, which are associated with reductions in child and adolescent unintentional and firearm suicide deaths, there is, at best, equivocal evidence of policy effects. This area is understudied, particularly in regard to nonfatal firearm injuries, for which the lack of a national surveillance system hampers research efforts. Further rigorous firearm policy evaluations are needed.

Prevention of Firearm Injuries Among Children and Adolescents: Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium

IMPORTANCE

Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality.

OBJECTIVE

The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development-funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic.

EVIDENCE REVIEW

A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium.

FINDINGS

Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement.

CONCLUSIONS AND RELEVANCE

These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.

Association of State Firearm Legislation With Female Intimate Partner Homicide

INTRODUCTION

The aim of this study was to assess the association between state firearm legislation and female intimate partner homicide.

METHODS

In 2017, the authors conducted a secondary data analysis of 16 states from 2010 to 2014, using data from the National Violent Death Reporting System, the State Firearm Law Database, and additional public sources. Poisson regression analyses quantified the association between the number of state restrictive firearm legislative provisions and the female population-based intimate partner homicide rate. For etiologic reasons, intimate partner homicide was disaggregated into homicide-suicide (intimate partner homicide followed by perpetrator suicide) and homicide-only intimate partner homicide (intimate partner homicide in the absence of perpetrator suicide).

RESULTS

There were 1,693 female intimate partner homicide deaths in the 16 states during 2010-2014; 67% were homicide-only intimate partner homicide. The number of state-level legislative provisions related to firearm restrictions ranged from four (Alaska) to 95 (Massachusetts). The intimate partner homicide rate in states with zero to 39 provisions was 1.16 per 100,000 person years (95% CI=1.10, 1.22) and in states with >40 provisions was 0.68 per 100,000 person years (95% CI=0.61, 0.72). The incidence of female intimate partner homicide was 56% lower in states with ≥40 legislative provisions (adjusted incidence rate ratio=0.44, 95% CI=0.28, 0.68), relative to states with zero to 39 provisions. This protective association was stronger for homicide-only intimate partner homicide than homicide-suicide intimate partner homicide.

CONCLUSIONS

More state-level restrictive firearm legislation is associated with a lower rate of female intimate partner homicides.

Firearm Deaths in America: Can We Learn From 462,000 Lives Lost?

OBJECTIVE

We sought to determine whether state firearm legislation correlated with firearm-related fatality rates (FFR) during a 15-year period.

BACKGROUND

The politicized and controversial topic of firearm legislation has been grossly understudied when the relative impact of American firearm violence is considered. Scientific evidence regarding gun legislation effectiveness remains scant.

METHODS

Demographic and intent data (1999-2013) were collected from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting System database and compared by state firearm legislation rankings with respect to FFR. State scorecards were obtained from firearm-restrictive (Brady Campaign/Law Center against Gun Violence [BC/LC]) and less-restrictive (National Rifle Association) groups. FFR were compared between restrictive and least-restrictive states during 3 periods (1999-2003, 2004-2008, 2009-2013).

RESULTS

During 1999 to 2013, 462,043 Americans were killed by firearms. Overall FFR did not change during the 3 periods (10.89 ± 3.99/100,000; 10.71 ± 3.93/100,000; 11.14 ± 3.91/100,000; P = 0.87). Within each period, least-restrictive states had greater unintentional, pediatric, and adult suicide, White and overall FFR than restrictive states (all P < 0.05). Conversely, no correlation was seen, during any of the 3 time periods, with either homicide or Black FFR-population subsets accounting for 41.7% of firearm deaths.

CONCLUSIONS

Restrictive firearm legislation is associated with decreased pediatric, unintentional, suicide, and overall FFR, but homicide and Black FFR appear unaffected. Future funding and research should be directed at both identifying the most effective aspects of firearm legislation and creating legislation that equally protects every segment of the American population.

Pediatric Firearm-Related Injuries in the United States

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury.

When love meets hate: The relationship between state policies on gay and lesbian rights and hate crime incidence

Do public policies on gay and lesbian rights affect the incidence of hate crimes based on sexual orientation? We propose that legal inequalities increase hate crimes because they provide discursive opportunities for bias, discrimination, and violence. Legal equality, however, will reduce violence. Using annual panel data from 2000 to 2012, a period of substantial policy change, we analyze how three state policies affect reported hate crimes: same-sex partnerships, employment non-discrimination, and hate crime laws. Hate crime and employment non-discrimination laws that include sexual orientation reduce hate crime incidence. Partnership recognition increases reported hate crimes, though it may not increase actual crime incidence. Because incidence is spatially correlated, policy changes in one state yield spillover benefits in other states. These results provide some of the first quantitative evidence that public policies affect hate crimes based on sexual orientation. Findings confirm the roles of institutional heterosexism and discursive opportunities in producing hate crimes.

Prevention and public health approaches to trauma and traumatic stress: a rationale and a call to action

BACKGROUND

The field of trauma and traumatic stress is dominated by studies on treatments for those who experience adversity from traumatic experiences. While this is important, we should not neglect the opportunity to consider trauma in a public health perspective. Such a perspective will help to develop prevention approaches as well as extend the reach of early interventions and treatments. The purpose of this paper is to provide an introduction to a public health approach to trauma and traumatic stress and identify key opportunities for trauma professionals and our professional societies (such as the International Society for Traumatic Stress Studies [ISTSS] and the European Society for Traumatic Stress Studies [ESTSS]) to increase our societal impact by adopting such an approach.

METHOD

This paper reviews and summarizes key findings related to the public health impact of trauma. The special case of children is explored, and a case example of the Norwegian terrorist attacks in 2011 illustrates the potential for improving our response to community level traumatic events. We also discuss how professional organizations such as ESTSS and ISTSS, as well as individual trauma professionals, can and should play an important role in promoting a public health approach.

RESULTS

Trauma is pervasive throughout the world and has negative impacts at the personal, family, community, and societal levels. A public health perspective may help to develop prevention approaches at all of these levels, as well as extend the reach of early interventions and treatments.

CONCLUSIONS

Professional organizations such as ESTSS and ISTSS can and should play an important role in promoting a public health approach. They should promote the inclusion of trauma in the global public health agenda and include public health in their activities.