Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. ...Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period.
In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law.
Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates.
State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts.
Prognostic and Epidemiologic; Level IV.
Firearm homicides disproportionately affect Black communities. Redlining – discriminatory lending practices of the early 20th century - are associated with current increased rates of firearm ...violence. Poverty and concentrated disadvantage are also associated with firearm violence. The interaction of these factors with racist redlining housing practices remains unclear.
We used generalized structural equation modeling to characterize the mediators through which redlining practices of the 1930s led to present rates of firearm violence in Boston using a negative binomial model. Principle component analysis was used to create four distinct mediating variables representing census block socioeconomic and built environment information, while reducing dimensionality. We calculated the direct effect between harmful (Red and Yellow) vs beneficial (Green) designations and firearm incident rate, indirect effect between redlining designation and firearm incident rate through each mediating variable, and the total effect. The percentage mediation of each mediator was subsequently calculated.
Red and Yellow areas of Boston were associated with an 11•1 (95% CI 5•5,22•4) and 11•4 (5•7,22•8) increased incident rate of shooting when compared to Green. In the pathway between Red designation and firearm incident rate, poverty and poor educational attainment mediated 20% of the interaction, share of rented housing mediated 8%, and Black share of the population 3%. In the pathway between Yellow designation and firearm incident rate, poverty and poor educational attainment mediated 16% of the association, and Black share of the population mediated 13%.
Redlining practices of the 1930s potentially contribute to increased rates of firearm violence through changes to neighborhood environments, namely through preclusion from homeownership, poverty, poor educational attainment, and concentration (i.e. segregation) of Black communities. These downstream mediating factors serve as points for policy interventions to address urban firearm violence.
Michael Poulson and Miriam Neufeld were supported by T32 Training Grants (HP10028, GM86308).
Much of the recorded medical literature focuses on individual-level factors that contribute to firearm violence. Recently, studies have highlighted higher incidence of firearm violence in ...historically redlined and marginalized areas, but few have gone on to study the downstream associations causing these differences. This study aims to understand the effects of historic redlining and current income mobility on firearm violence.
Using a retrospective cross-sectional design, shooting incidents were spatially joined with redlining vector files and linked to income mobility data (how much a child makes in adulthood). Participants included all assault and homicide incidents involving a firearm in the city of Boston, between 2016 and 2019. The exposure of interest was redlining designation as outlined by the Home Owner's Loan Corporation (HOLC) in the 1930s and income mobility, stratified by race, defined as the income of a child in their 30s compared with where they grew up (census tract level). The outcome measured was shooting rate per census block.
We find that increases in Black income mobility (BIM) and White income mobility (WIM) are associated with significant decreases in rates of firearm incidents in all HOLC designations; however, there is a larger decrease with increasing BIM (relative risk, 0.47 per unit increase in BIM 95% confidence interval, 0.35-0.64; relative risk, 0.81 per unit increase in WIM 95% confidence interval, 0.71-0.93). Plotting predicted rates of firearm violence in each HOLC designation at different levels of BIM, there were no significant differences in shooting rates between historically harmful and beneficial classifications above $50,000 of BIM. Despite level of WIM, there were continued disparities between harmful and beneficial HOLC classification.
These findings highlight the importance of structural racism in the form of redlining and discriminatory housing policies, and the preclusion from economic mobility therein, on the incidence of firearm violence today.
Prognostic and Epidemiological; Level IV.
Violence-related reinjury impacts both patients and health care systems. Mental illness (MI) is prevalent among violently injured individuals. The relationship between preexisting MI and violent ...reinjury among women has not been fully characterized. Our objective was to determine if risk of hospital reencounter-violent reinjury and all-cause-was associated with preexisting MI at time of index injury among female victims of violence.
All females (15-100 + years) presenting to a level I trauma center with violent injury (2002-2019) surviving to discharge were included (N = 1,056). Exposure was presence of preexisting MI. The primary outcome was hospital reencounters for violent reinjury and all-cause within one year (through 2020). The secondary outcome was the development of a new MI within one year of index injury. Odds of reencounter and development of new MI for those with and without preexisting MI were compared with multivariable logistic regression, stratified for interaction when appropriate.
There were 404 women (38%) with preexisting MI at time of index injury. Approximately 11% of patients with preexisting MI experienced violent reinjury compared to 5% of those without within 1 year ( p < 0.001). Specifically, those with MI in the absence of concomitant substance use had more than three times the odds of violent reinjury (adjusted Odds Ratio, 3.52 (1.57, 7.93); p = 0.002). Of those with preexisting MI, 64% had at least one reencounter for any reason compared to 46% of those without ( p < 0.001 ) . Odds of all-cause reencounter for those with preexisting MI were nearly twice of those without (adjusted Odds Ratio, 1.81 1.36, 2.42; p < 0.0001).
Among female victims of violence, preexisting MI is associated with a significantly increased risk of hospital reencounter and violent reinjury within the first year after index injury. Recognition of this vulnerable population and improved efforts at addressing MI in trauma patients is critical to ongoing prevention efforts to reduce violent reinjury.
Prognostic and Epidemiological; Level IV.
To compare donations to individual politicians from physician organization political action committees (PACs) and from the National Rifle Association Political Victory Fund (NRA PVF) in 2018.
We ...identified 7 organizations with published firearm injury prevention policy. We determined the difference in funds received from physician organization PACs and the NRA PVF for each congressmember. We examined their voting records on firearm-related legislation.
A total of 141 congressmembers received funds from both physician organization PACs and the NRA PVF. Of these, 99.3% voted for legislation not consistent with organization recommendations. The majority (70.2%) received more funds from the combined physician organization PACs than from the NRA PVF.
Physician organization PACs have a financial impact on NRA-backed congressmembers. They currently contribute to politicians with voting records inconsistent with their own policy recommendations. Firearm violence prevention does not currently outweigh other legislative priorities for physician organization PAC contributions.
The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to ...explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.
The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019–March 10, 2020 versus March 11, 2020–May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.
There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 0.51, 0.98) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 95% confidence interval 0.47–0.91) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 95% confidence interval 0.52–1.52); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 95% confidence interval 0.83–2.25).
The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care–use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.
Following the declaration of the COVID-19 pandemic, there were reports of decreased trauma hospitalizations, although violent crime persisted. COVID-19 has had the greatest impact on minoritized and ...vulnerable communities. Decreases in traumatic events may not extend to these communities, given pandemic-related socioeconomic and psychological burdens that increase the risk of exposure to trauma and violence.
This was a retrospective cohort study (n = 1634) of all trauma activations presenting to our institution January 1, 2020 to May 31, 2020, and same time periods in 2018 and 2019. Census tracts and associated Social Vulnerability Index quartiles were determined from patient addresses. Changes in trauma activations pre and post Massachusetts’ state-of-emergency declaration compared to a historical control were analyzed using a difference-in-differences methodology.
Weekly all-cause trauma activations fell from 26.44 to 8.25 (rate ratio = 0.36 0.26, 0.50) postdeclaration, with significant difference-in-differences compared to a historical control (P < 0.0001). Nonviolent trauma activations significantly decreased from 21.11 to 5.17 after the declaration (rate ratio = 0.27 0.37, 0.91; P < 0.0001), whereas there was no significant decrease in violent injury (5.33 to 3.08 rate ratio = 0.69 0.39, 1.22; P = 0.20). Stratified by vulnerability, the most vulnerable quartile had an increased proportion of all-cause trauma postdeclaration and had no decrease in violent trauma activations following the declaration compared to the historical control (rate ratio = 0.84 0.38-1.86; P = 0.67).
The state-of-emergency declaration was associated with significant decreases in overall trauma, to a greater extent in nonviolent injuries. Among those living in the most socially vulnerable communities, there was no decrease in violent trauma. These findings highlight the need for violence and injury prevention programs in vulnerable communities, particularly in times of crisis.
Violent trauma has lasting psychological impacts. Our institution’s Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and ...determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma.
Analysis included survivors (0–21 years) of violent penetrating injury at our institution (2011–2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization.
There was initial rapid uptake of CVRT (2011–2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation.
Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.
•Mental Health Services program successfully implemented in 3 years.•Strengthens existing hospital-based violence intervention programs.•Race associated with continued use of services but not initial engagement.•More work is needed to ensure that barriers to providing care are overcome.
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