Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis

Multi-institutional review of characteristics and management of gunshot wounds to the spine

BACKGROUND CONTEXT

Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data.

PURPOSE

To characterize the management and follow-up of GSWs to the spine.

STUDY DESIGN/SETTING

A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers.

PATIENT SAMPLE

Patients with GSWs to the spine between 2010-2021.

OUTCOME MEASURES

Measures included work status, follow-up healthcare utilization, and pain management were collected.

METHODS

Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY).

RESULTS

A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score.

CONCLUSIONS

Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

Evaluation of Self-Inflicted versus Non-Self-Inflicted Gunshot Wounds and Associated Injuries Involving the Hand and Upper Extremity

Orthopedic costs associated with gunshot wounds (GSWs) totaled approximately USD 510 million from 2005 to 2014. Previous studies have identified differences in injuries associated with self-inflicted (SI) GSWs; however, there remains a gap in understanding injury patterns. This study aims to expand upon the current literature and shed light on injury patterns and outcomes associated with SI vs. non-self-inflicted (NSI) GSWs. This is a retrospective cohort study of upper extremity GSWs from January 2012 to December 2022. Data were analyzed using the two-sample t-test, Pearson's chi-squared test, and Fisher's exact test. SI GSWs tended to be high-velocity GSWs and occurred more often in distal locations compared to NSI GSWs (p = 0.0014 and p < 0.0001, respectively). SI GSWs were associated with higher Gustilo-Anderson (GA) and Tscherne classifications (p < 0.0001 and p = 0.0048, respectively) and with a greater frequency of neurovascular damage (p = 0.0048). There was no difference in fracture rate or need for operative intervention between the groups. GA and Tscherne classifications were associated with the need for and type of surgery (p < 0.0001), with a higher classification being associated with more intricate operative intervention; however, GSW velocity was not associated with operative need (p = 0.42). Our findings demonstrate that velocity, wound grading systems, and other factors are associated with the manner in which GSWs to the upper extremity are inflicted and may thus have potential for use in the prediction of injury patterns and planning of trauma management and surgical intervention.

Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in 320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (P = 0.004), canal compromise (P < 0.001), dirty wounds (P < 0.001), bullet or bone fragment remains in the spinal canal (P < 0.001) and injury pattern (P < 0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

The Medical Costs of Firearm Injuries in the United States: A Systematic Review

BACKGROUND

Firearm injury poses a significant public health burden in the United States.

OBJECTIVES

The purpose of this systematic review was to provide a comprehensive accounting of the medical costs of firearm injuries in the United States.

METHODS

A systematic literature review was conducted to identify studies published between January 1, 2000 and July 13, 2022 that reported medical costs of firearm injuries. A search of Embase, PubMed, and the Cochrane Library databases was performed by a medical librarian. The National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate for risk of bias. Health care-related charges and costs per firearm injury were presented and trends were identified.

RESULTS

Sixty-four studies were included in the analysis. Study sample sizes ranged from 18 to 868,483 patients. Reported costs per injury ranged from $261 to $529,609. The median cost reported was $27,820 (interquartile range [IQR] $15,133-$40,124) and median charge reported was $53,832 (IQR $38,890-$98,632). Studies that divided initial hospitalization costs and follow-up medical costs identified that initial hospitalization accounts for about 60% of total costs.

CONCLUSIONS

We found a significant volume of literature about the medical costs of firearm injury, which identified a highly heterogeneous cost burden. A significant amount of cost burden occurs after the index hospitalization, which is the only cost reported in most studies. Limitations of this study include reporting bias that favors hospitalized patients as well as a large focus on hospital charges as measurements of cost identified in the literature.

Factors affecting return to work time and functional outcome after low-velocity gunshot injuries related to foot in civilian population

BACKGROUND

Purpose of this study was to identify factors affecting return to work time and functional outcomes after low-velocity gunshot injuries related to foot. Related complications are also analyzed.

METHOD

This study conducted as retrospective cohort study in tertiary care university hospital. Data on 26 patients obtained through retrospective database search. Type of causing weapon, anatomic location of wound, wound type according to Gustilo Anderson classification, extend of damage regarding injured structures, extend of soft tissue damage, duration of hospital stay, need of reconstructive surgery, return-to-work time, follow-up period and functional scores at final follow-up were recorded. Factors affecting functional outcome and return-to-work time were analyzed.

RESULTS

Total of 12 patients (46.2 %) experienced complications, with eight being deep soft tissue infections. The mean MFS score for the study group was 77.27 (±11.82). The mean MFS for the pistol group was 83.46 (±6.90), extent of soft tissue damage was an independent risk factor (OR 10.67, 95 % CI 1.70-66.72, p = 0.011) for poor outcomes. On average, patients took 10.12 months (±7.59) to return to work, the type of gun used was an independent variable associated with delayed return to work (OR 144, 95 % CI 8.04-2578.09, p = 0.011).

CONCLUSION

Gunshot injuries related to foot can lead to a high rate of complications, loss of workdays, and permanent functional losses. Therefore, it is crucial to develop appropriate treatment plans and manage inevitable complications in these injuries.

LEVEL OF EVIDENCE

Level IV, Case series.

Spinal gunshot wounds: A retrospective, multicenter, cohort study

INTRODUCTION AND OBJECTIVE

To describe the demographic and clinical characteristics and treatment of patients with spinal gunshot wounds across Latin America.

MATERIAL AND METHODS

Retrospective, multicenter cohort study of patients treated for gunshot wounds to the spine spanning 12 institutions across Latin America between January 2015 and January 2022. Demographic and clinical data were recorded, including the time of injury, initial assessment, characteristics of the vertebral gunshot injury, and treatment.

RESULTS

Data on 423 patients with spinal gunshot injuries were extracted from institutions in Mexico (82%), Argentina, Brazil, Colombia, and Venezuela. Patients were predominantly male civilians in low-risk-of-violence professions, and of lower/middle social status, and a sizeable majority of gunshots were from low-energy firearms. Vertebral injuries mainly affected the thoracic and lumbar spine. Neurological injury was documented in n=320 (76%) patients, with spinal cord injuries in 269 (63%). Treatment was largely conservative, with just 90 (21%) patients treated surgically, principally using posterior open midline approach to the spine (n=79; 87%). Injury features distinguishing surgical from non-surgical cases were neurological compromise (p=0.004), canal compromise (p<0.001), dirty wounds (p<0.001), bullet or bone fragment remains in the spinal canal (p<0.001) and injury pattern (p<0.001). After a multivariate analysis through a binary logistic regression model, the aforementioned variables remained statistically significant except neurological compromise.

CONCLUSIONS

In this multicenter study of spinal gunshot victims, most were treated non-surgically, despite neurological injury in 76% and spinal injury in 63% of patients.

The Economic Impact of Acute Firearm Injuries at a Trauma Center in New Orleans

INTRODUCTION

The objective of this study was to examine the payer mix and the economic impact of acute firearm injuries at a Level I Trauma Center in New Orleans.

METHODS

Acute firearm injury economic data were obtained from the trauma registry database of the University Medical Center in New Orleans, Louisiana for 2016 through 2019. Patients were identified by the ICD-10-CM external causes of morbidity codes found in their electronic medical records. All patients with codes for initial encounters for gunshot wounds were included. Abstracted data included total charges and payments. Using the hospital cost-to-charge ratio, the estimated costs and losses were tabulated. Data analysis for this study occurred from 2020 to 2021.

RESULTS

A total of 2,094 patients with acute firearm injuries were identified over the 4-year period. These patients incurred charges of $122,440.642, whereas $17,293,655 was collected as payment. The estimated cost associated with the encounters was $37,602,667, resulting in a net loss of $20,309,012 from 2016 to 2019 for the hospital.

CONCLUSIONS

Firearm injuries continue to plague the U.S. as a serious public health problem, causing preventable death, illness, and disability. They also continue to result in a major economic burden.