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.

Financial burden of pediatric firearm-related injury admissions in the United States

Pediatric firearm-related injuries pose a significant public health problem in the United States, yet the associated financial burden has not been well described. This is the first study examining national data on the cost of initial hospitalization for pediatric firearm-related injuries. In this retrospective review, the Healthcare Cost and Utilization Project Kids' Inpatient Database from the years 2003, 2006, 2009, and 2012 was used to identify all patients 18 years of age and under who were admitted with firearm-related injuries. We compared demographic and discharge-level data including injury severity score, hospital length of stay, income quartile, injury intent, and inflation-adjusted hospital costs across age groups (0-5, 6-9, 10-15, 16-18 years). There were approximately 4,753 pediatric firearm-related admissions each year, with a median hospitalization cost of $12,984 per patient. Annual initial hospitalization costs for pediatric firearm injuries were approximately $109 million during the study period. Pediatric firearm-related injuries predominately occured among older teenagers (74%, 16-18 years), males (89%), black individuals (55%), and those from the lowest income quartile (53%). We found significant cost variation based on patient race, income quartile, injury severity score, intent, hospital length of stay, disposition, and hospital region. Inflation-adjusted hospitalization costs have increased significantly over the study period (p < 0.001). Pediatric firearm-related injuries are a large financial burden to the United States healthcare system. There are significant variations in cost based on predictable factors like hospital length of stay and injury severity score; however, there are also substantial discrepancies based on hospital region, patient race, and income quartile that require further investigation.

United States trends in healthcare charges for pediatric firearm injuries

BACKGROUND

From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups.

METHODS

In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time.

RESULTS

Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries.

CONCLUSIONS

Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.

The Effect of Opioid Dependence on Firearm Injury Treatment Outcomes: A Nationwide Analysis

BACKGROUND

Both the opioid and gun violence epidemics are recurrent public health issues in the United States. We sought to determine the effect of opioid dependence on gunshot injury treatment outcomes.

MATERIALS AND METHODS

Using the 2016 National Readmission Database, patients were included if they had a principal diagnosis of firearm injury. Opioid dependence was identified using appropriate International Classification of Diseases, 10th Revision, Clinical Modification codes. The primary outcome was 30-day all-cause readmission. Secondary outcomes were in-hospital and 1-year mortality, resource utilization, and most common reasons for admission and readmission. Confounders were adjusted for using multivariate regression analysis.

RESULTS

A total of 31,303 patients were included, 695 of whom were opioid dependent. Opioid-dependent patients were more likely to be young (35.1 y, range: 33.4-36.7 y) and male (89.9%) compared with patients without opioid dependence. Opioid dependence was associated with higher 30-day readmission rates (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.12-2.50, P = 0.01). However, opioid dependence was associated with lower in-hospital (aOR: 0.16, CI: 0.07-0.38, P < 0.01) and 1-year (aOR: 0.15, CI: 0.06-0.38, P < 0.01) mortality, longer mean length of stay (adjusted mean difference [aMD]: 2.09 d, CI: 0.43-3.76, P = 0.03), and total hospitalization costs (aMD: $6,318, CI: $ 257-$12,380, P = 0.04). Both groups had similar total hospitalization charges (aMD: $$10,491, CI: -$12,618-$33,600, P-value = 0.37).

CONCLUSIONS

Opioid dependence leads to higher rates of 30-day readmission and resource utilization among patients with firearm injuries. However, the in-hospital and 1-year mortality rates are lower among patients with opioid dependence secondary to lower injury acuity.

Readmission risk and costs of firearm injuries in the United States, 2010-2015

BACKGROUND

In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms.

METHODS

We used the Nationwide Readmission Database 2010-2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs.

RESULTS

Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%.

CONCLUSIONS

From 2010-2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this.

Economic assessment of wild bird mortality induced by the use of lead gunshot in European wetlands

In European wetlands, at least 40 bird species are exposed to the risk of lead poisoning caused by ingestion of spent lead gunshot. Adopting a methodology developed in North America, we estimated that about 700,000 individuals of 16 waterbird species die annually in the European Union (EU) (6.1% of the wintering population) and one million in whole Europe (7.0%) due to acute effects of lead poisoning. Furthermore, threefold more birds suffer sub-lethal effects. We assessed the economic loss due to this lead-induced mortality of these 16 species by calculating the costs of replacing lethally poisoned wild birds by releasing captive-bred ones. We assessed the cost of buying captive-bred waterbirds for release from market surveys and calculated how many captive-bred birds would have to be released to compensate for the loss, taking into account the high mortality rate of captive birds (72.7%) in the months following release into the wild. Following this approach, the annual cost of waterbird mortality induced by lead shot ingestion is estimated at 105 million euros per year in the EU countries and 142 million euros in the whole of Europe. An alternative method, based upon lost opportunities for hunting caused by deaths due to lead poisoning, gave similar results of 129 million euros per year in the EU countries and 185 million euros per year in the whole of Europe. For several reasons these figures should be regarded as conservative. Inclusion of deaths of species for which there were insufficient data and delayed deaths caused indirectly by lead poisoning and effects on reproduction would probably increase the estimated losses substantially. Nevertheless, our results suggest that the benefits of a restriction on the use of lead gunshot over wetlands could exceed the cost of adapting to non-lead ammunition.

Economic and Educational Impact of Firearm-Related Injury on an Urban Trauma Center

As nonfatal firearm-related injuries continue to increase, calculating the financial cost these injuries have on an urban trauma center may help justify funding for intervention programs. The impact these injuries have on orthopedic resident education may lead to changes in the training of some urban-based programs. This is a retrospective review of patients with an acute firearm-related injury from 2007 to 2013 at Louisiana State University Interim Public Hospital in New Orleans, Louisiana. All patients with a diagnosis of an acute gunshot wound on presentation to the emergency department were included in the study. Patients with complications from a previous gunshot wound or treatment of that wound were excluded. A total of 3617 patient encounters were identified that met this criteria. The total amount billed by the hospital over the study period was $141,995,682 while collecting $30,922,953. The actual hospital costs from these encounters was $73,572,892, giving the hospital a loss of $42,649,938. Of the 3617 patient encounters, 59% required orthopedic consultation. Of that consultation group, 25% required inpatient orthopedic surgical intervention. Acute gunshot wounds accounted for 23% of orthopedic trauma consultations and 13% of the orthopedic daily census. The financial data provide justification from an economic perspective for funding intervention programs aimed at decreasing firearm-related injury. In addition, the proportion of orthopedic surgical training spent on firearm-related injury provides program directors of urban-based programs with valuable information, although no conclusions can be drawn as to the effect on orthopedic surgical education.

[58 people with bullet wounds in Gothenburg during 18 months. This demonstrates the need for preparedness and competence within trauma care]

From 1 January 2013 to 30 June 2014, 58 patients sustained gunshot wounds in the city of Gothenburg. 57 were males and the median age was 26 years. The majority of injuries were musculoskeletal. Ten patients died, of these 4 patients suffered single gunshot wounds to the head, while 6 patients had wounds to mediastinal structures and large abdominal vessels. 90 % of patients presented out-of-hours. The total length of stay for the 47 patients admitted was 316 days. Direct health care costs were calculated to 6.2 MSEK.

Firearm related injuries amongst children: estimates from the nationwide emergency department sample

OBJECTIVE

The objective of this study is to provide estimates of firearm related injuries in children seeking care in hospital based emergency departments.

METHODS

The Nationwide Emergency Department Sample (NEDS) for the year 2008 was used for the current study. All ED visits occurring amongst children aged less than or equal to 18 years and that had an External Cause of Injury (E-Code) for any of the firearm related injuries were selected for analysis.

RESULTS

A total of 14,831 ED visits (in children) in the United States had a firearm injury. The average age of the ED visits was 15.9 years. Males constituted a predominant proportion of all ED visits (89.2%). A total of 494 patients died in the emergency departments (3.4% of all ED visits) whilst 323 died following in-patient admission into the same hospital (6% of all inpatient admissions). The most frequently documented firearms were assaults by firearms and explosives (55% of all ED visits), accidents caused by firearms and air gun missiles (33.6%), and injuries by firearms that were undetermined (7.4%). The average charge for each ED visit was $3642 (25th percentile is $1146, median is $2003, and 75th percentile is $4404). The mean charge for those visits that resulted in in-patient admission into the same hospital was $70,164 (25th percentile is $16,704, median is $36,111, and 75th percentile is $74,165) and the total charges for the entire United States was about $371.33 million.

CONCLUSIONS

The current study used the largest all-payer hospital based emergency department dataset to provide national estimates of firearm related injuries amongst children in the United States during the year 2008 and highlights the public health impact of such injuries.

The cost of murder. Anti-violence groups, hospitals work to try and stop homicides, which have negative impacts on both the community and bottom lines

The brutal toll of homicide in their communities has some hospitals working with anti-violence groups to halt the slaughter by trying to stop retaliation. Talking to victims after an attack is "really this golden window of opportunity, when they're open to change", says Marla Becker, left, of Youth Alive.

Costs differences across demographic groups and types of occupational injuries and illnesses

BACKGROUND

Little is known about cost differences for demographic groups or across occupational injuries and illnesses.

METHODS

In this incidence study of nationwide data for 1993, an analysis was conducted on fatal and non-fatal injury and illness data recorded in government data sets. Costs data were from workers' compensation records, estimates of lost wages, and jury awards.

RESULTS

The youngest (age < or = 17) and oldest (age > or = 65) workers had exceptionally high fatality costs. Whereas men's costs for non-fatal incidents were nearly double those for women, men's costs for fatal injuries were 10 times the costs for women. The highest ranking occupation for combined fatal and non-fatal costs--farming, forestry, and fishing--had costs-per-worker (5,163 US dollars) over 18 times the lowest ranking occupation-executives and managers (279 US dollars). The occupation of handlers, cleaners, and laborers, ranked highest for non-fatal costs. Gunshot wounds generated especially high fatal costs. Compared to whites, African-Americans had a lower percentage of costs due to carpal tunnel syndrome, circulatory, and digestive diseases.

CONCLUSIONS

Costs comparisons can be drawn across age, race, gender, and occupational groups as well as categories of injuries and illnesses.

The cost of treating serious abdominal firearm-related injuries in South Africa

INTRODUCTION

Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15,000 lives annually. Up to 127,000 firearm-injured victims seek state health care assistance per annum. The fiscal burden of treating these injuries is not known.

METHODS

All serious abdominal firearm-related injuries (requiring admission to hospital and emergency surgery) presenting to a state hospital over a 6-month period were reviewed. A cost analysis using five variables was performed: operating theatre time, duration of hospital and high-care unit stay, pharmaceutical and blood products used, laboratory services used and diagnostic imaging studies performed.

RESULTS

Twenty-three patients with serious abdominal gunshot injuries were admitted, of whom 21 (91%) were treated at the hospital from admission until discharge. Each admission cost approximately US dollars 1,467. Hospital stay (47%) and operating theatre (30%) costs accounted for most of the total cost. Pharmaceuticals and blood products (20%), laboratory services (2%) and imaging studies (1%) contributed less than 25% to the total cost.

CONCLUSION

Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South African government expenditure on health. This fiscal burden of approximately US dollars 2.9 million, almost 4% of the annual health budget, does not include the cost of treating other serious gunshot injuries. These findings highlight the need for successful violence prevention strategies in South African.

A review of 187 gunshot wound admissions to a teaching hospital over a 54-month period: training and service implications

BACKGROUND

Violence involving the use of firearms has increased in the UK over the past decade. This study assesses the implications of such injuries for service provision and training by reviewing the experience at one hospital.

METHODS

Accident and emergency triage data were searched for patients presenting with gunshot wounds over a 54-month period. Case notes were reviewed and patterns of care established. The resources required for clinical management were ascertained, and the financial consequences determined at contemporary full cost.

RESULTS

There were 187 attendances with 247 wounds. Mean age was 21 years (range, 8-63 years). Of the attendances, 69% were out of normal working hours. Of the 187 cases, 97 patients were admitted to one hospital (83 of whom required surgery) and 10 patients were transferred to other hospitals (6 for plastic surgery not available at the Manchester Royal Infirmary and 4 due to lack of beds). Of the 80 patients who were not admitted, 4 died in accident and emergency, the rest were either air gun wounds or relatively simple higher calibre injuries. A wide range of surgical specialties was involved (limb injury, 53; thoraco-abdominal and vascular, 28; head and neck, 5; and orbit, 2), and combinations of injuries transgressed specialty and sub-specialty boundaries. The total cost of patient care was pound 267,000.

CONCLUSIONS

Gunshot wounds present a heavy demand on the clinical and financial resources of the receiving hospital, and surgeons responsible for unselected acute admissions in "general surgery" should be capable of dealing with these indiscriminate injuries. Current training and service trends towards increasing sub-specialisation may mitigate against them achieving or retaining this capability.

Outcomes in children and young adults who are hospitalized for firearms-related injuries

OBJECTIVES

To compare outcomes by intent of nonfatal firearms-related injuries in a hospitalized population, newborn to 19 years of age, and estimate the national incidence of ensuing disability.

METHODS

Descriptive statistics and comparative analysis using chi(2), odds ratio, and t test were applied to data from the National Pediatric Trauma Registry (NPTR) and the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Demographics, preinjury medical history, scene of injury, primary body part injured, severity of injury, utilization of resources, short-term and long-term disability, medical cause of disability, and disposition at discharge were studied.

RESULTS

NPTR unintentional (n = 268) and assault-related firearms-related injuries (n = 506) were compared. In both groups, the majority of patients were male (80%). Compared with the unintentionally injured, the assaulted children were older and more frequently black (59.3% vs 32.5%). Approximately 17% in both groups had a preinjury history of medical/psychosocial problems. Unintentional injuries occurred mainly in private dwellings (75.7%), and assaults occurred in public places/street (53.8%). In both groups, injuries to multiple body regions were prevalent, and a substantial proportion sustained injuries of serious to critical level. Most children were transported by ambulance, but a significant proportion in the unintentional group were transported by helicopter. The rate of admission to the intensive care unit was approximately 40% for both groups. The unintentionally injured had a higher rate of surgical intervention (66.8% vs 50.8%) and stayed in the hospital longer than the assaulted ones (median: 5 days vs 3 days). Almost half of the children in both groups were discharged with disability, and approximately 87% returned to their home. Applying the NPTR disability rate to National Electronic Injury Surveillance System estimates of hospitalization suggests that approximately 3200 children nationwide develop disability from firearms-related injuries annually.

CONCLUSIONS

Nonfatal firearms-related injuries in a pediatric population are associated with a high use of medical resources and lasting disability. Public policies should be developed and implemented to reduce the occurrence of these catastrophic events.

Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures--the public health disparities geocoding project

Use of multilevel frameworks and area-based socioeconomic measures (ABSMs) for public health monitoring can potentially overcome the absence of socioeconomic data in most US public health surveillance systems. To assess whether ABSMs can meaningfully be used for diverse race/ethnicity-gender groups, we geocoded and linked public health surveillance data from Massachusetts and Rhode Island to 1990 block group, tract, and zip code ABSMs. Outcomes comprised death, birth, cancer incidence, tuberculosis, sexually transmitted infections, childhood lead poisoning, and nonfatal weapons-related injuries. Among White, Black, and Hispanic women and men, measures of economic deprivation (e.g., percentage below poverty) were most sensitive to expected socioeconomic gradients in health, with the most consistent results and maximal geocoding linkage evident for tract-level analyses.

Spinal cord injury caused by gunshot wounds: the cost of rehabilitation

The current authors did a retrospective review of the medical records of 47 patients with spinal cord injury secondary to gunshot wounds who were admitted to National Rehabilitation Hospital between 1993 and 1999. There were 44 male patients and three female patients; the mean age of the patients was 24.7 years (range, 15-56 years). Thirty-seven patients had paraplegia (27 had complete paraplegia, 10 had incomplete paraplegia) as a result of their gunshot wounds, and 10 had quadriplegia (eight had complete quadriplegia, two had incomplete quadriplegia). None of the weapons were identified. The most common firearm types were low-velocity weapons. The length of acute hospitalization increased with the number of associated injuries. Rehabilitation total length of stay was proportional to the injury classification (paraplegia, quadriplegia). The daily occupancy fee in the National Rehabilitation Hospital was approximately 1900 US dollars. Patients were admitted to the hospital when acute medical and surgical problems had been cleared and when they were ready to participate in rehabilitation and therapy.

Monitoring socioeconomic inequalities in sexually transmitted infections, tuberculosis, and violence: geocoding and choice of area-based socioeconomic measures--the public health disparities geocoding project (US)

OBJECTIVES

To determine which area-based socioeconomic measures, at which level of geography, are suitable for monitoring socioeconomic inequalities in sexually transmitted infections (STIs), tuberculosis (TB), and violence in the United States.

METHODS

Cross-sectional analysis of public health surveillance data, geocoded and linked to area-based socioeconomic measures generated from 1990 census tract, block group, and ZIP Code data. We included all incident cases among residents of either Massachusetts (MA; 1990 population = 6016425) or Rhode Island (RI; 1990 population = 1003464) for: STIs (MA: 1994-1998, n = 26535 chlamydia, 7464 gonorrhea, 2619 syphilis; RI: 1994-1996, n = 4473 chlamydia, 1256 gonorrhea, 305 syphilis); TB (MA: 1993-1998, n = 1793; RI: 1985-1994, n = 576), and non-fatal weapons related injuries (MA: 1995-1997, n = 6628).

RESULTS

Analyses indicated that: (a). block group and tract socioeconomic measures performed similarly within and across both states, with results more variable for the ZIP Code level measures; (b). measures of economic deprivation consistently detected the steepest socioeconomic gradients, considered across all outcomes (incidence rate ratios on the order of 10 or higher for syphilis, gonorrhea, and non-fatal intentional weapons-related injuries, and 7 or higher for chlamydia and TB); and (c). results were similar for categories generated by quintiles and by a priori categorical cut-points.

CONCLUSIONS

Supplementing U.S. public health surveillance systems with census tract or block group area-based socioeconomic measures of economic deprivation could greatly enhance monitoring and analysis of social inequalities in health in the United States.

Congressional voting behavior on firearm control legislation: 1993-2000

Firearm morbidity and mortality place an enormous burden on the health care enterprise and society at large. Recent research has shown strong public support for strategies to regulate firearms yet effective federal legislation to control the types of firearms sold, conditions of sale and purchase, limitation in transportation and storage, and responsibility for use of personally owned firearms has been limited. Thus the purpose of this study was to evaluate the relationship between Congressional voting on firearm control legislation and the following: political affiliation, military service, geographic location of representation, education level, sex, and gun rights and gun control contributions. This was accomplished using a retrospective assessment of Congressional voting records from the 103rd-106th Congresses (1993-2000) regarding firearm control legislation. The study found that $6,270,553 was donated to members of Congress, $5,394,049 to members of the House and $876,504 to members of the Senate by groups concerned with firearm legislation. In the House, males (Odds Ratio [OR], 3.87), Republicans (OR, 13), those from the South (OR, 5), and those who received gun rights funds (OR, 13 to 203, depending on level of donations) were more likely to vote pro gun rights. In the Senate, support for gun rights occurred more often for those from the West (OR, 3.56), Republicans (OR, 130.50), or those who had received gun rights donations (OR, 28.00). This study has found a strong and consistent relationship between a Congressional member's position on firearm legislation and the amount of money received, political affiliation, and geographic location of representation.

Firearm injury in America

In 2000, nearly 29,000 people in the U.S. died from firearm injury.The vast majority of these people died from suicide (58%) or homicide (38%). And for every person who died, at least two others were shot and survived, often with permanent disability. The Firearm Injury Center at Penn (FICAP), founded in 1997, is a unique collaboration among health professionals, researchers and communities to address the magnitude and impact of firearm injury and violence. In this Issue Brief, FICAP presents an overview of firearm violence, and discusses public health approaches to reducing the toll of violent injury.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND

Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies.

METHODS

Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures.

RESULTS

Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation.

CONCLUSION

Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

[Cost variation of hospitalization due to injuries: head trauma and fire arm accidents]

This article proposes two linear regression models on cost variation of hospitalization (based on data from the Brazilian National Unified Health System - SUS) for two types of injuries: head trauma and related cases (n = 98,156); fire arm injuries and related cases (n = 8,970). Data were collected from the 1997 standardized Hospital Admittance Forms covering all of Brazil. Explanatory variables were gender, age, hospital administration model (public, private, etc.), region of the country, hospitalization in a capital city, use of ICU, surgery, death, duration of hospitalization, most frequent procedures, special procedures, and interaction among certain variables. The two models adjusted well, with R2 = 0.7264 for the first and 0.7663 for the second. Explanatory variables in the first model were all significant, and only three variables in the second failed to show statistical significance. The two main variables in both models were use of ICU and surgery. Diagnostics for detection of outliers, multicolinearity, model specification error, and homoscedasticity were performed.

Penetrating head injury: a prospective study of outcomes

The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement.

Calculating the costs of gun injuries. A new methodology

A new method for assessing the costs of gun injuries to a health system examines data on paid amounts, comprehensive medical expenses, and expenses over time. The authors extracted claims using injury diagnosis codes from billing forms and medical charts. The study demonstrates that a claims database can be used to accurately measure health care costs associated with gun injuries. The study is the first to include gun-related injuries treated in ambulatory care settings and to track actual payments over time.

Firearm-related injuries affecting the pediatric population. Committee on Injury and Poison Prevention. American Academy of Pediatrics. Pediatrics. 2000;105:888-895. [PMID: 10742344 DOI: 10.1542/peds.105.4.888]

This statement reaffirms the 1992 position of the American Academy of Pediatrics that the absence of guns from children's homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. A number of specific measures are supported to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on handguns and semiautomatic assault weapons; and expanded regulations of handguns for civilian use. In addition, this statement reviews recent data, trends, prevention, and intervention strategies of the past 5 years.

The case against the gun industry

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The price of peace: the personal and financial cost of paramilitary punishments in Northern Ireland

The aim of this study was to compare the injuries sustained during paramilitary punishments both before and after the onset of "peace" in Northern Ireland. A retrospective chart review was performed looking at age, injuries, treatments instituted, theatre time, length of hospital stay and overall cost of care. In the 10-month period before the ceasefire, 31 patients were treated after sustaining paramilitary punishment shootings. Mean age was 25.2 years. All patients had small entrance and exit wounds with minimal soft tissue disruption. A total of 18 fractures were recorded in 15 patients and 14 arteries required repair. Mean operative time was 2.6 h, mean hospital stay 7.61 days and mean cost per patient 3102 Pounds. In the following 10-month period 28 patients were admitted after punishments, only one of whom had been shot, all others had been beaten with sticks and clubs. Mean age was 27.4 years. In 52 limbs, 64 fractures were recorded and 44% of these were open; 15 of the fractures were Gustilo and Anderson Grade III or greater and 11 of the fractures were intra-articular. There were no arterial injuries. Mean operative time was 2.6 h, mean hospital stay 12.4 h and mean cost per patient 3849 Pounds.

The medical costs of gunshot injuries in the United States

CONTEXT

The cost of treating gunshot injuries imposes a financial burden on society. Estimates of such costs are relevant to evaluation of gun violence reduction programs and may help guide reimbursement policies.

OBJECTIVES

To develop reliable US estimates of the medical costs of treating gunshot injuries and to present national estimates for the sources of payment for treating these injuries.

DESIGN AND SETTING

Cost analysis using E-coded discharge data from hospitals in Maryland for 1994-1995 and New York for 1994 and from emergency departments in South Carolina for 1997. Other sources of data included the National Electronic Injury Surveillance System for 1994 incidence of nonfatal gun injuries, the National Spinal Cord Injury Statistical Center database for 1988-1992 estimates of lifetime medical costs of gun injuries, and the 1994 Vital Statistics census for incidence of fatal gun injuries.

MAIN OUTCOME MEASURES

Estimated national acute-care and follow-up treatment costs and payment sources for gunshot injuries.

RESULTS

At a mean medical cost per injury of about $17000, the 134445 (95% confidence interval [CI], 109465-159425) gunshot injuries in the United States in 1994 produced $2.3 billion (95% CI, $2.1 billion-$2.5 billion) in lifetime medical costs (in 1994 dollars, using a 3% real discount rate), of which $1.1 billion (49%) was paid by US taxpayers. Gunshot injuries due to assaults accounted for 74% of total costs.

CONCLUSIONS

Gunshot injury costs represent a substantial burden to the medical care system. Nearly half this cost is borne by US taxpayers.

A call to arms: the emergency physician, international perspectives on firearm injury prevention and the Canadian gun control debate

There are more than seven million firearms in Canada and approximately 1400 firearm-related deaths per year. These figures are far greater than those for most European countries, but far less than those for the United States. This article will discuss the different classes of firearm deaths and the associated costs. Public health issues will be explored, especially as they relate to the involvement of the Canadian Association of Emergency Physicians, as well as injury control recommendations.

Gunshot wounds to the hand: management and economic impact

Low-velocity firearms represent the majority of civilian gunshot wounds to the hand, yet much of the literature is based on high-velocity injuries. The authors reviewed their treatment regimen for civilian gunshot wounds to the hand and offer a treatment algorithm that emphasizes early debridement and fracture stabilization. They also address the economic impact on society. The authors reviewed 121 fractures in 90 patients with gunshot wounds to the hand treated at an urban trauma center during the last 5 years. All patients were managed with irrigation and debridement, elevation, intravenous antibiotics, and early fracture stabilization. Sixty fractures were managed with rigid internal or external fixation: Kirshner wires (26%), miniplates (16%), and external fixation (8%). Fifty-six fractures were managed with closed reduction. Five fractures required amputation. There was one subsequent infection and two late amputations. The cost of hospitalization and operative care was more than $1.7 million. For gunshot wounds to the hand the authors advocate immediate irrigation and debridement, intravenous antibiotics, early fracture stabilization, and a low threshold for internal fixation. This regimen is supported by their low infection and complication rates.

Spinal cord injuries in adolescents after gunshot wounds: an increasing phenomenon in urban North America

While much attention is focused on firearm fatalities, the purpose of this study was to determine the expense of acute medical care and the rehabilitation experience of surviving adolescent patients in the USA with spinal cord injury secondary to gunshot wounds. We analyzed a cohort of 19 patients, 18 of whom survived 12 months after spinal cord injury. The need for primary medical care related to the injury, current work and scholastic status, and satisfaction with the quality of rehabilitation were determined. Ten were not involved in any type of academic or meaningful activity, five had returned to school, three were undergoing rehabilitation, and one patient died. Major complications were present in 14 of the 18 patients. Thus, despite a high survival rate after spinal cord injury in this USA population, considerable long-term disability persists, and survivors report a low level of satisfaction with life.

Utility and cost-savings of diagnostic laparoscopy in low-probability gunshot wounds of the abdomen

Gunshot wounds of the abdomen are associated with a 90% or greater incidence of intra-abdominal injury, prompting many trauma centers to routinely explore these patients via laparotomy. Increasingly, diagnostic laparoscopy has been used to evaluated the abdomen to exclude peritoneal violation by the missile. Retrospective analysis of the experience at a Level I Trauma Center with 20 isolated abdominal gunshot wound patients who did not have obvious indications for laparotomy such as peritonitis or shock is detailed. Outcome and cost analysis were compared in patients who had diagnostic laparoscopy or laparotomy. Patients who underwent diagnostic laparoscopy instead of laparotomy had a 42% reduction in operative time, a 33% reduction in hospital charges, and a reduction in hospital length of stay from an average of 3.5 days to less than one day. The only operative complication noted was in a patient who underwent laparotomy. Diagnostic laparoscopy may be used in select patients to exclude significant intra-abdominal injuries following gunshot wounds of the abdomen with reduction in health care costs and morbidity.

Gunshot injuries in infants and children in KwaZulu-Natal--an emerging epidemic?

OBJECTIVES

To determine the pattern of firearm injuries in children under the age of 13 years admitted to a paediatric surgical unit in KwaZulu-Natal and to assess the impact of such injuries on hospital resources.

DESIGN

Retrospective review of the Department of Paediatric Surgery and hospital databases for all gunshot admissions, 1983-1995 inclusive.

SETTING

King Edward VIII Hospital, Durban.

SUBJECTS

Children aged 12 years and under admitted to the care of the Department of Paediatric Surgery for management of gunshot injuries.

METHODS

Data retrieved included demographic details, circumstances of injury, duration of hospital stay, management and outcome in terms of mortality and long-term morbidity.

RESULTS

One hundred and six patients were identified, of whom 96 were available for review. There has been a rapid escalation of numbers presenting. During 1994-1995, an additional 38 children with gunshot injuries were admitted to other units within Durban academic hospitals. The mean age of injury in patients admitted to the Department of Paediatric Surgery was 6.4 years and the abdomen was the most frequently injured area. Multiple injuries were common. The in-hospital mortality rate was 10.4%. Major morbidity, including paraplegia, hemiplegia, amputation and major peripheral nerve deficit, was seen in 11.4%. Duration of bed occupancy in the general surgical ward reached 247 days in 1995.

CONCLUSION

There is an increasing incidence of gunshot injuries in this region. Of children surviving to reach hospital, 10% die and 11% are left with lifelong major morbidity. Most victims are innocent bystanders and too young to be considered active participants. Prevention will require sociopolitical stability and the disarming of the community.

Firearm injury in Orleans parish: a 24-month perspective

This study is a retrospective review of all gunshot wounds treated at Charity Hospital, the Orleans Parish designated trauma center, for the 24-month period from November 1993 to November 1995. Its purpose was to define the magnitude of firearm injury in the parish and the impact on the health care system. One-thousand-six-hundred-sixty-nine gunshot wounds were analyzed. Most involved African-American males. Twenty percent were fatal. Two-thousand-forty-three emergent operations were performed. Ten percent of surviving patients had some permanent disability, 6% required institutional care. In 760 patients, initial hospital charges totaled $5,153,516. Extrapolation of these figures to the entire group yields an initial hospital cost of $11,317,392. Transport by the "911" system and in-house trauma team activation were required in most patients. In summary, firearm injury poses a serious economic problem and is a substantial drain on health care providers and their resources.

Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons

This article estimates the costs of U.S. gunshot and cut/stab wound by intent. It also compares U.S. to Canadian gunshot experience. Incidence data are from published sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS), and cause-coded emergency department discharge and hospital discharge data systems. Medical care payments and lost earnings per case come from National Crime Survey data, a literature review, and weighting of costs by diagnosis from Databook on Nonfatal Injury-Incidence. Costs, and Consequences by Miller et al. (The Urban Institute Press, Washington, DC. 1995) with the diagnosis distribution of penetrating injuries from the discharge data systems. Quality of life losses are estimated primarily from jury awards to penetrating injury victims. In 1992, gunshots killed 37,776 Americans; cut/stab wounds killed 4095. Another 134,000 gunshot survivors and 3,100,000 cut/stab wound survivors received medical treatment. Annually, gunshot wounds cost an estimated U.S. $126 billion. Cut/stab wounds cost another U.S. $51 billion. The gunshot and cut/stab totals include U.S. $40 billion and U.S. $13 billion respectively in medical, public services, and work-loss costs. Across medically treated cases, costs average U.S. $154,000 per gunshot survivor and U.S. $12,000 per cut/stab survivor. Gunshot wounds are more than three times as common in the U.S. than in Canada, which has strict handgun control. With the same quality of life loss per victim, gunshot costs per capita are an estimated U.S. $495 in the U.S. vs U.S. $180 in Canada. Per gun, however, the costs are higher in Canada, Gunshot wound rates rise linearly with gun ownership.

The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center

OBJECTIVE

To determine the prevalence of gunshot wound related orthopaedic injuries in an urban trauma center and outline the socioeconomic background of this patient population.

DESIGN

Retrospective study conducted from January 1, 1994, through December 30, 1994.

SETTING

University-affiliated level 1 trauma center.

PATIENTS

Strict inclusion and exclusion criteria were established.

INCLUSION CRITERIA

All patients were admitted through the emergency room with a gunshot wound for which the orthopaedic surgery service was consulted. The study group consisted of 284 patients.

EXCLUSION CRITERIA

Those individuals excluded from the study were patients with an orthopaedic injury who died during or before attempts at resuscitation in the emergency room and patients treated on an outpatient basis.

MAIN OUTCOME MEASURES

Orthopaedic and nonorthopaedic diagnoses, etiology, procedures performed, number of hours from admission to the first surgical procedure, average daily hospital census, drug and alcohol screen results, and patient financial status.

RESULTS

The orthopaedic service was consulted on 284 patients admitted with gunshot wounds. This group comprised 24% of all orthopaedic admissions, 33% of the average daily orthopaedic census, and 14% of all orthopaedic surgery cases performed. Ninety-four percent were African American and 87% were male, with a mean age of 27 years. Approximately half were tested for alcohol and/or drugs, 45% of whom were positive for alcohol and 65% for drugs. Only 4% of the patients were privately insured.

CONCLUSIONS

During the period of this study, gunshot wound injuries required more orthopaedic trauma resources than any other single diagnosis.

Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma

BACKGROUND

Diagnostic laparoscopy for the evaluation of injuries in patients with penetrating abdominal trauma has been shown to decrease the morbidity and mortality associated with mandatory laparotomy. The overall impact on patient care and hospital costs has not been thoroughly investigated. The goal of this study was to determine the economic impact of laparoscopy as a diagnostic tool in the management of patients following penetrating trauma to the abdomen or flank.

METHODS

Retrospective chart review of all hemodynamically stable patients with penetrating trauma to the abdomen or flank, but without other injuries requiring emergent intervention, admitted to a level I trauma center between January 1, 1992, and September 30, 1994. Those patients who underwent either laparoscopy (DL) or laparotomy (NL) or both (CONV) and who had no intraabdominal organ injuries requiring surgical therapeutic intervention were included in the study. Age, operative time, operative findings, length of hospitalization, Injury Severity Score (ISS), variable costs, and total costs were recorded for each patient.

RESULTS

Fourteen patients underwent negative/nontherapeutic laparoscopy (DL), 19 patients underwent negative/nontherapeutic laparotomy (NL), and four patients underwent both laparoscopy and laparotomy, a conversion procedure (CONV). There was no significant difference in age, operative times, or ISS between the DL and NL groups. Mean ISS of CONV patients was significantly greater than that of DL patients, 5.75 +/- 1.97 vs 2.43 +/- 0.63 (p < 0.05). Mean operative time for CONV patients was also significantly greater than both DL and NL patients, 106.5 +/- 17.00 min vs 66.1 +/- 6.55 and 47. 3 +/- 7.50 min, respectively (p < 0.05). The mean length of stay was significantly shorter in the DL group as compared to the NL or CONV groups, 1.43 +/- 0.20 vs 4.26 +/- 0.31 and 5.0 +/- 0.82 (p < 0.0001). The variable costs for the DL group were significantly lower than those incurred by patients in the NL and CONV groups, $2,917 +/- 175 vs $3,384 +/- 102 and $3,774 +/- 286, (p < 0.05). Variable costs were not significantly different between the NL and CONV groups. Total costs were also significantly lower in the DL group when compared to NL and CONV, $5,427 +/- 394 vs $7,026 +/- 251 and $7,855 +/- 750 (p < 0.005), but again, they were not statistically different between the NL and CONV groups. The overall total costs for laparoscopy, including the costs incurred by conversion patients, was significantly less than the total costs for laparotomy patients, $5,664 +/- 394 vs $7,028.47 +/- 250 (p < 0.005). This resulted in an overall savings of $1,059.44 per laparoscopy performed. The overall negative/nontherapeutic laparotomy rate during this study was 19.1%, which was significantly lower than the negative or nontherapeutic exploration rate during the time period prior to the use of laparoscopy (p < 0.01, z = 2.550).

CONCLUSION

Variable and total costs and length of stay were significantly lower in our population of patients who underwent DL as compared to NL. The rate of negative or nontherapeutic laparotomy was also significantly reduced when compared to the rate identified during the era prior to the use of laparoscopy. Laparoscopy resulted in an overall savings of $1,059 per laparoscopy performed when compared to laparotomy.