BALTIMORE (FRONTLINE MEDICAL NEWS) – The national problem of firearms-related deaths and injuries is the subject of political, social, and economic concern, and typically, the focus is on fatalities and the causes of violence. But for surgeons, this crisis comes down to the injured patient presenting at the emergency room or trauma center and the challenges of treatment and follow-up. For hospitals, rates of readmission and expanding costs are significant issues.

A study conducted by Jacob Avraham, MD , and his colleagues at New York University and presented at the annual American Association of the Surgeons of Trauma, looked at the numbers of patients seen at EDs for firearms-related injuries.

“If you consider where most of the firearms data are coming from, they are coming from police fatality statistics and not a lot is out there from patients who lived to be seen in an emergency department,” said Dr. Avraham during an interview. “There were 130,000 killed over 4 years looking at Centers for Disease Control and Prevention police statistics; while policy makers need to focus on wider epidemic of violence, it matters more [to surgeons] who the patients are and what can they do for them.”

Firearms injuries account for about 1% of all emergency department episodes. This means that more than “70,000 people are seen annually in this country for firearms-related injuries, and that violence is responsible for one-third of all ED trauma mortality,” said Dr. Avraham. “It really speaks to the lethality of this mechanism.”

The researchers used the Healthcare Cost and Utilization Program (HCUP) Nationwide Emergency Department Data Sample to review data on 282,542 patients with gunshot injuries during 2009-2012. Cases were identified using ICD9 E-codes and comprised fatalities and injuries, including ricochet injuries, tinnitus, and graze injuries, according to Dr. Avraham.

Overall, there was a 4% increase in the number of firearms-related injuries diagnosed during the 2009-2012 study period. Patients aged 18-44 years had approximately 45 injuries/100,000 people per year, compared with 10 injuries/100,000 per year among people both younger than 18 years and those aged 45-65 years, and 5 injuries/100,000 people among those older than 65 years. The number of 18-44 year-olds injured increased by 7.2% during the study period. While the numbers for children aged 0-4 years and 5-9 years injured by firearms remain relatively small, those numbers grew by 16% and 19%, respectively, over the study period.

The investigators looked at mortality rates for gunshot victims and concluded that most of these deaths occur on the scene or before arrival at EDs. In an interview, Dr. Avraham stressed the value of improving care of patients at the scene.

“Eighty percent of firearms-injured patients die at the scene or make it to the ambulance but arrive dead at the emergency department. There has been a lot of [research] into the approach of triage on the scene vs. scoop and triage,” said Dr. Avraham. “In terms of our care in hospitals, expanded trauma centers will be part of the solution, including [improvements in our understanding of] who needs to be triaged and who needs to be discharged.”

The good news is that investigators found 92% of those who were able to make it to the emergency department from the scene survived to be discharged from the hospital; 4% died in the ED, and 3% died after admission.

Overall, 38% of firearms-injured patients were admitted, while 48% were treated and sent home from the ED, and about 1% left the ED against medical advice.

The limitations of this study were the retrospective design. Variables such as complications from other injuries, outcomes of patients transferred to other hospitals, and longitudinal data on recidivism were not captured because of the limitations of the database.

Impact of firearms Injuries

Nicole A. Stassen, MD , FACS, a surgeon at the University of Rochester (N.Y.) Medical Center and former president of the Eastern Association for the Surgery of Trauma, spoke in an interview about the impact of the rising numbers of firearms-related injuries on trauma and emergency units and surgical services. She emphasized that the impact of firearms injury is not just homicides, but suicides and life-altering injuries, the effects of which ripple out from the lives of the victims to the families and communities. Trauma centers and emergency departments are on the front lines in handling all instances and circumstances of bullets damaging humans.

In reference to the increase in firearms injuries, Dr. Stassen said “A lot of the urban trauma centers are already experiencing operating room volumes that are significantly higher. Where you usually have two rooms open, now you’re on average doing three and four operations at the same time.”

While all hospitals have a disaster plans in place to deal with a high-volume crisis, hospitals have difficulty sustaining these routines on a daily basis, according to Dr. Stassen.

“If you’re having to activate your disaster plan every Friday night, that’s not a sustainable model,” said Dr. Stassen. “The daily increase is a huge strain and there aren’t perfect solutions to that.”

Surgeons are not the only ones who are affected, according to Dr. Stassen. All members of the emergency staff feel the brunt of this increase, which can lead to staff burning out faster and leaving, creating a void that puts a further burden on the trauma team.

With resources being strained, the question becomes how can trauma centers continue to provide care for the increase in firearms-injured patients? Dr. Stassen suggested that some redundant staff capacity to handle a surge of injuries may be effective, as are plans for sending overflow patients to neighboring institutions when necessary. Dr. Stassen encourages trauma centers and hospitals to focus on connecting with support systems and community outreach to decrease recidivism and prevent firearm injuries. She said that many urban trauma centers have invested in community prevention programs. She mentioned the Stop the Bleed program initiated by Lenworth M. Jacobs, MD , FACS, and the American College of Surgeons, as effective, as well as the program at her own institution. The key is to find community resources to build prevention capacity. Dr. Stassen mentioned the fact that research on firearms injury management and prevention is seriously underfunded.

“In our youth-violence intervention program, they watch a video [depicting funerals] that shows what you would be leaving behind, what the impact is on your family, and explains that [engaging in certain lifestyles] does not just affect you but creates a ripple through your entire community,” Dr. Stassen explained. “The emphasis in all of firearms injury is keeping in mind what’s important, which is not having lives end that could be saved by either preventing the injury from occurring or finding better ways to get that person through that [injury].”

The burden of payment

Sarabeth A. Spitzer, a medical student at Stanford (Calif.) University, and Kristan L. Staudenmayer, MD , FACS, of the department of surgery at Stanford University Medical Center, along with a team of investigators studied the financial burden of initial hospitalization of firearm injuries in the United States during 2006-2014 and determined who paid the bills ( Am J Public Health. 2017;107[5]:770-4 ). Some results from the Stanford team were also presented in a Quick Shot session at the AAST annual meeting.

They used the HCUP Nationwide Inpatient Sample ( NIS ) to examine E-codes related to firearms injuries and focused on costs from initial hospitalization to discharge. The NIS database provided information on charges billed for hospitalization, which was then inflation-adjusted to 2014 dollars using the Consumer Price Index.

The study found 267,265 firearms-injured patients were admitted to hospitals during 2006-2014. Patients were overwhelmingly male. Medicaid patients were younger, likely to be non-white, while Medicare patients were more likely to be white and from higher income brackets. Most of the firearm-injured Medicaid patients were admitted to large urban teaching hospitals.

The cost of these admissions was estimated to be $6.61 billion during the study period. Primary payer status was Medicare (6.0%), Medicaid (29.1%), private insurance (21.4%), self-pay (29.4%) and other (14.1%). Patients with no insurance accounted for about one-quarter of the costs. More than 80% of self-pay patients fell below the 50th income percentile, and the investigators stated that this group would be unlikely to be able to pay the full hospital charges, which ranged from $19,642 to $30,952 per admission. These costs, the authors wrote, often are written off as losses to hospitals.

Overall, the burden of payment for hospitalization for firearms injuries falls on government payers, the uninsured, and hospitals.

Frequent readmissions

A study conducted by Rishi Rattan, MD , and his colleagues at the University of Miami, looked at the of readmissions of firearms-injured patients and also the number of patients who are readmitted to a different hospital ( Ann Surg. 2017 Sep 15. doi: 10.1097/SLA.0000000000002529. [Epub ahead of print]) .

The HCUP Nationwide Readmission Database for the year 2013-2014 was queried for data on patients admitted for firearm-related injury. This database offers a nationally representative sample using a unique identifier to track patients across admissions to different hospitals. ICD9-CM E-codes for firearms injuries were used to look at readmissions, costs, injury severity, and other patient characteristics.

After excluding cases with missing data, 45,462 patients admitted for a firearms-related injury were included in the study. A total of 7.6% of these patients were readmitted within 30 days of their initial hospitalization and of these patients 16.8% were admitted to a different hospital.

The factors driving readmission of firearms-injured patients were self-inflicted injury, older age, having a major operating room procedure, and experiencing a nonroutine discharge. Factors associated with readmission to a different hospital were age 45-65 years, primary payer of Medicare, a psychiatric condition, greater severity of injury, higher income, and initial admission to a for-profit hospital. Most readmissions were caused by infection. The number of patients and the demographics of patients being readmitted to different hospital have implications for both cost and planning, which need further study, the investigators suggested.

The cost of admission for firearms-injured patients for the study year was estimated at $1.45 billion. Thirty-day readmissions cost $54.2 million, and 1-year readmissions cost another $131 million. The median cost of the initial hospitalization was $14,907. Thirty-day readmissions cost a median of $8,311 and 1-year readmissions cost a median of $10,108. Medicare/Medicaid or uninsured patients accounted for 65.4% of initial hospitalizations, 65.2% of 30-day readmissions, and 67.5% of 1-year readmissions.

A continuing problem

The debate on the political and social aspects of firearms violence continues, but the practical aspects of dealing with firearms-related injuries remain the responsibility of surgeons on a daily basis. In addition to human suffering, the injured patient presenting at the emergency department or trauma center represents a spectrum of challenges of treatment, follow-up, readmissions, and financial burden.

The investigators in this report indicated that they had no relevant disclosures.

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