Neil Osterweil

November 26, 2013

BOSTON — Firearm injuries in the United States resulted in a quarter of a million hospitalizations, more than 20,000 in-hospital deaths, and nearly $19 billion in healthcare charges over an 8-year period, investigators report.

Preliminary data show that in 2011 alone, there were 32,163 deaths in the United States from firearm injuries, including 19,766 suicides, 11,101 homicides, and 851 accidental or unspecified deaths, said Romesh Nalliah, BDS, from the Harvard School of Dental Medicine in Boston.

Those most at risk for firearm injuries were adolescents and young adults, males, blacks, and the uninsured.

"I'm not an expert on firearm injuries themselves, but based on our studies of high-risk groups, it seems like it would be worthwhile for clinicians to actually talk about these things with their patients," Nalliah told Medscape Medical News.

Physicians, dentists, and other clinicians should consider social issues such as exposure to gun violence as part of a holistic approach to patient care, Nalliah said here at the American Public Health Association 141st Annual Meeting.

His team from Harvard, from University Hospitals and Rainbow Babies and Children's Hospital in Cleveland, and from the University of Iowa in Iowa City looked at nationally representative longitudinal estimates of characteristics and outcomes of hospitalizations attributed to firearm injuries in the United States from 2003 to 2010.

When I told my parents that I was coming to America, the first thing they said was, 'Be careful you don't get shot.'

They used the Nationwide Inpatient Sample, the largest all-payer hospital-based database, to search for outcomes associated with firearm injury, including hospitalization charges, length of stay, mortality rates, type of injury, and patient disposition at discharge. Firearm-related hospitalizations were identified with ICD-9 CM codes indicating external causes of injury.

Over the study period, hospitalizations of patients with firearm injuries ranged from a low of 27,833 in 2008 to a high of 40,055 in 2010; the total number of hospitalizations during the 8-year period was 256,902.

Of these, 30% of the patients were 22 to 30 years of age, 19% were 18 to 21 years of age, and 19% were 31 to 40 years of age. The sample was 48% black, 27% white, 19% Hispanic, 1% Asian-Pacific Islander, 1% Native American, and 4% other.

Males were overwhelmingly more likely than females to be hospitalized for gunshot wounds (89% vs 11%).

Assaults accounted for 61% of the injuries, followed by accidents (22%), suicide and self-inflicted wounds (8%), legal interventions (2%), and undetermined causes (7%).

Uninsured patients comprised 34% of the injured patients, followed by those covered by Medicaid (27%), private insurance (23%), other insurance such as worker's compensation and other government programs (11%), and Medicare (5%).

Nearly three quarters of the patients were routinely discharged, but 8.1% died in the hospital; the remainder were discharged to either long-term or short-term rehabilitation or to home healthcare.

The average patient spent 7.1 days in the hospital, which adds up to 1.8 million days over the 8 years. Per patient hospitalization charges ranged from $61,640 in 2004 to $83,995 in 2010.

Table. Per Patient Hospital Charges Associated With Firearm Injuries

Year    Mean charge (US$)   
2003 81,597
2004 61,640
2005 67,255
2006 70,633
2007 78,303
2008 81,280
2009 82,120
2010 83,995


The ready availability of guns in the United States appears to be a major contributing factor to firearm injuries, Nalliah told Medscape Medical News.

"All of the members of our research team are from countries quite different from the United States. I'm from Australia, and my colleagues are from India and Korea. In all of our countries, it's very difficult to get a gun, and that was a big change when we came to this country. When I told my parents that I was coming to America, the first thing they said was, 'Be careful you don't get shot'," he said.

This analysis "gives us a very important picture of the magnitude of medical care related to gunshot wounds," said Steven Albert, PhD, from Pitt Public Health at the University of Pittsburgh, who was asked by Medscape Medical News to comment on the study.

"My own feeling is that if you could reduce the circulation of guns, you would probably eliminate some of these sorts of injuries that put people into the hospital," he said.

Dr. Albert, who studies homicides and gun violence, added that the figures in this study are likely a significant underestimate of the actual number of gun-related injuries and deaths.

"Some of the injuries are self-inflicted, such as failed suicides, some are from violent crime, and some of them are accidents, but all of them involve guns," he said. "Of course, you're missing the people who don't make it to the hospital because they have died from a gunshot."

Richard Garland, MSW, from the University of Pittsburgh Graduate School of Public Health, noted that the hospital charges estimated in the study are more than double those of previous estimates he has heard.

He and Dr. Albert are coleaders of a hospital-based community violence prevention project aimed at discovering violence patterns and preventable factors that contribute to homicide in Pittsburgh, where peer violence rather than gang-related violence appears to be the major contributor to firearm-related injuries.

Garland said that the idea is to get every aspect and every member of the community involved in violence prevention.

"I'm talking about barbershops, beauty shops, the five-and-dime story on the corner — the goal is to make everybody part of the intervention," he told Medscape Medical News.

Mr. Nalliah, Dr. Albert, and Mr. Garland have disclosed no relevant financial relationships.

American Public Health Association (APHA) 141st Annual Meeting. Presented November 4, 2013.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.