Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding
Department of Population Health, New York University School of Medicine, New York, New York 10016, USA.JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 08/2013; 310(5):532-4. DOI: 10.1001/jama.2013.119355
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ABSTRACT: Perceptions of violence are too often driven by individual sensational events, yet "routine" gunshot wound (GSW) injuries are largely underreported. Previous studies have mostly focused on fatal GSW. To illuminate this public health problem, we studied the health care burden of interpersonal GSW at a Level I trauma center. Retrospective analysis of GSW injuries (excluding self and law enforcement) treated from January 2000 to December 2011. Data collected included body regions injured, number of wounds per patient, and mortality. Costs were calculated using Medicare cost-charge modifiers. Geographic information system mapping of the incident location and home addresses were determined to identify hot spot locations and the characterization of those neighborhoods. A total of 6,322 patients were treated. There were significant increases in patients with three or more wounds (13-22%, p < 0.0001) and three or more body regions injured (6-16%, p < 0.0001). Mortality increased from 9% to 14% (p < 0.0001). Nineteen percent of the patients were never seen by the trauma service. Geographic information system mapping revealed significant clustering of GSWs. Five cities accounted for 85% of the GSWs, with rates per 100,000 ranging from 19 to 108 compared with a national rate of 20. Only 19% of the census tracts had no GSWs during the period, and 39% of the census tracts had at least one GSW per year for 12 years. Fifteen percent of the census tracts accounted for 50% of the GSWs. Seventy percent of the patients were shot in their home city, 25% within 168 m, and 55% within 1,600 m of their home. Total inpatient cost was $115 million, with cost per patient increasing more than three times over the course of the study; 75% were unreimbursed. GSW violence remains a significant public health problem, with escalating mortality and health costs. Relying on trauma registry data seriously underestimates GSW numbers. In contrast to episodic mass casualties, routine GSW violence is geographically restricted and not random. To combat this problem, policy makers must understand that the determinants of firearm violence reside at the community level. Epidemiologic study, level II.
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ABSTRACT: Research suggests that access to firearms in the home increases the risk for violent death. To understand current estimates of the association between firearm availability and suicide or homicide. PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science were searched without limitations and a gray-literature search was performed on 23 August 2013. All study types that assessed firearm access and outcomes between participants with and without firearm access. There were no restrictions on age, sex, or country. Two authors independently extracted data into a standardized, prepiloted data extraction form. Odds ratios (ORs) and 95% CIs were calculated, although published adjusted estimates were preferentially used. Summary effects were estimated using random- and fixed-effects models. Potential methodological reasons for differences in effects through subgroup analyses were explored. Data were pooled from 16 observational studies that assessed the odds of suicide or homicide, yielding pooled ORs of 3.24 (95% CI, 2.41 to 4.40) and 2.00 (CI, 1.56 to 3.02), respectively. When only studies that used interviews to determine firearm accessibility were considered, the pooled OR for suicide was 3.14 (CI, 2.29 to 4.43). Firearm accessibility was determined by survey interviews in most studies; misclassification of accessibility may have occurred. Heterogeneous populations of varying risks were synthesized to estimate pooled odds of death. Access to firearms is associated with risk for completed suicide and being the victim of homicide. None.
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ABSTRACT: The value of routine preoperative testing before most surgical procedures is widely considered to be low. To improve the quality of preoperative care and reduce waste, 2 professional societies released guidance on use of routine preoperative testing in 2002, but researchers and policymakers remain concerned about the health and cost burden of low-value care in the preoperative setting. To examine the long-term national effect of the 2002 professional guidance from the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists on physicians' use of routine preoperative testing. Retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to examine adults in the United States who were evaluated during preoperative visits from January 1, 1997, through December 31, 2010. A quasiexperimental, difference-in-difference (DID) approach evaluated whether the publication of professional guidance in 2002 was associated with changes in preoperative testing patterns, adjusting for temporal trends in routine testing, as captured by testing patterns in general medical examinations. Physician orders for outpatient plain radiography, hematocrit, urinalysis, electrocardiogram, and cardiac stress testing. During the 14-year period, the average annual number of preoperative visits in the United States increased from 6.8 million in 1997-1999 to 9.8 million in 2002-2004 and 14.3 million in 2008-2010. After accounting for temporal trends in routine testing, we found no statistically significant overall changes in the use of plain radiography (11.3% in 1997-2002 to 9.9% in 2003-2010; DID, -1.0 per 100 visits; 95% CI, -4.1 to 2.2), hematocrit (9.4% in 1997-2002 to 4.1% in 2003-2010; DID, 1.2 per 100 visits; 95% CI, -2.2 to 4.7), urinalysis (12.2% in 1997-2002 to 8.9% in 2003-2010; DID, 2.7 per 100 visits; 95% CI, -1.7 to 7.1), or cardiac stress testing (1.0% in 1997-2002 to 2.0% in 2003-2010; DID, 0.7 per 100 visits; 95% CI, -0.1 to 1.5) after the publication of professional guidance. However, the rate of electrocardiogram testing fell (19.4% in 1997-2002 to 14.3% in 2003-2010; DID, -6.7 per 100 visits; 95% CI, -10.6 to -2.7) in the period after the publication of guidance. The release of the 2002 guidance on routine preoperative testing was associated with a reduced the incidence of routine electrocardiogram testing but not of plain radiography, hematocrit, urinalysis, or cardiac stress testing. Because routine preoperative testing is generally considered to provide low incremental value, more concerted efforts to understand physician behavior and remove barriers to guideline adherence may improve health care quality and reduce costs.
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