Sarabeth A. Spitzer’s research while affiliated with Harvard Medical School and other places

Objective To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury. Background The association between insurance and injury admission has not been examined. Methods This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital. Results A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics. Conclusions Insurance was associated with hospital admission for minor isolated extremity firearm injury.

Importance Firearm injuries are an epidemic in the US; more than 45 000 fatal injuries were recorded in 2020 alone. Gaining a deeper understanding of socioeconomic factors that may contribute to increasing firearm injury rates is critical to prevent future injuries. Objective To explore whether neighborhood gentrification is associated with firearm injury incidence rates over time. Design, Setting, and Participants This cross-sectional study used nationwide, urban US Census tract–level data on gentrification between 2010 and 2019 and firearm injuries data collected between 2014 and 2019. All urban Census tracts, as defined by Rural Urban Commuting Area codes 1 to 3, were included in the analysis, for a total of 59 379 tracts examined from 2014 through 2019. Data were analyzed from January 2022 through April 2023. Exposure Gentrification, defined to be an area in a central city neighborhood with median housing prices appreciating over the median regional value and a median household income at or below the 40th percentile of the median regional household income and continuing for at least 2 consecutive years. Main Outcomes and Measures The number of firearm injuries, controlling for Census tract population characteristics. Results A total of 59 379 urban Census tracts were evaluated for gentrification; of these tracts, 14 125 (23.8%) were identified as gentrifying, involving approximately 57 million residents annually. The firearm injury incidence rate for gentrifying neighborhoods was 62% higher than the incidence rate in nongentrifying neighborhoods with similar sociodemographic characteristics (incidence rate ratio [IRR], 1.62; 95% CI, 1.56-1.69). In a multivariable analysis, firearm injury incidence rates increased by 57% per year for low-income Census tracts that did not gentrify (IRR, 1.57; 95% CI, 1.56-1.58), 42% per year for high-income tracts that did not gentrify (IRR, 1.42; 95% CI, 1.41-1.43), and 49% per year for gentrifying tracts (IRR, 1.49; 95% CI, 1.48-1.50). Neighborhoods undergoing the gentrification process experienced an additional 26% increase in firearm injury incidence above baseline increase experienced in neighborhoods not undergoing gentrification (IRR, 1.26; 95% CI, 1.23-1.30). Conclusions and Relevance Results of this study suggest that gentrification is associated with an increase in the incidence of firearm injuries within gentrifying neighborhoods. Social disruption and residential displacement associated with gentrification may help explain this finding, although future research is needed to evaluate the underlying mechanisms. These findings support use of targeted firearm prevention interventions in communities experiencing gentrification.

Introduction: Firearm injury-related hospitalizations in the United States cost $900 million annually. Prior to the Affordable Care Act (ACA), government insurance programs covered 41 Methods: This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. Impact of ACA expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses. Results: The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted injuries ($11,550; p=0.02); there were no state-level differences in assault or total per capita firearm-related hospitalization costs. ACA expansion increased government coverage of costs by 15 percentage points (95% CI 3-29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI 6-21). In 2016, states with weak firearm legislation and no ACA expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI 15-34). Conclusions: ACA expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had highest proportion of uninsured/self-pay patients. Level of evidence: Economic & Value Based Evaluations, Level III.

Objectives: To evaluate whether exposure to the United States' discriminatory housing practice of redlining, which occurred in over two-hundred cities in the 1930s, is associated with modern-day, community-level incidence of firearm injury. Summary background data: Firearm violence is a public health epidemic within the United States. Federal policies are crucial in both shaping and reducing the risk of firearm violence; identifying policies that might have contributed to risks also offers potential solutions. We analyzed whether 1930s exposure to the discriminatory housing practices that occurred in over two-hundred U.S. cities was associated with modern-day, community-level incidence of firearm injury. Methods: We performed a nationwide retrospective cohort study between 2014-2018. Urban Zip Code Tabulation Areas (ZCTAs) historically exposed to detrimental redlining (grades C and D) were matched to unexposed ZCTAs based on modern-day population-level demographic characteristics (i.e., age, Gini index, median income, percentage Black population, education level). Incidence of firearm injury was derived from the Gun Violence Archive and aggregated to ZCTA level counts. Our primary outcome was the incidence of firearm injury, modeled using zero inflated negative binomial regression. Results: When controlling for urban firearm risk factors, neighborhoods with detrimental redlining were associated with 2.6 additional firearm incidents annually, compared to non-redlined areas with similar modern-day risk factors. Over our study period, this accounts for an additional 23,000 firearm injuries. Conclusion: Historic, discriminatory Federal policy continue to impact modern-day firearm violence. Policies aimed at reversing detrimental redlining may offer an economic means to reduce firearm violence.

Background Firearm injuries’ association with individual-level socioeconomic risk is well described. Trauma research has suggested that neighborhood level risk factors may be associated with differences in firearm injury outcome. We analyzed the relationship between hospital length of stay (LOS), mortality and neighborhood level social markers from the Center for Disease Control (CDC) Social Vulnerability Index (SVI) after firearm injury. Materials and Methods We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) in 2016 to identify firearm injuries using ICD-10 E-codes. Patient locations were identified at the census tract level. The 2016 CDC SVI was used to evaluate neighborhood level social vulnerability. Logistic and linear multivariable regression were used to evaluate the association between SVI percentile rank, mortality, and LOS. Results We identified 9,764 cases of firearm injury in our database; 88.2% of individuals were male, and the average age was 33.8 years. Assault was the most common intent, accounting for 4682 (48.0%) of all admissions. Overall, SVI was correlated with the risk of firearm injury, but not associated with either outcome of length of stay or risk of death. Conclusions While there is significant disparity between SVI and risk of firearm injury, once admitted to the hospital outcomes are similar between low and high-vulnerable populations. To reduce disparities in risk, funding and effort should focus on primary prevention.

Importance: Estimates of the total economic cost of firearm violence are important in drawing attention to this public health issue; however, studies that consider violence more broadly are needed to further the understanding of the extent to which such costs can be avoided. Objectives: To estimate the association of firearm assaults with US hospital costs and deaths compared with other assault types. Design, setting, and participants: The 2016-2018 US Nationwide Emergency Department Sample and National Inpatient Sample, Healthcare Cost and Utilization Project were used in this cross-sectional study of emergency department (ED) and inpatient admissions for assaults involving a firearm, sharp object, blunt object, or bodily force identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Differences in ED and inpatient costs (2020 US dollars) across mechanisms were estimated using ordinary least-squares regression with and without adjustments for year and hospital, patient, and injury characteristics. The Centers for Disease Control and Prevention underlying cause of death data were used to estimate national death rates and hospital case-fatality rates across mechanisms. Cost analysis used a weighted sample. National death rates and hospital case-fatality rates used US resident death certificates, covering 976 million person-years. Hospital case-fatality rates also used nationally weighted ED records covering 2.7 million admissions. Data analysis was conducted from March 1, 2021, to March 31, 2022. Exposure: The primary exposure was the mechanism used in the assault. Main outcomes and measures: Emergency department and inpatient costs per record. National death rates and hospital case-fatality rates. Results: Overall, 2.4 million ED visits and 184 040 inpatient admissions for assault were included. Across all mechanisms, the mean age of the population was 32.7 (95% CI, 32.6-32.9) years in the ED and 36.4 (95% CI, 36.2-36.7) years in the inpatient setting; 41.9% (95% CI, 41.2%-42.5%) were female in the ED, and 19.1% (95% CI, 18.6%-19.6%) of inpatients were female. Most assaults recorded in the ED involved publicly insured or uninsured patients and hospitals in the Southern US. Emergency department costs were $678 (95$657-$699) for bodily force,$861 (95% CI, $813-$910) for blunt object, $996 (95$925-$1067) for sharp object, and$1388 (95% CI, $1254-$1522) for firearm assaults. Corresponding inpatient costs were $14 702 (95$14 178-$15 227) for bodily force,$17 906 (95% CI, $16 888-$18 923) for blunt object, $19 265 (95$18 475-$20 055) for sharp object, and$34 949 (95% CI, $33 654-$36 244) for firearm assaults. National death rates per 100 000 were 0.04 (95% CI, 0.03-0.04) for bodily force, 0.03 (95% CI, 0.03-0.03) for blunt object, 0.54 (95% CI, 0.52-0.55) for sharp object, and 4.40 (95% CI, 4.36-4.44) for firearm assaults. Hospital case fatality rates were 0.01% (95% CI, 0.009%-0.012%) for bodily force, 0.05% (95% CI, 0.04%-0.06%) for blunt object, 1.05% (95% CI, 1.00%-1.09%) for sharp object, and 15.26% (95% CI, 15.04%-15.49%) for firearm assaults. In regression analysis, ED costs for firearm assaults were 59% to 99% higher than costs for nonfirearm assaults, and inpatient costs were 67% to 118% higher. Conclusions and relevance: The findings of this study suggest that it may be useful for policies aimed at reducing the costs of firearm violence to consider violence more broadly to understand the extent to which costs can be avoided.

Background Firearm injuries are a costly, national public health emergency, and government-sponsored programs frequently pay these hospital costs. Understanding regional differences in firearm injury burden may be useful for crafting appropriate policies, especially with widely varying state gun laws. Objective To estimate the volume of, and hospital costs for, fatal and non-fatal firearm injuries from 2005 to 2015 for each region of the United States and analyze the proportionate cost by payer status. Methods We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2005 to 2015. We converted hospitalization charges to costs, which were inflation-adjusted to 2015 dollars. We used survey weights to create regional estimates. We used the Brady Gun Law to determine significance between firearm restrictiveness and firearm hospitalizations by region. Results There were a total of 317 479 firearm related admissions over the study period: 52 829 (16.66%), 66 671 (21.0%), 134 008 (42.2%), and 63 972 (20.2%) for the Northeast, Midwest, South, and West respectively, demonstrating high regional variability. In the Northeast, hospital costs were $1.98 billion (13.9$1.53 billion (19.7% of total), 40.4% of which was covered by government payers; in the South costs were highest at $3.2 billion (41.4$1.94 billion (25.0% of total), with government programs covering 41.6% of the cost burden. Conclusions Hospital admissions and costs for firearm injuries demonstrated wide variation by region, suggesting opportunities for financial savings. As government insurance programs cover 41.5% of costs, tax dollars heavily subsidize the financial burden of firearm injuries and cost recovery options for treating residents injured by firearms should be considered. Injury control strategies have not been well applied to this national public health crisis. Level of evidence Level II, Economic and Value Based Evaluation

An amendment to this paper has been published and can be accessed via the original article.

Background Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention. Method A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers. Results The most common barriers cited were not knowing what to do with patients’ answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p =0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms. Conclusions Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.