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Requests for reprints should be addressed to Shikhar Agarwal, MD, MPH, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J2-3, Cleveland, OH 44195.
Firearm-related hospitalizations are a major burden to the current health care infrastructure. We examined the trends in the incidence and case-fatality rates of firearm-related hospitalizations over the past decade. We also hypothesized that major national economic perturbations would be partly responsible and correlate temporally with national firearm-related hospitalization trends.
Methods
We used the 2001-2011 Nationwide Inpatient Sample for analysis. Firearm-related hospitalizations were identified using International Classification of Diseases, 9th Revision codes. In addition, we examined the relationship between the US stock market performance (Dow Jones Industrial Average) and the annual firearm-related hospitalization incidence rates.
Results
In the last decade, there has been a modest decline in firearm-related hospitalizations, interrupted by spikes in the annual incidence that closely corresponded to periods of national economic instability. In addition, the overall case-fatality rate following firearm-related hospitalization has been stable at ∼8%; the highest rates being present among those who attempted suicide using firearms. Also, there has been an increase in the prevalence of mental health disorders among individuals admitted with firearm-related injuries. Moreover, there was an increase in the length of stay and the cost/charges associated with hospitalization over the last decade.
Conclusion
Over 2001-2011, the national incidence of firearm-related hospitalizations has closely tracked the national stock market performance, suggesting that economic perturbations and resultant insecurities might underlie the perpetuation of firearm-related injuries. Although the case-fatality rates have remained stable, the length of stay and hospitalization costs have increased, imposing additional burden on existing health care resources.
Over the last decade, the incidence of firearm-related hospitalizations has closely tracked the national stock market performance, suggesting that economic perturbations and resultant insecurities might underlie the perpetuation of firearm-related injuries.
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Although the case-fatality rates have remained stable, the length of stay and hospitalization costs have increased, imposing additional burden on existing health care resources.
Firearms are the second leading cause of injury-related deaths after motor vehicle accidents in the US.
Although the rates of firearm-related injuries have decreased over the last 2 decades, mortality resulting from firearms in the US remains the highest in the world.
The mass shooting incidents that have occurred recently in Newtown, Connecticut; Tucson, Arizona; Virginia Tech University; Columbine High School; and at the Washington Navy Yard have brought firearm-related violence to the forefront of national discussion.
Health and Public Policy Committee of the American College of Physicians Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians.
Although these mass shootings killed several people, injured numerous others, and stirred up a major national debate about gun policies, these shootings represent only the tip of the iceberg. Approximately 88 people are believed to die every day due to a direct firearm-related injury, including suicides, homicides, unintentional injuries, or accidents.
Health and Public Policy Committee of the American College of Physicians Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians.
It appears that firearm-related injuries are a major burden on our health care system and consume a large portion of already-constrained health care resources. Besides being a criminal justice issue, firearm-related injuries have become a major public health challenge facing the nation. Although there is a large amount of literature detailing the vital statistics of firearm-related injuries, there is a conspicuous paucity of literature exploring the burden on health care resources imposed by firearm injuries. To that end, we conducted a detailed analysis of trends in the incidence rates and in-hospital case-fatality rates of firearm-related hospitalizations over the last decade using a large, well-validated nationwide database. Based on the understanding of the socioeconomic factors that contribute to the use of firearms in the current society, one could surmise that there would be a strong relationship between the national economic situation and national firearm-related hospitalization rates. This led us to hypothesize that major national economic perturbations partly would be responsible and correlate temporally with national firearm-related hospitalization trends.
Methods
Data Source
Data were obtained from the Nationwide Inpatient Sample (NIS) database from 2001-2011. The NIS is sponsored by the Agency for Healthcare Research and Quality (AHRQ) as a part of Healthcare Cost and Utilization Project (HCUP). The number of states that contribute the discharge-level data to the NIS has grown from 33 in 2001, covering 81% of the entire US population, to 44 in 2011, covering over 90% of the entire US population. Currently, the NIS contains discharge-level data from approximately 8 million hospitalizations annually from about 1000 hospitals across the US. This database is designed to represent a 20% stratified sample of all hospitals in the country. Criteria used for stratified sampling of hospitals into the NIS include location (urban or rural), teaching status, geographic region, patient volume, and hospital ownership. All data available from the HCUP have been de-identified and hence, the analysis is exempt from the federal regulations for the protection of human research participants. The dataset was obtained from the AHRQ after completing the data use agreement with HCUP.
Study Population
The NIS database provides up to 15 diagnoses and 15 procedures for each hospitalization record for the years 2001-2009. The number of diagnoses coded in the database was expanded to 25 for the years 2010-2011. All these have been coded using the standard International Classification of Diseases, 9th edition, Clinical Modification (ICD-9 CM) codes. In addition, we used the HCUP Clinical Classification Software (CCS) to identify patient comorbidities and specific procedures.
Information on firearm-related hospitalizations was derived using the E codes of the ICD-9 as well as the CCS. All firearm-related hospitalizations were identified using the CCS code 2605, in addition to the standard ICD-9 codes. Types of firearm-related hospitalization, as defined by the cause, included suicide (E950-E959), assault (E960-E969), and others; including accidents (E922.0-E922.3, E922.8, E922.9), legal intervention (E970), undetermined event (E985.0-E985.3), and war (E991).
The entire study duration of 2001-2011 was analyzed as 2 distinct intervals: an early period consisting of years 2001-2006, and a later period consisting of years 2007-2011. Demographic variables available for analysis included age, sex, race (white, black, other), primary source of payment, weekday vs weekend admission, along with relevant comorbidities including smoking, alcohol use, substance use, and mental health disorders. The history of smoking, alcohol use, substance use, and mental health disorders was reliably coded starting in 2007 in the NIS database and hence, analysis of these variables was restricted to the time period 2007-2011 only. The mental health disorders included adjustment disorders (CCS code 650), anxiety disorders (CCS code 651), attention-deficit, conduct, and disruptive behavior disorders (CCS code 652), delirium, dementia, cognitive, and amnestic disorders (CCS code 653), impulse control disorders (CCS code 656), mood disorders (CCS code 657), personality disorders (CCS code 658), and psychotic disorders (CCS code 659). Hospital characteristics such as region (Northeast, Midwest, South, West), bed size (small, medium, large), location (rural, urban), hospital control (government, private), and teaching status were also included. In addition, NIS has classified the residential zip code of each patient into quartiles based on median household income of each zip code, which was utilized as a surrogate for socioeconomic status of each firearm-related hospitalization. Several prior studies have validated this approach for imputing individual socioeconomic status in epidemiologic settings.
The incidence of firearm-related hospitalizations, expressed as a proportion of all hospitalizations as well as all injury-related hospitalizations each year, was the primary outcome of this study. We also examined the trends in in-hospital case fatality, patient disposition after hospitalization, as well as resource utilization across the 2 time periods. The resource utilization was evaluated using the total length of stay as well as the mean cost of hospitalization. The NIS database provides the total charges associated with each hospital stay claimed by the respective hospital for all years. The total charges of each hospital stay were converted to cost estimates using the group average all-payer in-hospital cost and charge information from the detailed reports by hospitals to the Centers of Medicare and Medicaid Services. All costs and charges were converted to projected estimates for the year 2011, after accounting for annual inflation rates based on consumer price index data available from the Bureau of Labor Statistics.
United States Department of Labor, Bureau of Labor Statisitcs. Consumer Price Index – Guide to CPI data. Available at: http://www.bls.gov/cpi/cpifact8.htm. Accessed May 16, 2014.
Based on the understanding of the socioeconomic factors that contribute to the use of firearms in current society, we hypothesized that there would be a strong relationship between the national economic situation and national firearm-related hospitalization rates. To test this hypothesis, we qualitatively examined the relationship between the US stock market performance (assessed using the Dow Jones Industrial Average) and the annual national firearm-related hospitalization rates.
Survey statistics traditionally used to analyze complex semi-random survey designs were employed to analyze these data. Data obtained from NIS were pooled using standard methods. Subsequently, appropriate NIS discharge and hospital weights were utilized to weight the entire sample to account for the clustered structure of the data according to the NIS stratum as well as the treating hospital. Variance was estimated using the method of Taylor series (linearization) variance estimation. Continuous variables are presented as mean ± standard error (SE) and categorical variables are presented as proportion ± SE. Student's t test was utilized for comparing means of continuous variables between 2 categories. For comparing the means of continuous variables among 3 or more categories, we utilized one-way analysis of variance. In cases of significant differences detected using analysis of variance, pairwise comparisons were performed utilizing Bonferroni correction for multiple comparisons. The chi-squared test was utilized for comparison of categorical variables. To evaluate for trends across the time periods or consecutive years, a test for linear trend across the years was performed using a linear contrast of coefficients derived using logistic regression analysis or linear regression analysis incorporating the calendar year as an indicator variable with multiple predictor levels.
Also, multivariable logistic regression analysis was utilized to understand the independent demographic predictors of in-hospital case fatality among those admitted with firearm-related injuries.
All statistical analyses were performed using the statistical software Stata v 13.1 (StataCorp, College Station, TX). All statistical tests were 2-tailed; a P-value < .05 was considered significant.
Results
Trends in Firearm-related Hospitalizations
From a total of 87,195,470 hospitalizations recorded in the NIS during 2001-2011, there were 11,221,897 injury-related hospitalizations designated using E codes. Of these, we identified 70,974 hospitalizations that were related to firearm-related injuries. Table 1 demonstrates the annual national incidence of firearm-related hospitalizations across the entire study duration. Compared with the year 2001, there was a modest increase in the annual incidence of firearm-related hospitalizations noted during 2002 and 2004, followed by a slow decline in the annual incidence until 2008. The years 2009 and 2010 demonstrated a sharp increase in the annual incidence rate of firearm-related hospitalizations, followed by a sharp decline in annual rates in 2011 (Figure 1).
Table 1Firearm-related Hospitalizations in the US
Year
Total Number
Injury-related Hospitalizations
Firearm-related Hospitalizations
Incidence (95% CI) of Firearm-related Hospitalizations (Per 100,000 Hospitalizations)
Incidence (95% CI) of Firearm-related Hospitalizations (Per 100,000 Injury-related Hospitalizations)
Figure 1Annual national incidence rate of firearm-related hospitalizations, expressed per 100,000 hospitalizations. The bars represent the incidence rate and the lines above each bar represent the standard error of the effect estimate.
Baseline Characteristics of Firearm-related Hospitalizations
Table 2 demonstrates the baseline characteristics of all firearm-related hospitalizations stratified according to the time period. Compared with the early period, there was a small but statistically significant increase in the age of patients admitted with firearm injuries (P < .001). Although the proportion of blacks admitted with firearm-related injuries was significantly higher than whites or other races, there were no significant changes in relative proportions across the study duration. A majority of the patients admitted with firearm-related injuries were either uninsured or had Medicaid as primary payor. Compared with the early time period, there was a small increase in the proportion of patients with Medicare and Medicaid, with a corresponding decrease in the proportion of patients with private insurance in the later period. Stratifying the entire population according to socioeconomic quartiles also demonstrated no significant changes over the 2 time periods. Most of the firearm-related hospitalizations were from the lowest socioeconomic quartiles.
Table 2Characteristics of Firearm-related Hospitalizations Stratified by the Time Period of Admission
Stratifying the entire population of all firearm-related hospitalizations by the type of injury demonstrated that a majority of patients were admitted with firearm-related assaults in both time periods (Table 2). Notably, there was a significant increase in the proportion of all firearm-related hospitalizations due to suicide, from 8.8% in 2001-2006 to 10.3% in 2007-2011 (P = .01). Table 3 demonstrates the differences in the baseline characteristics of the firearm-related hospitalizations during the most recent time period spanning 2007-2011. Although there was a significant increase in the prevalence of smoking among patients admitted with firearm-related injuries over 2007-2011, the prevalence of alcohol use and substance abuse remained relatively constant over this time period. In addition, there was a significant increase in the prevalence of mental health disorders from 26.9% in 2007 to 37.9% in 2011 (P = .001).
Table 3Baseline Characteristics of Firearm-related Hospitalizations in Recent Era, Stratified by Year
Table 4 demonstrates the characteristics of the hospitals treating patients admitted with firearm-related injuries during the study period. The majority of firearm-related hospitalizations occur in large hospitals, in urban locations, controlled by the government, which have been designated as teaching hospitals. Compared with the earlier time period, there was a statistically significant increase in the proportion of patients admitted to large hospitals located in urban areas, hospitals with a teaching status, as well as hospitals under government control. In terms of regional distribution, there was no significant change in the relative proportion of firearm-related hospitalizations across the nation. The highest proportion of all firearm-related hospitalizations was contributed to by the Southern states (40.6% in 2001-2006 and 42.4% in 2007-2011).
Table 4Characteristics of Hospitals Involved with Firearm-related Hospitalizations, Stratified by the Time Period
Hospital Characteristics
2001-2006
2006-2011
P-Value
N
Region (%)
Northeast
15.1 (2.0)
18.5 (2.2)
.10
Midwest
23.5 (3.5)
19.5 (2.7)
.25
South
40.6 (3.5)
42.4 (3.7)
.62
West
20.8 (2.7)
19.6 (2.7)
.69
Bed size (%)
Small
4.0 (0.5)
3.5 (0.6)
.52
Medium
24.0 (3.6)
18.3 (2.3)
.04
Large
72.0 (3.5)
78.2 (2.4)
.03
Hospital location (%)
Rural
4.9 (0.5)
3.5 (0.4)
.007
Urban
95.1 (0.5)
96.5 (0.4)
.007
Hospital control (%)
Government
83.6 (2.0)
87.3 (1.5)
.02
Private
16.4 (2.0)
12.7 (1.5)
.02
Teaching status (%)
Non-teaching hospital
23.6 (2.3)
18.7 (1.8)
.01
Teaching hospital
76.4 (2.3)
81.3 (1.8)
.01
All values are expressed as percentage (standard error), except where indicated.
Table 5 demonstrates outcomes following firearm-related hospitalizations, stratified by the time period. The in-hospital case-fatality during 2001-2006 and 2007-2011 was similar at 8.2% and 8.3%, respectively (P = .50). Figure 2 demonstrates the trend of in-hospital case-fatality following firearm-related hospitalizations (panel A), as compared with in-hospital case-fatality following other non-firearm-injury-related hospitalizations (panel B). Figure 3 demonstrates the proportion of all in-hospital deaths following injury-related hospitalizations that were secondary to firearm-related injuries. As evident in this figure, there was a slow decline in this proportion until 2008, interrupted by small spikes in the years 2002 and 2004. The years 2009 and 2010 witnessed a rapid increase in this proportion of all injury-related deaths secondary to firearm-related injuries, followed by a sharp decline in this proportion in 2011. In both early and late time periods, hospitalizations following suicides were associated with significantly higher case-fatality rates compared with those following assault injuries. The case fatality rates following suicide were 31.5% and 32.1% in early and late time periods, respectively, compared with 5.8% and 5.4% case fatality rate following assaults in the corresponding time periods (P < .001 for both comparisons).
Table 5Outcomes of Firearm-related Hospitalizations, Stratified by Time Period
Characteristics
2001-2006
2007-2011
P-Trend
N
38,369
32,597
In-hospital mortality
Total cohort
8.2 (0.2)
8.3 (0.2)
.50
Suicide
31.5 (1.0)
32.1 (0.9)
.62
Assault
5.8 (0.2)
5.4 (0.3)
.23
Other injuries
6.0 (0.3)
6.0 (0.3)
.84
Patient disposition
Home
73.0 (0.6)
71.1 (0.7)
.008
Short-term hospital
2.0 (0.1)
2.8 (0.2)
<.001
Skilled nursing facility, intermediate care or other facility
8.8 (3.1)
9.0 (0.3)
.68
Home health care
6.3 (0.4)
7.3 (0.6)
.02
Died
8.2 (0.2)
8.3 (0.2)
.50
Left against medical advice
1.7 (0.9)
1.5 (0.1)
.64
Mean (SE) length of stay
6.6 (0.2)
7.4 (0.2)
<.001
LOS ≥ 5 days
42.3 (0.7)
43.9 (0.6)
.02
LOS ≥ 10 days
18.1 (0.5)
20.8 (0.6)
<.001
Mean (SE) total charges (adjusted for inflation)
51,333 (2,001)
75,738 (2,913)
<.001
Mean (SE) total cost of hospitalization (adjusted for inflation)
20,686 (707)
25,155 (768)
<.001
All values are expressed as percentage (standard error), except where indicated.
Figure 2This figure demonstrates the trend of in-hospital case-fatality following firearm-related hospitalizations (panel A), as compared with in-hospital case-fatality following other non-firearm-injury-related hospitalizations (panel B). The bars represent the percent rate and the lines above each bar represent the standard error of the effect estimate.
Figure 3This figure demonstrates the proportion of all in-hospital deaths following injury-related hospitalizations that were secondary to firearm-related injuries. The bars represent the percent rate and the lines above each bar represent the standard error of the effect estimate.
Besides in-hospital case fatality, there have been changes in the patient disposition patterns following firearm-related hospitalizations over the entire study duration. Compared with 2001-2006, there was a small but statistically significant decrease in the proportion of patients who were discharged home during 2007-2011, with a simultaneous increase in the proportion of patients discharged to a short-term hospital or to home health care services in the latter time period. In addition, there was a significant increase in the mean length of stay following firearm-related hospitalizations, from 6.6 days in 2001-2006 to 7.4 days in 2007-2011 (P < .001). There was a significant increase in the proportion of patients with hospital stays ≥10 days from 18.1% in 2001-2006 to 20.8% in 2007-2011. Furthermore, there was a significant increase in the mean hospitalization cost from 2001-2006 (mean: $20,686) to 2007-2011 (mean: $25,155, P < .001).
Hospitalization Trends and National Stock Market Performance
Figure 4 demonstrates the correlation between the trend of firearm-related hospitalizations and the US stock market performance as measured by Dow Jones Industrial Average values. The decline in the US stock market performance during 2001-2003 coincided with an increase in the annual incidence rates of firearm-related hospitalizations. The years 2004-2008 demonstrated a recovery in the US stock market performance with a corresponding decline in the firearm-related hospitalization incidence rates. Subsequently, there was a major stock market crash in 2009, the effects of which manifested themselves in the form of a sharp increase in the annual incidence rates of firearm-related hospitalizations during 2009 and 2010. The stock market recovery in 2011 was associated with a simultaneous decline in the firearm-related hospitalization incidence rates in that year.
Figure 4This figure demonstrates the correlation between the trend of firearm-related hospitalizations and the US stock market performance as measured by Dow Jones Industrial Average values. Panel A demonstrates the trend of annual national incidence of firearm-related hospitalizations during 2001-2011. Panel B represents the trend of the Dow Jones Industrial Average during 2001-2011.
The current study has attempted to comprehensively explore the trends in firearm-related hospitalizations over the last decade in the US. There are several important findings in this study. First, the national incidence of firearm-related hospitalizations in the US has closely tracked the national stock market performance, suggesting that economic perturbations may be a “root cause” or at least an important predictor of firearm injuries. Second, a majority of patients with firearm-related hospitalizations are admitted as a result of assaults using firearms. Although the proportion of assaults have been stable across the last decade, there has been a small increase in the proportion of all firearm-related hospitalizations occurring due to suicides in the last few years. Third, there has been an increase in the incidence of mental health disorders among individuals admitted with firearm-related injuries. Fourth, the case-fatality rate following firearm-related hospitalization has been stable at ∼8%; the highest rates being present among those who attempted suicide using firearms. Lastly, there was an increase in the length of stay and the cost/charges associated with the hospitalization over the last decade. The average cost of hospitalization and the length of stay remain high, thereby imposing a large burden on the current health care resources.
There was a substantial decline in the incidence of fatal and nonfatal firearm-related hospitalizations during the late 1990s. Although the incidence of firearm-related hospitalizations seems to have remained relatively constant in the 2000s, there have been a few spikes in the incidence that closely correspond to periods of national economic instability. The large decline in the firearm-related hospitalizations in 1995 could be partially attributed to the Brady Handgun Violence Prevention Act (enacted November 1993) and the Federal Assault Weapons ban (enacted September 1994).
The former law was an Act of the US Congress that instituted federal background checks on firearm purchasers in the US. The latter mandate, also known as the crime bill, restricted the manufacture and transfer of certain newly manufactured semi-automatic firearms and ammunition feeding devices (magazines). There is significant controversy about the actual impact of these gun control laws in reducing the incidence of firearm-related injuries, as there was widespread existence of active black markets of guns, and the gun control policy implementation was not very stringent.
In addition, this period also witnessed a decline in the overall crime rate secondary to an increase in the number of police, increased incarceration for major crimes, and reduced use of crack cocaine.
A few studies like the current one have identified the loss of momentum in the decline of incidence of firearm-related injuries, without shedding much light on the reasons that underlie this trend.
The current study is one of the first of its kind to explore an extremely plausible reason for the firearm-related trends observed over the last decade. Economic instability and resultant insecurity can be speculated to increase the crime rates, many of which are committed using firearms. This also emphasizes the fact that although the firearm-related hospitalizations might be affected by a change in gun control policies, the most fundamental underpinning of firearm-related injuries might be economic stability and economic security among citizens, rather than federal mandates or policies. The root causes of crime and violence are often social, environmental, and behavioral in origin, which may include racism, poverty, crowded housing, weak family structure, poor education, anger, and alcohol and drug abuse, along with many other factors. In addition to the data presented above for the past decade, the association between the stock market and the firearm-related hospitalization was also evident in the earlier decade. The years 1995-2000 witnessed a steep increase in the Dow Jones Industrial Average (Supplementary Figure 1), which corresponded to a significant decline in the annual incidence of firearm-related hospitalizations during this period.
Firearm-related hospitalizations are a major burden on our health care resources. The most recent cost analysis has estimated the annual cost of care, accounting for both medical and socioeconomic domains, was approximately $174 billion.
Putting this cost into perspective, these estimated costs of care for patients with firearm-related injuries are roughly 3 times that of the entire budget of the US Department of Homeland Security and at least twice the budget of the US Department of Education.
The cost to care for the victims of firearm injuries is massive, especially if these result in permanent disability or chronic physical or mental impairments. As seen in our study, a large majority of the patients are young, which constitutes a substantial loss in the way of lost productivity. Furthermore, a large proportion of these patients are uninsured or underinsured, which adds to the amortized cost of care. Faced with lack of reimbursement for these hospitalizations, the hospitals are often forced to absorb the treatment cost, which ultimately results in health care resource depletion for other patients.
As mentioned earlier, there are several important socioeconomic variables that are of considerable importance in this cohort of patients admitted with firearm-related injuries. The most important was an increase in the prevalence of mental health disorders over the last 2 decades among patients admitted with firearm-related injuries. This underscores 2 important aspects of care. First, there needs to be an improvement in access to mental health services among subjects who may be considered “high-risk” for firearm-related injuries. Improvement in access to mental-health services might also serve to reduce the incidence of firearm-related suicides. The incidence of mortality is significantly higher among suicides committed using firearms as compared with other firearm-related injuries, underscoring the need to target this group with an utmost earnestness. Second, there is a need for a mandate that would restrict the ownership of guns from individuals with active mental health disorders. In addition, there has been an increase in the proportion of uninsured individuals being admitted with firearm-related injuries over the last 2 decades, which suggests a rapidly increasing burden on the available health care resources. Furthermore, there was a significant increase in the proportion of patients residing in the middle socioeconomic quartiles, getting admitted with firearm-related injuries over the study duration, reflecting the fact that this is no longer the problem of the poor only.
To date, numerous viewpoints, pleas, and statements have been published about ways to curtail the incidence of firearm-related hospitalizations. To inform policymakers about the current evidence that exists on this front, a distinguished committee from the National Academy of Sciences issued a landmark report in December 2004 detailing existing research on gun violence and the methods to improve the empirical basis for policy discussions.
The committee identified 5 major areas that form the basis of current mandates: 1) firearms and suicides; 2) deterrence and defense; 3) restricting access to firearms; 4) firearm injury prevention programs including safety innovations; and 5) criminal justice interventions. Interestingly, the committee noted that there was insufficient evidence to answer critical questions about the safety, efficacy, and cost-effectiveness of interventions in all these 5 arenas. They mentioned that most of the interventions have been studies using quasi-experimental designs and have urged that more rigorous study designs be utilized to study the effectiveness of these interventions. Despite this report, there are several lessons that can be learned from policies that govern other causes of injuries, like motor vehicle accidents.
We have learned that product modification by mandating collapsible steering columns, seatbelts, and energy-absorbing vehicle frames was a superior strategy compared with behavior modification in reducing accident-related deaths.
Similarly, efforts toward product modification of guns might be an effective strategy in reducing firearm-related injuries. Several of these have been proposed and tested, including loaded chamber indicator, grip safety, magazine safety, and drop safety, as well as personalizing handguns by using radiofrequency signals or fingerprinting.
It has been speculated that personalization technology could possibly prevent the use of stolen handguns, thereby shrinking the illegal gun market and potentially reducing the use of firearms by adolescents and young children.
Strengths and Limitations
The major strength of the study lies in the utilization of a large, nationally representative and well-validated database. The current study is one of the first of its kind to explore an extremely plausible reason for the firearm-related trends observed over the last decade. However, there are a few limitations. First, NIS is an administrative database, which may be subject to errors in coding of diseases or procedures. Second, this is a retrospective observational study, which may be subject to traditional biases of observational studies like selection bias. However, these limitations might be partially compensated due to a large NIS database and a uniform representation of all regions of the US. In addition, the NIS is unable to provide important contextual information on firearm-related injuries, such as the victim–offender relationship, the circumstances surrounding the shooting, and the location of the shooting. Thirdly, the population-wide estimates including those who were not hospitalized are not possible to calculate from this database due to its current structure. Therefore, incidence rates calculated in the current study reflect the incidence among the pool of all hospitalized patients rather than the community as a whole. Despite these limitations, NIS is currently regarded as a useful source of data on firearm-related hospitalizations. National estimates derived using the NIS have been found to be consistent with estimates of hospitalizations from other data sources.
Over the last decade, the national incidence of firearm-related hospitalizations in the United States has closely tracked the national stock market performance, suggesting that economic perturbations and resultant insecurities might underlie the perpetuation of firearm-related injuries. The in-hospital case-fatality rate among patients admitted with firearm-related injuries has been stable in the last decade, the highest rates being present among those who attempted suicide using firearms. Also, there has been an increase in the prevalence of mental health disorders among individuals admitted with firearm-related injuries. Furthermore, there has been an increase in the length of stay and the cost/charges associated with these hospitalizations over the last decade.
Acknowledgment
The author would like to acknowledge the help of Ms. Kathryn Brock in editing the manuscript.
Appendix
Supplementary Figure 1This figure demonstrates the correlation between the trend of firearm-related hospitalizations and the US stock market performance as measured by Dow Jones Industrial Average values. Panel A demonstrates the annual national incidence rate of firearm-related hospitalizations across the entire study duration of 1988-2011. Panel B demonstrates the Dow Jones Industrial Average across the entire study duration of 1988-2011. Panel C represents a magnified view of the trend of annual national incidence of firearm-related hospitalizations during 2000-2011. Panel D represents a magnified view of the trend of the Dow Jones Industrial Average during 2000-2011.
Health and Public Policy Committee of the American College of Physicians
Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians.
United States Department of Labor, Bureau of Labor Statisitcs. Consumer Price Index – Guide to CPI data. Available at: http://www.bls.gov/cpi/cpifact8.htm. Accessed May 16, 2014.
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