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Two studies document a rise in gun wounds, homicides

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National firearms injuries registry needed

Probably the most important message of the New Jersey study is that we need a reliable national database of firearm injuries. Most of the existing studies used trauma registries as their source of data. However, trauma registries, as was pointed out, do not include the victims who are treated and released from the emergency department. Further, victims can die at the scene and never reach hospital care; and not all victims are treated at trauma centers.

This major limitation of the registries causes a lot of confusion. For example, a recent front-page article in the Wall Street Journal reported a study that concluded that, over the last 6 years, the number of gunshot wounds has been increasing but the mortality rates have fallen, presumably because of better care. Another recent study reportedly found that over the same time period, the incidence of gunshot injuries has been going down while mortality has remained unchanged. It is obvious that we need a reliable national database to resolve these contradictions.

Dr. Demetrios Demetriades is a professor of surgery and director of acute care surgery at the University of Southern California, Los Angeles. He gave these remarks as the discussant of Dr. Livingston’s study at the meeting and reported having no financial disclosures.

Methodology, conclusions not firm

The issue of concealed-carry laws and their impact on violent crime has been a controversial political and public health issue in the United States. Currently, there are four types of concealed weapon laws. Five states now are unrestricted, like Arizona, where anyone can carry a concealed weapon without a state license. In 38 states, a permit is issued as long as the applicant meets certain requirements. Eight states "may" issue a permit and authorities may deny an applicant if a reasonable need to carry a concealed weapon in not met. The District of Columbia does not issue concealed weapons permits.

Proponents on both sides of this issue have used concealed-carry laws as a platform to espouse their viewpoints. However, today the general consensus of the public health community is that concealed weapons laws have minimal if any impact on violent crime in our nation relative to other legal political and societal factors.

Dr. Ginwalla and her colleagues sought to assess the impact of the state of Arizona’s repeal of its concealed-carry laws on gun-related injuries and deaths in the southern Arizona region. They concluded that after the repeal, gun-related homicides associated with violent crime increased significantly, presumably because of the increased presence of concealed weapons.

Although it seems intuitively reasonable that the increased access to concealed weapons would be related to the increase in gun-related fatalities in violent crimes, I have concerns regarding the study’s methodology and conclusions.

The entire "at-risk" population of violent crime decreased post repeal. Couldn’t we conclude that since there was less criminal activity after the repeal, concealed weapons were actually a deterrent?

Dr. Glen H. Tinkoff of Christiana Care Health System, Newark, Del., gave these comments as the discussant of Dr. Ginwall’s study at the meeting. He reported having no financial disclosures.


 

AT THE AAST ANNUAL MEETING

SAN FRANCISCO – Deaths from gunshot wounds doubled between 2000 and 2012 in the region served by one New Jersey trauma center and gun-related homicides as a proportion of violent crimes increased by 27% in southern Arizona after the state stopped requiring permits for concealed weapons, separate studies found.

In 2000, 8% of patients treated for gunshot wounds died. That rate increased to 15% in 2011, according to a retrospective study of 6,323 gunshot wounds seen at the New Jersey Trauma Center, a Level I trauma center in Newark. The proportion of 15-minute time increments in which the hospital was treating two or more patients for gunshot wounds increased from approximately 10% in 2000 to nearly 30% by the end of 2011, and the proportion of 15-minute increments in which three or more gunshot wounds were being treated increased from 1% to 16%, reported Dr. David H. Livingston and his associates.

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Surgery on 71% of these patients plus other services incurred $115 million in costs, 75% of it unreimbursed. The mean cost per patient increased by 282% during the study period, reported Dr. Livingston of University Hospital, Newark, N.J., and a professor of surgery at Rutgers University, also in Newark.

"I think nationally this could be billions of dollars," perhaps double that, if these conservative estimates are extrapolated, he said at the annual meeting of the American Association for the Surgery of Trauma.

The drain on trauma center resources is enormous, he said. Half of the patients in his study needed ICU care, a third needed a ventilator, and just less than a third needed blood transfusions. All of these parameters increased by 50% to 180% during the study period.

The search for data produced a surprise relying solely on trauma registries for data on gunshot wounds and deaths would have missed one out of every five cases because 19% of patients were treated in the emergency department (ED) and sometimes admitted to services other than the trauma unit, he said. The study tapped not only the trauma registry but also ED billing records and the hospital’s financial records.

Joshuashearn/Wikimedia Commons/Creative Commons License

Perceptions of gun violence tend to be driven by individual sensational events rather than "routine" gunshot wounds that happen much more frequently and in greater numbers, Dr. Livingston said.

Further, there was a doubling of both the proportion of cases with three or more gunshot wounds (from 10% to 20%) and the proportion of cases with three or more body areas that had been shot (from 5% to 10%).

Data suggest that gun violence in New Jersey is geographically restricted and not random, he said. Five cities in the state accounted for 85% of gunshot wounds (Newark, Irvington, East Orange, Orange, and Elizabeth); 75% of patients were shot in the city in which they lived, 55% within a mile of home, 25% within a block of home, and 15% in their homes. Half of gunshot wounds occurred in 15% of the region by Census tract.

The New Jersey study included only interpersonal gunshot injuries, not self-inflicted wounds or shots from police. Patients in that study were predominantly young, black men who had been shot with a handgun. The mean age was 27 years, and 98% of cases involved a handgun. The cohort was 86% black, 9% Hispanic, 4% white, and 1% Asian. "This demographic is different than the demographic of our catchment area," Dr. Livingston noted.

Dr. David H. Livingston

A separate study compared gun-related injury and deaths in the 2 years before and the 2 years after July 2010, when Arizona made it legal in that state to carry a concealed weapon without a permit or training. The proportion of homicides related to guns in southern Arizona increased significantly from 1.97% to 2.45% after that law was passed and deaths by firearms increased by 24% among victims of violent crimes and accidents, Dr. Rashna F. Ginwalla and her associates reported in a separate presentation.

The number of violent crimes and accidents stayed relatively stable, but the risk of any gun-related injury or death increased significantly by 11% after concealed-weapons regulations were eliminated, said Dr. Ginwalla, who led the study while at the University of Arizona, Tucson. Dr. Ginwalla now works in Rwanda for the University of Virginia, Charlottesville.

During the study period, Arizonans were more likely than was the general U.S. population to undergo a background check during a gun purchase, which the researchers used as a proxy for gun ownership. The study used data from the National Instant Criminal Background Check system, the trauma registry of the University of Arizona Medical Center (the only Level I trauma center for southern Arizona), the Pima County Medical Examiner’s Office, and the Tucson Police Department.

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