Skip to main content

A joinpoint analysis examining trends in firearm injuries at six us trauma centers from 2016 to 2022

Abstract

Background

There is an epidemic of firearm injuries in the United States since the mid-2000s. Thus, we sought to examine whether hospitalization from firearm injuries have increased over time, and to examine temporal changes in patient demographics, firearm injury intent, and injury severity.

Methods

This was a multicenter, retrospective, observational cohort study of patients hospitalized with a traumatic injury to six US level I trauma centers between 1/1/2016 and 6/30/2022. ICD-10-CM cause codes were used to identify and describe firearm injuries. Temporal trends were compared for demographics (age, sex, race, insured status), intent (assault, unintentional, self-harm, legal intervention, and undetermined), and severity (death, ICU admission, severe injury (injury severity score ≥ 16), receipt of blood transfusion, mechanical ventilation, and hospital and ICU LOS (days). Temporal trends were examined over 13 six-month intervals (H1, January–June; H2, July–December) using joinpoint regression and reported as semi-annual percent change (SPC); significance was p < 0.05.

Results

Firearm injuries accounted for 2.6% (1908 of 72,474) of trauma hospitalizations. The rate of firearm injuries initially declined from 2016-H1 to 2018-H2 (SPC = − 4.0%, p = 0.002), followed by increased rates from 2018-H2 to 2020-H1 (SPC = 9.0%, p = 0.005), before stabilizing from 2020-H1 to 2022-H1 (0.5%, p = 0.73). NH black patients had the greatest hospitalization rate from firearm injuries (14.0%) and were the only group to demonstrate a temporal increase (SPC = 6.3%, p < 0.001). The proportion of uninsured patients increased (SPC = 2.3%, p = 0.02) but there were no temporal changes by age or sex. ICU admission rates declined (SPC = − 2.2%, p < 0.001), but ICU LOS increased (SPC = 2.8%, p = 0.04). There were no significant changes over time in rates of death (SPC = 0.3%), severe injury (SPC = 1.6%), blood transfusion (SPC = 0.6%), and mechanical ventilation (SPC = 0.6%). When examined by intent, self-harm injuries declined over time (SPC = − 4.1%, p < 0.001), assaults declined through 2019-H2 (SPC = − 5.6%, p = 0.01) before increasing through 2022-H1 (SPC = 6.5%, p = 0.01), while undetermined injuries increased through 2019-H1 (SPC = 24.1%, p = 0.01) then stabilized (SPC = − 4.5%, p = 0.39); there were no temporal changes in unintentional injuries or legal intervention.

Conclusions

Hospitalizations from firearm injuries are increasing following a period of declines, driven by increases among NH Black patients. Trauma systems need to consider these changing trends to best address the needs of the injured population.

Background

There is an epidemic of firearm injuries in the United States (US) that impacts all ages, sexes, and races, but disproportionally affects males and racial/ethnic minorities (Fontanarosa and Bibbins-Domingo 2022; Mueller et al. 2023). More than 100,000 persons in the US suffer a firearm injury each year (Centers for Disease Control and Prevention 2023a). The US leads developed nations in firearm mortality, with nearly 49,000 firearm related deaths in 2021, up 30% from 38,000 deaths in 2016 (Centers for Disease Control and Prevention 2023b). Studies have reported a temporal increase in firearm related homicides and suicides over time (Wintemute 2015), and a spike during 2020, coinciding with the COVID-19 pandemic (Donnelly et al. 2023; McGraw et al. 2022). The largest temporal increases in firearm related homicides and suicides occurred among non-Hispanic (NH) black and other minority groups (Kegler et al. 2022).

Much is known about firearm mortality due to several available US national repositories including the Centers for Disease Control and Prevention (CDC) WISQARS and National Violent Death Reporting System, and the CDC WONDER National Vital Statistics System (Centers for Disease Control and Prevention 2023a, b). However, nearly 80% of victims of firearm violence survive their injury and there is no adequate national repository to track nonfatal firearm injuries (National Opinion Research Center (NORC) at the University of Chicago 2020) Studies examining temporal changes in firearm related injuries across all ages report disparate findings, with some studies suggesting increases (Livingston et al. 2014) and others demonstrating no change (Cook et al. 2017; Davoudi and Woodworth 2023) or declines in hospitalization (Gross et al. 2017) due to firearm injuries. At a national level, firearm related emergency department (ED) visits have remained steady, but the patterns of ED visits due to firearms are changing with declines in assaults and increases in unintentional firearm injuries (Kalesan et al. 2021).

However, most publications reporting on firearm injuries and hospitalizations present trends through 2016 (Cook et al. 2017; Gross et al. 2017; Kalesan et al. 2021, 2018; Gani et al. 2017; Smart et al. 2021). It is likely these data are not representative of present trends in firearm violence because there has been a nearly 30% increase in firearm mortality from 2016 to 2021 (Centers for Disease Control and Prevention 2023a), an increase in gun ownership from 39 to 45% from 2016 to 2021 (The Gallup Organization Guns 2024; Percentage of households in the United States owning one or more firearms from 1972 to 1972 2024), and an increase in permitless carry laws from 10 States in 2016 to 23 States in 2022 (Wikipedia Contributors 2024). Additionally, since 2016 there have been noteworthy events such as the COVID pandemic, demographic changes in the US with declines in the non-Hispanic (NH) white population (Census.gov. 2024), and the end of the federal funding freeze on gun violence research after more than 20 years (Rostron 2018).

The purpose of this study was to examine changes in firearm-related hospitalizations since 2016. Contemporaneous data-informed research is needed to understand who is affected by firearms, how frequently it occurs, and patterns of change so that we can properly address and treat firearm injuries. The specific aims were to determine the incidence of firearm injury hospitalizations since 2016 as well as temporal changes, demographic trends in firearm injury hospitalizations, and trends in firearm injury hospitalizations by intent and severity.

Methods

This was a multicenter, retrospective, observational cohort study of six non-academic U.S. trauma centers that form a collaborative network for trauma research. The study facilities are level I trauma centers in the Central and Mountain West regions of the United States; level I centers provide the highest level of care for trauma patients. The facilities are located in smaller cities (Penrose Hospital, Colorado Springs, CO; STHS-McAllen Hospital, McAllen TX; Wesley Hospital, Wichita, KS) or in suburban areas near Denver, CO and Dallas, TX (Swedish Medical Center, Englewood CO; St. Anthony Hospital, Lakewood CO; Medical City Plano, Plano TX).

The trauma registry was used to identify adult (age ≥ 18) trauma patients who arrived between 1/1/2016 and 6/30/2022. Patients whose race was unknown or not documented were excluded, which was just over 3% of patients.

In order to be included in the trauma registry of participating hospitals, patients needed to have been admitted to the hospital or observed, died during transit, or died in the ED. Patients who died at the scene or patients who were discharged from the ED were excluded. The trauma registry includes data from time of injury through discharge (or death); there were no post-hospitalization data available.

The 10th revision of the International Statistical Classification of Diseases, Clinical Modification (ICD-10-CM) external cause code was used to identify firearm-related injuries, intent of firearm injury, and type of firearm used. Firearm injury intent was defined as assault (including homicide), unintentional (accidental) discharge, self-harm (suicide/attempt), legal intervention (law enforcement), and undetermined intent. If the ICD-10-CM external code was missing the trauma registrar-assigned cause code was used (n = 10, 0.5% with firearm injury). Type of firearm was defined as handgun (e.g., pistol), longarm (e.g., shotguns, rifles, and other long barreled firearms), unspecified firearm discharge, and other firearm discharge.

Demographics were examined as age (18–30 vs. > 30 years, based on the median age of 30 years), sex, insurance status (uninsured/self-pay vs. insured) and race: Hispanic, NH White, NH Black, NH Asian American or Pacific Islander or American Indian / Alaska Native (AAPI /AIAN), and NH-other (patients that self-identified as “other race”); one facility did not differentiate race and ethnicity, and thus Hispanic ethnicity was coded as a race for our analysis. At the other five facilities, Hispanic patients who also self-identified as either Black or AAPI/AIAN were categorized as Hispanic.

Severity and resource utilization was examined with the injury severity score (ISS; < 16 vs. ≥ 16), receipt of a blood transfusion (yes/no), mechanical ventilation (yes/no), intensive care unit (ICU) admission (yes/no), ICU length of stay (LOS, days), hospital LOS, and death (vs. discharged alive).

Statistical analysis

SAS® version 9.4 was used to summarize data. Joinpoint regression analyses were used to analyze temporal changes in firearm injuries using the National Cancer Institute (NCI) joinpoint software program version 5.0.2 (Joinpoint Regression Program, Version 5.0.2 2023), using the methods proposed by Kim et al. (2022). A joinpoint regression model segments time series data into groups of data points with similar linear trends to identify inflection points (i.e., joinpoints). The time series used semi-annual (every 6 months, where H1 is January through June and H2 is July through December) averages and standard errors in firearm hospitalization rates to report the semi-annual percentage change (SPC). A linear model with zero joinpoints was initially fit and additional joinpoints were added when the slope of the line between joinpoints was significantly different from zero (p < 0.05 based on the SPC compared to zero). A stable or non-significant trend was defined based on a p ≥ 0.05 when comparing the SPC to zero. The maximum number of joinpoints for our dataset was 3 based on 13 data points in our series. Joinpoint models were used to examine overall changes in firearm injuries over time as well as temporal changes by demographic characteristics (age, sex, race, insurance status), firearm injury intent and firearm type, and severity and resource use (ISS, blood transfusion, mechanical ventilation, ICU admission, ICU and hospital LOS, and death).

Due to the complexity of interpreting the joinpoint analysis, we also performed a supplementary analysis of linear, annual trends in firearm injury hospitalization, intent, demographics, and severity characteristics in SAS® using Cochran-Armitage trend tests (Supplementary Table 1).

Results

Firearm-related injuries, overall and by hospital

There were 72,474 trauma patients identified and 1908 (2.6%) were injured by firearm. Compared to patients injured by other means, patients injured by firearm were more likely to be younger, male, uninsured, and were less likely to be white and more likely to be racial and ethnic minority groups; they also had worse injuries including greater than two-fold rates of severe injury (ISS ≥ 16), mechanical ventilation, and blood transfusions, and had significantly greater mortality compared to patients injured by non-firearm means (Table 1).

Table 1 Comparison of traumatic injuries by firearm, using trauma registry data at 6 US level I trauma centers, 1/1/2016–6/30/2022

The final model examining changes in firearm injuries over time included 2 joinpoints: the rate of firearm injuries initially declined between the start of 2016 to the second half of 2018 (SPC = − 4.0%, p = 0.002), followed by increased rates from the second half of 2018 to the first half of 2020 (SPC = 9.0%, p = 0.005), before stabilizing through the first half of 2022 (0.5%, p = 0.73), Fig. 1. The absolute number of firearm hospitalizations also increased over time (Fig. 1).

Fig. 1
figure 1

Semi-annual percent change (SPC) of trauma admissions with firearm injuries. Legend: Data from registries of 6 US level I trauma centers, 1/1/2016–6/30/2022. H1, January–June; H2, July–December. * denotes p < 0.05

There were some differences across facilities in trends of firearm injuries over time. For five of six hospitals, there was a non-significant linear change in firearm injuries over time (SPCs = 0.7, 1.3, 1.6, 4.0, 5.5%). For the sixth facility, there was no initial change in firearm injuries from 2016 through 2019 (SPC = 0.4%), followed by an increase from 2019-H2 to 2021-H1 (SPC = 17.6%, p < 0.001), then a decline from 2021-H1 to 2022-H1 (SPC = − 11.9%, p < 0.001).

Trends in firearm type and intent

Approximately half (49.7%) of firearm injuries involved a handgun, 9.2% involved a longarm, 41.1% had an ‘unspecified’ firearm discharge, and 2.2% had ‘other’ type of firearm discharge. When examined by type, there was a significant increase in firearm injuries involving an unspecified firearm (SPC = 4.9%, p < 0.001), a significant decline in firearm injuries involving a longarm (SPC = − 8.5%, p = 0.04), and no change over time in firearm injuries involving a handgun (SPC = − 2.2%, p = 0.09).

Nearly half (46.8%) of firearm injuries were due to assault, followed by unintentional discharge (23.3%), self-harm (14.9%), undetermined intent (12.3%), and legal intervention (2.7%). Self-harm injuries declined over time (SPC = − 4.1%, p < 0.001), Fig. 2. There were no temporal changes in unintentional injuries (SPC = − 0.8%, p = 0.66) or legal intervention (SPC = 2.3%, p = 0.50). Undetermined injuries increased between 2016 and the first half of 2019 (SPC = 24.1%, p = 0.01) then stabilized (SPC = − 4.5%, p = 0.39). The model examining assaults demonstrated two joinpoints: there was an initial increase that was not significant from 2016 to the first half of 2017 (SPC = 6.3%, p = 0.16), then assaults declined from the second half of 2017 to the second half of 2019 (SPC = − 5.6%, p = 0.01) before increasing in 2020 to 2022 (SPC = 6.5%, p = 0.01).

Fig. 2
figure 2

Semi-annual percent change (SPC) by intent for patients with firearm injuries. Legend: Data from trauma registries at 6 US level I trauma centers, 1/1/2016–6/30/2022. H1, January–June; H2, July–December. FSM = Final selected model (number of joinpoints). * denotes p < 0.05

Demographic trends of patients injured by firearm

NH white patients comprised half (49.4%) of firearm hospitalizations, 24.3% were NH black, 20.7% were Hispanic, 1.6% were AAPI/AIAN, and 4.1% were NH other; four patients self-identified as Hispanic and Black or AAPI/AIAN. Firearm injuries accounted for 14.0% of all hospitalizations for traumatic injury for NH black patients, whereas firearm injury accounted for between 1.7 and 3.4% of trauma admissions for all other groups.

The joinpoint analysis by race produced linear trends (0 joinpoints). NH black patients were the only group to have a significant change in firearm injuries, increasing 6.3% on a bi-annual basis (SPC = 6.3%, p < 0.001). There were no changes for any other race/ethnicity group (Fig. 3). The proportion of uninsured/self-pay patients also significantly increased over time (SPC = 2.3%, p = 0.02), while there were no temporal changes in the proportion of firearm victims that were 18–30 years old (SPC = 0.7%, p = 0.39) or who were female (SPC = − 0.5%, p = 0.73).

Fig. 3
figure 3

Semi-annual percent change (SPC) of patients with firearm injuries, by race/ethnicity. Legend: Data from trauma registries at 6 US level I trauma centers, 1/1/2016–6/30/2022. H1, January–June; H2, July – December. * denotes p < 0.05

Trends in severity and resource use of patients injured by firearm

The joinpoint analysis by severity produced linear trends (0 joinpoints), Fig. 4. ICU admission rates significantly declined (SPC = − 2.2%, p < 0.001). There were no significant changes over time in rates of severe injury (SPC = 1.6%, p = 0.22), blood transfusion (SPC = 0.6%, p = 0.68), and mechanical ventilation (SPC = 0.6%, p = 0.72). There were also no changes in mortality over time (SPC = 0.3%, p = 0.77). The majority (50.9%) of firearm deaths were from self-harm, 31.3% were homicide/assault, 5.0% of deaths involved legal intervention, 3.2% of deaths were unintentional, and 9.6% of deaths from firearm were undetermined. Most (66.1%) patients died on the day of admission while 8.5% died en route or in the ED and 25.4% died later in the hospitalization.

Fig. 4
figure 4

Semi-annual percent change (SPC) by severity and resource utilization for patients with firearm injuries. Legend: Data obtained from trauma registries at 6 US level I trauma centers from 1/1/2016 to 6/30/2022. H1, January–June; H2, July–December. FSM = Final selected model. * denotes p < 0.05

The mean number of days in the ICU LOS increased by 2.8% bi-annually (SPC = 2.8%, p = 0.04), whereas hospital LOS initially increased from 2016 through 2019 (SPC = 3.7%, p = 0.03), then began declining in 2020 (SPC = − 5.9%, p = 0.03), Fig. 5.

Fig. 5
figure 5

Semi-annual percent change (SPC) of hospital and ICU LOS (days) for patients with firearm injuries. Legend: Data obtained from trauma registries at 6 US level I trauma centers from 1/1/2016 to 6/30/2022. H1, January–June; H2, July–December. FSM = Final selected model. * denotes p < 0.05. ICU LOS calculated for those admitted to the ICU

Discussion

This study demonstrated significant changes in hospitalization from firearm-related injuries over time. The rate of firearm injuries initially declined from 2.7 to 2.2% of all trauma hospitalizations between 2016 and the first half of 2018, significantly increasing to approximately 3% through the first half of 2020, and leveling out at 3% through the first half of 2022. This significant rise in firearm hospitalizations occurred prior to the COVID-19 period, and only one of the six hospitals in our study had a notable spike in 2020 and the first half of 2021 that coincided with the pandemic. This study also showed that firearm injuries are increasing in suburban and semi-urban settings in the U.S., reflecting national trends and bringing to light that firearm hospitalizations do not solely impact academic medical centers in large metropolitan areas. These results suggest that hospitals and trauma systems should plan and prepare for increased firearm admissions and the accompanying high resource utilization.

Racial disparities persisted during the study period. While this finding is not surprising, what is concerning is that the disparities appeared to strengthen during this recent 6.5-year time frame. Specifically, there was a high prevalence of firearm injuries among NH black patients, and this was the only group to see a steady increase in firearm hospitalizations over time, doubling from 9% of all trauma admissions in 2016 to 18% in 2022. Rates of firearm injuries for NH black patients also peaked in the second half of 2020 through the first half of 2021, overlapping with the COVID pandemic and Black Lives Matter protests following the murder of George Floyd.

The proportion of patients who were uninsured (or self-pay) increased over time, which hospital systems should be aware of and plan for. Hospitalization costs for firearm injuries are over $1 billion annually which is nearly triple that of non-firearm related care (U.S. Government Accountability Office 2021), with total hospital charges for firearm injuries ranging from $116,000 to $214,000 per patient in 2016–2019 (Silver et al. 2023).

Firearm injuries of undetermined intent significantly increased from 2016 through the first half of 2019 before trending lower, whereas firearm injuries due to assault followed the opposite pattern, significantly decreasing between 2017 through 2019 before increasing in 2020–2022. An analysis comparing ICD-9 coded firearm injuries to researcher-adjudicated intent at three level I trauma centers reported undetermined firearm injuries most closely resembled assaults (Miller et al. 2022). One interpretation of these trends we observed is that assaulted patients may not be disclosing their attack, potentially for fear of retribution, which may explain the increase in undetermined injuries and parallel decrease in assaults between 2016 and 2019 that warrants further study.

Self-inflicted firearm injuries decreased over the study period, from 17 to 12% of firearm injuries. Unintentional firearm injuries remained stable during the study period and represented nearly one-fourth of all admissions due to firearms—a substantial amount given this population excluded children and teens who are frequently the victims of unintentional firearm injuries (Wilson et al. 2023). There may be opportunities for directing gun owners to firearm safety education or implementing changes to policies requiring firearm safety education. In the states studied, both Texas and Kansas passed constitutional carry laws during the study period, removing the requirement for taking a concealed carry class prior to obtaining a permit. Prior research suggests that states that no longer required training for concealed carry weapons had a 32% increase in gun assaults (Doucette et al. 2023). Further, in person education opportunities for new firearm owners may have been limited in the setting of the COVID pandemic. This combination could increase the risk of unintentional injuries, though more specific research would be needed to assess this risk. Prior evidence-based reviews demonstrate gun locks and other safe storage methods prevent unintentional firearm injuries (Violano et al. 2018). One opportunity for further research would be to examine unintentional injuries by specific activity, to determine whether these injuries are occurring during firearm manipulation, cleaning, training, or inadvertent discharge, which would provide better insight into specific education that could address these injuries.

Severity and resource utilization from firearm injuries was high, with 44% admitted to the ICU, 26% ventilated and one in five patients requiring a blood transfusion. However, this study did not identify temporal changes in severity from firearm injuries, including mortality. Prior research suggests firearm death rates have remained relatively stable during the twenty-first century (2000–2012), following a 31% decline during the 1990s (Fowler et al. 2015).

On the contrary, we identified a significant decline in ICU admission rates and an increase in ICU admission LOS (days). One possible explanation for these findings, without a change in other markers of severity, is that the Brain Injury Guidelines (BIG) were implemented at varying times across facilities during the study period (Joseph et al. 2014). The BIG protocol grades patients with traumatic brain injury (TBI) by severity and only the most severe patients (BIG 3) require ICU admission; historically, treatment of TBI included ICU admission to monitor the patient closely for clinical deterioration. We also found an increase in hospital LOS from 2016 through 2019, followed by a significant decline in hospital LOS in 2020–2022. This latter finding may be related to the COVID-19 pandemic, as prior studies have shown a decreased LOS in trauma patients during 2020 as a result of the pandemic (Berg et al. 2021; Yeates et al. 2022).

The primary study limitation is that trauma registry data underestimates firearm injuries, especially because between 53 and 59% of firearm victims deaths occur at the scene (Agoubi et al. 2023; Sauaia et al. 2016), and upwards of 88% of suicide victims die at the scene (Kaufman et al. 2021). The trauma registry also excludes patients that were routinely discharged from the ED. In one study conducted at a level I trauma center, 19% of firearm victims were discharged from the ED, most with very peripheral or tangential gunshot wounds (Livingston et al. 2014). Across all EDs including non-trauma centers approximately 43% of firearm victims are treated and released (Fowler et al. 2015). Additionally, patients who do not seek medical care are also excluded, but without a national repository the estimates are not known.

Generalizability is another study limitation, as the study was conducted at level 1 trauma centers that treat a higher volume of serious firearm injuries requiring hospitalization compared to than lower level or non-trauma centers (Coupet et al. 2019; Hatfield et al. 2024). Moreover, three of six study sites are located in Colorado which has one of the lowest rates of firearm injuries (Smart et al. 2021). We also excluded children; in 2021, firearm injuries were the leading cause of death among US children and adolescents (Roberts et al. 2023) and the burden of pediatric firearm death has disproportionately affected communities of color (Olufajo et al. 2020). Prior research has shown that the incidence of firearm injuries is increasing in children < 18 years of age (Fraser Doh et al. 2023), similar to what we found in our adult population. A final limitation is a potential bias in ICD10 coding that has been demonstrated to overestimate unintentional injuries (Miller et al. 2022; Barber et al. 2021). The Center for Medicaid and Medicare Services codebook states “Undetermined intent is only for use when there is specific documentation in the record that the intent of the injury cannot be determined. If no such documentation is present, code to accidental (unintentional).” Our data did not show an increase in unintentional injuries but rather an increase in undetermined intent injuries, where the cause of the injury could not be determined. Another area of study is to evaluate whether clinician training on firearm counseling and intervention practices, or greater implementation of hospital-based violence intervention programs, may improve documentation of intent (among other benefits). Medical professionals are in a unique position to apply evidence-based strategies to address firearm violence (Betz et al. 2022; Cunningham et al. 2009), but prior studies have shown that only 24% of level I trauma centers conduct firearm screening and intervention (Bulger et al. 2022). Moreover, the hospitals in our study, being ACS verified level I trauma centers, have a responsibility to explore ways to mitigate firearm violence through injury prevention efforts.

Conclusion

Our findings provide a contemporary overview of the change in firearm hospitalizations, demonstrating a period of initial declines followed by an increase beginning in 2018, prior to the COVID-19 pandemic. The increase in firearm injuries was driven by persisting racial disparities in firearm violence, with a significant, steady increase in firearm injuries for NH black patients. Hospitals, trauma systems and injury prevention programs will need to attend to these changing trends to best address the needs of the injured population.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AAPI:

Asian American Pacific Islander

AIAN:

American Indian Alaska Native

BIG:

Brain injury guidelines

CDC:

Centers for Disease Control and Prevention

COVID-19:

Coronavirus disease 2019

ED:

Emergency department

EMS:

Emergency medical services

ICD:

International Statistical Classification of Diseases

ICU:

Intensive care unit

ISS:

Injury severity score

LOS:

Length of stay

NH:

Non-Hispanic

TBI:

Traumatic brain injury

US:

United States

References

  • Agoubi LL, Duan N, Rowhani-Rahbar A, Nehra D, Sakran JV, Rivara FP. Patterns in location of death from firearm injury in the US. JAMA Surg. 2023;158(6):669–70.

    Article  PubMed  PubMed Central  Google Scholar 

  • Barber C, Goralnick E, Miller M. The Problem with ICD-coded firearm injuries. JAMA Intern Med. 2021;181(8):1132–3.

    Article  PubMed  Google Scholar 

  • Berg GM, Wyse RJ, Morse JL, Chipko J, Garland JM, Slivinski A, et al. Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system. Trauma Surg Acute Care Open. 2021;6(1):e000642.

    Article  PubMed  PubMed Central  Google Scholar 

  • Betz ME, Thomas AC, Simonetti JA. Firearms, suicide, and approaches for prevention. JAMA. 2022;328(12):1179–80.

    Article  PubMed  Google Scholar 

  • Bulger EM, Johnson P, Parker L, Moloney KE, Roberts MK, Vaziri N, et al. Nationwide survey of trauma center screening and intervention practices for posttraumatic stress disorder, firearm violence, mental health, and substance use disorders. J Am Coll Surg. 2022;234(3):274–87.

    Article  PubMed  PubMed Central  Google Scholar 

  • Census.gov. 2024. Accessed 30 Jan 2024, from https://data.census.gov/.

  • Centers for Disease Control and Prevention. WISQARS- Wed-Based Injury Statistics Query and Reporting System 2023. 2023a. Available from: https://www.cdc.gov/injury/wisqars/index.html.

  • Centers for Disease Control and Prevention. National Center for Health Statistics Mortaltiy Data from CDC WONDER 2023. 2023b. Available from: https://wonder.cdc.gov/Deaths-by-Underlying-Cause.html.

  • Cook A, Osler T, Hosmer D, Glance L, Rogers F, Gross B, et al. Gunshot wounds resulting in hospitalization in the United States: 2004–2013. Injury. 2017;48(3):621–7.

    Article  PubMed  Google Scholar 

  • Coupet E Jr, Huang Y, Delgado MK. US emergency department encounters for firearm injuries according to presentation at trauma vs nontrauma centers. JAMA Surg. 2019;154(4):360–2.

    Article  PubMed  PubMed Central  Google Scholar 

  • Cunningham R, Knox L, Fein J, Harrison S, Frisch K, Walton M, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med. 2009;53(4):490–500.

    Article  PubMed  Google Scholar 

  • Davoudi A, Woodworth L. The burden of firearm injuries on the hospital system, 2000–2020. Inj Epidemiol. 2023;10(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  • Donnelly M, Grigorian A, Inaba K, Nguyen N, de Virgilio C, Schubl S, et al. Trends in mass shootings in the United States (2013–2021): a worsening American epidemic of death. Am J Surg. 2023;226(2):197–201.

    Article  PubMed  Google Scholar 

  • Doucette MLCC, McCourt AD, Ward JA, Fix RL, Webster DW. Deregulation of public civilian gun carrying and violent crimes: a longitudinal analysis 1981–2019. Criminol Public Policy. 2023;1:1–29.

    Google Scholar 

  • Fontanarosa PB, Bibbins-Domingo K. The unrelenting epidemic of firearm violence. JAMA. 2022;328(12):1201–3.

    Article  PubMed  Google Scholar 

  • Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015;79:5–14.

    Article  PubMed  PubMed Central  Google Scholar 

  • Fraser Doh K, Chaudhary S, Ruest SM, Shaahinfar A, Chun T, Cooper N, et al. Variability in firearm injury among major pediatric trauma centers across the USA. Trauma Surg Acute Care Open. 2023;8(1):e001014.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gani F, Sakran JV, Canner JK. Emergency department visits for firearm-related injuries in the United States, 2006–14. Health Aff. 2017;36(10):1729–38.

    Article  Google Scholar 

  • Gross BW, Cook AD, Rinehart CD, Lynch CA, Bradburn EH, Bupp KA, et al. An epidemiologic overview of 13 years of firearm hospitalizations in Pennsylvania. J Surg Res. 2017;210:188–95.

    Article  PubMed  Google Scholar 

  • Hatfield SA, Medina S, Gorman E, Barie PS, Winchell RJ, Villegas CV. A decade of firearm injuries: have we improved? J Trauma Acute Care Surg. 2024. https://doi.org/10.1097/TA.0000000000004249.

    Article  PubMed  Google Scholar 

  • Joinpoint Regression Program, Version 5.0.2. Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute; 2023.

  • Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965–9.

    Article  PubMed  Google Scholar 

  • Kalesan B, Zuo Y, Xuan Z, Siegel MB, Fagan J, Branas C, et al. A multi-decade joinpoint analysis of firearm injury severity. Trauma Surg Acute Care Open. 2018;3(1):e000139.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kalesan B, Siracuse JJ, Cook A, Prosperi M, Fagan J, Galea S. Prevalence and hospital charges from firearm injuries treated in US emergency departments from 2006 to 2016. Surgery. 2021;169(5):1188–98.

    Article  PubMed  Google Scholar 

  • Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009–2017. JAMA Intern Med. 2021;181(2):237–44.

    Article  PubMed  Google Scholar 

  • Kegler SR, Stone DM, Mercy JA, Dahlberg LL. Firearm homicides and suicides in major metropolitan areas—United States, 2015–2016 and 2018–2019. MMWR Morb Mortal Wkly Rep. 2022;71(1):14–8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kim HJ, Chen HS, Byrne J, Wheeler B, Feuer EJ. Twenty years since Joinpoint 1.0: two major enhancements, their justification, and impact. Stat Med. 2022;41(16):3102–30.

    Article  PubMed  Google Scholar 

  • Livingston DH, Lavery RF, Lopreiato MC, Lavery DF, Passannante MR. Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center. J Trauma Acute Care Surg. 2014;76(1):2–9.

    Article  PubMed  Google Scholar 

  • McGraw C, Jarvis S, Carrick M, Lieser M, Madayag RM, Berg GM, et al. Examining trends in gun violence injuries before and during the COVID-19 pandemic across six trauma centers. Trauma Surg Acute Care Open. 2022;7(1):e000801.

    Article  PubMed  Google Scholar 

  • Miller M, Azrael D, Yenduri R, Barber C, Bowen A, MacPhaul E, et al. Assessment of the accuracy of firearm injury intent coding at 3 US hospitals. JAMA Netw Open. 2022;5(12):e2246429.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mueller KL, Lovelady NN, Ranney ML. Firearm injuries and death: a United States epidemic with public health solutions. PLOS Glob Public Health. 2023;3(5):e0001913.

    Article  PubMed  PubMed Central  Google Scholar 

  • National Opinion Research Center (NORC) at the University of Chicago. The State of Firearms Data in 2019. University of Chicago; 2020.

  • Olufajo OA, Zeineddin A, Nonez H, Okorie NC, De La Cruz E, Cornwell EE 3rd, et al. Trends in firearm injuries among children and teenagers in the United States. J Surg Res. 2020;245:529–36.

    Article  PubMed  Google Scholar 

  • Percentage of Households in the United States Owning One or More Firearms from 1972 to 2023. Statista. 2024. Accessed 13 Feb 2024. Available from: https://www.statista.com/statistics/249740/percentage-of-households-in-the-united-states-owning-a-firearm/.

  • Roberts BK, Nofi CP, Cornell E, Kapoor S, Harrison L, Sathya C. Trends and disparities in firearm deaths among children. Pediatrics. 2023. https://doi.org/10.1542/peds.2023-061296.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rostron A. The Dickey Amendment on federal funding for research on gun violence: a legal dissection. Am J Public Health. 2018;108(7):865–7.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sauaia A, Gonzalez E, Moore HB, Bol K, Moore EE. Fatality and severity of firearm injuries in a Denver trauma center, 2000–2013. JAMA. 2016;315(22):2465–7.

    Article  PubMed  Google Scholar 

  • Silver JH, Ramos TA, Stamm MA, Gladden PB, Martin MP, Mulcahey MK. Examining the healthcare and economic burden of gun violence in a major US Metropolitan City. J Am Acad Orthop Surg Glob Res Rev. 2023. https://doi.org/10.5435/JAAOSGlobal-D-22-00158.

    Article  PubMed  PubMed Central  Google Scholar 

  • Smart R, Peterson S, Schell TL, Kerber R, Morral AR. Inpatient Hospitalizations for Firearm Injury: Estimating State-Level Rates from 2000 to 2016. Santa Monica. CA: RAND Corporation; 2021. https://www.rand.org/pubs/tools/TLA243-3.html.

  • The Gallup Organization Guns. Washington, DC2024. 2024. Accessed 30 Jan 2024, from https://news.gallup.com/poll/1645/guns.aspx.

  • U.S. Government Accountability Office. Firearm Injuries: Health Care Service Needs and Costs. 2024. GAO-21-515. Accessed 22 Apr 2024.

  • Violano P, Bonne S, Duncan T, Pappas P, Christmas AB, Dennis A, et al. Prevention of firearm injuries with gun safety devices and safe storage: an Eastern Association for the Surgery of Trauma Systematic Review. J Trauma Acute Care Surg. 2018;84(6):1003–11.

    Article  PubMed  Google Scholar 

  • Wikipedia contributors. Constitutional carry. In Wikipedia, The Free Encyclopedia. 2024. Accessed 30 Jan 2024, from https://en.wikipedia.org/w/index.php?title=Constitutional_carry&oldid=1194875816.

  • Wilson RF, Mintz S, Blair JM, Betz CJ, Collier A, Fowler KA. Unintentional firearm injury deaths among children and adolescents aged 0–17 years—National Violent Death Reporting System, United States, 2003–2021. MMWR Morb Mortal Wkly Rep. 2023;72(50):1338–45.

    Article  PubMed  PubMed Central  Google Scholar 

  • Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Annu Rev Public Health. 2015;36:5–19.

    Article  PubMed  Google Scholar 

  • Yeates EO, Grigorian A, Schellenberg M, Owattanapanich N, Barmparas G, Margulies D, et al. Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic. Am J Surg. 2022;224:90–5.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable. Disclaimers (1) The views, opinions, findings, and conclusions or recommendations expressed in these papers and articles are strictly those of the author(s). They do not necessarily reflect the views of STHS System, its affiliates, or its parent company. South Texas Health System takes no responsibility for any errors or omissions in, or for the correctness of, the information contained in papers and articles. (2) This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity (Swedish Medical Center, Wesley Medical Center, Medical City Plano). The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Funding

None.

Author information

Authors and Affiliations

Authors

Contributions

KS drafted the manuscript and analyzed and interpreted the data. RJ Sliter drafted the manuscript and interpreted the data; GM, CP-L, GQ, DH, RM, and GB provided interpretation of data and revisions to the manuscript. DB-O provided supervision, interpretation of data and revisions to the manuscript, and is responsible for the overall content.

Corresponding author

Correspondence to David Bar-Or.

Ethics declarations

Ethics approval and Consent to participate

This study received institutional review board (IRB) approval with a waiver of informed consent from the following IRBs: HealthOne IRB approval #1947165 (Medical City Plano), 1946238 (Swedish Medical Center, Wesley Medical Center; CommonSpirit Health Research Institute IRB approval #1946464 (St Anthony Hospital, Penrose Hospital), WCG IRB approval #20224508 (STHS-McAllen). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Salottolo, K., Sliter, R.J., Marshall, G. et al. A joinpoint analysis examining trends in firearm injuries at six us trauma centers from 2016 to 2022. Inj. Epidemiol. 11, 18 (2024). https://doi.org/10.1186/s40621-024-00505-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40621-024-00505-5

Keywords