Abstract
Purpose
Firearm ownership and gun control are subjects of great contention. As healthcare professionals responsible for treating firearm-related injuries, the opinions of hand surgeons are particularly relevant. The aim of this study is to determine the association between exposure to gun violence and opinions regarding gun control or the role of the surgeon in the gun control debate and if gun ownership status correlates with these opinions.
Methods
A survey comprised of 24 multiple-choice and free text questions was distributed to the email database of the ASSH. The survey identified factors related to surgeon's practices, such as practice setting, location, and training background. Questions regarding surgeons' experiences with firearms and opinions on the responsibility of surgeons to take part in policymaking were assessed. Chi square, Kendall, binary logistic, and ordinal regression analyses were conducted as appropriate.
Results
A total of 578 responses were received. Approximately 17 % of respondents reported treating firearm injuries frequently (several times per month). The majority of respondents report feeling comfortable with treating such injuries.
Disagreement with current gun policies was found in half of respondents. The majority of surgeons feel that they do not have a responsibility to be involved in the gun control debate. Firearm ownership was positively associated with belief in the second amendment as a basic right, acceptable recreational gun use, the belief that guns create a safer home, and the belief that adequate resources are available. Years of practice and comfort in treating firearm-related injuries were not associated with any response.
Conclusions
These objective findings may better inform on the opinions of healthcare professionals directly involved in the treatment of firearm injuries. Awareness of the origins of opinions on both sides of the debate are critical to fostering productive conversations.
Keywords: ASSH, Firearm, Hand surgery, Survey
1. Introduction
Firearm use and injury are controversial topics in the United States. Despite the trends in annual firearm-related injuries and fatalities, this debate is consistently at the forefront of the political arena and media exposure. Regardless of which side of the debate an individual lies on, there is no denying the objective data that in 2016, the Centers for Disease Control (CDC) reported 155,072 injuries from accidental or non-accidental discharge of firearms. This resulted in 38,658 fatalities (24.9 %). In addition, this is an upward trend compared to previous years.1 According to a study in JAMA from 2018, this number represents the second highest number of firearm related deaths in the world, following Brazil with a death rate ranked 20th in the world.2 With numbers this high, assessment from a public health standpoint cannot be ignored. As of 2017, it is also estimated that 42 % of households in the United States have at least one gun on the premises (50 million).3
In addition, in the age of healthcare cost containment, there are significant financial implications related to these injuries. With respect to hospitalization costs, firearm-related injuries are thought to represent between $622 and 679 million per year.4,5 This was supported by a study in 2017 by Spitzer et al., demonstrating a $6.6 billion cost from 2006 to 2014 ($733 million/year) with Medicaid enduring the largest proportion of the costs ($2.3 billion).4,6 When social factors such as lost work are factored in, the costs further rise. From 2006 to 2010, Lee et al. estimated an overall $88 billion total cost to society, while Fowler et al. estimate this number to be as high as $48 billion per year.4,7,8
This study, spawned by a difference of opinion of two of the authors, hypothesized that there would be no correlation on the opinions regarding gun control or the surgeon's role in the gun control debate of the members of the American Society for Surgery of the Hand (ASSH) based on their exposure to gun violence. A secondary hypothesis was that an individual's gun ownership status would have a stronger correlation to the aforementioned opinions.
2. Materials and methods
After protocol approval from the ASSH, a survey comprised of 24 multiple-choice and free text questions was built to determine the opinions of hand and upper extremity surgeons pertaining to gun violence and gun control based on experience, locality, practice factors, and views on gun policy. These questions were uploaded to an anonymous online survey platform (SurveyMonkey, San Mateo, CA) and distributed to the e-mail database of the current membership of the ASSH. The survey was sent out twice with 2 weeks separating the releases, per ASSH policy. The survey was issued to 3363 ASSH members.
The survey identified factors related to surgeons’ practices, such as practice setting, location of practice, and training background. In addition, the survey sought to identify the volume of firearms-related injuries that practitioners treat on an annual basis and how likely they are to treat these injuries surgically. With respect to firearms-specific questions, members were asked if they own firearms, what type of firearms, for what primary purpose these were purchased, and if they are members of the National Rifle Association (NRA). In addition, opinions on the current gun control policies of the United States and what role surgeons should play, if any, in policymaking activities were assessed.
Responses were analyzed to evaluate correlations between surgeons’ opinions towards gun violence and gun policy based on practice factors, experience, age, ownership of firearms, and status of membership in the National Rifle Association (NRA).
2.1. Statistical methods
Bivariate analyses with Chi-square and Kendall's tau tests were performed as appropriate. Significant results from these tests were included in the multivariate regressions. For items with Likert Scale options, ordinal regression was used to determine factors associated with more positive responses. For items with binary response options, binary logistic regression was used. Significance was defined as p < 0.05.
3. Results
A total of 578 responses were received, generating a response rate of 17.2 % for analysis. The largest proportion came from surgeons who are employed in an urban setting and have a training background in orthopaedic surgery. The majority of respondents were Caucasian. There was a bimodal pattern of experience with a significant proportion in practice for less than 10 years and over 20 years.
Of the responses recorded regarding experience in managing gunshot injuries, the largest proportion of clinicians treat these types of injuries infrequently, defined as several per year. While many of hand surgeons treat these injuries frequently, defined as several times per month, only 2.3 % never treat them. The highest proportion of clinicians feel that operative management is indicated in more than half of the cases that they treat. The majority of respondents are very to extremely comfortable managing injuries from firearm discharge.
Slightly less than half of respondents own firearms and a minority are members of the National Rifle Association (NRA). The most owned firearm is a handgun. Recreational shooting is the most common reason for ownership amongst those who chose to answer (Table 1).
Table 1.
Descriptive data of survey participants.
| Comfort in Treating GSWsa | |
| Extremely comfortable | 253 (44.08 %) |
| Very comfortable | 245 (42.68 %) |
| Slightly comfortable' | 68 (11.85 %) |
| Not at all comfortable | 8 (1.39 %) |
| Frequency of Treating GSWsa | |
| Rarely (Once per year or less) | 137 (23.91 %) |
| Occasionally (Once per month) | 139 (24.26 %) |
| Infrequently (Several times per year) | 185 (32.3 %) |
| Frequently (Several times per month) | 99 (17.28 %) |
| Never | 13 (2.3 %) |
| Primary Purpose of Gun Ownership (if one is owned) | |
| Recreational | 101 (35.6 %) |
| Hunting | 67 (23.6 %) |
| Home protection | 54 (19.01 %) |
| Other | 62 (21.83 %) |
| NRA Membership | 67 (11.9 %) |
| Percent of GSWa Patients Requiring Surgery | |
| >50 | 277 (48.8 %) |
| 31-50 | 123 (21.7 %) |
| 16-30 | 93 (16.4 %) |
| 0-15 | 75 (13.2 %) |
| Practice Setting | |
| Rural | 40 (6.92 %) |
| Suburban | 251 (43.4 %) |
| Urban | 287 (49.7 %) |
| Race | |
| American Indian or Alaskan Native | 3 (0.53 %) |
| Asian/Pacific Islander | 26 (4.55 %) |
| Black or African American | 10 (1.75 %) |
| Hispanic | 17 (2.98 %) |
| Multiple ethnicity/Other | 15 (2.63 %) |
| Caucasian | 500 (87.5 %) |
| Region of Practice | |
| East North Central | 95 (16.46 %) |
| East South Central | 26 (4.51 %) |
| Mid Atlantic | 80 (13.86 %) |
| Mountain | 37 (6.41 %) |
| New England | 49 (8.49 %) |
| Pacific | 87 (15.08 %) |
| South Atlantic | 103 (17.85 %) |
| West North Central | 49 (8.49 %) |
| West South Central | 51 (8.84 %) |
| Primary Specialty | |
| Orthopedic | 450 (77.9 %) |
| Plastic | 96 (16.61 %) |
| General | 32 (5.54 %) |
| Years of Practice | |
| 0 to 4 | 128 (22.3 %) |
| 5 to 9 | 80 (13.9 %) |
| 10 to 14 | 54 (9.4 %) |
| 15-19 | 69 (12.0 %) |
| 20+ | 244 (42.4 %) |
| Type of Gun Owned (if any) | |
| Hunting Rifle | 10 (1.78 %) |
| Pistol/Handgun | 267 (47.51 %) |
| Assault Rifle | 23 (4.09 %) |
| Shotgun | 253 (45.02 %) |
| BB Gun | 7 (1.25 %) |
| Multiple Firearms Owned (% of those who reported at least 1 firearm owned) | |
| No | 215 (38.39 %) |
| Yes | 345 (61.61 %) |
Gunshot Wounds.
The most variability in the responses came with the attitudes towards gun ownership. The second amendment is felt to be a basic right by most surgeons, but the majority feel as if there need to be some restrictions in place (Table 2). Factors predictive of second amendment support were American Indian or Alaskan native ethnicity, firearm ownership, and membership in the NRA. Factors predictive of less likely supporting the second amendment were practicing in the Mid Atlantic, Mountain, South Atlantic, or West North Central Regions (Table 3).
Table 2.
Responses to survey questions.
| Do you agree with the current gun policy in America? | |
| Strongly disagree | 147 (25.6 %) |
| Disagree | 139 (24.2 %) |
| Neutral | 98 (17.1 %) |
| Agree | 134 (23.3 %) |
| Strongly Agree | 56 (9.8 %) |
| Do you agree that people should be allowed to have guns in their house for personal protection? | |
| Strongly disagree | 30 (5.2 %) |
| Disagree | 33 (5.8 %) |
| Neutral | 72 (12.5 %) |
| Agree | 161 (28.1 %) |
| Strongly Agree | 278 (48.4 %) |
| Do you agree that people should be allowed to have guns for recreational use (hunting, target practice, etc.)? | |
| Strongly disagree | 10 (1.7 %) |
| Disagree | 27 (4.7 %) |
| Neutral | 40 (7.0 %) |
| Agree | 222 (38.6 %) |
| Strongly Agree | 276 (48.0 %) |
| Do you agree that having a gun in the house makes the home safer? | |
| Strongly disagree | 119 (20.7 %) |
| Disagree | 123 (21.4 %) |
| Neutral | 153 (26.7 %) |
| Agree | 78 (13.6 %) |
| Strongly Agree | 101 (17.6 %) |
| Do you agree that stricter gun laws make society safer? | |
| Strongly disagree | 117 (20.3 %) |
| Disagree | 93 (16.2 %) |
| Neutral | 60 (10.4 %) |
| Agree | 149 (25.9 %) |
| Strongly Agree | 157 (27.3 %) |
| Do you think as a surgeon you have a responsibility to be involved in the gun control debate? | |
| Strongly disagree | 407 (71.5 %) |
| Disagree | 162 (28.5 %) |
| Do you feel as if adequate resources are available pertaining to treatment of gunshot wounds to the upper extremity? | |
| Strongly disagree | 110 (19.3 %) |
| Disagree | 461 (80.7 %) |
| Do you believe that the Second Amendment is a basic right for US citizens? | |
| No | 60 (10.5 %) |
| Yes, but with some restrictions | 292 (51.3 %) |
| Yes | 217 (38.1 %) |
| Do you think as a surgeon you have a responsibility to be involved in the gun control debate? | |
| No | 330 (58.0 %) |
| Yes | 239 (42.0 %) |
Table 3.
Factors associated with belief in the second amendment, ordinal regression.
| Variable | P value | or (95 % CI) |
|---|---|---|
| Race | ||
| American Indian or Alaskan Native | <0.01 | 1.98 × 107 (1.98 × 107 -1.98 × 107) |
| Asian/Pacific Islander | 0.47 | 0.57 (0.12–2.61) |
| Black or African American | 0.24 | 0.28 (0.03–2.31) |
| Hispanic | 0.17 | 0.28 (0.05–1.71) |
| Multiple ethnicity/Other | 0.15 | 5.72 (0.54–60.94) |
| White/Caucasian | Ref | Ref |
| Owning Firearms | <0.01 | 10.75 (3.18–36.4) |
| Purpose of Gun Ownership | ||
| Recreational | 0.10 | 0.38 (0.12–1.19) |
| Hunting | 0.05 | 0.30 (0.09–0.98) |
| Home Protection | 0.32 | 0.54 (0.16–1.79) |
| Other | Ref | Ref |
| NRA Membership | <0.01 | 6.79 (2.92–15.78) |
| Region | ||
| East North Central | 0.24 | 0.53 (0.18–1.54) |
| East South Central | 0.12 | 0.32 (0.07–1.34) |
| Mid Atlantic | <0.01 | 0.15 (0.05–0.5) |
| Mountain | 0.02 | 0.23 (0.06–0.81) |
| New England | 0.14 | 0.32 (0.07–1.46) |
| Pacific | 0.11 | 0.39 (0.12–1.24) |
| South Atlantic | 0.02 | 0.29 (0.1–0.82) |
| West North Central | 0.01 | 0.21 (0.06–0.71) |
| West South Central | Ref | Ref |
| Years Practicing | ||
| 20+ | 0.60 | 0.82 (0.38–1.75) |
| 15-19 | 0.05 | 0.35 (0.12–0.99) |
| 10-14 | 0.17 | 2.07 (0.73–5.86) |
| 5-9 | 0.06 | 0.32 (0.1–1.06) |
| 0-4 | Ref | Ref |
| Comfort in Treating GSW | ||
| Extremely Comfortable | 0.96 | 0.95 (0.09–9.56) |
| Very Comfortable | 0.53 | 0.48 (0.05–4.93) |
| Slightly Comfortable | 0.32 | 0.29 (0.03–3.36) |
| Not at all comfortable | Ref | Ref |
The use of guns for recreational purposes, defined as hunting or target practice, is deemed acceptable by most respondents. Firearm ownership and NRA membership were significant predictors for support of gun ownership for recreational activities. Practicing in the Mid-Atlantic region was associated with a low likelihood of the support of firearms for recreation (Table 4).
Table 4.
Factors associated with belief in the use of guns for recreation, ordinal regression.
| Variable | P value | or (95 % CI) |
|---|---|---|
| Owning Firearms | 0.02 | 3.80 (1.21–11.95) |
| Purpose of Gun Ownership | ||
| Recreational | 0.398 | 1.61 (0.54–4.82) |
| Hunting | 0.211 | 2.09 (0.66–6.66) |
| Home Protection | 0.709 | 1.25 (0.39–4.02) |
| Other | Ref | Ref |
| NRA Membership | <0.01 | 18.08 (4.08–80.12) |
| Practice Setting | ||
| Rural | 0.697 | 1.26 (0.40–3.97) |
| Suburban | 0.311 | 1.38 (0.74–2.59) |
| Urban | Ref | Ref |
| Region | ||
| East North Central | 0.435 | 0.62 (0.18–2.07) |
| East South Central | 0.054 | 0.24 (0.06–1.03) |
| Mid Atlantic | 0.042 | 0.27 (0.07–0.95) |
| Mountain | 0.117 | 0.34 (0.09–1.30) |
| New England | 0.189 | 0.35 (0.07–1.67) |
| Pacific | 0.207 | 0.45 (0.13–1.55) |
| South Atlantic | 0.280 | 0.52 (0.16–1.69) |
| West North Central | 0.814 | 0.84 (0.19–3.65) |
| West South Central | Ref | Ref |
| Comfort in Treating GSWa | ||
| Extremely Comfortable | 0.587 | 1.83 (0.21–16.03) |
| Very Comfortable | 0.967 | 0.96 (0.11–8.54) |
| Slightly Comfortable | 0.445 | 0.41 (0.04–4.01) |
| Not at all comfortable | Ref | Ref |
Gunshot Wounds.
Although most respondents feel that a gun should be allowed for home protection, few feel that the firearm makes the home safer. With respect to support of a gun in the house, only NRA membership was found to be significant. Belief that the home is safer is correlated with firearm ownership and NRA membership (Table 5).
Table 5.
Factors associated with belief in the use of guns for protection, ordinal regression.
| Variable | P value | or (95 % CI) |
|---|---|---|
| Firearm Ownership | 0.073 | 2.82 (0.91–8.75) |
| Frequency of Treatment of GSW | ||
| Rarely | 0.424 | 0.36 (0.03–4.34) |
| Occasionally (Once per month) | 0.893 | 0.84 (0.07–10.74) |
| Infrequently (Several times per year) | 0.584 | 0.50 (0.04–5.98) |
| Frequently (Several times per month) | 0.436 | 0.36 (0.03–4.63) |
| Never | Ref | Ref |
| Purpose of Gun Ownership | ||
| Recreational | 0.276 | 1.84 (0.61–5.53) |
| Hunting | 0.290 | 1.86 (0.59–5.90) |
| Home Protection | 0.178 | 2.28 (0.69–7.59) |
| Other | Ref | Ref |
| NRA membership | <0.01 | 15.78 (3.62–68.84) |
| Region | ||
| East North Central | 0.548 | 0.68 (0.20–2.36) |
| East South Central | 0.274 | 0.42 (0.09–1.98) |
| Mid Atlantic | 0.209 | 0.43 (0.12–1.60) |
| Mountain | 0.345 | 0.51 (0.13–2.06) |
| New England | 0.553 | 0.59 (0.11–3.33) |
| Pacific | 0.109 | 0.37 (0.11–1.25) |
| South Atlantic | 0.027 | 0.28 (0.09–0.86) |
| West North Central | 0.214 | 0.42 (0.11–1.64) |
| West South Central | Ref | Ref |
| Comfort in Treating GSWa | ||
| Extremely Comfortable | 0.249 | 4.89 (0.33–72.75) |
| Very Comfortable | 0.459 | 2.75 (0.19–40.29) |
| Slightly Comfortable | 0.598 | 2.13 (0.13–35.65) |
| Not at all comfortable | Ref | Ref |
Gunshot Wounds.
Disagreement with the current gun policy in the United States was reported by nearly half of respondents, which most correlated with practicing in the New England and South Atlantic regions. Firearm ownership and NRA membership were associated with disagreement that stricter gun laws contribute to a safer society (Table 6).
Table 6.
Factors associated with belief that guns help create a safer society, ordinal regression.
| Variable | P value | OR (95 % CI) |
|---|---|---|
| Firearm Ownership | <0.01 | 0.44 (0.30–0.65) |
| NRA Membership | <0.01 | 0.17 (0.07–0.42) |
| Practice Setting | ||
| Rural | 0.212 | 0.63 (0.30–1.31) |
| Suburban | 0.311 | 0.83 (0.58–1.19) |
| Urban | Ref | Ref |
| Residency Type | ||
| Orthopaedic Surgery | 0.327 | 0.68 (0.31–1.47) |
| Plastic Surgery | 0.348 | 0.67 (0.28–1.56) |
| General Surgery | Ref | Ref |
| Region | ||
| East North Central | 0.984 | 0.99 (0.47–2.11) |
| East South Central | 0.886 | 0.93 (0.33–2.60) |
| Mid Atlantic | 0.277 | 1.52 (0.71–3.25) |
| Mountain | 0.230 | 0.57 (0.23–1.43) |
| New England | 0.257 | 1.62 (0.70–3.75) |
| Pacific | 0.287 | 1.49 (0.71–3.13) |
| South Atlantic | 0.173 | 0.60 (0.29–1.25) |
| West North Central | 0.896 | 1.06 (0.45–2.50) |
| West South Central | Ref | Ref |
Most surgeons feel that surgeons do not have a responsibility to be involved in the gun control debate, while less than 30 % report being actively involved. Active involvement in the debate is most correlated with NRA membership, a background in orthopaedic surgery, and having greater than 20 years of practice experience (Table 7, Table 8).
Table 7.
Factors associated with involvement in gun debate, logistic regression.
| Firearm Ownership | 0.90 | 1.03 (0.65–1.62) |
| Percent of Patients Requiring Operative Intervention | ||
| >50 % | 0.05 | 2.02 (1.01–4.04) |
| 31–50 % | 0.91 | 1.05 (0.48–2.29) |
| 16–30 % | 0.39 | 1.43 (0.63–3.24) |
| 0–15 % | Ref | Ref |
| NRA Membership | <0.01 | 4.00 (2.16–7.42) |
| Residency Type | Ref | Ref |
| Orthopaedic Surgery | 0.03 | 3.57 (1.14–11.14) |
| Plastic Surgery | 0.18 | 2.31 (0.67–7.91) |
| General Surgery | Ref | Ref |
| Years Practicing | ||
| 20+ | 0.01 | 2.21 (1.22–3.98) |
| 15-19 | 0.34 | 1.45 (0.68–3.08) |
| 10-14 | 0.18 | 1.64 (0.80–3.38) |
| 5-9 | 0.91 | 0.95 (0.38–2.38) |
| 0-4 | Ref | Ref |
| Comfort in Treating GSWa | ||
| Extremely Comfortable | 1.00 | 802952511.61 (0–0) |
| Very Comfortable | 1.00 | 459240362.36 (0–0) |
| Slightly Comfortable | 1.00 | 499337642.86 (0–0) |
| Not at all comfortable | Ref | Ref |
Gunshot Wounds.
Table 8.
Remaining outcomes.
| Factors Associated with Belief that Guns Help Create a Safer Home, Ordinal Regression | ||
| Variable | P value | OR (95 % CI) |
| Firearm Ownership | <0.01 | 12.17 (4.04–36.65) |
| Purpose of Gun Ownership | ||
| Recreational | 0.025 | 0.36 (0.15–0.88) |
| Hunting | 0.008 | 0.27 (0.11–0.71) |
| Home Protection | 0.508 | 1.39 (0.53–3.64) |
| Other | Ref | Ref |
| NRA Membership | <0.01 | 7.49 (3.91–14.35) |
| Region | ||
| East North Central | 0.044 | 0.40 (0.16–0.97) |
| East South Central | 0.831 | 1.15 (0.32–4.08) |
| Mid Atlantic | 0.002 | 0.18 (0.06–0.54) |
| Mountain | 0.182 | 0.48 (0.16–1.42) |
| New England | 0.095 | 0.32 (0.09–1.22) |
| Pacific | 0.009 | 0.28 (0.11–0.73) |
| South Atlantic | 0.013 | 0.33 (0.14–0.79) |
| West North Central | 0.375 | 0.6 (0.19–1.87) |
| West South Central | Ref | Ref |
| Years Practicing | ||
| 20+ | 0.644 | 0.85 (0.43–1.69) |
| 15-19 | 0.345 | 0.63 (0.24–1.65) |
| 10-14 | 0.517 | 1.34 (0.55–3.28) |
| 5-9 | 0.206 | 0.49 (0.17–1.47) |
| 0-4 | Ref | Ref |
| Comfort in Treating GSW | ||
| Extremely Comfortable | 0.955 | 0.94 (0.13–70.0) |
| Very Comfortable | 0.841 | 0.81 (0.11–6.18) |
| Slightly Comfortable | 0.167 | 0.22 (0.03–1.88) |
| Not at all comfortable | Ref | Ref |
|
Factors Associated with Agreement with the Current Gun Policy in America, Ordinal Regression | ||
|---|---|---|
| Variable | P value | OR (95 % CI) |
| Type of Firearm Owned | ||
| Hunting Rifle | <0.01 | 9.71 × 108 (9.71x108-9.71 × 108) |
| BB Gun | 0.46 | 0.48 (0.07–3.33) |
| Shotgun | 0.68 | 1.12 (0.65–1.96) |
| Assault Rifle | 0.49 | 1.58 (0.42–5.92) |
| Only Pistol/Handgun | Ref | Ref |
| Owning Firearms | 0.42 | 1.63 (0.5–5.34) |
| Purpose of Gun Ownership | ||
| Recreational | 0.27 | 1.65 (0.68–3.98) |
| Hunting | 0.19 | 1.88 (0.74–4.82) |
| Home Protection | 0.22 | 1.85 (0.7–4.9) |
| Other | Ref | Ref |
| NRA Membership | 0.01 | 2.58 (1.32–5.05) |
| Region | ||
| East North Central | 0.13 | 0.50 (0.20–1.24) |
| East South Central | 0.1 | 0.28 (0.06–1.26) |
| Mid Atlantic | 0.06 | 0.32 (0.10–1.03) |
| Mountain | 0.09 | 0.35 (0.11–1.16) |
| New England | 0.01 | 0.11 (0.02–0.60) |
| Pacific | 0.05 | 0.37 (0.14–1.01) |
| South Atlantic | 0.01 | 0.28 (0.11–0.69) |
| West North Central | 0.19 | 0.46 (0.14–1.48) |
| West South Central | Ref | Ref |
| Years Practicing | ||
| 20+ | 0.21 | 1.59 (0.77–3.29) |
| 15-19 | 0.84 | 1.12 (0.39–3.17) |
| 10-14 | 0.97 | 0.98 (0.38–2.55) |
| 5-9 | 0.48 | 0.67 (0.22–2.04) |
| 0-4 | Ref | Ref |
|
Factors Associated with Belief that Surgeons Have a Responsibility in the Gun Debate, Logistic Regression | ||
|---|---|---|
| Variable | P value | OR (95 % CI) |
| Frequency of Treatment of GSW | ||
| Rarely | 0.53 | 0.66 (0.18–2.44) |
| Occasionally (Once per month) | 0.96 | 1.03 (0.27–3.93) |
| Infrequently (Several times per year) | 0.51 | 0.64 (0.17–2.4) |
| Frequently (Several times per month) | 0.56 | 1.49 (0.39–5.78) |
| Never | Ref | Ref |
| Comfort in Treating GSW | ||
| Extremely Comfortable | 0.67 | 1.42 (0.28–7.21) |
| Very Comfortable | 0.97 | 0.97 (0.19–4.88) |
| Slightly Comfortable | 0.84 | 0.84 (0.16–4.36) |
| Not at all comfortable | Ref | Ref |
|
Factors Associated with Belief that Adequate Resources are Available, Logistic Regression | ||
|---|---|---|
| Variable | P value | OR (95 % CI) |
| Firearm Ownership | 0.01 | 1.84 (1.16–2.93) |
| Comfort in Treating GSW | Ref | Ref |
| Extremely Comfortable | <0.01 | 15.56 (2.99–81.05) |
| Very Comfortable | <0.01 | 17.07 (3.27–89.25) |
| Slightly Comfortable | 0.09 | 4.34 (0.8–23.49) |
| Not at all comfortable | Ref | Ref |
4. Discussion
In the current environment of the healthcare system in the United States, an increasing elderly population and high costs of care delivery put a significant financial burden on the economy. Of this cost, when all factors are considered, up to $48 billion per year may be attributed to gun violence.7 What is interesting about this number is that based on previous studies, the direct costs are likely between $622 and $733 million per year, which represents a relatively small portion of this overall cost.4, 5, 6 This implies that these injuries represent a financial impact far beyond the time of admission and initial care received.
Recent studies have focused on the risk of readmission and the costs associated with them.9, 10, 11 A study by Kalesan et al., focused on 90-day readmissions in patients after hospitalization for firearm injuries in 2013–2014 using the Nationwide Readmission Database. The study cohort was compared to a group consisting of patients involved in motor vehicle collisions and pedestrians struck. The authors demonstrated that in the firearms injury group, the readmission rate was 20 %, which was 34 % higher than the readmission rate in the motor vehicle group. From a cost-perspective, the cost of readmission was $1675.00 lower in the firearms group with a slightly longer length of stay. The majority of this burden was borne by Medicaid.10 In another recent study, Spitzer et al., looked at the readmission risks and costs in the first 6 months after injury from 2010 to 2015. They found that the readmission rate was 15.6 % and that 10 % of the overall costs associated with firearm-related injuries was comprised of readmissions. In their series, Medicare and Medicaid was responsible for 45.2 % of the costs, while 20.1 % of the patients were uninsured.11 In the pediatric population, the patients have a higher rate of secondary hospitalizations and visits. Evans et al., have demonstrated that 73 % of pediatric patients are admitted to a hospital after a firearm-related injury, and 43 % of these patients will go on to require further treatment in an inpatient setting through readmission, through the emergency department, or via outpatient procedures. In their series, only patients with private insurance carriers generated a positive revenue. This again underscores the financial impact on government-based insurance and hospitals.9 These studies demonstrate the impact of these readmissions, which in today's healthcare landscape have significant implications on hospital reimbursement.
Interestingly, regardless of which side of the debate one chooses to be on, the data seem to suggest that the strongest influences on a surgeon's opinion with respect to the aforementioned topics is individual firearm ownership and NRA membership. The satisfaction and dissatisfaction with current gun laws was almost evenly distributed, and most physicians do not feel that they have a role in the gun control debate, yet nearly half of respondents disagree with current gun laws in the United States. Notably, this does not imply that the other half agrees with the current policies, but many instead are neutral on this topic. Overall, the fact that there are no consistent findings associated with factors such as region, practice type, an experience show that these opinions are likely to be more founded in an individual's beliefs outside of their medical training and exposure. This supports both our primary and secondary hypotheses. In essence, the background, location, and practice pattern of the clinician as well as the societal view and financial impact of gun violence are not the driving factor of the opinions. This likely underscores the idea that the viewpoint on this topic is something that is rooted in one's world view prior to the exposure to medicine and these injuries. This is not to say that people cannot be swayed one way or the other but that their beliefs are rather fixed by this point. Again, while not an absolute certainty, this is certainly the case with the authors in this paper.
In addition, the strength of these convictions is often conveyed in the free text responses. When asked about the type of firearms owned by respondents, answers ranged from a list of firearms to free text responses such as (expletives removed), “None of your business. It has no bearing on anything and you know it.” Reponses to the purpose of firearm ownership garnered responses such as, “dealing with surveyors” and “Again, none of your business.” Upon analysis of the societal cost question, responses varied widely. We received responses that were reflective of certain individuals’ insights and beliefs and others that were more politically motivated. This is further supported that often, the same question would provoke an accusation of bias, but from both sides of the gun control debate.
As with any survey, there are limitations to this study, as the data are completely reliant on respondent answers. A potential source of this could be that when taking a survey on something so politically-charged, the surveyed party may answer how they think that they should respond, thus falsely representing their thoughts. In addition, generalizability can be compromised with a response rate of 17.2 %, which may be more representative of those with stronger feelings on either side of the issue, leaving those with a less firm standpoint as a silent majority.
5. Conclusions
Incidence of firearm-related injuries and their financial implications cannot be ignored, regardless of one's political beliefs regarding firearms. Furthermore, in the age of cost containment in healthcare in the United States, sensitivity towards and awareness of the origins of opinions on both sides of the debate are critical to objective, productive conversations, whether or not the surgeon chooses to have a role in policymaking.
Declaration
Dr. Irfan Ahmed and Dr. Michael Vosbikian are participating members of the American Society for Surgery of the Hand.
Ethical approval text
Not applicable (protocol approved by ASSH)
Patient consent statement
Not applicable.
CRediT authorship contribution statement
Dominick V. Congiusta: Project conception, statistics, manuscript preparation, Kiauntee Murray: Project conception, statistics, manuscript preparation, Michael Vosbikian: Project conception, manuscript preparation, Irfan Ahmed: Project conception, manuscript preparation.
Funding
None.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
Contributor Information
Michael M. Vosbikian, Email: vosbikmm@njms.rutgers.edu.
Kiauntee Murray, Email: murrayk3@njms.rutgers.edu.
Dominick V. Congiusta, Email: dvc33@njms.rutgers.edu.
Irfan H. Ahmed, Email: ahmedi2@njms.rutgers.edu.
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