The Cost of Firearm Violence Survivorship

On average, around 300 people suffer firearm injuries every day in the United States.¹ For every three who die as a result of firearm injury, seven will survive their injuries. The article in this issue of AJPH by Spitzer and Weiser (p.770) places the spotlight on research regarding firearm violence survivorship. The use of nationally representative hospitalization data and the large sample size is an advantage of this study. In addition, the authors used standardized methods of estimation of costs to assess trends in initial hospitalization costs after sustaining firearm injury. The authors observed the average annual cost for treating initial firearm injury–related hospitalizations between 2006 and 2014 to be around $0.7 billion, and $6.6 billion for the nine-year time period. They note that their calculations may underestimate the real costs, because of the conservative inclusion–exclusion criteria used in their report. The authors also estimated that the aggregate cost of treatment during initial hospitalizations following firearm injuries mostly was covered by Medicaid (34.8%), followed by self-pay (23.6%) and private insurance (20.0%), and the rest by other methods of payment.

The report by Spitzer and Weiser focuses on the most severe aspect of the acute phase of firearm injury and quantifies the associated enormous economic burden. The investigators identified that Medicaid-insured and the uninsured bore the largest share of the economic burden attributable to initial firearm hospitalizations, with per-incident cost greatest for those paying with Medicaid insurance, and the uninsured paying the lowest. The increased economic burden on Medicaid insurance and self-pay reported in this study has also been previously reported in other studies that assessed both firearm hospitalization and emergency department (ED) admissions.^2–4 Similarly, the economic burden related to firearm-related ED visits also fell largely on the Medicaid-insured and the uninsured.^3,5 The authors present compelling evidence of the substantial economic burden related to firearm hospitalization that reflects a combination of increasing total financial burden over time along with the costs absorbed largely by the government and the excess burden on the uninsured. As a consequence, treatment of nonfatal firearm injuries poses a dual problem—the bulk of it primarily to the health care system while simultaneously shifting part of the burden to vulnerable individuals who will have the added medical and social costs, not to mention the possible disability related to the injury that may exist throughout their lifetime.

TWO MISSED OPPORTUNITIES

The authors need to be commended for their thoughtful approach; however, the report reflects two missed opportunities. First, Spitzer and Weiser analyzed firearm hospitalizations between 2006 and 2014, which is a relatively short period of time. The national hospitalization data are available from 1988 onward. From 2001 to 2010, the national firearm death rates have plateaued at around 10.2 per 100 000 persons,⁶ whereas the nonfatal firearm injury rates have increased from 21.7 to 25.5 per 100 000 during this time, indicative of a national firearm violence public health problem driven by nonfatal injuries.¹ With the availability of such data, this analysis presented a unique opportunity to assess the temporal trends of the costs of initial firearm hospitalization from 2001 onward, to understand whether the increasing inflation-adjusted cost of initial hospitalization follows the pattern of increasing nonfatal firearm injuries during a longer time period.

Second, when one considers that 39% of people who survive the firearm injury are treated in the ED and released, and 57% are treated in the ED and admitted to a hospital for further treatment,¹ the analysis of initial firearm hospitalizations alone by Spitzer and Weiser is not complete on its own, and may not truly capture the magnitude of all the costs associated with all the firearm injury–related morbidity. In this context, it is important to note that the total cost of firearm injury–associated ED visits from 2006 to 2010 in the country was reported to be $88.6 billion, with an estimated average annual cost of $17.7 billion.² Therefore, the total annual costs of treating nonfatal firearm injury that includes both ED use and hospitalization during the acute phase alone is roughly $18.4 billion, and is in fact driven by costs associated with care received in the ED.

FIREARM VIOLENCE SURVIVORSHIP

The results reported by Spitzer and Weiser lead to several questions that require a focus on medical care and costs related to firearm violence survivorship. First, what are the short- and long-term health and disease consequences of firearm injury, and the costs associated with treatment of these consequences? Second, are there different profiles of firearm injury on the basis of the location (body region) of the injury sustained and its severity, and whether the cost of treatment differs on the basis of these varying clinical profiles of firearm injury? Third, are there age-, gender-, intent-, and race/ethnicity–specific differences in treatment and costs related to the acute phase (ED and hospitalization) of firearm injury? Fourth, are there differences in survival after the acute phase of hospitalization based on the age, gender, race/ethnicity, intent, body region location, and the severity of injury? Fifth, when we consider the enormous cost of firearm violence mainly attributable to treatment of nonfatal injuries, what is the role of nonfatal firearm injuries and firearm injury survivorship in a societal context and within the framework of the public, political, and policy research and debates surrounding firearm violence in our country?

AN IMMENSE ECONOMIC BURDEN

In conclusion, the report by Spitzer and Weiser indicates an immense economic burden related to the acute-phase treatment of the most severe, nonfatal firearm injury, which, in the context of high and increasing rates of nonfatal firearm injuries, suggests the need for a multipronged approach for the prevention and the treatment of firearm injuries. Most importantly, adequate funding should be made available for firearm violence research, particularly in the field of firearm violence survivorship, because of the heavy economic burden posed by nonfatal firearm injury.