Ali Rowhani-Rahbar, MD, MPH, PhD; Douglas Zatzick, MD; Jin Wang, PhD; Brianna M. Mills, MA; Joseph A. Simonetti, MD, MPH; Mary D. Fan, MPhil, JD; Frederick P. Rivara, MD, MPH
Acknowledgment: The authors thank Jeffrey Love of the Harborview Injury Prevention & Research Center at the University of Washington; Bill O'Brien of the Department of Epidemiology at the University of Washington; Jennifer Sabel, PhD, of the Washington State Department of Health; Kanwar Thind of the University of Washington; and other colleagues at the Washington State Department of Health, Washington State Patrol, and Washington State Administrative Office of the Courts for their contributions to this project. They also thank Noel Weiss, MD, DPH, of the Department of Epidemiology at the University of Washington for his critical review of the manuscript.
Financial Support: By the Seattle City Council and the University of Washington Royalty Research Fund.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2362.
Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Rowhani-Rahbar (e-mail, rowhani@uw.edu).
Requests for Single Reprints: Ali Rowhani-Rahbar, MD, MPH, PhD, Department of Epidemiology, University of Washington, Box 357236, Seattle, WA 98195.
Current Author Addresses: Dr. Rowhani-Rahbar and Ms. Mills: Department of Epidemiology, University of Washington, Box 357236, Seattle, WA 98195.
Dr. Zatzick: Department of Psychiatry & Behavioral Sciences, University of Washington, 325 Ninth Avenue, Box 359911, Seattle, WA 98104.
Drs. Wang and Rivara: Harborview Injury Prevention & Research Center, University of Washington, 325 Ninth Avenue, Box 359960, Seattle, WA 98104.
Dr. Simonetti: Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101.
Dr. Fan: University of Washington School of Law, Gates Hall, Room 315, Box 353020, Seattle, WA 98195.
Author Contributions: Conception and design: A. Rowhani-Rahbar, D. Zatzick, F.P. Rivara.
Analysis and interpretation of the data: A. Rowhani-Rahbar, D. Zatzick, J. Wang, B.M. Mills, J.A. Simonetti, M.D. Fan, F.P. Rivara.
Drafting of the article: A. Rowhani-Rahbar, D. Zatzick, B.M. Mills, J.A. Simonetti, M.D. Fan, F.P. Rivara.
Critical revision of the article for important intellectual content: A. Rowhani-Rahbar, D. Zatzick, J. Wang, B.M. Mills, J.A. Simonetti, M.D. Fan, F.P. Rivara.
Final approval of the article: A. Rowhani-Rahbar, D. Zatzick, J. Wang, B.M. Mills, J.A. Simonetti, M.D. Fan, F.P. Rivara.
Provision of study materials or patients: A. Rowhani-Rahbar, D. Zatzick, F.P. Rivara.
Statistical expertise: A. Rowhani-Rahbar, D. Zatzick, J. Wang, B.M. Mills.
Obtaining of funding: A. Rowhani-Rahbar, D. Zatzick, F.P. Rivara.
Administrative, technical, or logistic support: A. Rowhani-Rahbar, D. Zatzick, B.M. Mills, M.D. Fan, F.P. Rivara.
Collection and assembly of data: A. Rowhani-Rahbar, D. Zatzick, F.P. Rivara.
Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions.
To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population.
Retrospective cohort study.
All hospitals in Washington.
Patients with an FRH and a random sample of those with a non–injury-related hospitalization in 2006 to 2007 (index hospitalization).
Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011.
Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non–injury-related index hospitalization.
Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification.
Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted.
Seattle City Council and University of Washington Royalty Research Fund.
Understanding the risks faced by patients after a firearm-related hospitalization (FRH) may help efforts to prevent further injury and improve outcomes.
This statewide-study found that after a FRH, patients were at markedly elevated risks for recurrent FRH, firearm-related death, and firearm- or violence-related arrest.
Identification of variables associated with the risk for subsequent adverse outcomes may help guide inter-ventions at the time of FRH.
Pictorial representation of study design.
Table 1. Characteristics of the Study Population, by Type of Index Hospitalization
Table 2. Absolute Rates of Violence-Related Hospitalization, Arrest, or Death After Discharge, by Type of Index Hospitalization
Cumulative incidence of primary outcomes after index hospitalization discharge.
Top. Firearm-related hospitalization. Middle. Firearm-related death. Bottom. Firearm- or violence-related arrest.
Cumulative incidence of nonfirearm assault-related hospitalization (top) and nonfirearm assault-related death (bottom) after index hospitalization discharge.
Cumulative incidence of nonfirearm, self-inflicted, injury-related hospitalization (top) and nonfirearm, self-inflicted, injury-related death (bottom) after index hospitalization discharge.
Cumulative incidence of nonfirearm nonviolent arrest after index hospitalization discharge.
Table 3. sHRs of Violence-Related Hospitalization, Arrest, or Death After Discharge, by Type of Index Hospitalization
Appendix Table 1. sHRs of Violence-Related Hospitalization, Arrest, or Death After Discharge, by Type of Index Hospitalization and Controlled for History of Arrest and Conviction
Appendix Table 2. sHRs of Violence-Related Hospitalization, Arrest, or Death After Discharge, by History and Type of Arrest and Psychiatric Disorder Diagnosis
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Bindu Kalesan, Sandro Galea
Columbia University, Boston University
February 26, 2015
Future directions for firearm violence research
Rowhani-Rahbar presents an elegant analysis to assess violent injury, death, or other crime after firearm hospitalization. This study makes a contribution, and points to several open questions in the field. First, this paper adds to our understanding of the consequences of firearm use, raising the question: what is the total burden of disability and illness attributed to firearm injury? This paper suggests that we have long been underestimating the consequences of firearms in the country. Second, what are the differences in consequences of firearm injuries between assault and unintentional injuries? This might have important implications for our public health efforts to mitigate the consequences of firearm use. Third, what are the effective prevention policies that will reduce both morbidity and mortality associated with firearm violence? Having data-driven guidance on effective policies could go a long way towards upstream efforts to stem the tide of firearm-related consequences.
Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration: A Cohort Study. Ann Intern Med. ;162:492–500. doi: 10.7326/M14-2362
Download citation file:
© 2019
Published: Ann Intern Med. 2015;162(7):492-500.
DOI: 10.7326/M14-2362
Hospital Medicine.
Results provided by: