Ali Rowhani-Rahbar, MD, MPH, PhD; Mary D. Fan, MPhil, JD; Joseph A. Simonetti, MD, MPH; Vivian H. Lyons, MPH; Jin Wang, PhD; Douglas Zatzick, MD; Frederick P. Rivara, MD, MPH
Acknowledgment: The authors thank Jeffrey Love and Bill O'Brien of the University of Washington and colleagues at the Washington State Department of Health and Washington State Patrol for their contributions to this project.
Disclosures: Dr. Rivara reports grants from the City of Seattle during the conduct of the study. Dr. Zatzick reports a contract (number 124195) from the City of Seattle during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1596.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Rowhani-Rahbar (e-mail, email@example.com). Data set: Not available.
Requests for Reprints: Ali Rowhani-Rahbar, MD, MPH, PhD, Department of Epidemiology, University of Washington School of Public Health, 1959 Northeast Pacific Street, Health Sciences Building, F-250D, Box 357236, Seattle, WA 98195; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Rowhani-Rahbar: Department of Epidemiology, University of Washington School of Public Health, 1959 Northeast Pacific Street, Health Sciences Building, F-250D, Box 357236, Seattle, WA 98195.
Drs. Fan, Wang, and Rivara, and Ms. Lyons: Harborview Injury Prevention and Research Center, 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. Zatzick: Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 325 Ninth Avenue, Box 359911, Seattle, WA 98104.
Author Contributions: Conception and design: A. Rowhani-Rahbar, D. Zatzick, F.P. Rivara.
Analysis and interpretation of the data: A. Rowhani-Rahbar, M.D. Fan, J.A. Simonetti, V.H. Lyons, J. Wang, D. Zatzick, F.P. Rivara.
Drafting of the article: A. Rowhani-Rahbar, M.D. Fan, V.H. Lyons, D. Zatzick.
Critical revision of the article for important intellectual content: A. Rowhani-Rahbar, M.D. Fan, J.A. Simonetti, V.H. Lyons, D. Zatzick, F.P. Rivara.
Final approval of the article: A. Rowhani-Rahbar, M.D. Fan, J.A. Simonetti, V.H. Lyons, J. Wang, D. Zatzick, F.P. Rivara.
Provision of study materials or patients: A. Rowhani-Rahbar, D. Zatzick.
Statistical expertise: A. Rowhani-Rahbar, V.H. Lyons, J. Wang.
Obtaining of funding: D. Zatzick, F.P. Rivara.
Administrative, technical, or logistic support: M.D. Fan, F.P. Rivara.
Hospital-based violence intervention programs typically focus on patients whose firearm injury occurred through interpersonal violence (assault). Knowledge of violence perpetration by victims of unintentional (accidental) firearm injury is limited.
To examine violence perpetration before and after a patient becomes hospitalized for firearm injury according to injury intent (intentional [assault] or unintentional [accidental]).
A case–control study and a retrospective cohort study.
Hospitals in Washington.
Persons aged 15 years or older hospitalized for a firearm injury, other injuries, or a noninjury reason from 2006 to 2007.
In the case–control study, the odds of violence-related arrest from 2001 through hospitalization by injury intent among 3 groups were compared. In the cohort study, the rates of violence-related arrest from hospitalization through 2011 by injury intent among 3 groups were compared.
Patients with unintentional firearm injuries (n = 180) were more likely than those with other unintentional injuries (n = 62 795; odds ratio [OR], 2.01 [95% CI, 1.31 to 3.09]) and no injuries (n = 172 830; OR, 3.43 [CI, 2.22 to 5.32]) to have been arrested for a violent crime before hospitalization. Prior violence-related arrest did not differ between patients with assault-related firearm injuries (n = 339) and those with other assault-related injuries (n = 2342; OR, 1.10 [CI, 0.84 to 1.46]). During follow-up, the cumulative incidence of violence-related arrest for patients with unintentional and assault-related firearm injuries was 10% and 15% (subhazard ratio, 1.88 [CI, 1.11 to 3.17] and 1.61 [CI, 1.08 to 2.44]), respectively, compared with 1% for those without injuries.
Exclusion of self-inflicted injuries, misclassification of intent, and ascertainment bias.
Some firearm injuries classified as accidental may indicate involvement in the cycle of violence and present an opportunity for intervention.
City of Seattle and the University of Washington Royalty Research Fund.
Design of the 2 studies.
Table 1. Characteristics of the Study Population, by Reason for Hospitalization*
Appendix Table. Mechanism of Injuries in the Study Population, by Injury Intent*
Table 2. Case–Control Study: Association Between Prior Arrest for Violent Crime (Exposure) and Reason for Subsequent Hospitalization (Outcome), by Injury Intent
Cumulative incidence of first violence-related arrest after hospitalization discharge among the 3 groups, by injury intent.
Table 3. Cohort Study: Association Between Reason for Hospitalization (Exposure) and First Arrest for Violent Crime After Discharge (Outcome), by Injury Intent
Michael E Pauszek MD FACP
Johnson Memorial Hospital, Franklin
December 19, 2016
Letter to The Editor
Regarding the Rowhani-Rahber et al article about violence pereptuation in the Dec 20, 2016 volume, I would refer the authors and readers to Doctor Robert Sklaroff's Letter to the Editor in the same issue. It regards a discussion about guns in the home with patients. It is impossible to improve upon his argument. That argument and his final sentence applies well to this article about recurrent violence. I thank him for his comments, especially his "broad brush assertion" comment. Like Doctor Sklaroff, I see my clinical role as being narrower than the authors.
Rowhani-Rahbar A, Fan MD, Simonetti JA, et al. Violence Perpetration Among Patients Hospitalized for Unintentional and Assault-Related Firearm Injury: A Case–Control Study and a Cohort Study. Ann Intern Med. 2016;165:841–847. [Epub ahead of print 18 October 2016]. doi: https://doi.org/10.7326/M16-1596
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Published: Ann Intern Med. 2016;165(12):841-847.
Published at www.annals.org on 18 October 2016
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