Jason E. Goldstick, PhD; Patrick M. Carter, MD; Maureen A. Walton, MPH, PhD; Linda L. Dahlberg, PhD; Steven A. Sumner, MD, MSc; Marc A. Zimmerman, PhD; Rebecca M. Cunningham, MD
Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Acknowledgment: The authors thank the staff and patients of Hurley Medical Center for their support of this project and Wendi Mohl, BS, and Sonia Kamat, MS, for their assistance with manuscript preparation.
Grant Support: National Institute on Drug Abuse grant R01 024646 (principal investigator, Rebecca M. Cunningham), 1 June 2009 to 30 April 2014; National Institutes of Health/National Institute on Drug Abuse (NIDA) grants K23DA039341 (principal investigator: Patrick M. Carter) and 16IPA605200 (principal investigator: Jason Goldstick), 1 July 2016 to 30 June 2017.
Disclosures: Dr. Walton reports grants from NIDA 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=M16-1927
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 data set: Not available. Statistical code: Available from Dr. Goldstick (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: Jason Goldstick, PhD, University of Michigan Injury Center, University of Michigan School of Medicine, 2800 Plymouth Road, NCRC G10-080, Ann Arbor, MI 48109; e-mail, email@example.com.
Current Author Addresses: Drs. Goldstick, Carter, and Cunningham: University of Michigan Injury Center, University of Michigan School of Medicine, 2800 Plymouth Road, NCRC G10-080, Ann Arbor, MI 48109.
Dr. Walton: Department of Psychiatry, University of Michigan Addiction Research Center, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109.
Dr. Zimmerman: Michigan Youth Violence Prevention Center, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109.
Drs. Dahlberg and Sumner: Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-F64, Atlanta, GA 30341.
Author Contributions: Conception and design: P.M. Carter, R. Cunningham, L.L. Dahlberg, J. Goldstick, M. Walton, M.A. Zimmerman.
Analysis and interpretation of the data: P.M. Carter, R. Cunningham, J. Goldstick, S.A. Sumner.
Drafting of the article: P.M. Carter, L.L. Dahlberg, J. Goldstick, M.A. Zimmerman.
Critical revision for important intellectual content: J. Goldstick, S.A. Sumner, M.A. Zimmerman.
Final approval of the article: P.M. Carter, R. Cunningham, L.L. Dahlberg, J. Goldstick, S.A. Sumner, M. Walton, M.A. Zimmerman.
Provision of study materials or patients: M. Walton.
Statistical expertise: J. Goldstick, S.A. Sumner.
Obtaining of funding: M. Walton, M.A. Zimmerman.
Administrative, technical, or logistic support: P.M. Carter, R. Cunningham, S.A. Sumner.
Collection and assembly of data: M. Walton.
Interpersonal firearm violence among youth is a substantial public health problem, and emergency department (ED) physicians require a clinical screening tool to identify high-risk youth.
To derive a clinically feasible risk index for firearm violence.
24-month prospective cohort study.
Urban, level 1 ED.
Substance-using youths, aged 14 to 24 years, seeking ED care for an assault-related injury and a proportionately sampled group of non–assault-injured youth enrolled from September 2009 through December 2011.
Firearm violence (victimization/perpetration) and validated questionnaire items.
A total of 599 youths were enrolled, and presence/absence of future firearm violence during follow-up could be ascertained in 483 (52.2% were positive). The sample was randomly split into training (75%) and post–score-construction validation (25%) sets. Using elastic-net penalized logistic regression, 118 baseline predictors were jointly analyzed; the most predictive variables fell predominantly into 4 domains: violence victimization, community exposure, peer influences, and fighting. By selection of 1 item from each domain, the 10-point SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score was derived. SaFETy was associated with firearm violence in the validation set (odds ratio [OR], 1.47 [95% CI, 1.23 to 1.79]); this association remained (OR, 1.44 [CI, 1.20 to 1.76]) after adjustment for reason for ED visit. In 5 risk strata observed in the training data, firearm violence rates in the validation set were 18.2% (2 of 11), 40.0% (18 of 45), 55.8% (24 of 43), 81.3% (13 of 16), and 100.0% (6 of 6), respectively.
The study was conducted in a single ED and involved substance-using youths. SaFETy was not externally validated.
The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence.
National Institute on Drug Abuse R01024646.
Flint Youth Injury study flow chart.
ED = emergency department.
Variable importance determined by the predictive model, expressed as standardized regression coefficients (divided by the minimum so that the smallest score is 1).
POV = point of view.
Table 1. Highest-Ranked Prognostic Factors for Future Firearm Violence
Table 2. Rules for Calculation of the SaFETy Score
Distribution of SaFETy scores among youth with and without firearm violence during the follow-up period in the validation data.
SaFETy = Serious fighting, Friend weapon carrying, community Environment, and firearm Threats.
Table 3. Sensitivity and Specificity for SaFETy Score Thresholds Between 1 and 10 in the Validation Set
Appendix Table 1. Sensitivity and Specificity for SaFETy Score Thresholds Between 1 and 10 in the Training Set
Future firearm violence rates in the validation data set (dashed line) in 5 risk strata identified by using the training data set (solid line).
SaFETy = Serious fighting, Friend weapon carrying, community Environment, and firearm Threats.
Appendix Table 2. Joint Distribution of Violent Injury and Future Firearm Violence Status
Appendix Table 3. Relationship Between Future Firearm Violence and SaFETy Score and Assault Injury Presentation
Appendix Table 4. Description of Highest-Ranked Factors for Future Firearm Violence Among Those Presenting for Violent Injury
Appendix Table 5. Description of Highest-Ranked Factors for Future Firearm Violence Among Those Not Presenting for Violent Injury
Appendix Table 6. Sensitivity and Specificity in the Validation Set, Stratified by AI or Non-AI Group (95% CIs)
Appendix Table 7. Frequency Tables of the SaFETy Score in the Validation Data Set, Stratified by Group Membership
Appendix Table 8. Sensitivity and Specificity in the Training Set, Stratified by AI or Non-AI Group (95% CIs)
Appendix Table 9. Frequency Tables of the SaFETy Score in the Training Data Set, Stratified by Group Membership
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Goldstick JE, Carter PM, Walton MA, et al. Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk. Ann Intern Med. 2017;166:707–714. [Epub ahead of print 11 April 2017]. doi: 10.7326/M16-1927
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Published: Ann Intern Med. 2017;166(10):707-714.
Published at www.annals.org on 11 April 2017
Emergency Medicine, Prevention/Screening, Tobacco, Alcohol, and Other Substance Abuse.
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