The Journal of Emergency Medicine, Vol. 44, No. 3, pp. 585–591, 2013Copyright � 2013 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2012.07.058

RECEIVED: 10 DACCEPTED: 4 Jul

OriginalContributions

GUNSHOT VICTIMS AT A MAJOR LEVEL I TRAUMA CENTER: A STUDY OF343,866 EMERGENCY DEPARTMENT VISITS

David C. Moore, BA,* Zachary T. Yoneda, BA,* Mallory Powell, BA,† Daniel L. Howard, PHD,‡A. Alex Jahangir, MD,† Kristin R. Archer, PHD, DPT,† Jesse M. Ehrenfeld, MD, MPH,§

William T. Obremskey, MD, MPH,† and Manish K. Sethi, MD†

*Vanderbilt University School of Medicine, Nashville, Tennessee, †Department of Orthopedic Surgery and Rehabilitation, Vanderbilt UniversityMedical Center, Nashville, Tennessee, ‡Robert Wood Johnson Foundation Center for Health Policy, Meharry Medical College, Nashville,

Tennessee, and §Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

Reprint Address: Manish K. Sethi, MD, Department of Orthopedic Surgery and Rehabilitation, Vanderbilt University Medical Center,Medical Center East, South Tower, Suite 4200, Nashville, TN 37232-8774

, Abstract—Background: Disturbing trends regardingthe sex, age, and race of gunshot victims have been reportedin previous national studies; however, gunshot trends havenot been well documented in individual cities in the south-eastern United States. Objectives: 1) Analyze trends in gun-shot wounds, particularly the association between gunshotwounds and race, among victims presenting to a Level ITrauma Center in Middle Tennessee; 2) Compare specificcharacteristics of gunshot victims to the general EmergencyDepartment (ED) population. Methods: This is a retrospec-tive cohort study of 343,866 ED visits from 2004 to 2009. Re-sults: Compared to the general ED population, gunshotvictims were more predominantly male (87.5% vs. 43.4%),black (57.6% vs. 29.5%), younger (47.8% under age 25years vs. 31.6%), and demonstrated higher Medicaid enroll-ment (78.6% vs. 44.7%). The majority of black gunshot vic-tims were aged 18–25 years (47.1%) and victims of assault(65.9%). Non-black gunshot victims suffered more uninten-tional (40.2% vs. 28.2%) and self-inflicted (9.1% vs. 0.4%)injuries and were more evenly distributed among ages18–55 years. Black patients were 3.03 (95% confidence inter-val 2.93–3.14) times more likely to present to this ED forgunshot wounds than non-black patients, after controllingfor age, sex, and insurance status (p < 0.001). Conclusions:Our study demonstrates that black patients between 18and 25 years of age presenting to this trauma center aremore likely to be victims of gun violence than their non-

ecember 2011; FINAL SUBMISSION RECEIVED: 16 Ay 2012

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black counterparts. Our study evaluates trends in gunviolence in the Southeast, particularly in relation to race,age, and insurance status. � 2013 Elsevier Inc.

, Keywords—gun shot wounds; health policy; crime vic-tims; trauma centers; urban health

INTRODUCTION

Despite decades of research, gun violence remains a sig-nificant cause of mortality, morbidity, and preventablehealth care spending (1–3). Previous national studiesand retrospective reviews have demonstrated clearracial disparities regarding the incidence of gunshotwounds (4,5). Nationally, firearm-associated deaths inthe black population have been reported at rates of 2.2times higher than their white counterparts (6). Similarly,in 1996 Vassar and Kizer described gunshot victims in thestate of California as predominantly black males aged15–24 years (5). With regard to gunshot wounds specifi-cally among the black population, multiple national data-base studies have demonstrated similar trends (7–12). Incontrast, attempts to identify race or insurance status asindependent predictors of mortality after a gunshotwound have produced mixed results (8,13–17).

pril 2012;

586 D. C. Moore et al.

Although previous studies over the past two decadeshave demonstrated disparities in gun violence specificallyin the black population, these observations have beennoted predominantly in the context of national databasereviews. It is important to examine whether these nation-ally documented trends regarding gun violence are appli-cable to individual cities around the country so thatappropriate educational, prevention, and interventionstrategies can be developed. In this study, we used datafrom one of the nation’s busiest Level I Trauma Centersto determine the demographic and injury profiles of gun-shot victims presenting to the Emergency Department(ED) relative to the general Emergency Department(GED) population, and subsequently, to distinguishunique characteristics and trends of the gunshot wound(GSW) population. Because this institution maintainsthe only Level I Trauma Center within a 150-mile radius,it treats all life- and limb-threatening GSWs and is there-fore uniquely positioned to examine the general trends offirearm-related injuries in middle Tennessee. This retro-spective cohort study simultaneously examines the char-acteristics of patients sustaining GSWs, specifically age,race, sex, insurance status, and their mechanism of injuryat a major Level I Trauma Center. By highlighting re-gional trends in gun violence, this study provides policy-makers with sound evidence on which to develop newprevention strategies. Additionally, such data can beused to educate communities about the specific risksand trends of GSWs.

METHODS

Data Acquisition

Data were acquired by extraction of all visits to the Van-derbilt University Medical Center ED from January 1,2004 through December 31, 2009 from the hospital bill-ing database. This Medical Center in Nashville David-son County is middle Tennessee’s only Level ITrauma Center within a 150-mile radius. Each entryrepresents a separate charge for the first 30 min of anED visit. Gunshot victims were identified as havingany of the following International Classification of Dis-eases, 9th Revision (ICD-9) codes within the first fourICD-9 descriptors (E922.0–E922.9, E955.0–E955.4,E965.0–E965.4, and E985.0–E985.4), which also wereused to determine the mechanism of injury. Gunshotvictims were described only once, unless a patient suf-fered a separate GSW on another occasion. Subsequentvisits to the ED pertaining to the same GSW were in-cluded within the GED population. Age, insurance sta-tus, sex, race, and method of injury were recorded asdescribed in the patient record for that visit. Race wasself-reported from a fixed set of categories or deter-

mined by a nurse if the patient was incapacitated. Pa-tients described as Asian/Pacific Islander, AmericanIndian, Hispanic, or unknown were recorded as ‘‘other’’in our study. For simplicity, our bivariate and multivar-iate analysis was limited only to those patients whoserace was recorded as black vs. all others (non-black). In-surance class descriptions were extracted from financialdata and grouped into one of five categories: Medicare,Medicaid (including all government health insuranceprograms), commercial, uninsured, and unknown.

Statistical Methods

All EDvisits from the years 2004 through 2009 for patientsolder than 13 years of age were considered for analysis(343,866 patients). Children under the age of 14 wereexcluded from our analysis because this demographic hasbeen previously described and is not prevalent in thispatient population (11). For purposes of analysis, age wasplaced into seven categories: 14–17 years, 18–25, 26–35,36–45, 46–55, 56–65, and more than 65 years. For22,223patients presenting to theED (6.46%of total), insur-ance statuswas unknown. To account for incomplete insur-ance data for patients, data for this category were multiplyimputed eight times using logistic regressions from allother variables available. To further characterize theGSW population, we compared their demographic infor-mation to that of the GED population at the same TraumaCenter. For analysis within the GSW population, a Fisher’sexact test was used for method of injury and insurance sta-tus and chi-squared and Student’s t-tests were used for agedistribution. For sensitivity, a Fisher’s exact test was per-formed on each of the eight imputed data sets for insurancestatus and the original data, without change in trend.We fita multivariable logistic regression model to the total EDpopulation $14 years of age from the years 2004 to2009, with a GSW diagnosis being the dependent variable.The multivariable model included race, insurance status,sex, and age <25 years. As gunshots may exhibit a yearlyvariance in incidence from year to year (clustering), overalltrends in the gunshot incidence were taken into account byclustering the data by year. As a reference category, resultsare presented compared to a non-blackmale over the age of25 years with commercial health insurance.

RESULTS

Using our selection criteria, 343,866 individual ED en-counters were identified during a 6-year period (2004through 2009). Characteristics of the GED populationare presented in Table 1. The majority (70.5%) of theGED population was non-black. Gender distributionshowed a slight female predominance (51.8%) in numberof visits and a highly skewed and tapering age distribution

Table 1. Descriptive Statistics of the Vanderbilt ED andGunshot Populations from 2004 to 2009

CharacteristicED Population

n (%)Gunshot Population

n (%)

SexMale 149,215 (43.4) 1982 (87.5)Female 194,651 (56.6) 284 (12.5)

Age, years14–17 32,721 (9.5) 183 (8.1)18–25 75,932 (22.1) 899 (39.7)26–35 67,934 (19.8) 596 (26.3)36–45 56,151 (16.3) 347 (15.3)46–55 49,343 (14.4) 170 (7.5)56–65 28,825 (8.4) 54 (2.3)65+ 33,061 (9.6) 19 (0.8)

Death within 30 days 3679 (1.1) 91 (4.0)Race

Black 101,295 (29.5) 1305 (57.6)Non-black 242,571 (70.5) 961 (42.4)

Insurance statusCommercial 131,109 (38.1) 419 (18.5)Medicaid 153,813 (44.7) 1782 (78.6)Medicare 54,657 (15.9) 48 (2.1)Uninsured 4287 (1.3) 17 (0.8)

Total 343,866 2,266

ED = Emergency Department.

Table 2. Injury, Insurance, and Age Distributions by Race inthe GSW Population

Race*

p Value†Black

(n = 1305)Non-black(n = 761)

Injury type, n (%)Unintentional 368 (28.2) 386 (40.2)Suicide 5 (0.4) 87 (9.1)Assault 860 (65.9) 408 (42.5) <0.001Unknown 68 (5.2) 68 (7.1)Other 4 (0.3) 12 (1.3)

Age, years, n (%)14–17 134 (10.3) 49 (5.1)18–25 615 (47.1) 284 (29.6)26–35 338 (25.9) 258 (26.9)36–45 145 (11.1) 202 (21.0) <0.00146–55 54 (4.1) 116 (12.1)56–65 16 (1.2) 38 (4.0)65+ 3 (0.2) 14 (1.5)

Insurance,‡ n (%)Commercial 181 (13.9) 238 (25.5)Medicaid 1106 (84.8) 676 (72.5)Medicare 12 (0.9) 12 (1.3) <0.001Uninsured 6 (0.1) 6 (0.6)

* All percentages are reported as a percentage of the total gun-shot wound (GSW) population for a given race.† p Values for insurance and injury method were obtained fromFisher’s exact tests. Due to computational power limitations,p value for age was obtained through a Pearson chi-squared.‡ Reporting the results of one imputation. In none of the eightimputations did the p value obtained through Fisher’s exactexceed .001.

Gunshot Victims at a Major Level I Trauma Center 587

from young to old, most likely reflective of cumulativemortality within the general population. Overall, theGED population distribution followed these trends acrossall races (Figure 1A).

The GSWpopulation was different from the GED pop-ulation in nearly all dimensions (Table 1). The majority(87.5%) of GSW patients were male. Although themean age of the GSW population was older than that ofthe GED population, the age distribution was narrower:47.8% of the GSW population was 25 years of age oryounger, compared to only 31.6% of the GED population.Racial differences were also found between the GSWandGED populations. Less than 30% of the GED populationwas black, whereas almost two-thirds (57.6%) of theGSW population was black. In terms of insurance,a smaller percentage (61.9%) of the GED populationwas enrolled in government insurance programs or unin-sured compared to the GSW population (81.5%). Specif-ically, the GSW population demonstrated a much higherrepresentation ofMedicaid patients than the GED popula-tion, with 78.6% of GSW patients enrolled in Medicaid,compared to 44.7% of GED patients (Table 1).

Within the GSW population, there was variation in racewith respect to age,mechanismof injury, and insurance sta-tus (Table 2). In addition to having a higher peak and a nar-rower age distribution than the GED population, the GSWpopulation demonstrated different trends in age distribu-tions among black and non-black patients presenting withGSWs (Figure 1B). The blackGSWpopulationwas signif-icantly more likely to present at a younger age (26.7 vs.33.5, p < 0.0001), as a victim of assault (65.9% black vs

42.5%non-black,p<0.001), and to be insuredbyMedicaid(84.8% black vs 72.5% non-black). Twenty repeat gunshotvictims (defined as presenting with a GSWon two or moreseparate occasions) were identified, all 20 of whom wereblack males between the ages of 18 and 30 years.

Multivariable logistic regression (Table 3) showed thatblack patients were 3.03 (95% confidence interval [CI]2.93–3.14) times more likely to present to the ED fora GSW than non-black patients after correcting for age,sex, and insurance status, and after controlling for poten-tial clustering on the basis of year of encounter. The dif-ferences within the distribution of ages was further borneout by a 1.56 (95% CI 1.42–1.72) times greater likelihoodof presenting with a GSW if younger than the age of 25years. Patients with Medicaid were more likely to presentwith a GSW (odds ratio [OR] 3.00; 95% CI 2.67–3.37),and those with Medicare less likely (OR 0.26; 95% CI0.19–0.34) compared to patients with private insurance.Also, gender differences in GSW patients were noted,with women less likely than men to present witha GSW (OR 0.09; 95% CI 0.07–0.10).

DISCUSSION

In this study we found that black patients were over threetimes more likely to present to the ED with a GSW than

Figure 1. Age distributions for ED (A) and GSW (B) populations.

588 D. C. Moore et al.

their non-black counterparts after controlling for sex, age,and insurance status. A more detailed analysis of gunshotvictims revealed that they were overwhelmingly male(87.5%), black (57.6%), 18–25 years old (39.7%), andparticipants in government insurance programs or unin-sured (81.5%). Furthermore, drastic differences werefound between the GSW population and the GED popu-lation, as well as between the GSW population and localcity and state populations.

Comparison to the GED population during the sametime period revealed that the findings among theGSWpop-ulation were not a simple reflection of the GED populationcared for at this Trauma Center. Significant differenceswere documented between theGEDandGSWpopulations,particularly in terms of sex, race, and insurance status.Although the majority of GED patients were female, theoverwhelming majority of GSW patients were male. Sim-ilarly, the GED population was predominantly non-black,whereas the GSW population was predominantly black.It is important to note that non-black patients were unlikelyto receive care elsewhere for GSWs, as our hospital is theonly Level I Trauma Center within a 150-mile radius and

Table 3. Result of the Multivariable Logistic Regression forthe Odds Ratio of GSW and Race

Variable OR (95% CI) p Value

Black vs. non-black 3.03 (2.93–3.14) <0.001Age <25 vs. $25 years 1.56 (1.42–1.72) <0.001Female vs. male 0.09 (0.07–0.10) <0.001Medicaid vs. private 3.00 (2.67–3.37) <0.001Medicare vs. private 0.26 (0.19–0.34) <0.001Self vs. private 1.27 (0.64–2.49) 0.497

GSW= gunshotwound; OR= odds ratio; CI = confidence interval.

therefore treats essentially all gunshot victims regardlessof race. There is also no indication that non-black patientssustained less serious GSWs that would allow them to betreated elsewhere. Finally, 20% less of the GED populationwas enrolled in government insurance programs or unin-sured compared to the GSW population, suggesting possi-ble socioeconomic differences between the GSWandGEDpopulations.

Furthermore, our study demonstrates significant racialdifferences within the GSW population with regard to ageand mechanism of injury. Specifically, black GSWpatients were more likely to be under the age of 25 yearsand victims of assault, whereas non-black GSW victimswere more evenly distributed among ages 18–55 yearsand were significantly more likely to have received unin-tentional or self-inflicted injuries. All patients with mul-tiple encounters with gun violence were black malesunder age 30 years. Highlighting such nuances of thelocal GSW population is important for both physiciansand policymakers in developing a clear understandingof local GSW trends. Additionally, identifying trends inGSWs is a powerful tool for educating patients most atrisk for accidental, self-inflicted, or assault-related injury.

The demographics of the GSW population were alsodramatically different than those of the local city and statepopulations, which number 628,133 and 6,403,353, re-spectively. Whereas only 48.4% of Nashville DavidsonCounty residents and 48.7% of Tennessee residents aremale, 87.5% of GSW patients were male. Similarly,whereas the majority (57.6%) of GSW patients was black,only 27.9% of Nashville Davidson County residents and16.9% of Tennessee residents are black. With respect toage, 47.8% of GSW patients were between the ages of

Gunshot Victims at a Major Level I Trauma Center 589

14 and 25 years, whereas only 13.7% of the Tennesseepopulation falls in the 15–24-year age bracket used bythe U.S. Census Bureau (18). Rates of government insur-ance enrollment and uninsurancewere significantly higheramong the GSW patients, of whom 81.5%were uninsuredor enrolled in government insurance, compared to only56% of Tennessee residents enrolled in government insur-ance programs or uninsured (19,20). The differences indemographics of GSW patients compared to the localcity and state populations highlight that individuals whoare young, male, black, and uninsured or government-insured carry a disproportionate burden of GSWs.

The main findings of this investigation are consistentwith studies that have independently described racial dis-parities in gunshot victims (5,7,8,13). Nevertheless, theseresults demonstrate a lower percentage of black GSWpatients to be victims of assault (65.9%) compared tothe work of Vassar and Kizer in 1996 (82.7%) (5). Thisstudy did identify a higher proportion of black victimscompared to non-black victims in this GSW populationcompared to the aforementioned study (57.4% vs.32.3%). These differences suggest that at-risk popula-tions may vary by location, whereas, unfortunately, theirsimilarities suggest that overall trends in gun violencehave not changed in over 15 years.

With gun violence at the center of media attention, themedical community requires sound research on which tobase future health policy recommendations as well asclinical decisions. The strength of this study lies in its ex-amination of a large ED population at the only Level ITrauma Center within 150 miles to reveal that the major-ity of gunshot injuries in Nashville were sustained byyoung, black, male victims of assault. This study high-lights that gun violence trends noted on both a nationalscale and in other urban settings are applicable to individ-ual cities, and provides a comprehensive description ofa population at risk for gunshot injuries, which can beused in development of prevention and intervention strat-egies. For example, the authors have used these data topartner with the local public school system and commu-nity leaders to implement a novel violence preventionprogram in area middle schools. The findings of this studyhave also created a conversation within the trauma centerregarding development of a hospital-based interventionprogram for violently injured youth to reduce retaliatoryviolence and violent trauma recidivism. A decrease in thenumber of ED visits due to GSWs and their subsequentcomplications would, furthermore, have a marked impacton health care costs at local and national levels (1).

Limitations

This retrospective cohort study reflecting a 6-year span ata single medical center has several limitations. Inclusion

in the study was dependent on the accurate coding ofdiagnoses and was determined solely from financial data-bases, resulting in possible selection bias. Although ourdata reflect all encounters billed for the first 30 min ofan ED visit, it is possible that patients pronounced deadon arrival (DOA) are not included in this data set. Thesedata likely under-represent the number of suicides,because these patients are more likely to be DOA aswell. Similarly, using ICD-9 code descriptors may reflectphysician bias in diagnosis or billing, rather than actualmechanism of injury. As patient education level and rela-tionship to the federal poverty level was not ascertain-able, we attempted to control for socioeconomic status(SES) using insurance status. Without adequate markersfor confounding factors such as SES, our study in noway deems race a causative agent for gunshot injuries(21). Finally, although our study reflects gunshot victimstaken to the only area Level I Trauma Center which servesdiverse catchment areas, it does not completely portraythe overall burden of gun violence in Nashville. Datafrom other area hospitals were not collected because thereis no indication that other hospitals saw a significant num-ber of GSW victims. However, the authors acknowledgethat the lack of other hospitals’ data could potentially in-troduce bias. The authors also acknowledge that as theonly Level I Trauma Center in the area, our institutiontreats all GSW patients who are transported to an EDvia ambulance. In contrast, patients with non-traumaticchief complaints who arrive independently may havea greater degree of choice in which ED they visit.

CONCLUSION

Our study of GSW victims treated at a Level I TraumaCenter in Nashville, Tennessee demonstrates that blackpatients between the ages of 18 and 25 years are morelikely to be victims of gun violence than their non-black counterparts. Specifically, a black patient present-ing to the ED is 3.03 times more likely to present witha gunshot injury than non-black patients. For blackGSW victims, the mechanism of injury is more likelyto be secondary to assault, whereas non-black victimsare more likely to sustain an unintentional injury. Thesefindings are reflective of the universality of the nationallydocumented demographics of GSW victims. It is hopedthat this information might be used by other communitiesto develop educational and prevention programs to targetpopulations most likely to be harmed by gun violence.

Acknowledgments—This study was supported by the Depart-ment of Orthopaedic Surgery and Rehabilitation at VanderbiltUniversityMedical Center. This study was approved by the Van-derbilt University Institutional Review Board. We thank SusanMoon and Elizabeth Maxey, MBA, Department of Orthopaedic

590 D. C. Moore et al.

Surgery and Rehabilitation for their help in data acquisition. Wealso thank Kay Daugherty, Medical Editor, Department of Or-thopaedic Surgery at University of Tennessee-Memphis forher critical revision of the manuscript.

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ARTICLE SUMMARY

1. Why is this topic important?Gun violence is a major public health issue that has

been demonstrated within database reviews andAmerica’s major urban centers. However, studies of gunviolence are not often conducted in individual cities, par-ticularly in the Southeast, to develop appropriate preven-tion and intervention responses.2. What does this study attempt to show?

This study attempts to demonstrate the characteristicsof gunshot victims and trends of gun violence in individ-ual cities like Nashville, TN.3. What are the key findings?

Black patients are 3.03 times more likely to present toan Emergency Department for a gunshot wound than non-black patients, after controlling for age, sex, and insurancestatus. This study demonstrates that trends in gun violencedocumented nationally are applicable to individual cities.4. How is patient care impacted?

This study demonstrates that gun violence is clearlya problem among the African-American community inNashville, TN. This study supports gun violence preven-tion and intervention programs that are being initiated inNashville targeting young African Americans betweenthe ages of 18 and 25 years.