Firearm-related injury, whether unintentional or intentional, is the second leading cause of death in children and adolescents; and per WHO data, the United States has higher rates of firearm-related unintentional and suicide deaths compared to many other developed nations. Moreover, multiple studies indicate that firearm-related deaths in adolescents is higher in rural population compared to urban centers. But a granular understanding of the rate of firearm exposure and storage practice patterns is not well characterized in rural parts of the country. This study explored these characteristics of firearm ownership as well as the demographic factors associated with firearm presence within rural households.
This cross-sectional survey study utilized a convenience sample of adolescents aged 13 to 18 attending a youth leadership conference in Iowa to garner information about adolescent exposure to firearms as well as household storage practice patterns. In addition to basic demographic information, participants were asked about the presence of firearms in the home (e.g., handguns vs rifles/shotgun vs both), and whether those arms were considered locked or unlocked and loaded or unloaded. Of 1,382 participants surveyed, 84% reported the presence of a shotgun or rifle in their home, 58% reported the presence of a handgun, and 56% reported some combination of both. For both handguns and rifles/shotguns, participants were largely Caucasian males aged 16-18 years old residing on farms compared to town residences. Males, older teens, and farm residence were all independent predictors of residing in a residence with at least one unsafely stored weapon for both firearm categories. Perhaps most concerning, only 33% of residences with rifles/shotguns and 37% of residences with handguns reported safe storage practices (i.e., firearms always stored unloaded and locked). Of all participants polled, 82% reported at least one firearm stored unsafely.
This study demonstrated an alarming prevalence of unsafe storage methods for firearms within rural residences and a high rate of exposure to older teens, specifically males. The societal implications of these findings cannot be understated. Firearm-related pediatric deaths remain a leading cause of mortality, and the findings of this study indicate that rural youth are at particularly high risk of unsafe firearm exposure. A thorough understanding of locoregional practice patterns for firearm storage may yield avenues for region-specific preventative interventions to limit firearm exposure in rural pediatric populations.
Deaths from the opioid crisis continue to mount, as do rates of firearm injury. There is limited evidence as to whether increases in firearm injury are related to opioid misuse. This study aims to identify correlation between firearm injury and opioid misuse through a novel use of emergency department diagnosis codes for both firearm injury and drug overdose, state reported drug monitoring program data, as well as county-level socioeconomic variables.
This county-level analysis included the years 2010-2017, across the state of Kentucky. Counties were classified as metro, metro-adjacent, and rural. The relationship between ED visits for drug overdose and firearm admissions was evaluated. There was a positive association between overdose deaths and firearm ED visits across all years, with an increase in each successive year with a county-level rate ratio of 1.14 (95%CI 1.09-1.20). Interestingly, overdose ED visits did not vary with rurality, but firearm injury, high-dose opioid prescriptions and criminal firearm deaths worsened with increasing rurality, heroin overdose improved with rurality (p<0.05). Although implementation of a state drug prescription reporting system resulted in fewer high-dose opioid prescriptions, overdose ED visits and deaths have continued to increase. Similarly increases in firearm injury and deaths have increase. There is an inverse relationship between heroin overdose and firearm injury and death, as well as heroin overdose and rural county location.
This study demonstrates the temporally related increases in firearm injury or death and opioid misuse or death. There are several interesting results. Notably, that rural counties have increasing levels of firearm ED visits and overdose ED visits. It is not completely clear what drives this correlation, however a continued increase in fentanyl and illicit opioids driven by increased scrutiny over opioid prescriptions is a possible cause. Additionally, there is an increased prevalence of homes with firearms in rural areas. Interestingly, there was not an increase in firearm injury in counties with increased heroin deaths. This may be due to the relationship of heroin with primarily urban areas, which have a relatively lower prevalence of firearms. Injury prevention efforts should consider the overlap between opioid misuse and potential for firearm injury.
There is no objective, data-driven process for determining need and distribution of trauma centers. Trauma center development if often driven by local or state-level politics or economic interests. This has resulted a patchwork of trauma center density throughout the country, often with rural populations located a long distance from the nearest trauma center. This study aims to develop a data-driven method to determine trauma center need based on injury epidemiology and geography that would be reproducible and transferrable.
The Vermont Statewide Incident Reporting Network was used to collect all prehospital EMS records for injured patients. These incidents were geocoded and mapped using incident address. A database of potential trauma centers was built, and road information included. Multiple models were built to identify the optimum distribution of trauma centers to provide prompt access to trauma care (within 60 minutes). Using these data, the authors identified that 29.7% of Vermont residents live >60 minutes away from any Level I trauma center (including surrounding states). Two potential hospitals were identified through the models that would decrease the proportion of residents without prompt access from 29.7% to 5.8%.
This article demonstrates that geospatial location-allocation modeling can be used to identify candidate hospitals for implementation of a trauma system to improve access to care. The hospitals identified may be targeted for development of a trauma center and improve travel times across rural states. Further work will need to be done to identify the impact of air medical transport on these models. This novel method is a promising development in building an intentional trauma system that provides equitable care.
Traumatic brain injury remains a high cause of mortality with older patients being particularly susceptible for hospitalization and death. An oft overlook malady, however, is in post-acute care needs including need for skilled nursing facilities (SNFs) and successful discharge from post-acute care facilities. This problem is compounded by the differences in care between rural and urban populations. Anderson et al. address this difference in post-acute care discharge needs and rates of successful discharge in their entitled work. Their aims were to 1) quantize the rates of successful discharge from SNF in urban and rural communities, and 2) characterize the reasons why patients may not have reached successful discharge.
To accomplish this, the authors queried several CMS data sources from 2011-2015. All Medicare beneficiaries aged 65 or older with an ICD-9 code specific to TBI were included, but notably any patient that had an inpatient or hospice admission that within the year prior were excluded from analysis. The primary outcome was successful community discharge defined as discharge from a SNF within 100 days of SNF admission and remaining within the community for at least 30 days without death or re-admission. The authors also characterized failure for unsuccessful discharge including remaining in a SNF for >100 days, discharging to a hospital, dying in a SNF, or admission to a hospital, hospice, or death within 30 days.
The results conform with a growing appreciation of rural/urban disparity in patient outcomes and access to care. This study found a significant lower rate of unadjusted successful discharge from SNFs between urban and rural patients (52.1% vs 58.5%, p < 0.01). On multivariate analysis, rural patients had a 16% lower chance of successful discharge (AOR 0.84, 95% CI 0.8-0.88). Patients with severe functional and cognitive impairment during their hospitalization had lower rates of successful discharge (AOR 0.37, 95% CI 0.34-0.04; 0.37, 95% CI 0.36-0.38). Likewise, patients admitted to lower quality SNFs (less than 5-star rating), had lower odds of successful discharge. Reasons for not having a successful discharge varied between groups, with rural patients more likely dying in SNFs (10.8% vs 13.5%) and less likely to be re-hospitalized within 30 days (10.6% vs 7.7%), indicative of likely poor access to locoregional care. Limitations of this paper are notable including the lack of inclusion of injury severity, severity of TBI, or presence of concomitant injuries. Likewise, the exclusion of patients admitted within the prior year of injury neglects a large subset of patients that may be more affected by the effect of poor care access and unsuccessful discharge from post-acute care facilities. Nevertheless, this paper highlights the differences between two populations suffering from the same disease process and the need for more research done into targeted interventions to improve care in the rural setting.
This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email litreview@east.org. Previous issues available on the EAST website.
