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Original Investigation
December 19, 2018

Trends in Firearm Injury and Motor Vehicle Crash Case Fatality by Age Group, 2003-2013

Author Affiliations
  • 1Harborview Injury Prevention and Research Center, Seattle, Washington
  • 2Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Department of Surgery, University of Washington, Seattle
  • 4Department of Pediatrics, University of Washington, Seattle
  • 5Editor, JAMA Network Open
JAMA Surg. Published online December 19, 2018. doi:10.1001/jamasurg.2018.4685
Key Points

Question  Does juxtaposition of lethality trends for motor vehicle crashes and firearm injuries expose mechanism-specific injury severity trends?

Findings  In this repeated cross-sectional measures analysis of data on patients treated at level I or II trauma centers from 2003 to 2013, firearm assault and self-inflicted firearm injury were highly lethal in terms of case-fatality percentage and the percentage of out-of-hospital deaths. Annual trends significantly declined for motor vehicle crashes in all age groups but not for firearms in any intent or age group.

Meaning  Seen alongside trends in case-fatality percentage for motor vehicle crashes, it appears that injuries resulting from firearms may be worsening in severity.


Importance  If changes over time in trauma care apply to both firearm injuries and motor vehicle crashes (MVCs) similarly, differences in mechanism-specific case-fatality trends may suggest changes over time in injury severity.

Objectives  To analyze national trends in case-fatality percentages at levels I and II trauma centers for injuries due to MVC, firearm assault, self-inflicted firearm injury, and unintentional firearm injury by age and to analyze trends in injury severity scores (ISSs) and the percentage of out-of-hospital deaths by mechanism.

Design, Setting, and Participants  From November 15, 2017, to July 4, 2018, repeated cross-sectional measures analysis of 1 335 044 patients treated at level I or II trauma centers from January 1, 2003, through December 31, 2013, was conducted using 2 data sources: the National Trauma Data Bank National Sample Program, with survey weights to estimate annual median ISS, total injuries and total deaths at levels I and II trauma centers, and the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research for percentages of out-of-hospital deaths.

Main Outcome Measures  The main outcome was annual case-fatality percentage (total died/total injured), calculated by mechanism across 3 age groups (15-34 years, 35-54 years, and ≥55 years) and 5 categories of ISS (1-15 [mild] 16-24, 25-40, 41-66, and 67-75 [severe]). Linear regression was performed to estimate annual trends in case-fatality percentage by mechanism, age group, and ISS. Annual trends in percentages of out-of-hospital deaths and median ISSs by mechanism were estimated. Sensitivity analyses included the Durbin-Watson statistic for autocorrelation and Prais-Winsten regression models.

Results  Among 1 335 044 patients treated at level I or II trauma centers, self-inflicted firearm injury had a case-fatality percentage of 42.8%, and assault with a firearm had a case-fatality percentage of 11.1%, the 2 highest of the injuries studied. The injury case-fatality percentage was lower each year for MVCs but did not change for any firearm intent overall or for any age group. Overall, median ISS increased annually for firearm suicide (0.31; 95% CI, 0.00-0.61). The annual percentage of out-of-hospital deaths was lower each year for MVCs (−0.24; 95% CI, −0.43 to −0.05) but not for any firearm intents. In sensitivity analyses, the annual percentage of out-of-hospital deaths for MVCs no longer showed a decline.

Conclusions and Relevance  Stagnant case-fatality percentages for firearm injuries juxtaposed to improvements for MVCs across age-groups and ISS categories suggests worsening severity of firearm injuries over the study period.

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