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Original Investigation
November 20, 2019

Long-term Functional, Psychological, Emotional, and Social Outcomes in Survivors of Firearm Injuries

Author Affiliations
  • 1Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 2currently affiliated with Division of Acute Care Surgery and Trauma, University of Rochester Medical Center, Rochester, New York
  • 3Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 4currently affiliated with Department of Surgery, Stanford University, Palo Alto, California
  • 5medical student, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 6Department of Anesthesia and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA Surg. Published online November 20, 2019. doi:https://doi.org/10.1001/jamasurg.2019.4533
Key Points

Question  What are the long-term physical, mental, emotional, and social outcomes among individuals with gunshot wounds?

Findings  In this cohort study of patient-reported outcome measures, 183 young adult patients (median age, 27 years) who survived gunshot wounds (median time from injury, 5.9 years) reported worse physical and mental health compared with the general population, 48.6% had positive screen findings for probable posttraumatic stress disorder, and unemployment and substance use increased by 14.3% and 13.2%, respectively, after injury.

Meaning  These findings suggest that the outcomes of firearm injury reach far beyond mortality statistics; survivors of gunshot wounds may benefit from early identification and the initiation of long-term, multidisciplinary longitudinal care to improve recovery.

Abstract

Importance  The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied.

Objective  To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries.

Design, Setting, and Participants  This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019.

Exposures  A GSW sustained from January 1, 2008, through December 31, 2017.

Main Outcomes and Measures  Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Results  Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P < .001), Global Mental Health (48 [11]; P = .03), and Physical Function (45 [12]; P < .001) PROMIS metrics. Eighty-nine participants (48.6%) had a positive screen for probable PTSD. Patients who required intensive care unit admission (n = 64) had worse mean (SD) Physical Function scores (42 [13] vs 46 [11]; P = .045) than those not requiring the intensive care unit. Survivors no more than 5 years after injury had greater PTSD risk (38 of 63 [60.3%] vs 51 of 119 [42.9%]; P = .03) but better mean (SD) Global Physical Health scores (47 [11] vs 43 [11]; P = .04) than those more than 5 years after injury.

Conclusions and Relevance  This study’s results suggest that the lasting effects of firearm injury reach far beyond mortality and economic burden. Survivors of GSWs may have negative outcomes for years after injury. These findings suggest that early identification and initiation of long-term longitudinal care is paramount.

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