US National Trends in Violent and Unintentional Injuries, 2000 to 2016

Injury remains one of the leading causes of death among Americans.¹ Although the 1980s and 1990s demonstrated improvements in most injuries,² recent trends seem to be eroding the promising survival gains.³ Closely monitoring trends in injury rates due to all mechanisms and intentions and among all groups is essential to update and adapt interventions and policy to further reduce fatalities. We studied temporal patterns of injury fatalities in the United States from 2000 to 2016.

We queried the Web-based Injury Statistics Query and Reporting System (WISQARS) database⁴ for temporal trends of fatal injuries, stratified by intent (homicides, suicides, or unintentional), major racial/ethnic groups, and injury mechanism. Legal intervention–related injuries were not included. All rates were age adjusted. The study used publicly available files and was thus exempt from institutional review board approval. Joinpoint regression modeling was used to identify major turning points in trends. The modeling fits the simplest joinpoint model (the model with the smallest number of joinpoints such that the improvement is not statistically significant if 1 more joinpoint is added) via a Monte Carlo permutation method. Once the simplest, significant model was defined, we tested whether an apparent trend change (measured by annual percentage changes [APCs]) within each time segment (ie, the slope of the segment) was statistically significant. The APCs with 95% CIs are presented for each trend period derived from the joinpoint regression. The test of APCs is based on asymptotic t test, and the number of joinpoints is determined by permutation test, which is more reliable. Because there are fewer data points in each segment, the power to detect a significant APC in each segment decreases, while the omnibus test combining all segments is more powerful to detect the overall trends for all segments. Analyses were performed using the Joinpoint Regression Program (version 4.5.0.1) developed by the National Cancer Institute.⁵

As summarized in the Table, trends in overall injuries showed large, significant increases from 2014 to 2016, reducing survival gains observed since 2001. Black non-Latino individuals retained the highest homicide fatality rates across the entire period and had the highest increase of all racial/ethnic groups from 2014 to 2016. Similar patterns were observed for unintentional injuries (Table and Figure, A and C). Suicides (Figure, B) appeared to increase steadily for white non-Latino individuals and black non-Latino individuals, with a small but significant acceleration starting in 2006. In comparison, white Latino individuals experienced a larger, significant increase in suicide fatalities starting in 2013. About half of suicides were firearm related, and these increased significantly from 2006 to 2016 after 6 years of significant decline (Table and Figure, D). Two-thirds of homicides were firearm related; this subgroup observed the largest increase from 2014 to 2016 compared with all other injury mechanisms. Notably, motor vehicle–associated fatalities exhibited an increase from 2014 to 2016 after more than a decade of steady, significant declines (Table and Figure, D). Similar directional changes with upward trends after 2014 were noted in all age groups (data not shown) younger than 45 years for violence-related injuries. Unintentional injuries also spiked after 2014 for most age groups, with the exception of individuals 16 years or younger. As expected, given the aging US population, unintentional falls have increased steadily since 2000 (Table and Figure, D).

These data demonstrate alarming upward trends in both violent and unintentional injuries, spiking after 2014. Even mechanisms and populations previously showing promising reductions exhibited increases in the last few years. Federal Bureau of Investigation⁶ reports of crime rates and the National Highway Traffic Safety Administration⁷ fatal traffic crash data report similarly disturbing statistics across the nation. These growing rates warrant concerted, decisive efforts by academia, society, and policymakers to support trauma-focused research.

Accepted for Publication: May 14, 2018.

Corresponding Author: Angela Sauaia, MD, PhD, Department of Surgery, Denver Health Medical Center, 13011 E 17th Pl, Room E-3360-C, Aurora, CO 80045 (angela.sauaia@ucdenver.edu).

Published Online: August 1, 2018. doi:10.1001/jamasurg.2018.2496

Author Contributions: Dr Sauaia had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lawless, E. E, Moore, Cohen, Sauaia.

Acquisition, analysis, or interpretation of data: Lawless, Cohen, H. B. Moore, Sauaia.

Drafting of the manuscript: Cohen, Sauaia.

Critical revision of the manuscript for important intellectual content: Lawless, E. E. Moore, H. B. Moore, Sauaia.

Statistical analysis: Lawless, Sauaia.

Administrative, technical, or material support: Cohen, H. B. Moore.

Supervision: E. E. Moore, Cohen.

Conflict of Interest Disclosures: None reported.