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Epidemiologic Trends in Fatal and Nonfatal Firearm Injuries in the US, 2009-2017

Educational Objective: To describe estimates of incidence and trends over time of fatal and nonfatal firearm injuries.
1 Credit CME
Key Points

Question  What is the incidence of fatal and nonfatal firearm injury in the US, including self-harm, assault, and unintentional injury?

Findings  In this cross-sectional study of data from nationwide US databases, from 2009 to 2017, there was an annual average of 85 694 emergency department visits for nonfatal firearm injury and 34 538 deaths from firearm injury. Although suicide accounted for 61% of deaths, self-harm accounted for only 3% of nonfatal injuries; assaults accounted for 35% of deaths and 41% of nonfatal injuries, and unintentional injuries accounted for 2% of deaths and 51% of nonfatal injuries.

Meaning  In the US, nonfatal firearm injuries are more than twice as prevalent as deaths from firearm injury; the most common injuries are self-harm among deaths, unintentional injuries among nonfatal injuries, and assaults overall.


Importance  Firearm injury research in the US has focused on fatal injuries. The incidence and epidemiologic factors associated with nonfatal firearm injuries are less understood.

Objective  To evaluate estimates of incidence and trends over time of fatal and nonfatal firearm injuries.

Design, Setting, and Participants  A cross-sectional, ecologic study was conducted using data throughout the US from 2009 to 2017. Data on fatal injuries from the Centers for Disease Control and Prevention were combined with national data on emergency department visits for nonfatal firearm injury from the Nationwide Emergency Department (ED) sample. Data analysis was conducted from August 2019 to September 2020.

Exposures  Firearm injuries identified with International Classification of Diseases external cause of injury codes and categorized by intent of injury, age group, and urban-rural location.

Main Outcomes and Measures  Incidence, case fatality rate, and trends over time of firearm injury according to intent, age group, and urban-rural location.

Results  From 2009 to 2017, there was a mean of 85 694 ED visits for nonfatal firearm injury and 34 538 deaths each year. An annual mean of 26 445 deaths (76.6%) occurred outside of the hospital. Assault was the most common overall mechanism (38.9%), followed by unintentional injuries (36.9%) and intentional self-harm (19.6%). Self-harm, which accounted for 21 128 deaths (61.2%), had the highest case fatality rate (89.4%; 95% CI, 88.5%-90.4%), followed by assault (25.9%; 95% CI, 23.7%-28.6%) and legal intervention (23.4%; 95% CI, 21.6%-25.5%). Unintentional injuries were the most common nonfatal injuries (43 729 [51.0%]) and had the lowest case fatality rate (1.2%; 95% CI, 1.1%-1.3%). Self-harm deaths, 87.8% of which occurred outside the hospital, increased in all age groups in both rural and urban areas during the study period and were most common among people aged 55 years and older. The rate of fatal assault injuries was higher in urban than in rural areas (16.6 vs 9.0 per 100 000 per year) and highest among people aged 15 to 34 years (38.6 per 100 000 per year). Rates of unintentional injury were higher in rural than in urban areas (18.5 per 100 000 vs 12.4 per 100 000).

Conclusions and Relevance  In this cross-sectional study, suicide appears to be the most common cause of firearm injury death in the US, and most people who die from suicide never reach the hospital. These findings suggest that assaults and unintentional injuries account for most nonfatal and overall firearm injuries and for most of the injuries that are treated in hospitals.

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Article Information

Accepted for Publication: September 24, 2020.

Published Online: December 7, 2020. doi:10.1001/jamainternmed.2020.6696

Corresponding Author: Elinore J. Kaufman, MD, MSHP, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, 51 N 39th St, Medical Office Building, Ste 120, Philadelphia, PA 19104 (elinore.kaufman@pennmedicine.upenn.edu).

Author Contributions: Dr Kaufman 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: Kaufman, Wiebe, Morrison, Seamon, Delgado.

Acquisition, analysis, or interpretation of data: Kaufman, Xiong, Delgado.

Drafting of the manuscript: Kaufman, Wiebe, Xiong, Morrison, Delgado.

Critical revision of the manuscript for important intellectual content: Kaufman, Wiebe, Morrison, Seamon, Delgado.

Statistical analysis: Kaufman, Xiong, Morrison.

Obtained funding: Delgado.

Administrative, technical, or material support: Kaufman, Delgado.

Supervision: Kaufman, Wiebe, Delgado.

Conflict of Interest Disclosures: Dr Delgado reported receiving grants from the National Institutes of Health and from the Abramson Family Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Delgado was supported by the National Institute of Child Health and Human Development (grant K23HD090272001) and by a philanthropic grant from the Abramson Family Foundation.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This study was presented at the 15th Annual Academic Surgical Congress; February 5, 2020; Orlando, Florida.

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