Hospitals need to address root causes of violence, experts say

Trauma surgeons are not wasting money by saving the lives of gunshot victims, even if they live in violent neighborhoods that make them statistically likely to return with future injuries, a new study finds.

But hospitals could do a better job of interrupting cycles of trauma recidivism.

The study of Baltimore trauma patients published online in the Annals of Surgery compared long-term survival rates for victims of intentional injuries like gunshots and stabbings, versus those who were treated for injuries from accidental causes like car crashes. The study analyzed federal death data on 2,062 trauma patients who stayed more than 24 hours at Johns Hopkins Hospital, Baltimore, between 1998 and 2000.

After controlling for variations in age, sex, race, insurance and other factors, the study found no significant difference in nine-year survival rates between accidental trauma patients and those injured by guns or knives.

“We have been asked … are we saving lives only to lose them in the near future to more violence?” said lead study author Dr. Adil Haider, a Johns Hopkins trauma surgeon. “This study shows that these patients live as long as anyone who has survived serious injury. Saving a life is always worth it and should never be seen as an exercise in futility.”

But examining the 302 patients who did die within a decade of discharge reveals trends documented in other studies of the topic.

The Johns Hopkins study found that patients who lived in low-income neighborhoods were more likely to have died from any cause than those from areas around Baltimore with average incomes of more than $25,000 a year.

And about one-third of the patients with intentional injuries between 1998 and 2000—who hailed primarily from lower-income neighborhoods—were killed in subsequent violence within a decade. That's compared with the 5% of violent deaths for patients treated previously for unintentional injuries.

“These findings suggest that violence can be understood as a disease of poverty,” the study concludes. “The symptoms are treated in the ED, but the underlying cause remains untouched in environments of deprivation.”

After decades of inaction, officials at urban trauma centers are realizing that their mission to care for victims of violence may require them to address the root causes of trauma in their surrounding communities, said Dr. Michael Hirsch, a pediatric surgeon at UMass Memorial Medical Center, Worcester, Mass., and co-director of the Injury Free Coalition for Kids.

“You can't be a Level I or Level II trauma center unless you have a program that is trying to address some of these tough social issues, like why young people go into gangs or how youth get their hands on guns,” Hirsch said.

That means trauma surgeons today may spend time attending church meetings or visiting community organizations instead of relaxing on their days off, he said.

And the recent emphasis on population-based health and capitated payment models is likely to accelerate the trend, as injury prevention becomes “the lowest hanging fruit” in the drive to reduce overall healthcare costs. That encompasses everything from encouraging the use of bike helmets and seat belts to providing youth with alternatives to joining gangs.

“We're returning these victims of violent trauma to environments where incidence of violence is high. That sets them up for recidivism,” he said. “And the trauma center bears some responsibility to partner with other community elements to try to fight that recidivism.”

Follow Joe Carlson on Twitter: @MHJCarlson