Cost of hospitalization for firearm injuries by firearm, and payer in the United States

I no longer participate in Facebook. There are a number of reasons for this, not the least being the harassment at work a relative of mine suffered from subordinates in the workplace due to my antinuclear facebook content. The Mueller shows quite clearly how anti-democratic governments infiltrate social media in order to create silos of intolerance and manipulation in Western societies.

So, in matters which engage me, and for debates that I wish to participate in, my blog will, from to time, include non-nuclear topics.

The horrific mass murder of US school children and university students in the USA has over the years grabbed the attention of the whole world. Many of us who do not live in the United States cannot fathom how members of national and state governments in the USA can bear to look at themselves in the mirror every day. They have failed in their primary duty of protecting children at school. It is state and federal law which mandate that children must attend school. And so each death from any cause of a child at school is an indictment upon those who, by force of law, herd children into what are, due to the combined effects of US laws and attitudes, too often, killing fields. Given the nature of the injuries inflicted by weapons of military or semi military specifications, many survivors will suffer chronic pain, disability and repeat surgeries over many years.

The following paper details the Cost of gun shot injuries in the USA. Below the quotes from this academic paper I should include the text of the US Second Amendment and will study and discuss what the text actually says and what the text actually means. Has the provisions of the US Second Amendment actually ever been fully implemented? If not, why not?

Cost of hospitalization for firearm injuries by firearm type, intent, and payer in the United States

Corinne Peek-Asa,corresponding author1 Brandon Butcher,2 and Joseph E. Cavanaugh2 1The Department of Occupational and Environmental Health, College of Public Health, University of Iowa, 145 North Riverside Drive, S143 CPHB, Iowa City, IA 52242 USA
2The Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa USA

Copyright © The Author(s). 2017
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Abstract
Background
Firearm injuries disproportionately affect young, male, non-White populations, causing substantial individual and societal burden. Annual costs for hospitalized firearm injuries have not been widely described, as most previous cost studies have focused on lifetime costs. We examined a nationally-representative database of hospitalizations in the US to estimate per-hospital and overall hospital costs for firearm injuries by intent, type of weapon, and payer source.

Methods
We conducted a retrospective cohort study of all firearm injury hospitalizations in the National Inpatient Sample from 2003 through 2013. The National Inpatient Sample, maintained by the Healthcare Utilization Project, is a stratified and weighted national sample of more than 20% of all hospitals. All admissions for firearm injuries were identified through Ecodes, yielding a weighted total of 336,785 for the study period. Average annual per-patient and overall hospital costs were estimated using generalized linear modelling, controlling for patient and hospital variables. Costs by intent, firearm type, and payer sources were estimated.

Results
Annually from 2003 through 2013, 30,617 hospital admissions were for firearm injuries, for an annual rate of 10.1 admissions per 100,000 US population. More than 80% of hospitalizations were among individuals aged 15–44, and rates were nine times higher for males than females and nearly ten times higher for the Black than the White population. More than 60% of admissions were for assaults, and 70% of the injuries that had a known firearm type were from handguns. The average annual admission cost was $622 million. The highest per-admission costs were for injuries from assault weapons ($32,237 per admission) and for legal intervention ($33,462 per admission), but the highest total costs were for unspecific firearm type ($373 million) and assaults ($389 million). A quarter of firearm injury hospitalizations were among the uninsured, yielding average annual total costs of $155 million.

Conclusion
Hospitals can project that government insurance will be the highest source for firearm injury reimbursement, and depending on healthcare access laws, that many of their firearm injury admissions will not be covered by insurance.

Background
Among all injury deaths in the United States in 2015, 17% were caused by a firearm (National Center for Injury Prevention and Control & US Centers for Disease Control and Prevention, 2015; Karp, 2011). Among youth aged 15–24 this percent increased to 29.6%, and for Black youth firearms were the leading overall cause of death, resulting in 58.6% of all injury deaths. Individual firearm ownership is high but not unique to the United States, although the burden of firearm violence is: World Health Organization mortality data from 2010 indicate that US gun-related homicide rates were 25 times higher than in a comparison group of 23 high income countries (Cook & Ludwig, 1997; Council on Injury, Violence, and Poison Prevention Executive Committee & American Academy of Pediatrics, 2012; Grinshteyn & Hemenway, 2016). While the majority of research has been on firearm deaths, the individual, family, and community burden is also high for those with non-fatal firearm injuries.

Research to reduce the health and societal burden of firearm injuries has been lacking, and medical and public health groups have published calls to build an evidence base for prevention (Karp, 2011; Branas et al., 2017; Strong et al., 2016). Understanding the economic burden of firearm injuries is a critical element of advancing our knowledge base. Of seven studies reporting the cost burden of firearm injuries (Salemi et al., 2015; Spitzer et al., 2017; Corso et al., 2007; Lee et al., 2014; Miller, 2012; Fowler et al., 2015; Allareddy et al., 2012), two have estimated hospitalization costs for firearm injuries in the US population (Salemi et al., 2015; Spitzer et al., 2017). Salemi et al. (2015) estimated annual hospitalization costs at $679 million and reported hospitalization costs by patient and hospital (Salemi et al., 2015). Spitzer et al. (2017) estimated total hospitalization costs for the period of 2006–2014 at $6.6 billion and reported costs by payer source (Spitzer et al., 2017). Neither of these studies conducted multivariable analysis to examine cost components from firearm injuries. Of the other firearm cost studies, three focused on the overall lifetime costs associated with firearm deaths and injuries (Corso et al., 2007; Lee et al., 2014; Miller, 2012), one focused on lifetime medical costs and productivity loss (Fowler et al., 2015), and one that examined hospital costs included only children (Allareddy et al., 2012).

The aim of this study was to estimate annual and per-hospitalization cost for firearm injuries by intent, weapon type, and payer source, controlling for patient and hospital characteristics. We examined data from the National Inpatient Sample from 2003 through 2013. The healthcare industry will benefit from information about the annual direct medical costs associated with firearm injuries and the main contributors to these costs, as this information can be used to anticipate costs and to compare to a national benchmark. Information about patient characteristics, injury intent, type of weapon, and payer source will alsobe helpful, but these relationships have not been examined routinely in previous studies. These data will also be helpful to those planning intervention programs by bringing more attention to the economic burden of firearm injuries in the US. …..”

Demographic characteristics and payer source by firearm injury intent
Overall, 60.6% of firearm injuries were assaults, 22.6% were unintentional, and 8.6% were self-harm (Table ​(Table2).2). Among children, firearm injuries of unintentional intent were the most common, comprising 55.8% of firearm injuries to children aged five and younger and 42.4% of those aged five to 14. From the ages of 15 through 64, assault was the most common intent, followed by unintentional injuries. The proportion of firearm injuries caused by self-harm increased with age, reaching 38.8% among those aged 65 and over. Among this age group, 32.8% of firearm injuries were unintentional. Although assault was the most common intent for both males and females, a higher proportion of males (61.5%) than females (52.8%) were due to assault.

Costs for firearm injury hospitalizations by intent, type of weapon, and payer source
The average hospital admission costs for firearm injuries exceeded $622 million per year, which represents a small portion of overall firearm death and injury costs. Results from the multivariable model estimating annual costs per patient and total annual costs, controlling for age, race, income, disposition, death during hospitalization, year, and hospital bed size and region are presented in Table ​Table44.

For admissions for which the type of firearm was known, handguns accounted for over 70% of the costs, which exceeded $183 million. This was the highest total admission cost per known firearm type, although handgun injuries were the least costly per admission. Assault weapons, although the most expensive at over $32,000 per admission, had the lowest annual costs at $2.7 million. Admissions from shotguns, which had the second highest cost per admission, had the second highest total annual cost of over $50 million. All pairwise comparisons by type of firearm were statistically significant with p < 0.05 with the exception of handgun vs. hunting rifle.

By intent, legal intervention had the highest per-admission average cost of $33,463, followed by self-harm at $24,369. Admissions from assaults had an average per-admission cost of $20,989 but accounted for $389 million in average annual costs – by far the highest overall cost by any intent. Admissions from unintentional firearm injuries were the second highest overall annual cost at over $117 million. All pairwise comparisons were statistically significant with p < 0.05.

Among payer sources, Medicaid had both the highest per-admission average at $24,714 and the highest total annual average of more than $205 million. Uninsured patients accounted for an annual average of $155 million. In sum, government and uninsured admissions from firearm injuries accounted for nearly $400 million in average costs per year, or 65% of all firearm admission costs. All pairwise comparisons by type of firearm were statistically significant with p < 0.05 with the Medicare vs. Private/HMO.

Our cost estimates provide only a small component of the overall burden of firearm injuries. Studies reporting lifetime medical and productivity costs range from $48 to $175 billion (Corso et al., 2007; Lee et al., 2014; Miller, 2012; Fowler et al., 2015; Allareddy et al., 2012), with differences based on the source of firearm incidence data, types of firearm injuries included, sources of cost estimates, and types of costs included in the estimate. Lost productivity from premature death as well as work time loss was the largest component of these costs, with a smaller proportion from direct medical care.

We found that firearm injuries disproportionately affect youth, males, and a non-White population. These trends have been widely reported in previous research (Fowler et al., 2015; Allareddy et al., 2012; Leventhal et al., 2014). In addition, we found that assaults caused more than 60% of admissions, followed by unintentional injuries. These trends are also similar to those reported in other studies of non-fatal firearm injuries (Fowler et al., 2015; Leventhal et al., 2014). However, because firearms are such a lethal means of suicide, suicide comprises a higher proportion of firearm mortality by intent (Fowler et al., 2015). Rates of firearm hospital admissions did not change significantly from 2003 through 2013. Previous studies have found that hospitalizations decreased between 1998 and 2011 among children injured by a firearm (Kalesan et al., 2016), and for all firearm hospitalizations from 2000 to 2010 (Kalesan et al., 2013).

Handguns and assaults posed the largest overall hospitalization cost burden. Although the highest per-hospital cost was for assault weapons, handguns comprised over 70% of firearm injuries among those for which the weapon type was known and the total annual hospitalization costs were nearly $183 million. Assaults had the third-highest cost per hospitalization and were the most frequent intent, costing an annual total of nearly $373 million. Two other studies reported costs by injury intent. Fowler et al. reported lifetime medical and lost work time costs among those admitted to a hospital to be approximately $475 million for unintentional firearm injuries, $600 million for self-harm/suicide, and over $2 billion for assault/homicide (Fowler et al., 2015). Corso et al. reported the lifetime costs medical costs for assaults as $800 million and for self-harm as $124 million (this study included only violent firearm injuries) (Corso et al., 2007). While these study’s estimates are higher due to factors described above, the trends by intent are similar.

Conclusion
These findings demonstrate the high healthcare cost burden of firearm injuries. Firearm disproportionately impacts a young, minority, and uninsured population. Hospitals can expect that the largest proportion of treatment for firearm injury admissions will be reimbursed by public sources, and, depending on trends in health insurance coverage, that a fifth of patients will have no insurance. While individual treatment costs will be highest for assault weapon injuries and legal intervention, overall costs will be highest for handguns and assaults. Efforts to prevent firearm injuries, particularly among assaults and injuries caused by handguns, could reduce this cost burden.

Funding
This analysis was not externally funded. end partial quote. The full paper can be read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515719/

Dealing in dollars has to be translated into the cost in death and suffering, which continues for many years. Military grade weapons are commonly designed to ensure that injuries tie up as many enemy resources as possible in a war theatre. In the context of a civil society allegedly at peace with itself (?) it can be seen that the availability of variants of military specified weapons a high cost upon society and upon individuals both in terms of blood and money. Hand guns, not surprisingly are the weapons of choice of criminals seeking to rob or harm other for criminal benefit.

Every lay person on the planet knows that where mass murder is planned in the USA, the weapons of choice has been and remains those weapons patterned after military rifles such as the M16 and AR-15.
The civilian derivatives vary widely in calibre, rate of fire, accurate and inaccurate range. Everyone knows this for sure because each time there is a massacre in the USA the type of weapon used is described in published reports. Invariably, the mass murder does not use a hand gun, they do not use a bolt action weapon, they choose to use a variant of a military rifle. Of the type that is highly inaccurate in close quarter combat. You have to aim them very high to hit an actual target who is close by.

The above paper reports that : "World Health Organization mortality data from 2010 indicate that US gun-related homicide rates were 25 times higher than in a comparison group of 23 high income countries (Cook & Ludwig, 1997; Council on Injury, Violence, and Poison Prevention Executive Committee & American Academy of Pediatrics, 2012; Grinshteyn & Hemenway, 2016). While the majority of research has been on firearm deaths, the individual, family, and community burden is also high for those with non-fatal firearm injuries.

The conventional wisdom which I observe to be commonly expressed by people in support of present gun habits in the USA (which have produced the facts and consequences described in the paper above) goes something like this: As everyone in the USA is free to bear arms, everyone who does is safer than those who don’t. Therefore, if you take away the right to bear arms, everyone is becomes more vulnerable to the criminal and in particular to the mass murderer.

However, when I compare that line of reasoning as an Australian to the statistics which actually compare social safety in the USA to other comparable nations I am left wondering how people in America can claim to have created the safest of all possible societies in the context of US gun culture. For you see, the paper quoted above also states that : “Individual firearm ownership is high but not unique to the United States, although the burden of firearm violence is

When the USA is compared to nations with a similar level of gun ownership among civilians, the USA is revealed to be 25 times worse off in terms of harms caused by those civilian owned guns ?

That to me is a very important point. Why is American society so violent?

It is very difficult. I need to read the US Secondment Amendment. So here goes:

Second Amendment

The Second Amendment of the United States Constitution reads: “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

The plain reading of the text from my perspective goes like this.
In the context of a well regulated Militia, by which the democratic State ensures its own security and the security of its people, the right of the people to bear arms is guaranteed.

The conditions which precede the right determine the obligations of both the nation and the individual in terms of gun ownership.

That is, it is with the parameters of a WELL REGULATED MILITIA that individuals have an unfettered right to bear arms.

No such militia exists in the USA. Not every gun owner is a member of the US National Guard.

Could it possibly be that the authors of second amendment were actually stipulating that to own a gun as a civilian outside of occupation use in the USA one had to become a member of the described organisation? That is the well regulated US Militia?

I think so. I can’t confirm it for the authors of the Second Amendment are dead. And it seems to me everyone has only ever paid attention to the right to bear arms and has totally ignored the obligation which precedes that right and which produces that right.

Where ever there is a right, there is always an obligation. This case is no different.

The ownership of firearms in the USA at the present time seems to me to be ill disciplined and based a upon a demonstrated myth – the myth that Americans are safer because of unfettered gun ownership.

Well the facts give the reality – people in the USA suffer 25 times the level of gun violence death and injury than other comparable nations with the same level of gun ownership. A high level of gun level ownership is NOT unique to the USA.

So what makes Americans suffer 25 times the level of gun violence than any similar advanced nation?

Are Americans just violent people? If you took away the guns would people being using machetes instead? The death toll would be lower if they did, that’s for sure.

Mass shootings of children at school in the USA have been perceived to be routine by people around the world, including myself. The failure of government to protect children at school is a grave dereliction of duty on the part of lawmakers.

Having said that, it is obvious that American society is a very violent society and the weapon of choice is the firearm. It is, basically, 25 times more violence in terms of gun death and injury than other relevant nations.

How does a government which has led a habitually violent society for generations turn schools into islands of peace and safety without addressing the actual causes of the violence in America?

I have seen no statistics which compare armaments owned by civilians in nations comparable in gun ownership to the USA.

In terms of rate of fire, range, injury types and permitted ammunition holdings though, I suspect people in the USA “enjoy” civilian access to more potent, injurious and lethal weapons than most other nations permit.

Certainly a military or variant of a military rifle is by and large illegal to own in Australia. And has been since the Port Arthur Massacre. Basically I can make a good case for owning a .22 bolt action rifle if I was so inclined, but I can’t go to Big W and buy anything resembling the weapon of choice used by people who regularly mow down children at their school desks in the USA.

And the vast majority of Australians are very thankful for that. However I have strong suspicion that were Australian law adopted for use in the USA, in this regard, it would indeed spark an armed rebellion.

I see nothing wrong with a “well regulated militia” being the only context in which civilians, on the whole, are allowed to bear arms. Join up, go to training every Friday night and Saturday morning, or else forgo your weapon. That, after all, is the proviso of the Second Amendment. Before the right comes the obligation. If you are incapable of fulfilling the obligation but still have a weapon, you are in breach of the US Second Amendment. And under it therefore you are not entitled to bear arms. Not everyone is fit for duty. Not everyone should carry a gun nor should they have the right to do so. In the absence of a cohort of people who are well regulated by an organisation to which they are subordinate, and who know each other very well because they are brothers and sisters in arms, who the hell is going to really know who should and who should not carry a gun in America?

As for the violent nature of American society compared to other compatible nations, well, if the Adult American creates, en masse, the tone of the society, who is there for the vulnerable and disturbed and angry and latently suicidal/murderous (same coin folks) to emulate and be inspired by?

Sure, I vaguely understand that the ethos of American self sufficiently dictates to many that they be able to hold off the bandits at least until the police get there, but I can also see that most victims of crime in America either can’t use their weapon in time or have it stolen from them by their assailant. In the Australian context pulling a gun on a robber or rapist is quick way for the victim to suffer and die. For the criminal is ready to act and victims do not walk down the street with weapon drawn, loaded, safety off, as if they were on point duty in the Mekong Delta in 1972.

There is in my view no valid reason for a civilian to own a military assault weapon. None what so ever. It is not needed for defence, such weapons have such as a range as to be totally inaccurate in close quarter engagements.

Unlike the statistics which reveal American society as being comparatively very violent, and the stats which show the cost of gun use and abuse in America, my views about assault rifles in the hands of civilians are just my opinions.

The question for Americans is : If we do nothing this time, what will we do next time, the time after that, and the time after that? Are bullet riddled schools and maimed and dead children really what we want on an escalating basis? How do we stop it from happening next time, and the time after that etc etc etc.

Luckily for me, I am not an American, I don’t live there, and I sure as hell don’t want Australia to import American culture. It costs too many innocent lives.

If you keep your mouth shut, you are safer in China. And yea, it seems American is moving that way too…..

Meanwhile, the organised gun lobby in the USA resists with steely determination any attempt by authorities and the people to impose well crafted, realistic regulation upon American gun ownership and purpose. As demanded by the very text of the Second Amendment.

Such regulation being the Constitutional demand imposed upon the resultant right of civilian gun in the United States of America.

Under the Second Amendment the purpose of gun ownership is for the protection of democracy. As it stands millions want change. Those that stand in the way of that change will loose eventually. The time it takes for change to occur will be clocked by an increasing body count.

There is no such thing as a right without matching obligations. All rights are conferred by the nation to the people for it is the duty of the government to make and amend laws according to the wishes of the majority. One person one vote defines the boundaries of the fundamental political freedom in a democracy. Acts of force by individuals and collections of individuals against the state and to thwart the state in the making of just laws is treason. Pure and simple.

If the most powerful nation on earth cannot keep its children safe from routine mass murder at school, how powerful is it really and what signal does its actual weakness send to the enemies of freedom?

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