Costs of Fatal and Nonfatal Firearm Injuries in the U.S., 2019 and 2020.

INTRODUCTION: Firearm-related injuries are among the five leading causes of death for people aged 1-44 years in the U.S. The immediate and long-term harms of firearm injuries pose an economic burden on society. Fatal and nonfatal firearm injury costs in the U.S. were estimated providing up-to-date economic burden estimates. METHODS: Counts of nonfatal firearm injuries were obtained from the 2019-2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Data on nonfatal injury intent were obtained from the National Electronic Injury Surveillance System - Firearm Injury Surveillance System. Counts of deaths (firearm as underlying cause) were obtained from the 2019-2020 multiple cause-of-death mortality data from the National Vital Statistics System. Analyses were conducted in 2023. RESULTS: The total cost of firearm related injuries and deaths in the U.S. for 2020 was $493.2 billion, a 16 percent increase compared with 2019. There are significant disparities in the cost of firearm deaths in 2019-2020, with non-Hispanic Black people, males, and young and middle-aged groups being the most affected. CONCLUSIONS: Most of the nonfatal firearm injury-related costs are attributed to hospitalization. These findings highlight the racial/ethnic differences in fatal firearm injuries and the disproportionate cost burden to urban areas. Addressing this important public health problem can help ameliorate the costs to our society from the rising rates of firearm injuries.

Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults.

Importance: Adverse childhood experiences (ACEs) are preventable, potentially traumatic events in childhood, such as experiencing abuse or neglect, witnessing violence, or living in a household with substance use disorder, mental health problems, or instability from parental separation or incarceration. Adults who had ACEs have more harmful risk behaviors and worse health outcomes; the economic burden associated with these issues is uncertain. Objective: To estimate the economic burden of ACE-associated health conditions among US adults. Design, Setting, and Participants: In this economic evaluation, regression models of cross-sectional survey data from the 2019-2020 Behavioral Risk Factor Surveillance System (BRFSS) and previous studies were used to estimate ACE population-attributable fractions (PAFs) (ie, the fraction of total cases associated with a specific exposure) for selected health outcomes (anxiety, arthritis, asthma, cancer, chronic obstructive pulmonary disease, depression, diabetes, heart disease, kidney disease, stroke, and violence) and risk factors (heavy drinking, illicit drug use, overweight and obesity, and smoking) among the 2019 US adult population. Adverse childhood experience PAFs were used to calculate the proportion of total condition-specific medical spending and lost healthy life-years related to ACEs using Global Burden of Disease Study data. Data analysis was performed from September 10, 2021, to November 29, 2022. Exposure: Adverse childhood experiences (age <18 years). Main Outcomes and Measures: Monetary valuation of ACE-associated morbidity and mortality using standard US value of statistical life methods and presented in terms of annual and lifetime per affected person and total population estimates at the national and state levels. Results: A total of 820 673 adults, representing 255 million individuals, participated in the BRFSS in 2019 and 2020. An estimated 160 million of the total 255 million US adult population (63%) had 1 or more ACE, associated with an annual economic burden of $14.1 trillion ($183 billion in direct medical spending and $13.9 trillion in lost healthy life-years). This was $88 000 per affected adult annually and $2.4 million over their lifetimes. The lifetime economic burden per affected adult was lowest in North Dakota ($1.3 million) and highest in Arkansas ($4.3 million). Twenty-two percent of adults had 4 or more ACEs and comprised 58% of the total economic burden-the estimated per person lifetime economic burden for those adults was $4.0 million. Conclusions and Relevance: In this cross-sectional analysis of the US adult population, the economic burden of ACE-related health conditions was substantial. The findings suggest that measuring the economic burden of ACEs can support decision-making about investing in strategies to improve population health.

Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention - 25 States, 2015-2017.

INTRODUCTION: Adverse childhood experiences, such as violence victimization, substance misuse in the household, or witnessing intimate partner violence, have been linked to leading causes of adult morbidity and mortality. Therefore, reducing adverse childhood experiences is critical to avoiding multiple negative health and socioeconomic outcomes in adulthood. METHODS: Behavioral Risk Factor Surveillance System data were collected from 25 states that included state-added adverse childhood experience items during 2015-2017. Outcomes were self-reported status for coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, cancer (excluding skin cancer), kidney disease, diabetes, depression, overweight or obesity, current smoking, heavy drinking, less than high school completion, unemployment, and lack of health insurance. Logistic regression modeling adjusting for age group, race/ethnicity, and sex was used to calculate population attributable fractions representing the potential reduction in outcomes associated with preventing adverse childhood experiences. RESULTS: Nearly one in six adults in the study population (15.6%) reported four or more types of adverse childhood experiences. Adverse childhood experiences were significantly associated with poorer health outcomes, health risk behaviors, and socioeconomic challenges. Potential percentage reductions in the number of observed cases as indicated by population attributable fractions ranged from 1.7% for overweight or obesity to 23.9% for heavy drinking, 27.0% for chronic obstructive pulmonary disease, and 44.1% for depression. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Efforts that prevent adverse childhood experiences could also potentially prevent adult chronic conditions, depression, health risk behaviors, and negative socioeconomic outcomes. States can use comprehensive public health approaches derived from the best available evidence to prevent childhood adversity before it begins. By creating the conditions for healthy communities and focusing on primary prevention, it is possible to reduce risk for adverse childhood experiences while also mitigating consequences for those already affected by these experiences.

The economic burden of child sexual abuse in the United States.

The present study provides an estimate of the U.S. economic impact of child sexual abuse (CSA). Costs of CSA were measured from the societal perspective and include health care costs, productivity losses, child welfare costs, violence/crime costs, special education costs, and suicide death costs. We separately estimated quality-adjusted life year (QALY) losses. For each category, we used the best available secondary data to develop cost per case estimates. All costs were estimated in U.S. dollars and adjusted to the reference year 2015. Estimating 20 new cases of fatal and 40,387 new substantiated cases of nonfatal CSA that occurred in 2015, the lifetime economic burden of CSA is approximately $9.3 billion, the lifetime cost for victims of fatal CSA per female and male victim is on average $1,128,334 and $1,482,933, respectively, and the average lifetime cost for victims of nonfatal CSA is of $282,734 per female victim. For male victims of nonfatal CSA, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of $74,691 per male victim. If we included QALYs, these costs would increase by approximately $40,000 per victim. With the exception of male productivity losses, all estimates were based on robust, replicable incidence-based costing methods. The availability of accurate, up-to-date estimates should contribute to policy analysis, facilitate comparisons with other public health problems, and support future economic evaluations of CSA-specific policy and practice. In particular, we hope the availability of credible and contemporary estimates will support increased attention to primary prevention of CSA.

Violence in the United States: Status, Challenges, and Opportunities.

IMPORTANCE: Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence. OBJECTIVES: To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities. DATA SOURCES: We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigation's Uniform Crime Reports, the US Justice Department's National Crime Victimization Survey, the National Survey of Children's Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System-All Injury Program. RESULTS: Homicide rates have decreased from a peak of 10.7 per 100,000 persons in 1980 to 5.1 per 100,000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100,000 in 1992 to 242 per 100,000 in 2012. Nevertheless, annually, there are more than 16,000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE: Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.

The burden of child maltreatment in the East Asia and Pacific region.

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region's per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region's GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

A national survey of childhood physical abuse among females in Swaziland.

OBJECTIVE: This study describes the scope and characteristics of childhood physical abuse in a nationally representative sample of 13-24 year-old females in Swaziland. The current study also examined health consequences and risk factors of childhood physical abuse. METHODS: The study utilized a two-stage cluster sampling design in order to conduct the household survey. Retrospective reports of childhood physical abuse and relevant risk factors were collected from 1292 females. Bivariate and multivariate logistic regression models examined associations between childhood physical abuse and both health consequences and risk factors. RESULTS: Nearly 1 in 5 females in Swaziland has experienced childhood physical abuse in their lifetime, with nearly 1 in 20 having experienced abuse that was so severe that it required medical attention. A number of risk factors for lifetime childhood physical abuse were identified including: maternal death prior to age 13; having lived with three or more families during their childhood; and having experienced emotional abuse prior to age 13. CONCLUSIONS: Preventing childhood physical abuse in Swaziland may be addressed through: promoting safe, stable, and nurturing relationships between children and their caretakers; addressing social norms that contribute to harsh physical punishment; and addressing underlying stressors associated with severe social and economic disadvantage.

The economic burden of child maltreatment in the United States and implications for prevention.

OBJECTIVES: To present new estimates of the average lifetime costs per child maltreatment victim and aggregate lifetime costs for all new child maltreatment cases incurred in 2008 using an incidence-based approach. METHODS: This study used the best available secondary data to develop cost per case estimates. For each cost category, the paper used attributable costs whenever possible. For those categories that attributable cost data were not available, costs were estimated as the product of incremental effect of child maltreatment on a specific outcome multiplied by the estimated cost associated with that outcome. The estimate of the aggregate lifetime cost of child maltreatment in 2008 was obtained by multiplying per-victim lifetime cost estimates by the estimated cases of new child maltreatment in 2008. RESULTS: The estimated average lifetime cost per victim of nonfatal child maltreatment is $210,012 in 2010 dollars, including $32,648 in childhood health care costs; $10,530 in adult medical costs; $144,360 in productivity losses; $7,728 in child welfare costs; $6,747 in criminal justice costs; and $7,999 in special education costs. The estimated average lifetime cost per death is $1,272,900, including $14,100 in medical costs and $1,258,800 in productivity losses. The total lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the United States in 2008 is approximately $124 billion. In sensitivity analysis, the total burden is estimated to be as large as $585 billion. CONCLUSIONS: Compared with other health problems, the burden of child maltreatment is substantial, indicating the importance of prevention efforts to address the high prevalence of child maltreatment.

Benefits of preventing a death associated with child maltreatment: evidence from willingness-to-pay survey data.

Although assessing the costs of an intervention to prevent child maltreatment is straightforward, placing a monetary value on benefits is challenging. Respondents participating in a statewide random-digit-dialed survey were asked how much they would be willing to pay to prevent a death caused by child maltreatment. Our results suggested that society may value preventing a death from child maltreatment at $15 million. If a child maltreatment intervention is effective enough to save even 1 life, then in many cases, its benefits will outweigh its costs.

Sexual violence and its health consequences for female children in Swaziland: a cluster survey study.

BACKGROUND: Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. We report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences. METHODS: We obtained data from a nationally representative sample of girls and women aged 13-24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96.3%), of whom 1242 provided retrospective responses to questions about sexual violence. We used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions. FINDINGS: 33.2% (95% CI 29.9-36.7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent's neighbourhood (32.3% [28.8-36.1]) and boyfriends or husbands (26.2% [22.2-30.7]). The first incident most often took place in the respondent's own home (26.1% [21.6-31.2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3.69 [95% CI 1.78-7.66]), pregnancy complications or miscarriages (3.54 [1.47-8.55]), unwanted pregnancy (2.92 [1.87-4.55]), and self-report of feeling depressed (2.30 [1.70-3.11]). INTERPRETATION: Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies. FUNDING: UNICEF.

The impact of violence on health in low- to middle-income countries.

More than 90% of violence-related deaths occur in low- to middle-income countries (LMICs), where the mortality rate due to violence is almost 2.5 times greater than in high-income countries. Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. Several studies describe the deleterious impact of different types of violence on a range of health outcomes, but no review has yet been undertaken that presents a composite overview of the current state of knowledge in LMICs. This paper reviews the scientific literature describing the nature, magnitude and impact of violence on health, describing the current state of violence-prevention policy developments within the global health agenda and highlighting the health consequences, disease burden and economic costs of violence. Although data are limited, the review indicates that costs relating to violence deplete health care budgets considerably and that scarce resources could be better used to address other health threats that hamper development.

Preventing violence in developing countries: a framework for action.

Violence is an enormous global public health problem that increases the risk of injury, disease and poor mental health while also impeding economic and social development. This paper articulates a framework for violence prevention in developing countries that is grounded in the knowledge gained from research and programmatic efforts in rich and in poor countries over several decades. This framework can be used by countries and funding agencies as a guide to building strong foundations for ongoing violence prevention efforts and for identifying violence prevention strategies most likely to be effective. The world has learned a lot about preventing violence and, without a doubt, there is a great deal more to learn. As a global community, however, it is not possible to wait for perfect solutions to these problems to act. The obligation is to act now to use the valuable knowledge that has been gained about violence prevention to improve the world.

The impact of violence on development in low- to middle-income countries.

Along with the numerous trauma-related impacts of violence and its effects on other health outcomes, the social toll of violence is further exacerbated by economic costs that represent formidable threats to fiscal growth and development. A companion piece to a review of the scientific literature describing the nature, magnitude and impact of violence on health (Matzopoulos, Bowman, Butchart & Mercy, 2008) in this issue, this paper reviews the current knowledge base on violence and development with a specific focus on low- to middle-income countries. It describes how violence impacts on all eight goals of the Millennium Development Plan and exerts a considerable economic burden on already stressed state systems and social spending. Violence will become an increasingly important threat to development and is receiving growing recognition among the global health community and within health ministries. The near absence of violence prevention within the global development agenda is, however, cause for concern. There is an urgent need to mobilise the international development community to provide financial and technical support for intersectoral collaboration, multilateral research cooperation and the development of research capacity towards addressing violence as a significant threat to development.

Methods for estimating medical expenditures attributable to intimate partner violence.

This article compares three methods for estimating the medical cost burden of intimate partner violence against U.S. adult women (18 years and older), 1 year postvictimization. To compute the estimates, prevalence data from the National Violence Against Women Survey are combined with cost data from the Medical Expenditure Panel Survey, the Medicare 5% sample, and published studies and with relative risk estimates from published studies. Results are compared and reasons for difference are explored, including the advantages and disadvantages of each approach. Estimates of the medical cost burden of intimate partner violence within the first 12 months after victimization range from USD 2.3 billion to USD 7.0 billion, depending on the method used. Although limited to women victimized in the last year, each method reveals that intimate partner violence imposes a substantial burden on the health care system. Among the approaches, there is no clear gold standard nor any evidence of bias.

Medical costs and productivity losses due to interpersonal and self-directed violence in the United States.

BACKGROUND: Violence-related injuries, including suicide, adversely affect the health and welfare of all Americans through premature death, disability, medical costs, and lost productivity. Estimating the magnitude of the economic burden of violence is critical for understanding the potential amount of resources that can be saved if cost-effective violence prevention efforts can be broadly applied. From 2003 to 2005, the lifetime medical costs and productivity losses associated with medically treated injuries due to interpersonal and self-directed violence occurring in the United States in 2000 were assessed. METHODS: Several nationally representative data sets were combined to estimate the incidence of fatal and nonfatal injuries due to violence. Unit medical and productivity costs were computed and then multiplied by corresponding incidence estimates to yield total lifetime costs of violence-related injuries occurring in 2000. RESULTS: The total costs associated with nonfatal injuries and deaths due to violence in 2000 were more than $64.8 [corrected] billion. Most of this cost ($64.4 billion or 92%) was due to lost productivity. However, an estimated $5.6 billion was spent on medical care for the more than 2.5 million injuries due to interpersonal and self-directed violence. CONCLUSIONS: The burden estimates reported here provide evidence of the large health and economic burden of violence-related injuries in the U.S. But the true burden is likely far greater and the need for more research on violence surveillance and prevention are discussed.

Do laws restricting access to firearms by domestic violence offenders prevent intimate partner homicide?

Domestic violence imposes a large cost on society. The authors exploit state variation in timing to examine the impact of three types of law on intimate partner homicides. These laws restrict access to firearms by individuals who are subject to a restraining order or have been convicted of a domestic violence misdemeanor or allow law enforcement officers to confiscate firearms at a domestic violence scene. The authors find that female intimate partner homicide rates decline 7% after a state passes a restraining order law. They find no effect from the domestic violence misdemeanor or confiscation laws.

Violence and health: the United States in a global perspective.

Violence is a public health problem that can be understood and changed. Research over the past 2 decades has demonstrated that violence can be prevented and that, in some cases, prevention programs are more cost-effective than other policy options such as incarceration. The United States has much to contribute to-and stands to gain much from-global efforts to prevent violence. A new World Health Organization initiative presents an opportunity for the United States to work with other nations to find cost-effective ways of preventing violence and reducing its enormous costs.