Death by the minute: Inequities in trauma care for victims of firearm violence.

BACKGROUND: Gunshot wounds (GSWs) remain a significant source of mortality in the United States. Timely delivery of trauma care is known to be critical for survival. We sought to understand the relationship of predicted transport time and death after GSW. Given large racial disparities in firearm violence, we also sought to understand disparities in transport times and death by victim race, an unstudied phenomenon. METHODS: Firearm mortality data were obtained from the Boston Police Department 2005 to 2023. Firearm incidents were mapped using ArcGIS. Predicted transport times for each incident to the closest trauma center were calculated in ArcGIS. Spatial autoregressive models were used to understand the relationship between victim race, transport time to a trauma center, and mortality associated with the shooting incidents. RESULTS: There were 4,545 shooting victims with 758 deaths. Among those who lived, the median transport time was 9.4 minutes (interquartile range, 5.8-13.8) and 10.5 minutes (interquartile range, 6.4-14.6; p = 0.003) for those who died. In the multivariable logistic regression, increased transport time to the nearest trauma center (odds ratio, 1.024; 95% confidence interval, 1.01-1.04) and age (odds ratio, 1.016; 95% confidence interval, 1.01-1.02) were associated with mortality. There was a modest difference in median transport time to the nearest trauma center by race with non-Hispanic Black at 10.1 minutes, Black Hispanic 9.2 minutes, White Hispanic 8.5 minutes, and non-Hispanic White 8.3 minutes ( p < 0.001). CONCLUSION: Our results highlight the relationship of transport time to a trauma center and death after a GSW. Non-White individuals had significantly longer transport times to a trauma center and predicted mortality would have been lower with White victim transport times. These data underscore the importance of timely trauma care for GSW victims and can be used to direct more equitable trauma systems. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

Colleges and Crime-Comparing Homicide and Suicide Rates Among College Towns and Their Counterparts.

INTRODUCTION: To investigate differences in homicide and suicide rates across college town status and determine whether college towns were predisposed to changes in rates over time. METHODS: We analyzed county-level homicide and suicide rates (total and by firearm) across college town status using 2015-2019 CDC death certificate data and data from the American Communities Project. RESULTS: Population-level homicide rates were similar across college town status, but younger age groups were at increased risk for firearm homicide and total homicide in college towns. College town status was associated with lower population-level firearm suicide rates, but individuals aged less than 18 y were at increased risk for total and firearm suicide. Finally, college towns were not classified as outliers for changes in either firearm homicide or suicide rates over time. CONCLUSIONS: College towns had similar homicide rates and significantly lower firearm suicide rates than other counties; however, individuals aged less than 18 y were at increased risk for both outcomes. The distinctive demographic, social, economic, and cultural features of college towns may contribute to differing risk profiles among certain age groups, thus may also be amenable to focused prevention efforts.

Costs of Summer Youth Employment to Prevent Violence: an Analysis and Implementer's Tool.

Gun homicide rates have risen 35% across the USA since the start of the COVID-19 pandemic. One promising intervention to prevent violent crime is summer youth employment programs (SYEPs), which provide youth with meaningful workplace experiences, prosocial engagements, and developmental opportunities during the summer months, when many otherwise lack structure. This paper presents a cost analysis of violence prevention-focused SYEPs to help implementers understand the costs generally and in their own community contexts-to advocate for adoption and secure funding of, effectively budget for, and successfully implement SYEPs. Researchers use an ingredient-based costing approach and provide a template for implementers to use and adapt for their context. SYEPs with the goal of reaching youth who are justice-involved or at risk of being victims or perpetrators of violence can cost $3331 per youth assisted, with 54% of this cost directly paid to youth through stipends. Cost per youth is driven by the intensity of the mentoring and support that community organizations provide to the program participants. Knowing the cost per youth assisted can inform further analysis, implementation, and expansion of SYEPs.

Assessing the Gun Violence Archive as an Epidemiologic Data Source for Community Firearm Violence in 4 US Cities.

Importance: Firearm injury is a major public health burden in the US, and yet there is no single, validated national data source to study community firearm violence, including firearm homicide and nonfatal shootings that result from interpersonal violence. Objective: To assess the validity of the Gun Violence Archive as a source of data on events of community firearm violence and to examine the characteristics of individuals injured in shootings. Design, Setting, and Participants: This cross-sectional observational study compared data on community firearm violence from the Gun Violence Archive with publicly available police department data, which were assumed to be the reference standard, between January 1, 2015, and December 31, 2020. Cities included in the study (Philadelphia, Pennsylvania; New York, New York; Chicago, Illinois; and Cincinnati, Ohio) had a population of greater than 300 000 people according to the 2020 US Census and had publicly available shooting data from the city police department. A large city was defined as having a population greater than or equal to 500 000 (ie, Philadelphia, New York City, and Chicago). Data analysis was performed in December 2022. Main Outcomes and Measures: Events of community firearm violence from the Gun Violence Archive were matched to police department shootings by date and location. The sensitivity and positive predictive value of the data were calculated (0.9-1.0, excellent; 0.8-0.9, good; 0.7-0.8, fair; 0.6-0.7, poor; and <0.6, failed). Results: A total of 26 679 and 32 588 shooting events were documented in the Gun Violence Archive and the police department databases, respectively, during the study period. The overall sensitivity of the Gun Violence Archive over the 6-year period was 81.1%, and the positive predictive value was 99.0%. The sensitivity steadily improved over time. Shootings involving multiple individuals and those involving women and children were less likely to be missing from the Gun Violence Archive, suggesting a systematic missingness. Conclusions and Relevance: These findings support the use of the Gun Violence Archive in large cities for research requiring its unique advantages (ie, spatial resolution, timeliness, and geographic coverage), albeit with caution regarding a more granular examination of epidemiology given its apparent bias toward shootings involving multiple persons and those involving women and children.

Curbing the Epidemic of Community Firearm Violence after the Bruen Decision.

The Supreme Court's decision in New York State Rifle & Pistol Association Inc. v. Bruen undermines the ability of cities and states to regulate firearms safety. Nonetheless, we remain hopeful that firearm violence can decline even after the Bruen decision. Several promising public health approaches have gained broader adoption in recent years. This essay examines the key drivers of community firearm violence and reviews promising strategies to reverse those conditions, including community violence intervention (CVI) programs and place-based and structural interventions.

Exposure to Neighborhood Racialized Economic Segregation and Reinjury and Violence Perpetration Among Survivors of Violent Injuries.

Importance: Much is unknown about how individual and neighborhood factors converge in the association with risk for violent reinjury and violence perpetration. Objectives: To investigate the association of exposure to neighborhood racialized economic segregation with reinjury and use of violence against others among survivors of violent penetrating injury. Design, Setting, and Participants: This retrospective cohort study was performed using data obtained from hospital, police, and state vital records. The study was performed at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. The cohort included all patients treated for a nonfatal violent penetrating injury from 2013 to 2018. Patients with no Boston metropolitan area home address were excluded. Individuals were followed up through 2021. Data were analyzed from February to August 2022. Exposure: American Community Survey data were used to measure neighborhood deprivation using the racialized economic Index of Concentration at the Extremes (ICE) for patient residential address upon hospital discharge. ICE was measured on a scale from -1 (most deprived) to 1 (most privileged). Main Outcomes and Measures: Primary outcomes were violent reinjury and police-reported perpetration of violence within 3 years of an index injury. Results: Of 1843 survivors of violence (median [IQR] age, 27 [22-37] years; 1557 men [84.5%]; 351 Hispanic [19.5%], 1271 non-Hispanic Black [70.5%], and 149 non-Hispanic White [8.3%] among 1804 patients with race and ethnicity data), the cohort was skewed toward residing in neighborhoods with higher racialized economic segregation (median [IQR] ICE = -0.15 [-0.22 to 0.07]) compared with the state overall (ICE = 0.27). There were police encounters for violence perpetration among 161 individuals (8.7%) and violent reinjuries among 214 individuals (11.6%) within 3 years after surviving a violent penetrating injury. For each 0.1-unit increase in neighborhood deprivation, there was a 13% (hazard ratio [HR], 1.13; 95% CI, 1.03 to 1.25; P = .01) increase in risk of violence perpetration but no difference in risk for violent reinjury (HR, 1.03; 95% CI, 0.96 to 1.11; P = .38). The greatest occurrence for each outcome was within the first year after index injury; for example, incidents of violence perpetration occurred among 48 of 614 patients (7.8%) at year 1 vs 10 of 542 patients (1.8%) at year 3 in tertile 3 of neighborhood deprivation. Conclusions and Relevance: This study found that living in a more economically deprived and socially marginalized area was associated with increased risk of using violence against others. The finding suggests that interventions may need to include investments in neighborhoods with the highest levels of violence to help reduce downstream transmission of violence.

Analyzing Child Firearm Assault Injuries by Race and Ethnicity During the COVID-19 Pandemic in 4 Major US Cities.

This cross-sectional study examines changes in rates and disparities of fatal and nonfatal firearm assaults among children in New York, Los Angeles, Chicago, and Philadelphia before and during the COVID-19 pandemic.

Analysis of Daily Ambient Temperature and Firearm Violence in 100 US Cities.

Importance: Firearm violence is a leading public health crisis in the US. Understanding whether and how ambient temperature is associated with firearm violence may identify new avenues for prevention and intervention. Objective: To estimate the overall and regional association between hotter temperatures and higher risk of firearm violence in the US. Design, Setting, and Participants: This cross-sectional study used distributed lag nonlinear models, controlling for seasonality and long-term time trends by city and pooled results overall and by climate region. The most populous cities in the US with the highest number of assault-related firearm incidence (ie, shootings) from 2015 to 2020 were analyzed. Data analysis was performed from October 2021 to June 2022. Exposures: Maximum daily temperature by city. Main Outcomes and Measures: The primary outcome was the number of assault-related firearm shootings by city. Results: A total of 116 511 shootings in 100 cities were included in this analysis. The pooled analysis estimated that 6.85% (95% CI, 6.09%-7.46%) of all shootings were attributable to days hotter than city-specific median temperatures. This equates to 7973 total shootings (95% CI, 7092-8688 total shootings) across the 100 cities over the 6-year study period, although the number of total persons injured or killed would be higher. Estimated risk of firearm incidents increased almost monotonically with higher temperatures, with a local peak at the 84th percentile of the temperature range corresponding to a relative risk of 1.17 (95% CI, 1.12-1.21) compared with the median temperature. However, even moderately hot temperatures were associated with higher risk of shootings. Although significant, there was low heterogeneity between cities (I2 = 11.7%; Cochran Q test, P = .02), indicating regional or climate-specific variation in the daily temperature and incident shootings relationship. Conclusions and Relevance: These findings underscore the importance of heat adaptation strategies broadly throughout the year to reduce shootings, rather than focusing on only the hottest days.

Neighborhood segregation, tree cover and firearm violence in 6 U.S. cities, 2015-2020.

Neighborhood segregation by race and income is a structural determinant of firearm violence. Addressing green space deficits in segregated neighborhoods is a promising prevention strategy. This study assessed the potential for reducing firearm violence disparities by increasing access to tree cover. Units of analysis were census tracts in six U.S. cities (Baltimore, MD; Philadelphia, PA; Richmond, VA; Syracuse, NY; Washington, DC; Wilmington, DE). We measured segregation using the index of concentration at the extremes (ICE) for race-income. We calculated proportion tree cover based on 2013-2014 imagery. Outcomes were 2015-2020 fatal and non-fatal shootings from the Gun Violence Archive. We modeled firearm violence as a function of ICE, tree cover, and covariates representing the social and built environment. Next, we simulated possible effects of "tree equity" programs, i.e., raising tract-level tree cover to a specified baseline level. In our fully-adjusted model, higher privilege on the ICE measure (1 standard deviation, SD) was associated with a 42% reduction in shootings (incidence rate ratio (IRR) = 0.58, 95% CI [0.54 0.62], p < 0.001). A 1-SD increase in tree cover was associated with a 9% reduction (IRR = 0.91, 95% CI [0.86, 0.97], p < 0.01). Simulated achievement of 40% baseline tree cover was associated with reductions in firearm violence, with the largest reductions in highly-deprived neighborhoods. Advancing tree equity would not disrupt the fundamental causes of racial disparities in firearm violence exposure, but may have the potential to help mitigate those disparities.

Use of smartphone mobility data to analyze city park visits during the COVID-19 pandemic.

Introduction: The COVID-19 pandemic focused attention on city parks as important public resources. However, monitoring park use over time poses practical challenges. Thus, pandemic-related trends are unknown. Methods: We analyzed monthly mobility data from a large panel of smartphone devices, to assess park visits from January 2018 to November 2020 in the 50 largest U.S. cities. Results: In our sample of 11,890 city parks, visits declined by 36.0 % (95 % CI [27.3, 43.6], p < 0.001) from March through November 2020, compared to prior levels and trends. When we segmented the COVID-19 period into widespread closures (March-April) and reopenings (May-November), we estimated a small rebound in visits during reopenings. In park service areas where a greater proportion of residents were White and highincome, this rebound effect was larger. Conclusions: Smartphone data can address an important gap for monitoring park visits. Park visits declined substantially in 2020 and disparities appeared to increase.

Agent-Based Modeling: an Underutilized Tool in Community Violence Research.

Purpose of Review: Community violence is a serious public health problem, and generational investments are being made to address it. Agent-based models (ABMs) are computational tools that can help to optimize allocation of those investments, analogous to how computer simulation models, broadly, have informed decision making in other fields, such as infectious disease control. In this review, we describe ABMs, explain their potential role in community violence research, discuss recent studies that have applied ABMs to community violence, and point to opportunities for further progress. Recent Findings: We identified three recent studies that applied ABMs to community violence research, which points to the paucity of this line of work. Each of these works leverages a major advantage of ABMs-their ability to study the natural evolution of a process governed by the actions of autonomous agents, and how that evolution changes under counterfactual conditions, such as different intervention strategies (e.g., violence interruption), and policy changes (e.g., alcohol outlet licensing policies). Summary: ABMs continue to be an underutilized tool for the study of community violence. Their increased use could add important information to help stakeholders decide between competing intervention strategies in terms of their costs and the overall resulting changes in violence rates. In addition, ABMs have value in identifying unintended changes/diffusions resulting from interventions. Regardless of the application, ABMs can only be impactful if stakeholders believe and use the information, pointing to the importance of engaging policy makers and other stakeholders in the model formulation process when possible.

A database of US state policies to mitigate COVID-19 and its economic consequences.

BACKGROUND: Since COVID-19 first appeared in the United States (US) in January 2020, US states have pursued a wide range of policies to mitigate the spread of the virus and its economic ramifications. Without unified federal guidance, states have been the front lines of the policy response. MAIN TEXT: We created the COVID-19 US State Policy (CUSP) database ( https://statepolicies.com/ ) to document the dates and components of economic relief and public health measures issued at the state level in response to the COVID-19 pandemic. Documented interventions included school and business closures, face mask mandates, directives on vaccine eligibility, eviction moratoria, and expanded unemployment insurance benefits. By providing continually updated information, CUSP was designed to inform rapid-response, policy-relevant research in the context of the COVID-19 pandemic and has been widely used to investigate the impact of state policies on population health and health equity. This paper introduces the CUSP database and highlights how it is already informing the COVID-19 pandemic response in the US. CONCLUSION: CUSP is the most comprehensive publicly available policy database of health, social, and economic policies in response to the COVID-19 pandemic in the US. CUSP documents widespread variation in state policy decisions and implementation dates across the US and serves as a freely available and valuable resource to policymakers and researchers.

Racial Disparities in Child Exposure to Firearm Violence Before and During COVID-19.

INTRODUCTION: Childhood exposure to neighborhood firearm violence adversely affects mental and physical health across the life course. Study objectives were to (1) quantify racial disparities in these exposures across the U.S. and (2) assess changes during the COVID-19 pandemic, when firearm violence increased. METHODS: The study used counts of children aged 5-17 years, disaggregated by U.S. Census racial category, for every census tract (N=73,056). Neighborhood firearm violence was the number of fatal shootings per census tract, based on 2015-2021 Gun Violence Archive data. Quasi-Poisson regressions were used to estimate baseline disparities and COVID-19‒related changes and examined differences across geographic regions. RESULTS: Prepandemic exposure was lowest among White children and highest among Black children, who experienced 4.44 times more neighborhood firearm violence exposure (95% CI=4.33, 4.56, p<0.001) than White children. The pandemic increased exposure by 27% in the lowest risk group (i.e., White children; 95% CI=20%, 34%, p<0.001), but pandemic effects were even greater for children in nearly all non-White categories. Baseline violence levels and racial disparities varied considerably by region, with the highest levels in the South and the largest magnitude disparities observed in the Northeast and Midwest. CONCLUSIONS: Large-scale racial disparities exist in child exposure to neighborhood firearm violence, and these disparities grew during the pandemic. Equitable access to trauma-informed programs, community-based prevention, and structural reforms are urgently needed.

Trends in Violent Penetrating Injuries During the First Year of the COVID-19 Pandemic.

Importance: Public health measures instituted to reduce the spread of COVID-19 led to severe disruptions to the structure of daily life, and the resultant social and financial impact may have contributed to an increase in violence. Objective: To examine the trends in violent penetrating injuries during the first COVID-19 pandemic year compared with previous years. Design, Setting, and Participants: This retrospective cross-sectional study was performed to compare the prevalence of violent penetrating injuries during the first COVID-19 pandemic year, March 2020 to February 2021, with the previous 5 years, March 2015 to February 2020. This study was performed among all patients with a violent penetrating injury presenting at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. Data were analyzed from January 4 to November 29, 2021. Main Outcomes and Measures: The primary outcomes were the incidence and timing of emergency department presentation for violent penetrating injuries during the first year of the COVID-19 pandemic compared with the previous 5 years. Patient demographics and injury characteristics were also assessed. Results: A total of 2383 patients (median [IQR] age, 29.5 [23.4-39.3] years; 2032 [85.4%] men and 351 [14.6%] women) presenting for a violent penetrating injury were evaluated, including 1567 Black patients (65.7%), 448 Hispanic patients (18.8%), and 210 White patients (8.8%). There was an increase in injuries during the first pandemic year compared with the previous 5 years, with an increase in shootings (mean [SD], 0.61 [0.89] injuries per day vs 0.46 [0.76] injuries per day; P = .002) but not stabbings (mean [SD], 0.60 [0.79] injuries per day vs 0.60 [0.82] injuries per day; P = .78). This surge in firearm violence began while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. Patients presenting with violent penetrating injuries in the pandemic surge months (April-October 2020) compared with the same period in previous years were disproportionately male (153 patients [93.3%] vs 510 patients [87.6%]; P = .04), unemployed (70 patients [57.4%] vs 221 patients [46.6%]; P = .03), and Hispanic (40 patients [26.0%] vs 99 patients [17.9%]; P = .009), with a concurrent decrease in White patients (0 patients vs 26 patients [4.7%]), and were more likely to have no previous history of violent penetrating injury (146 patients [89.0%] vs 471 patients [80.9%]; P = .02). Conclusions and Relevance: These findings suggest that unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence. As the pandemic abates, efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence.

Effects of demolishing abandoned buildings on firearm violence: a moderation analysis using aerial imagery and deep learning.

PURPOSE: Demolishing abandoned buildings has been found to reduce nearby firearm violence. However, these effects might vary within cities and across time scales. We aimed to identify potential moderators of the effects of demolitions on firearm violence using a novel approach that combined machine learning and aerial imagery. METHODS: Outcomes were annual counts of fatal and non-fatal shootings in Rochester, New York, from 2000 to 2020. Treatment was demolitions conducted from 2009 to 2019. Units of analysis were 152×152 m grid squares. We used a difference-in-differences approach to test effects: (A) the year after each demolition and (B) as demolitions accumulated over time. As moderators, we used a built environment typology generated by extracting information from aerial imagery using convolutional neural networks, a deep learning approach, combined with k-means clustering. We stratified our main models by built environment cluster to test for moderation. RESULTS: One demolition was associated with a 14% shootings reduction (incident rate ratio (IRR)=0.86, 95% CI 0.83 to 0.90, p<0.001) the following year. Demolitions were also associated with a long-term, 2% reduction in shootings per year for each cumulative demolition (IRR=0.98, 95% CI 0.95 to 1.00, p=0.02). In the stratified models, densely built areas with higher street connectivity displayed following-year effects, but not long-term effects. Areas with lower density and larger parcels displayed long-term effects but not following-year effects. CONCLUSIONS: The built environment might influence the magnitude and duration of the effects of demolitions on firearm violence. Policymakers may consider complementary programmes to help sustain these effects in high-density areas.

Commentary: Reducing youth firearm violence and the associated health disparities requires enhanced surveillance and modern behavioral intervention strategies - a commentary on Bottiani et al. (2021).

Youth firearm injury is a worsening public health crisis, and the risks are not distributed evenly. Bottiani et al. skillfully explicated those health disparities, described sociological factors underlying them, and explored avenues for prevention. We supplement their analysis by detailing problems and solutions related to a critical barrier to firearm violence prevention - the nonexistence both of reliable 'gold standard' nonfatal firearm injury surveillance data, and systems for near real-time surveillance of firearm injuries at granular spatial scales that would enable to optimization of rapid response protocols and neighborhood-based prevention programs. We conclude with a discussion of modern, scalable, behavioral intervention approaches that could be leveraged to fill the largely absent evidence base resulting from the documented underfunding of youth firearm violence prevention research.

Neighbourhood income and physical distancing during the COVID-19 pandemic in the United States.

Physical distancing has been the primary strategy to control COVID-19 in the United States. We used mobility data from a large, anonymized sample of smartphone users to assess the relationship between neighbourhood income and physical distancing during the pandemic. We found a strong gradient between neighbourhood income and physical distancing. Individuals in high-income neighbourhoods increased their days at home substantially more than individuals in low-income neighbourhoods did. Residents of low-income neighbourhoods were more likely to work outside the home, compared to residents in higher-income neighbourhoods, but were not more likely to visit locations such as supermarkets, parks and hospitals. Finally, we found that state orders were only associated with small increases in staying home in low-income neighbourhoods. Our findings indicate that people in lower-income neighbourhoods have faced barriers to physical distancing, particularly needing to work outside the home, and that state physical distancing policies have not mitigated these disparities.