Gun injuries are increasingly viewed as a public health threat. Experts weigh in on what hospitals can do

Just hours after hearing the news of a mass shooting at an El Paso, Texas, shopping center last Saturday, Lucas Neff, M.D., found himself racing to the Wake Forest University Baptist Medical Center.

As a pediatric trauma surgeon, he'd been called in to help save a 15-year-old who'd been shot three times.

By the time surgery on the North Carolina teenager was complete, Neff learned the news about the mass shooting in Ohio. On that particular day, three adults were also brought into the trauma center for gunshot wounds. 

"It almost felt like the world was going crazy," Neff told FierceHealthcare about his own experiences amid the high-profile shootings over the weekend. 

Those instances of mass shootings have reignited the national debate—including among those in healthcare—about how to stem the number of deaths and injuries from individuals with firearms and an intent to harm as many people as they can.

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"That's not where the overall population benefit is. It's the constant flow—drip, drip, drip—in ones and twos. It's the intimate partner violence, accidental discharge where a child gets hurt. All the little things that happen in the background that never make front-page news," Neff said.  

Neff is among a groundswell of trauma experts and doctors around the U.S. who have been pushing for a public health approach to firearm injuries. While firearm injuries have traditionally been viewed through the lens of criminal justice, injury prevention experts say in recent months health systems have shown an increasing interest in embracing their role in the dialogue around guns from a public health perspective.

"We know gun violence is a health issue. When you're shot, you're taken to the hospital just like if you had a stroke or a heart attack. It makes it by definition a health issue," said Therese S. Richmond, Ph.D., who is the associate dean for Research and Innovation at the University of Pennsylvania's School of Nursing and an executive committee member at the Penn Injury Science Center. "I think healthcare systems are just now beginning to see that."

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For instance, the American Hospital Association and Kaiser Permanente sponsored a workshop at the National Academies of Sciences last fall to talk about health system interventions around firearm injuries and deaths. The American College of Surgeons hosted a summit of more than 40 medical organizations to talk about gun violence prevention and published their consensus summaries. 

Kaiser Permanente also notably announced a $2 million commitment to gun violence research and prevention last year. "Why did they do that? Because they take care of thousands of gunshot patients every year. I think they see a potential way to improve care by preventing gun violence by moving upstream just like we pay attention to preventing heart disease. What is your cholesterol? What are you eating? How much do you weigh? Health systems are saying we should be doing the same thing now with firearm violence. From a system perspective, that is a significant change and it's a good change within the healthcare world," Richmond said. 

Framing the issue

Experts in injury prevention say a shift in the conversation in healthcare about guns began with clinicians and researchers.

But when the National Rifle Association told doctors in a tweet last year to "stay in their lane" when addressing the politically charged issue of guns, it galvanized a groundswell of support from physicians and prompted an editorial response in the Annals of Internal Medicine, Neff said.

"That was a really big moment because that brought everyone out of the woodwork. Personal stories started being shared and it raised the level of awareness," Neff said. "That's an example of how, in the popular culture, the conversation really exploded and doctors really woke up and said 'This is our lane.'" 

That ultimately led to major medical organizations adopting positions or releasing statements, including the American Medical Association, the American College of Surgeons and the AHA. "Then the hospital systems start to see that. It really opened up and gave people permission to engage," Neff said. 

The shift to value-based care may also play a role in driving the health system's interest, Richmond said. 

"As healthcare systems, we're more focused on population health and we're more focused on the entire person from preventing the disease to improving outcome," Richmond said. "From a return on investment, if you prevent the disease—you prevent the heart attack, you prevent the stroke, you prevent the shooting—that's cheap. If we think of capitated payments and I'm in charge of a health system where I get a certain amount of money for taking care of certain groups of patients, the best investment is to prevent it."

Health systems and payers are becoming more proactive about understanding and addressing social determinants of health, she said. 

"They are saying: 'I need to be involved in my community. I need to understand the issues of my community. We need to invest in the community to understand upstream social determinants of health and a good investment in keeping their populations healthy," Richmond said. 

Health systems' interest in leading on this issue may vary depending on where they're located and if they are in a red state versus a blue state, experts acknowledged. But some issues, such as pushing for Congress to pass federal funding to support research on firearm injuries and prevention, is an area of concern that all providers can rally around, they said.

"This is a constant endemic challenge healthcare systems are handling," Stephen Hargarten, M.D., director of the Comprehensive Injury Center at the Medical College of Wisconsin, told FierceHealthcare. "If we were battling a disease we knew little about, we would be advocating for more research funding to better understand what we can and need to do to inform healthcare systems about what the best practices are. What's working? What's not? We don't have the research looking at that." 

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