Research
Original Investigation
Impact of Facial Fractures and Intracranial Injuries on Hospitalization Outcomes Following Firearm Injuries Veerajalandhar Allareddy, MD, MBA; Romesh Nalliah, BDS; Min Kyeong Lee, DMD; Sankeerth Rampa, MBA, MPH; Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD
IMPORTANCE Firearm injuries (FAIs) play a major role in unintentional injuries, suicides, and
homicides. It is important that policy makers, public health authorities, physicians, and the public are kept abreast of current trends in FAIs so that preventive programs can be tailored to the needs of cohorts that are at highest risk for such injuries. OBJECTIVES To provide nationally representative longitudinal estimates of outcomes associated with hospitalizations attributed to FAIs in all age groups in the United States during the years 2003 to 2010; to obtain prevalence estimates of skull and/or facial fractures and intracranial injuries among those hospitalized owing to firearm injuries; and to examine the association between the occurrence of skull and/or facial fractures and/or intracranial injuries and in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS In this retrospective analysis of the largest all-payer hospitalization data set in the United States, we evaluate a Nationwide Inpatient Sample of patients hospitalized for FAIs during the years 2003 to 2010. EXPOSURES Face and/or skull fracture and/or intracranial injuries due to firearm injuries. MAIN OUTCOMES AND MEASURES The main outcome of interest was in-hospital mortality. The primary independent variables included occurrence of face and/or skull fracture and/or intracranial injuries. RESULTS During the study period, 252 181 visits were attributed to FAIs. Adolescents and young adults accounted for nearly 80% of all hospitalizations, with more than half of these in the 18- to 29-year-old, high-risk group. Male patients consistently accounted for 89% of the hospitalizations. The uninsured population accounted for nearly a third of hospitalizations. A total of 214 221 FAI hospitalizations did not involve facial and/or skull fractures or intracranial injuries; 13 090 involved a facial and/or skull fracture without a concomitant intracranial injury; 20 453 involved an intracranial injury without a concomitant facial and/or skull fracture; and 4417 involved both a facial and/or skull fracture and intracranial injury. Those with intracranial injuries without concomitant facial and/or skull fractures (odds ratio [OR], 58.40; 95% CI, 50.08-68.11) (P < .001) and those with both facial and/or skull fractures and intracranial injuries (OR, 17.45; 95% CI, 13.98-21.79) (P < .001) were associated with higher odds of in-hospital mortality than those without these injuries. Teaching hospitals were associated with higher odds of in-hospital mortality than nonteaching hospitals (OR, 1.31; 95% CI, 1.14-1.49) (P < .001). Teaching hospitals also tended to treat a higher proportion of complex cases. The uninsured had higher odds of in-hospital mortality than those with private insurance (OR, 1.55; 95% CI, 1.35-1.78). CONCLUSIONS AND RELEVANCE Occurrence of intracranial injuries was an independent risk factor for poor outcomes. Teaching hospitals had higher mortality rates but also treated more complex cases than nonteaching hospitals.
JAMA Otolaryngol Head Neck Surg. 2014;140(4):303-311. doi:10.1001/jamaoto.2014.61 Published online March 6, 2014.
Author Affiliations: Department of Pediatric Critical Care, Case Western Reserve University School of Medicine, Cleveland, Ohio (Veerajalandhar Allareddy); Department of Global Health, Harvard School of Dental Medicine, Boston, Massachusetts (Nalliah); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts (Lee); Texas A&M University Health Science Center, School of Rural Public Health, College Station, Texas (Rampa); Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City (Veerasathpurush Allareddy). Corresponding Author: Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, College of Dentistry, The University of Iowa, Iowa City, IA 52242 (Veerasathpurush-Allareddy @uiowa.edu).
303
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Research Original Investigation
Facial Fracture and Intracranial Firearms Injuries
F
irearm injuries (FAIs) play a major role in unintentional injuries, suicides, and homicides,1 which are the 3 leading causes of death among 15- to 34-year-olds2 in the United States. Years of life lost owing to unintentional injuries are substantial.3 Firearm injury has been perceived as a public health issue,4 and plans for firearm law reforms have been proposed.5 Estimates from the past decade show that about half of all self-inflicted FAIs and about 14% of FAIs associated with assaults result in head and neck injuries.6 Very few studies have reviewed FAIs resulting in head and neck injuries.7-10 National estimates of the economic impact of FAIs are unclear. Furthermore, nationally representative estimates of prevalence and impact of facial and intracranial injuries on hospitalization outcomes following the use of firearms—unintentional, selfinflicted, or associated with assault—are lacking. It is important that policy makers, public health authorities, physicians, and the public are kept abreast of current trends in FAIs so that preventive programs can be tailored to the needs of cohorts that are at highest risk for such injuries. The objectives of the present study are to provide nationally representative longitudinal estimates of outcomes associated with hospitalizations attributed to FAIs in all age groups in the United States during the years 2003 to 2010; to obtain prevalence estimates of skull and/or facial fractures and intracranial injuries among those hospitalized owing to FAIs; and to examine the association between occurrence of skull and/or facial fractures and/or intracranial injuries and in-hospital mortality.
Methods Description of Database The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project for the years 2003-201011 was used.11 The NIS is the largest all-payer hospital-based inpatient database of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality (AHRQ). The NIS is a stratified 20% sample of all acute-care hospitals in the United States. Each hospitalization in the NIS database is assigned a discharge weight that can be used to project all estimates and outcomes to nationally representative levels. We completed a data user agreement with HCUP-AHRQ and obtained the NIS data sets. The present study was exempt from institutional review board approval. Per the data user agreement, any individual table cell counts of 10 or lower cannot be presented to preserve patient confidentiality. In accordance with this data user agreement, such low cell counts are designated by the abbreviation DS, meaning discharge information suppressed.
Case Selection and Variables All hospitalizations with an external cause of injury code (E-code) for FAI were selected for analysis. The E-codes used in the study are summarized in Table 1. Occurrence of skull and/or facial fractures and intracranial injuries were identified by the use of clinical classification software codes for these injuries in the primary and secondary diagnosis fields of the data set. The clinical classification software codes grouped to304
gether clusters of ICD-9-CM codes (International Classification of Diseases, Ninth Revision, Clinical Modification) that mapped to a set of diagnostic conditions.12,13 The presence of other bodily injuries including trauma-related joint disorders and/or dislocations, fracture of a femur, spinal cord injuries, fracture of an upper limb, fracture of a lower limb, other fractures, sprains and/or strains, crushing injury or internal injury, open wounds of the head and/or neck and/or trunk, and open wounds of extremities were also identified using clinical classification software codes. Demographic and hospital characteristics examined included age, sex, race, insurance status, hospital region, and hospital teaching status. Outcomes examined included disposition status following hospitalization for FAI, length of stay in the hospital, hospitalization charges, and in-hospital mortality. All hospitalization charges were adjusted to year 2010 US dollar values using the inflation rates for in-hospital care obtained from the Bureau of Labor Statistics.14
Analytical Approach Descriptive statistics were used to examine the demographic characteristics. The association between patient demographics and/or types of injuries and/or hospital characteristics and in-hospital mortality was examined by a multivariable logistic regression model. Odds ratios (ORs) for different levels of independent variables and associated 95% CIs were computed. Each individual hospitalization was the unit of analysis, and NIS stratum was used as the stratification unit. Effects of clustering of outcomes within hospitals was adjusted in the regression model. All statistical tests were 2-sided and P < .05 was deemed to be statistically significant. All statistical analyses were conducted using SAS software, version 9.3 (SAS Institute) and SUDAAN software, version 10.0.1 (RTI International).
Results During the study period of over 8 years, 252 181 visits were attributed to FAIs. Adolescents and young adults accounted for nearly 80% of all hospitalizations, with more than half of these in the 18- to 29-year-old, high-risk group. Male patients consistently accounted for 89% of the hospitalizations. Black patients accounted for nearly half of the cases. The uninsured population accounted for nearly a third of hospitalizations. The characteristics of FAI hospitalizations by injuries are summarized in Table 2. A total of 214 221 FAI hospitalizations did not involve facial and/or skull fractures or intracranial injuries; 13 090 involved a facial and/or skull fracture without a concomitant intracranial injury; 20 453 involved an intracranial injury without a concomitant facial and/ or skull fracture; and 4417 involved both a facial and/or skull fracture and intracranial injury. Overall, there were no differences in distribution of different age groups and sex groups by different types of fractures. With regard to race, close to 50.6% of those with an FAI and no concomitant facial and/or skull fracture or intracranial injuries were black, while blacks made up only 44.1% of those with facial and/or skull fractures without concomitant intracranial
JAMA Otolaryngology–Head & Neck Surgery April 2014 Volume 140, Number 4
Copyright 2014 American Medical Association. All rights reserved.
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Facial Fracture and Intracranial Firearms Injuries
Original Investigation Research
Table 1. Types of Firearm Causes and Resulting Injuries Injuries, No. (%)a No Facial Fracture or Intracranial Injury (n = 214 221)
Type of Firearm Cause (E-Code)
Facial and/or Skull Fracture Without Concomitant Intracranial Injury (n = 13 090)
Intracranial Injury Without Concomitant Facial and/or Skull Fracture (n = 20 453)
Both Facial and/or Skull Fracture and Intracranial Injury (n = 4417)
Self-inflicted injury by handgun (E955.0)
5207 (0.6)
961 (7.3)
3854 (18.8)
807 (18.3)
Self-inflicted injury by shotgun (E955.1)
1233 (0.6)
363 (2.8)
277 (1.3)
158 (3.6)
829 (0.4)
136 (1.0)
248 (1.2)
83 (1.9)
Self-inflicted injury by hunting rifle (E955.2) Self-inflicted injury by military firearms (E955.3) Self-inflicted injury by other and unspecified firearm (E955.4)
35 (0.02)
0
2784 (1.3)
531 (4.1)
0
DS
2654 (13.0)
493 (11.2)
Accident caused by handgun (E922.0)
15 106 (7.0)
572 (4.4)
785 (3.8)
108 (2.4)
Accident caused by shotgun (E922.1)
4800 (2.2)
134 (1.0)
139 (0.7)
48 (1.1)
Accident caused by hunting rifle (E922.2)
2936 (1.4)
62 (0.5)
96 (0.5)
24 (0.5)
Accident caused by military firearms (E922.3) Accident caused by other specified firearm missile (E922.8) Accident caused by unspecified firearm missile (E922.9) Other accident cause (E928.7) (code is no longer in use)
193 (0.1)
0
DS
0
3763 (1.8)
118 (0.9)
163 (0.8)
30 (0.7)
24 026 (11.2)
1018 (7.8)
1599 (7.8)
258 (5.8)
325 (0.1)
DS
20 (0.1)
0
Assault by handgun (E965.0)
41 725 (19.5)
2885 (22.0)
2513 (12.3)
570 (12.9)
Assault by shotgun (E965.1)
9122 (4.2)
521 (4.0)
493 (2.4)
168 (3.8)
Assault by hunting rifle (E965.2)
436 (0.2)
34 (0.3)
20 (0.1)
DS
Assault by military firearms (E965.3)
391 (0.2)
25 (0.2)
14 (
Original Investigation
Impact of Facial Fractures and Intracranial Injuries on Hospitalization Outcomes Following Firearm Injuries Veerajalandhar Allareddy, MD, MBA; Romesh Nalliah, BDS; Min Kyeong Lee, DMD; Sankeerth Rampa, MBA, MPH; Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, PhD
IMPORTANCE Firearm injuries (FAIs) play a major role in unintentional injuries, suicides, and
homicides. It is important that policy makers, public health authorities, physicians, and the public are kept abreast of current trends in FAIs so that preventive programs can be tailored to the needs of cohorts that are at highest risk for such injuries. OBJECTIVES To provide nationally representative longitudinal estimates of outcomes associated with hospitalizations attributed to FAIs in all age groups in the United States during the years 2003 to 2010; to obtain prevalence estimates of skull and/or facial fractures and intracranial injuries among those hospitalized owing to firearm injuries; and to examine the association between the occurrence of skull and/or facial fractures and/or intracranial injuries and in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS In this retrospective analysis of the largest all-payer hospitalization data set in the United States, we evaluate a Nationwide Inpatient Sample of patients hospitalized for FAIs during the years 2003 to 2010. EXPOSURES Face and/or skull fracture and/or intracranial injuries due to firearm injuries. MAIN OUTCOMES AND MEASURES The main outcome of interest was in-hospital mortality. The primary independent variables included occurrence of face and/or skull fracture and/or intracranial injuries. RESULTS During the study period, 252 181 visits were attributed to FAIs. Adolescents and young adults accounted for nearly 80% of all hospitalizations, with more than half of these in the 18- to 29-year-old, high-risk group. Male patients consistently accounted for 89% of the hospitalizations. The uninsured population accounted for nearly a third of hospitalizations. A total of 214 221 FAI hospitalizations did not involve facial and/or skull fractures or intracranial injuries; 13 090 involved a facial and/or skull fracture without a concomitant intracranial injury; 20 453 involved an intracranial injury without a concomitant facial and/or skull fracture; and 4417 involved both a facial and/or skull fracture and intracranial injury. Those with intracranial injuries without concomitant facial and/or skull fractures (odds ratio [OR], 58.40; 95% CI, 50.08-68.11) (P < .001) and those with both facial and/or skull fractures and intracranial injuries (OR, 17.45; 95% CI, 13.98-21.79) (P < .001) were associated with higher odds of in-hospital mortality than those without these injuries. Teaching hospitals were associated with higher odds of in-hospital mortality than nonteaching hospitals (OR, 1.31; 95% CI, 1.14-1.49) (P < .001). Teaching hospitals also tended to treat a higher proportion of complex cases. The uninsured had higher odds of in-hospital mortality than those with private insurance (OR, 1.55; 95% CI, 1.35-1.78). CONCLUSIONS AND RELEVANCE Occurrence of intracranial injuries was an independent risk factor for poor outcomes. Teaching hospitals had higher mortality rates but also treated more complex cases than nonteaching hospitals.
JAMA Otolaryngol Head Neck Surg. 2014;140(4):303-311. doi:10.1001/jamaoto.2014.61 Published online March 6, 2014.
Author Affiliations: Department of Pediatric Critical Care, Case Western Reserve University School of Medicine, Cleveland, Ohio (Veerajalandhar Allareddy); Department of Global Health, Harvard School of Dental Medicine, Boston, Massachusetts (Nalliah); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts (Lee); Texas A&M University Health Science Center, School of Rural Public Health, College Station, Texas (Rampa); Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City (Veerasathpurush Allareddy). Corresponding Author: Veerasathpurush Allareddy, BDS, MBA, MHA, MMSc, College of Dentistry, The University of Iowa, Iowa City, IA 52242 (Veerasathpurush-Allareddy @uiowa.edu).
303
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Research Original Investigation
Facial Fracture and Intracranial Firearms Injuries
F
irearm injuries (FAIs) play a major role in unintentional injuries, suicides, and homicides,1 which are the 3 leading causes of death among 15- to 34-year-olds2 in the United States. Years of life lost owing to unintentional injuries are substantial.3 Firearm injury has been perceived as a public health issue,4 and plans for firearm law reforms have been proposed.5 Estimates from the past decade show that about half of all self-inflicted FAIs and about 14% of FAIs associated with assaults result in head and neck injuries.6 Very few studies have reviewed FAIs resulting in head and neck injuries.7-10 National estimates of the economic impact of FAIs are unclear. Furthermore, nationally representative estimates of prevalence and impact of facial and intracranial injuries on hospitalization outcomes following the use of firearms—unintentional, selfinflicted, or associated with assault—are lacking. It is important that policy makers, public health authorities, physicians, and the public are kept abreast of current trends in FAIs so that preventive programs can be tailored to the needs of cohorts that are at highest risk for such injuries. The objectives of the present study are to provide nationally representative longitudinal estimates of outcomes associated with hospitalizations attributed to FAIs in all age groups in the United States during the years 2003 to 2010; to obtain prevalence estimates of skull and/or facial fractures and intracranial injuries among those hospitalized owing to FAIs; and to examine the association between occurrence of skull and/or facial fractures and/or intracranial injuries and in-hospital mortality.
Methods Description of Database The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project for the years 2003-201011 was used.11 The NIS is the largest all-payer hospital-based inpatient database of the Healthcare Cost and Utilization Project (HCUP) sponsored by the Agency for Healthcare Research and Quality (AHRQ). The NIS is a stratified 20% sample of all acute-care hospitals in the United States. Each hospitalization in the NIS database is assigned a discharge weight that can be used to project all estimates and outcomes to nationally representative levels. We completed a data user agreement with HCUP-AHRQ and obtained the NIS data sets. The present study was exempt from institutional review board approval. Per the data user agreement, any individual table cell counts of 10 or lower cannot be presented to preserve patient confidentiality. In accordance with this data user agreement, such low cell counts are designated by the abbreviation DS, meaning discharge information suppressed.
Case Selection and Variables All hospitalizations with an external cause of injury code (E-code) for FAI were selected for analysis. The E-codes used in the study are summarized in Table 1. Occurrence of skull and/or facial fractures and intracranial injuries were identified by the use of clinical classification software codes for these injuries in the primary and secondary diagnosis fields of the data set. The clinical classification software codes grouped to304
gether clusters of ICD-9-CM codes (International Classification of Diseases, Ninth Revision, Clinical Modification) that mapped to a set of diagnostic conditions.12,13 The presence of other bodily injuries including trauma-related joint disorders and/or dislocations, fracture of a femur, spinal cord injuries, fracture of an upper limb, fracture of a lower limb, other fractures, sprains and/or strains, crushing injury or internal injury, open wounds of the head and/or neck and/or trunk, and open wounds of extremities were also identified using clinical classification software codes. Demographic and hospital characteristics examined included age, sex, race, insurance status, hospital region, and hospital teaching status. Outcomes examined included disposition status following hospitalization for FAI, length of stay in the hospital, hospitalization charges, and in-hospital mortality. All hospitalization charges were adjusted to year 2010 US dollar values using the inflation rates for in-hospital care obtained from the Bureau of Labor Statistics.14
Analytical Approach Descriptive statistics were used to examine the demographic characteristics. The association between patient demographics and/or types of injuries and/or hospital characteristics and in-hospital mortality was examined by a multivariable logistic regression model. Odds ratios (ORs) for different levels of independent variables and associated 95% CIs were computed. Each individual hospitalization was the unit of analysis, and NIS stratum was used as the stratification unit. Effects of clustering of outcomes within hospitals was adjusted in the regression model. All statistical tests were 2-sided and P < .05 was deemed to be statistically significant. All statistical analyses were conducted using SAS software, version 9.3 (SAS Institute) and SUDAAN software, version 10.0.1 (RTI International).
Results During the study period of over 8 years, 252 181 visits were attributed to FAIs. Adolescents and young adults accounted for nearly 80% of all hospitalizations, with more than half of these in the 18- to 29-year-old, high-risk group. Male patients consistently accounted for 89% of the hospitalizations. Black patients accounted for nearly half of the cases. The uninsured population accounted for nearly a third of hospitalizations. The characteristics of FAI hospitalizations by injuries are summarized in Table 2. A total of 214 221 FAI hospitalizations did not involve facial and/or skull fractures or intracranial injuries; 13 090 involved a facial and/or skull fracture without a concomitant intracranial injury; 20 453 involved an intracranial injury without a concomitant facial and/ or skull fracture; and 4417 involved both a facial and/or skull fracture and intracranial injury. Overall, there were no differences in distribution of different age groups and sex groups by different types of fractures. With regard to race, close to 50.6% of those with an FAI and no concomitant facial and/or skull fracture or intracranial injuries were black, while blacks made up only 44.1% of those with facial and/or skull fractures without concomitant intracranial
JAMA Otolaryngology–Head & Neck Surgery April 2014 Volume 140, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of North Dakota User on 05/17/2015
jamaotolaryngology.com
Facial Fracture and Intracranial Firearms Injuries
Original Investigation Research
Table 1. Types of Firearm Causes and Resulting Injuries Injuries, No. (%)a No Facial Fracture or Intracranial Injury (n = 214 221)
Type of Firearm Cause (E-Code)
Facial and/or Skull Fracture Without Concomitant Intracranial Injury (n = 13 090)
Intracranial Injury Without Concomitant Facial and/or Skull Fracture (n = 20 453)
Both Facial and/or Skull Fracture and Intracranial Injury (n = 4417)
Self-inflicted injury by handgun (E955.0)
5207 (0.6)
961 (7.3)
3854 (18.8)
807 (18.3)
Self-inflicted injury by shotgun (E955.1)
1233 (0.6)
363 (2.8)
277 (1.3)
158 (3.6)
829 (0.4)
136 (1.0)
248 (1.2)
83 (1.9)
Self-inflicted injury by hunting rifle (E955.2) Self-inflicted injury by military firearms (E955.3) Self-inflicted injury by other and unspecified firearm (E955.4)
35 (0.02)
0
2784 (1.3)
531 (4.1)
0
DS
2654 (13.0)
493 (11.2)
Accident caused by handgun (E922.0)
15 106 (7.0)
572 (4.4)
785 (3.8)
108 (2.4)
Accident caused by shotgun (E922.1)
4800 (2.2)
134 (1.0)
139 (0.7)
48 (1.1)
Accident caused by hunting rifle (E922.2)
2936 (1.4)
62 (0.5)
96 (0.5)
24 (0.5)
Accident caused by military firearms (E922.3) Accident caused by other specified firearm missile (E922.8) Accident caused by unspecified firearm missile (E922.9) Other accident cause (E928.7) (code is no longer in use)
193 (0.1)
0
DS
0
3763 (1.8)
118 (0.9)
163 (0.8)
30 (0.7)
24 026 (11.2)
1018 (7.8)
1599 (7.8)
258 (5.8)
325 (0.1)
DS
20 (0.1)
0
Assault by handgun (E965.0)
41 725 (19.5)
2885 (22.0)
2513 (12.3)
570 (12.9)
Assault by shotgun (E965.1)
9122 (4.2)
521 (4.0)
493 (2.4)
168 (3.8)
Assault by hunting rifle (E965.2)
436 (0.2)
34 (0.3)
20 (0.1)
DS
Assault by military firearms (E965.3)
391 (0.2)
25 (0.2)
14 (
