Physicians and hospitals are quite literally on the front lines battling gun violence injury and death on a daily basis -- so much so, in fact, that the American Medical Association has officially dubbed it a public health crisis.
That designation was announced amidst a proliferation of high-profile mass shootings. But physicians and researchers said it's the never-ending stream of victims that come through the doors of their emergency departments that is really driving their decision to examine how they can affect change and to get started doing it.
California healthcare giant Kaiser Permanente is pulling together a task force of experts, frontline staff and physicians and possibly even patients to identify strategies that are "within the reach of healthcare systems," to better understand how to decrease firearm injury and death. Kaiser Permanente's task force hopes to develop and implement best practices that drive real change and to align with and bolster community resources that could help stem the tide of violence.
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Kaiser Permanente is also looking into ways to identify at-risk patients already in the system, screening and treatment for depression, and developing interventions for those at risk of hurting themselves, including with guns.
"There are some opportunities to look across our system, understand best practices and try to standardize those across our system," said David Grossman, MD, Senior Investigator at the Kaiser Permanente Washington Health Research Institute.
Research will almost certainly be one of the designated work groups, as gross shortfalls in government funding of research on firearm injury and death persist. Details are still being worked out. Multiple workgroups are expected.
While undeniably horrific, mass shootings actually represent a small proportion of gun deaths nationwide. Firearm suicides, rather, represent a large share of gun deaths, and a subset of homicides that Grossman said Kaiser Permanente might be able to impact is intimate partner violence. He said the system is already heavily involved in screening early on in the emergency department and primary care settings for opportunities to intervene, as about half of homicides of women are related to intimate partner violence. Another area the task force will focus on is community-level interventions that can support prevention of firearm injury.
In 2016 and 2017, 11,000 people were treated in the Kaiser Permanente system for firearm injuries. Those were the victims that at least made it to a medical facility. Scores of victims don't. That's why the task force is trying to obtain death certificate data, to get a clearer picture of all those that died from gun violence. This will be foundational to their research.
"It's not research for the sake of research. It's really about identifying the type of interventions to help us to do our work differently but now with evidence behind it," Kaiser Permanente Chief Community Health Officer Bechara Choucair, MD, said.
The impact of gun violence resonates on multiple levels throughout society and the healthcare industry, said Johns Hopkins research fellow Faiz Gana. First there is the direct impact - loss of life and loss to community and families-something we usually talk about.
But less spoken about and less studied are the people who are injured and don't die, Gana said
They go home but are debilitated, can't work and incur significant cost. Often times, people have multiple operations and that further adds to loss of quality of life and activity as well.
What's worse, many times patients return home to the same environment and societal issues that spurned their original incident. They end up getting shot again and going back to the ED.
Gana said he's heard trauma surgeons talk about how they've seen families where multiple people have been shot and injured, whether in separate incidents or a single one. This compounds problems for that family in that they lose multiple people or have multiple members with serious health issues.
Part of being able to implement effective strategies and information is understanding the environment you live in and what is driving gun violence incidents.
"You have to contextualize your policies. The causes of mass shootings can be very different than the day to day violence," Gana said.
The financial impact to hospitals also can be staggering. Gana's research showed that looking at the ED, the average charge was around $5000, but inpatient charges are significantly higher, around $100,000 per patient per admission. From a health system view, that's $2.8 billion in ED or inpatient charges per year. When researchers included a data set from the CDC that incorporated loss of quality of life and productivity and did projections including those factors, the numbers were closer to $40 billion, according to Gana.
Even more alarming is when he and his colleagues looked at the victims, they were largely uninsured or self-pay, with no insurance company bargaining for them. Even though the charge is greater than what their actual cost might be, it's hard to imagine someone being able to pay such a bill.
"Those numbers are extremely sobering on their own," Gana said.
Grossman said it's also important to note that acute care is just the beginning of a long episode of care that also often goes to rehabilitation. Spinal cord or brain injuries result in protracted hospital and rehab stays, and sadly often yield incomplete recovery. Rehab is, therefore, a key part of any long-term strategy around preventing secondary problems.
Gana agreed that care coordination is just one area where hospitals and health systems can play a role in reversing the tide of misery that victims are swept up in. As a hospital, simply caring for patients and giving the best care, researching and acting on best practices for trauma, and doing a better job of making sure individuals have access to rehab regardless of their ability to pay once they are discharged are all actionable items. Mental health services should also be far more accessible for those who need it following an episode of care, he said.
As far as prevention, physicians should be able to talk openly with patients about whether there are guns in the home and whether they are practicing safety with them. This doesn't need to be a political issue. Anything that could harm their patients or their families they should be able to talk about, Gana said.
Education and awareness can and should be incited by hospitals, such as disseminating findings on the best safety measures to safely store a gun. Third, as academic medical centers get bigger they have more leverage to enact positive change. Develop community partnerships with local groups to gain a better understanding of needs, and figure out how best to do outreach in concert with those groups.
Make sure research makes it into the right hands and the right people are empowered with the data. Use research to inform and implement policies, Gana said.
"There is a sense of frustration. These are things that can be prevented by better, more sensible policies and prevention. There's a sense of helplessness as well. But then comes a sense of duty to study these things and play our role as a medical practitioner or public health professional or member of society to contribute in some form and address the issue."
Thinking outside the box and taking a holistic approach should also be a key principle of a provider approach, said Paul Kivela, president of the American College of Emergency Physicians. Something ACEP hopes to do as medical community outreach is teaching citizens and bystanders to stop bleeding and perform CPR to give victims a greater chance of survival.
"There are potentially preventable lives lost because there's not a first responder there that knows what to do. And we can change some of that," Kivela added. "It's not going to stop the problem but it may decrease morbidity and mortality. It also empowers the people who are right there and saying what do I do -- it empowers them that they can save a life."
Kivela said ACEP also agrees that screening for depression and psychosis could help identify at-risk patients and talking to patients about threats to their well-being, including the presence of guns, makes sense. He said even though the subject might be taboo, the doctor's office is often the place where people reach out for help.
He also said it's not just about doctors stepping up. More social workers and screening staff are needed to help patients understand what resources are available.
"It's hard to ask the docs and nurses to do something when there is no follow up. So there needs to be more community programs in place and social workers and outreach. Just understanding what resources are available to ppl in their community is a tremendous first step. Having social workers and other support people who can sit down and meet these people when they're at and discuss the challenges that they face," Kivela said. "A lot of problems in our society come from feeling frustrated, not knowing what to do and feeling like they don't have a chance. I think giving those resources would go a long way to people not feeling like they are alone or isolated. But that is going to take a lot of resources and it has to go beyond just hospitals."
He also said the whole idea of how we look at mental health must change. Often time these patients are warehoused in the ED waiting for a psych bed or psychiatrist that may never come.
One of the things that ACEP will be pushing physicians to do is to be more proactive in the management of those patients, screening for mental health issues even possibly starting patients on psychiatric meds in the ED, then following up with psych patients wherever they are at so they have the support they need following their discharge.
Telemedicine, telepsychiatry whether engaged in an inpatient setting or in the patient's home, could also be solutions, even tele-social workers so people aren't stagnating in the ED not receiving the care they need. There are a lot of innovative solutions out there, Kivela said, but we have to flexible and smart about this. "We need to have multiple solutions," he added, "and we can't be afraid to fail until we find something that works for each community."
The bottom line, Grossman and Choucair agreed, is the victims are people they treat. The bond between a physician and patient is immensely important and should be used to ensure the well-being of those in their care. Physicians and other clinicians are in a better position to do prevention than postvention. Postvention, including investigating, is something they are leaving to law enforcement.
"We believe that we can leverage what we do best to help tackle this issue. Whether it's suicide, homicide or accidental death from a firearm, we know that we can contribute to the prevention," Choucair said. "We are not by any means suggesting that this work will end gun violence but we recognize that we as a health system can do more and we are excited to do that work."