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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2019. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25354.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

HEALTH SYSTEMS INTERVENTIONS TO PREVENT FIREARM INJURIES AND DEATH PROCEEDINGS OF A WORKSHOP Joe Alper, Melissa French, and Alexis Wojtowicz, Rapporteurs Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY­ Uncorrected Proofs —

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the American Hospital Association and Kaiser Permanente. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25354 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Health systems interventions to prevent firearm injuries and death: Proceed- ings of a workshop. Washington, DC: The National Academies Press. doi: https:// doi.org/10.17226/25354. PREPUBLICATION COPY­ Uncorrected Proofs —

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and ­echnology. Members are elected t by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was estab­ished in 1970 under the charter of the National Academy of ­ ciences to l S advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, E ­ ngineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in ­ atters of science, engineering, and medicine. m Learn more about the National Academies of Sciences, Engineering, and ­ edicine M at www.nationalacademies.org. PREPUBLICATION COPY­ Uncorrected Proofs —

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opin- ions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY­ Uncorrected Proofs —

PLANNING COMMITTEE ON HEALTH SYSTEMS INTERVENTIONS TO PREVENT FIREARM INJURIES AND DEATH1 GEORGE J. ISHAM (Chair), Senior Fellow, HealthPartners Institute DAVID BRENT, Academic Chief, Child and Adolescent Psychiatry, Endowed Chair in Suicide Studies, Western Psychiatric Institute and Clinic; Professor of Psychiatry, Pediatrics, Epidemiology and Clinical Translational Science, University of Pittsburgh School of Medicine CARNELL COOPER, Founder, Violence Intervention Program; Adjunct Professor of Surgery, University of Maryland School of Medicine; and Chief Medical Officer, Northeast Methodist Hospital, San Antonio, Texas JOEL A. FEIN, Professor of Pediatrics and Emergency Medicine, University of Pennsylvania Perelman School of Medicine; Co-Director, Children’s Hospital of Philadelphia Violence Prevention Initiative; and Research Co-Director, National Network of Hospital-Based Violence Intervention Programs STEPHEN HARGARTEN, Director, Comprehensive Injury Center; Professor of Emergency Medicine, Medical College of Wisconsin THEA L. JAMES, Associate Professor of Emergency Medicine, Associate Chief Medical Officer, Vice President of Mission, and Director of the Violence Intervention Advocacy Program, Boston Medical Center LUCAS P. NEFF, Assistant Professor of Pediatric Surgery, Wake Forest University Baptist Medical Center JOHN A. RICH, Professor of Health Management and Policy, and Director, Center for Nonviolence and Social Justice, Drexel University School of Public Health THERESE S. RICHMOND, Andrea B. Laporte Professor, Associate Dean for Research and Innovation, University of Pennsylvania School of Nursing; Penn Injury Science Center ALI ROWHANI-RAHBAR, Bartley Dobb Professor for the Study and Prevention of Violence, Associate Professor of Epidemiology, and Pediatrics, Violence Prevention Section Leader at Harborview Injury Prevention and Research Center, University of Washington 1  The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. v PREPUBLICATION COPY­ Uncorrected Proofs —

Health and Medicine Division Staff MELISSA G. FRENCH, Senior Program Officer ALEXIS WOJTOWICZ, Research Associate ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice vi PREPUBLICATION COPY­ Uncorrected Proofs —

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evi- dence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: THEODORE CORBIN, Drexel University DEBRA HOURY, Centers for Disease Control and Prevention JOSEPH RICHARDSON, University of Maryland PAOLA RIJOS-SAITTA, Institute for Public Health Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by ANTONIA M. VILLARRUEL, University of Pennsylvania School of Nursing. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. vii PREPUBLICATION COPY­ Uncorrected Proofs —

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Contents BOX, FIGURES, AND TABLES xiii ACRONYMS AND ABBREVIATIONS xv 1 INTRODUCTION 1 Organization of the Proceedings, 4 2 WHY DO HEALTH SYSTEMS HAVE A ROLE? 5 Gun Violence: A Complex Biopsychosocial Disease Requiring a Strengthened Health Care System Response, 6 3 THE TOLL ON INDIVIDUALS AND COMMUNITIES 11 A Pediatric Victim and Opportunities the Health System Had to Intervene, 11 The Psychological and Social Burden of Firearm Violence on Communities, 15 Discussion, 21 4 IDENTIFYING INDIVIDUALS AT HIGHER RISK FOR 27 FIREARM VIOLENCE Identifying Survivors of Domestic Violence Who Are at High Risk for Firearm-Related Violence, 28 Applying a Medical Model of Disease to Identify Those at Risk of Firearm Violence, 29 ix PREPUBLICATION COPY­ Uncorrected Proofs —

x CONTENTS Factors to Consider When Thinking About Identifying Risk of Firearm Violence, 30 Discussion, 31 5 DEVELOPING HEALTH SYSTEM INTERVENTIONS 37 Developing a Firearm Storage Decision Aid to Enhance Counseling on Access to Lethal Means, 37 Creating Consensus: Developing a Firearm Injury Research Agenda, 41 Discussion, 44 6 KEY ISSUES FROM THE WORKSHOP’S FIRST DAY 47 Getting Health Systems Involved, 48 Helping Providers with the Aftermath of Gun Violence, 50 Helping Health System Leaders Act, 51 Shifting the Paradigm, 51 Discussion, 52 7 PROGRAMS AND RESEARCH 55 Project Ujima, 56 Helping Individuals with Firearm Injuries Clinical Trial, 59 SafERteens: An Evidence-Based Youth Violence Prevention Program, 61 Participatory Approaches to Implementing Firearm Safety Promotion in Pediatric Primary Care, 66 State of the Science for Hospital-Based Violence: Research and Policy Implications, 69 Discussion, 71 8 DEVELOPING NETWORKS AND SHARING INFORMATION 75 Building a Learning Health Care System for Suicide Prevention, 75 Violence Intervention and Collaboration, 79 Discussion, 81 9 DEVELOPING A CULTURE OF HEALTH CARE PROVIDERS 85 AS INTERVENERS Hospitals Against Violence Initiative, 85 Consensus-Based Firearm Injury Prevention Strategy, 87 The Cure Violence Approach, 89 Discussion, 91 10 CLOSING REMARKS 97 PREPUBLICATION COPY­ Uncorrected Proofs —

CONTENTS xi REFERENCES 99 APPENDIXES A Workshop Agenda 105 B Speaker Biographical Sketches 113 PREPUBLICATION COPY­ Uncorrected Proofs —

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Box, Figures, and Tables BOX 2-1 Antecedents of Homicide and Suicide Death, 7 FIGURES 3-1 Leading cause of pediatric deaths in trauma centers in the United States, 2010–2016, 12 3-2 Pediatric trauma case fatality rate, 2010–2016, 13 3-3 Atlanta firearm injury data, 14 3-4 Urban and rural shifts in intentional firearm deaths, 15 3-5 Pathways to recurrent trauma among young African American men, 19 4-1 Haddon Matrix applied to firearm violence, 28 5-1 Funding of research on gun violence and other leading causes of death, 43 5-2 In-hospital case fatality rate for traumatic injuries, 43 7-1 Project Ujima summer camp improves patient-reported outcomes, 58 7-2 Organization of the Firearm Safety Among Children and Teens (FACTS) consortium, 65 7-3 The many traumas that occur before and after a violent injury, 69 xiii PREPUBLICATION COPY­ Uncorrected Proofs —

xiv BOX, FIGURES, AND TABLES 9-1 A framework for creating a health system to prevent violence, 92 10-1 Leading cause of pediatric deaths in trauma centers in the United States, 2010–2016, 98 TABLES 3-1 Likelihood of Gun Violence in a Person’s Social Network, 2013, 17 3-2 Firearm-Related Homicides and Suicides per 100,000 Individuals in Three Communities, 18 7-1 Youth Victims of Violence Score Significantly Worse Than Healthy Youth on Patient-Reported Outcomes, 57 7-2 Suffering a Gunshot Wound Increases the Risk of Getting Shot Again, 60 7-3 Federal Funding of Firearm Research and Number of Deaths Compared to Other Disorders, 64 PREPUBLICATION COPY­ Uncorrected Proofs —

Acronyms and Abbreviations AAP American Academy of Pediatrics ACA Patient Protection and Affordable Care Act ACEP American College of Emergency Physicians AFFIRM American Foundation for Firearm Injury Reduction in Medicine AHA American Hospital Association CALM Counseling on Access to Lethal Means CDC Centers for Disease Control and Prevention CTI critical time intervention DLIVE Detroit Life Is Valuable Everyday EHR electronic health record ERPO extreme risk protective order FACTS Firearm Safety Among Children and Teens consortium HAV Hospitals Against Violence HIPAA Health Insurance Portability and Accountability Act HVIP hospital-based violence intervention program IOM Institute of Medicine IPV intimate partner violence xv PREPUBLICATION COPY­ Uncorrected Proofs —

xvi ACRONYMS AND ABBREVIATIONS NIMH National Institute of Mental Health NNHVIP National Network of Hospital-Based Violence Intervention Programs NRC National Research Council PHQ-9 Patient Health Questionnaire-9 USPSTF U.S. Preventive Services Task Force VA Department of Veterans Affairs VHA Veterans Health Administration PREPUBLICATION COPY­ Uncorrected Proofs —

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Firearm injuries and death are a serious public health concern in the United States. Firearm-related injuries account for tens of thousands of premature deaths of adults and children each year and significantly increase the burden of injury and disability. Firearm injuries are also costly to the health system, accounting for nearly $3 billion in emergency department and inpatient care each year.

The National Academies of Sciences, Engineering, and Medicine convened a workshop to examine the roles that health systems can play in addressing the epidemic of firearm violence in the United States. This publication summarizes the presentations and discussions from the workshop.

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