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Why Do Health Systems Have a Role?

The reason that health systems should be involved in conducting research on firearm injuries and death and developing intervention and prevention strategies is simple, said Bechara Choucair, a senior vice president and the chief community health officer at Kaiser Permanente. “Every single day in America, health professionals find themselves on the front lines of treating patients injured by firearms,” Choucair said. “From our emergency departments and primary care settings to behavioral health and specialty care, there are many touch points where health care systems grapple with firearm-related injuries and death. Supporting these dedicated professionals is the right thing to do for patient care and also for the well-being of the communities we serve.”

Kaiser Permanente, he said, will take the same approach to studying firearm injuries as it does with cancer, heart disease, and other leading causes of preventable death in America, drawing on the organization’s research expertise, rich data sources, and delivery system environment. He made clear, though, that Kaiser Permanente’s commitment to research is not about taking a political position on guns. “It is about how we leverage science and research to guide what we do in our hospitals and our clinics and to solve a public health issue,” he said. He added that in 2016 and 2017, Kaiser Permanente physicians and nurses treated more than 11,000 victims of gunshot wounds.

As with other epidemics, firearm violence disproportionately affects specific segments of the population, including children and teens, women, and African Americans. Choucair said that on an average day, seven children and teens are killed by firearms in the United States, and each month,

50 women are shot to death by intimate partners. African American men are 13 times more likely than white men to be shot and killed. “This [disproportionate impact] is a big part of the reasons why in April 2018 Kaiser Permanente announced a $2 million investment in research for firearm-related injury prevention and the formation of a task force to address critical health issues around firearm-related deaths and injuries,” he said. Toward that end, he said, it was his hope that the discussions at the workshop would both describe the problem and discuss approaches for solving it. “There is no one magic solution to ending this health epidemic,” he said, “but there is a growing appetite to address it, as evidenced by the deep expertise in this room.”

According to Elizabeth McGlynn, the vice president of Kaiser Permanente Research and the executive director of the Kaiser Permanente Center for Effectiveness and Safety Research, her organization’s geographic reach, which covers eight regions across the United States, will enable it to explore how different approaches work in diverse areas of the country. “In looking at our own statistics, we see considerable variation in the rates of emergency department visits for firearm-related causes,” she said. “We can see the relative risks for people of different ages, for men and women, by race and ethnicity, by household income, and within very small geographic areas. Having these baseline statistics will help us set priorities and evaluate the effectiveness of different approaches to prevention.” McGlynn added that she and her colleagues are committed to sharing its findings broadly, noting that Kaiser Permanente has a history of working collaboratively with other health systems and, in particular, with the safety net systems that operate in the communities it serves. “We expect there will be considerable interest in the insights from our research and look forward to sharing those results with you and others,” she said. “Beyond our own work, we hope to inspire a great many others to step in and fill the gaps in knowledge that exist today. This workshop is one of many steps on the path to filling the gaps in our evidence base, and enhancing our ability to deliver effective care in this area.”

GUN VIOLENCE: A COMPLEX BIOPSYCHOSOCIAL DISEASE REQUIRING A STRENGTHENED HEALTH CARE SYSTEM RESPONSE

In the workshop’s first presentation, Stephen Hargarten, a professor of emergency medicine, an associate dean for global health, and the director of the Comprehensive Injury Center at the Medical College of Wisconsin, framed gun violence as a complex biopsychosocial disease and defined gun violence prevention as a role that health systems should take as civic leaders of health care. He noted that the prevention of gun violence is at its heart

a scientific issue and that any solution will only come with research and scientific understanding.

Hargarten said that more than 500,000 parasuicides—attempts in self-harm in which death is not the aim—using any method are seen in emergency departments annually along with more than 1.6 million victims of assault. There are individuals in both of these groups who are at risk of dying by suicide once discharged from the hospital, he explained, but little is known about the subtle signs and antecedents that might identify those who are at risk and may benefit from intervention. Gunshot victims are also at risk of themselves becoming perpetrators of violence and shooting someone else. “We need to do—and have an opportunity to do—a better job of identifying those potential victims and screening them appropriately,” Hargarten said. He added that aside from the physical and psychological effects of gun-related violence, a recent analysis found that among hospital-treated non-fatal injuries, the most costly to treat are near-drownings, self-harm, and firearm-related violence (Zonfrillo, 2018).

It is clear from looking at a list of antecedents for all manners of homicide and suicide death (see Box 2-1), Hargarten said, that health care systems can play a significant and more effective role in identifying patients

at risk, identifying protective factors, and affecting individuals who may be at risk of a homicide or suicide event in the future. He noted that intimate partner violence accounts for almost half of female homicides and that the U.S. Preventive Services Task Force has issued guidelines on how to screen for intimate partner violence and what steps to take.¹

The horrific biologic effects of a gunshot wound on the human body result from the transfer of a bullet’s kinetic energy to human tissue, Hargarten explained. In many instances, he said, the damage is so severe that victims will experience lifelong disability, but in some instances the resulting injury can be subtle and only appear later. In one example, a gunshot victim suffered an occult fracture of the femur that was not diagnosed until 2 weeks after the patient was treated initially. In that case, Hargarten said, “we did not prevent additional disability for this patient because we did not understand the dynamics of this disease process.” The lifetime of disability that often results from a gunshot wound and the relative brevity of the pathophysiology of this disease argues for primary prevention as a major thrust for action, he added.

Hargarten said that he sees firearm violence as a complex biopsychosocial disease and believes that, as such, it needs to be studied and treated as a disease. In this case, the disease framework would define the disease agents as the kinetic energy imparted by a bullet; the vector of disease as a gun; and the environment in which the disease occurs as homes, parks, streets, schools, and workplaces; while the high-risk groups of this disease would include young African American men, middle-aged women, and older white men. Framing firearm violence as a disease, one with a social context and psychological antecedents, pulls in other professions to address its causes and symptoms, Hargarten observed. It also broadens the outcome goals for treating violent injury to include psychosocial health and well-being (Monopoli et al., 2018). In short, Hargarten said that he considers firearm violence to be a disease of the 21st century, just as the National Academies identified injury resulting in accidental death and disability as a neglected disease of modern society more than 50 years ago (NAS and NRC, 1966).

The primary prevention challenge for a health systems approach to reducing gun violence is to be more effective at conducting behavioral health screenings, including for adverse childhood events and for any social determinants that raise the risk of experiencing violence, across all sectors of the system. In addition, he said, health systems will need to strengthen secondary prevention by broadening the expertise of the teams caring

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¹ See https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening (accessed December 20, 2018).

for patients and tertiary prevention by committing over the long term to addressing community health as a means of reducing readmissions, complications, and recidivism. “This is a framework for us to understand where health care systems can play an effective role by focusing on patients as we do for other disease processes,” Hargarten said.

The case for preventing gun violence is unique to gun violence, he said, because it has the highest case fatality ratio for both suicide and homicide and the exposure to the disease agent—the kinetic energy imparted by the bullet—is so brief that there are no opportunities for acute intervention during that moment of energy release (Hargarten et al., 2018). “We pick up the pieces in trauma centers with trauma surgeons and others who effectively stop the bleeding and biologically treat the patient, but we have other opportunities to do a better job,” he said. “Broadening the biomedical model to a psychosocial model strengthens the care of our patients.” He noted that surgeons have started selecting patients for a variety of surgical procedures, such as hip replacements, based on their behavioral and social determinants because outcomes differ, which suggests that a bio-psychological approach to disease is starting to permeate the U.S. health care system in general; such an approach should strengthen care, lower costs, improve quality of life, and allow health care systems to focus their strategies on prevention, he said.

One advantage of framing gun violence as a complex biopsychosocial disease is that allows research and care to be driven by science and to consider a gunshot wound as a sterile injury with complex pre- and post-psychosocial elements. “It pulls us in as health care system leaders, it informs and focuses the management of patients, and it prioritizes primary prevention because of the high case fatality ratios,” Hargarten said. “And [this framing] offers a paradigm shift for research support.” He credited Kaiser Permanente with leading the effort to understand gun violence through research, citing its March 2018 announcement that it was allocating $2 million to fund research on the subject. He then quoted Kaiser executive Bechara Choucair, who said, “Going forward, we will study interventions to prevent gun injuries the same way we study cancer, heart disease, and other leading causes of preventable death in America. The best-in-class preventive and specialized care Kaiser Permanente provides is accomplished, in part, by using rigorous research, without bias, to determine which strategies are effective.”

Advancing injury science in health care systems for improved outcomes has led to a greater involvement of health care systems in the prevention of falls, suicide, domestic violence, tetanus, and at-risk alcohol use and abuse, Hargarten said. As an example, he recounted how on a recent trip to a dermatologist for a routine skin check, the first thing he was asked was if he had fallen in the past 30 days. At first, he thought that that question

was odd, given the setting, but he then realized that it is expected of health care systems today to be involved in falls prevention. He did note, though, that training health care professionals on how to screen for dangers such as a risk for domestic violence has to improve.

In closing, Hargarten quoted Albert Einstein, who said, “The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” His point was that society must rethink gun violence. “We must move away from political and social debates to constructive discussions to advance complex biopsychosocial disease management and prevention, supporting research all along the way, just like we do for other diseases,” he said.