Health care reform in the U.S. has been characterized by significant successes, numerous challenges, and constant political debate. In the last century alone, milestone laws have been enacted, including the Social Security Act Amendments of 1965, which established Medicare and Medicaid; the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986; the Health Insurance Portability and Accountability Act of 1996; and the Affordable Care Act (ACA) of 2010. These laws have resulted in expanded access to care, improved quality of care, and lowered the costs of surgical care for millions of Americans.1,2 Surgeons have pioneered countless advances in public health. In 2020 alone, the United Network for Organ Sharing and the HIV (human immunodeficiency virus) Organ Policy Equity Act has extended the lives of more than 39,000 individuals with life-threatening illnesses.3,4 And with quality improvement programs, such as the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP®), Surgical Care Improvement Project, and the Universal Protocol, research motivated by surgical patient encounters has continuously led to meaningful improvements in public health.
In contrast, one of the most heart-wrenching public health challenges for Americans today—and one surrounded by constant political debate—pertains to firearm-related violence. In 2018, the Centers for Disease Control and Prevention (CDC) reported that approximately 109 people in the U.S. die each day from a firearm-related injury—six out of every 10 from suicide and more than three out of 10 from homicide.5 In 2020, approximately 38,000 individuals lost their lives to firearm-related violence, and Federal Bureau of Investigation-reported active shooter incidents increased to 28 in 2019 from 20 in 2016 (see Figure 1).5-8
FIGURE 1. FBI-REPORTED ACTIVE SHOOTER INCIDENT STATISTICS
Research and advocacy on firearm-related injury prevention is complex and multifaceted, addressing not only the social underpinnings of firearm-related violence and recidivism, but also interventions for protection at the individual, family, and community levels. Federal funding for such research has been limited previously because of the Dickey Amendment in 1996, a provision lobbied for by the National Rifle Association (NRA), which mandated that “none of the funds made available for injury prevention and control at the…CDC may be used to advocate or promote gun control.”9
The ACS Committee on Trauma (COT) has taken a leadership role in supporting firearm violence prevention initiatives, including legislation that limits civilian access to assault weapons, enhances mandatory background checks, and increases federal funding for firearm violence prevention research (see Table 1).10
The ACS and other medical and surgical societies typically remain politically neutral, but in the past few years, their stances on firearm safety have stirred up controversy. In November 2018, the American College of Physicians published an article supporting the rights of physicians to discuss firearm safety with their patients and advocating for universal background checks and waiting periods for gun purchases, as well as banning semiautomatic weapons and large-capacity magazines.11 The article referenced the constitutional right of gun ownership as listed in the Second Amendment and cautioned that any new legislation should respect this right. Although overall it was a noncontroversial stance, the NRA took offense to its publication and responded on Twitter: “Someone should tell self-important anti-gun doctors to stay in their lane.”12
The NRA’s response spurred an outcry, with providers, especially trauma surgeons, speaking out on their unique ability to address the issue of firearm safety, given that they are the physicians who provide care to victims of gun violence. A social media hashtag, #ThisIsMyLane, was popularized and amplified by many members of the surgical community. This movement gained national attention and its leaders were interviewed by several major news outlets.13 Finally, more than 20 years after the Dickey Amendment, Congress passed legislation in December 2019 to allow for funding of firearm-injury prevention research.14
In terms of current research and advocacy, the availability, accessibility, acceptability, and quality (AAAQ) health care delivery framework serves as a useful model for describing the multiple facets of firearm-related violence prevention.15 Though the research is nascent on prevention of firearm injuries, the evidence available at this time allows us to better define the surgeon’s role in protecting our communities from preventable injury and death.
Per the AAAQ framework, the availability of health care refers to communities having sufficient resources and support to implement recommended guidelines. Since the establishment of the first two U.S. civilian trauma centers in 1966, the ACS has verified 535 trauma centers nationwide.16 This growth has been tremendous, yet approximately 11.7 percent of Americans still live more than 60 minutes from a trauma center.17 An analysis of national emergency department (ED) data in 2018 demonstrated that almost one-third of individuals who suffer firearm-related injuries present to EDs that are not trauma centers at any level.18 Because mortality rates are significantly lower in trauma centers than nontrauma centers, a substantial underserved population of trauma victims remains.19
Another ongoing challenge in ensuring communities are protected from firearm-related violence involves addressing the social underpinnings of violent injuries. The establishment of civilian trauma centers has significantly reduced rates of mortality and physical disability from firearm-related violence, but tremendous progress is needed for prevention and protection against recidivism. Outside of the hospital, several community-led programs exist to reduce firearm violence, including focused deterrence programs, Safe Passage programs, and community outreach programs. Within the hospital, Hospital Violence Intervention Programs (HVIPs) first emerged in the mid-1990s as multidisciplinary efforts to address risk factors and protect against violent injuries. Although limited data are available, the implementation of HVIPs has been encouraging. One study in 2006 demonstrated that victims of firearm-related violence who participated in a HVIP were less likely to be re-hospitalized for a similar injury or convicted of violent crimes.20 Another study from 2012 indicated that implementation of a HVIP led to a fourfold decrease in recidivism rates.21 Still, other studies have shown no differences in recidivism or cost-benefit, and, as such, violence intervention programs have been implemented only in about 40 trauma centers nationwide.22 Limited by a paucity of data, a systematic review from the Eastern Association for the Surgery of Trauma (EAST) in 2016 ultimately found insufficient evidence to recommend HVIP implementation.23
Implementing preventative measures and researching current preventative strategies represents an urgent need for surgeons and trauma centers alike to address, and the ACS COT has taken a leading role in developing these resources (see Table 2).24
Accessibility affects all aspects of health care—from prevention to rehabilitation. Given the pervasive nature of trauma on physical, emotional, and psychosocial well-being, the concept of trauma-informed care aims to promote healing environments beyond the hospital. Survivors of firearm injuries experience high rates of posttraumatic stress disorder and depression. They also experience long-term pain, disability, and decreased overall health.25,26 Individuals who have sustained a firearm injury are at high risk of recurrent violent injury, particularly if associated with residence in a lower socioeconomic status neighborhood.27,28 For these individuals, it is critical to ensure sufficient access to rehabilitative services and programs to prevent recidivism.
TABLE 1. COT VIOLENCE INTERVENTION
In addition to providing resources for health care in every community, care must be accessible to all without discrimination. Health equity, as it relates to social justice and structural violence, only recently has begun to be discussed and researched, and in many aspects of health care delivery, racial and ethnic minority communities have less access to care than their white counterparts.29
Perhaps the most durable legislation to ensure accessible care for trauma patients, EMTALA, was enacted in 1986 and mandates that all patients receive necessary stabilizing care for emergent medical conditions, regardless of their ability to pay or their country of citizenship.30 Since the introduction of EMTALA, reported rates of “patient dumping” by EDs, or refusal to provide this care, have decreased substantially to about 1.7 citations per million ED visits.31
Additionally, passage of the ACA and Medicaid expansion have resulted in millions of Americans gaining access to health insurance coverage, and various reports have associated this increased coverage with higher rates of discharge to rehabilitation facilities.32 However, more than 20 percent of states have opted not to expand Medicaid,33 and a report from the Kaiser Family Foundation (2020) reported that in 2018, uninsured rates for indigenous Americans and Alaskan Native, Hispanic/Latinx, and Black nonelderly populations were 21.8 percent, 19.0 percent, and 11.5 percent, respectively.34 As such, the ACS has supported ongoing efforts to ensure access to surgical care for all individuals and has supported legislation to lower health care costs, particularly for patients who undergo emergency treatment.35,36
The acceptability of health care refers to the social and cultural distance between health systems and the communities of people to whom they provide care.15 In disadvantaged communities, a lack of trust in institutions such as law enforcement, along with social discrimination, income inequality, diminished economic opportunity, and lack of access to health care services—particularly substance abuse and mental health services, all have been associated with increased rates of firearm-related violence.29,37 Disparities in health equity, especially as they relate to firearm-related violence, indicate roles for surgeons and trauma centers to intervene in their local communities as a way to develop or expand violence prevention programs, advocate for and rehabilitate victims of firearm-related violence, and prevent recidivism in a manner that is respectful of local cultures.
TABLE 2. ACS COT GUIDANCE ON PREVENTION OF FIREARM INJURIES
Acceptability from our local communities begins with trust, and this trust may be formed through listening, understanding, validation, and advocacy at the individual and community structural levels. This approach may otherwise be referred to as using a “trauma-informed lens,” or recognizing the impact that trauma can have on individuals, as well as understanding potential paths to recovery. Throughout history, narratives belonging to racial and ethnic minority communities have been silenced, invalidated, or simply ignored, so clinicians must first develop safe, diverse spaces for individuals from these communities to share personal traumas. Developing these safe spaces may empower communities that have been perpetually marginalized and encourage individuals from these communities to share their experiences.38
To enact any type of change, and in order to make recommendations that are as effective as possible, it is important to adhere to guidelines that ensure all recommendations are scientifically and medically approved and are of good quality. The ACS COT outlined and developed the first Optimal Hospital Resources for Care of the Injured Patient in 1976, and today, the renamed Resources for Optimal Care of the Injured Patient outlines the responsibilities of surgeons and trauma centers alike in constant reassessment and refinement of trauma care provision. These responsibilities include participation in performance improvement and patient safety programs, local and nationwide trauma registries, and public outreach.
Inspired by the Veterans Administration and the ACS NSQIP®, the ACS Trauma Quality Improvement Program (TQIP®) is designed to collect data from specific trauma centers and analyzes trends in order to improve patient outcomes. At present, more than 750 participating trauma centers worldwide contribute to the TQIP database. The database has helped to create several processes-of-care metrics for hospitals to create treatment algorithms, as well as for physicians to assess which practices are associated with optimal outcomes.
In addition to the ACS, the American Medical Association, and the American College of Emergency Physicians, a number of organizations and foundations are committed to researching and reducing firearm-associated violence. These groups include the American Foundation for Firearm Injury Reduction in Medicine, the National Mass Violence Victimization Resource Center, the Health Alliance for Violence Intervention, as well as the American Association for the Surgery of Trauma, EAST, Western Trauma Association, and more.
Time and again, surgeons have proven that any challenge can be faced with innovation and creativity. Preventing firearm-related violence and injury is an important challenge our surgical community faces, given a political climate that has historically restricted discussion and research. The ACS, and specifically the COT, has become a leader in providing bipartisan guidelines for caring for patients of firearm-related injury. At the end of the day, every surgeon is advocating for their patients, regardless of the laws. However, we must be active in maneuvering the politics to get lawmakers on our side with regard to policies—not necessarily restrictive of firearm ownership, but that would make trauma care of these patients readily available, accessible, acceptable, and of the highest quality.
- Manchikanti L, Helm Ii S, Benyamin RM, Hirsch JA. Evolution of U.S. health care reform. Pain Physician. 2017;20(3):107-110.
- Obama B. United States health care reform: Progress to date and next steps. JAMA. 2016;316(5):525-532.
- HOPE Act continues at five-year milestone. UNOS. In Focus. 2000. Available at: https://unos.org/news/in-focus/hope-act-impact-continues-at-five-year-milestone/. Accessed June 29, 2021.
- More deceased-donor organ transplants than ever. UNOS. 2000. Available at: https://unos.org/data/transplant-trends/. Accessed June 29, 2021.
- Centers for Disease Control and Prevention. Firearm violence prevention: Fast facts. 2000. Available at: www.cdc.gov/violenceprevention/firearms/fastfact.html. Accessed June 29, 2021.
- U.S. Department of Justice. Active shooter incidents in the United States from 2000–2018. Federal Bureau of Investigation. Available at: www.fbi.gov/file-repository/active-shooter-incidents-2000-2018.pdf/view. Accessed July 5, 2021.
- U.S. Department of Justice. Active shooter incidents in the United States in 2019. Federal Bureau of Investigation. Available at: www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2019-042820.pdf/view. Accessed July 5, 2021.
- Global Burden of Disease Injury Collaborators, Naghavi M, Marczak LB, et al. Global mortality from firearms, 1990–2016. JAMA. 2018;320(8):792-814.
- H.R.3610 – Omnibus Consolidated Appropriations Act, 1997. Available at: www.congress.gov/bill/104th-congress/house-bill/3610. Accessed July 5, 2021.
- American College of Surgeons. Statement on Firearm Injuries. January 16, 2013. Available at: www.facs.org/about-acs/statements/12-firearm-injuries. Accessed July 5, 2021.
- Butkus R, Doherty R, Bornstein SS, Health, Public Policy Committee of the American College of Physicians. Reducing firearm injuries and deaths in the United States: A position paper from the American College of Physicians. Ann Intern Med. 2018;169(10):704-707.
- National Rifle Association. @NRA. “Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.” November 7, 2018. Available at: https://twitter.com/nra/status/1060256567914909702?lang=en. Accessed July 5, 2021.
- Wamsley R. After NRA mocks doctors, physicians reply: ‘This Is Our Lane.’ National Public Radio. Available at: www.npr.org/2018/11/11/666762890/after-nra-mocks-doctors-physicians-reply-this-is-our-lane. Accessed July 5, 2021.
- Subbaraman N. United States to fund gun-violence research after 20-year freeze. Nature. 2020;577(7788):12.
- World Health Organization. AAAQ framework. Available at: www.who.int/gender-equity-rights/knowledge/AAAQ.pdf?ua=1. Accessed July 5, 2021.
- American College of Surgeons. The Committee on Trauma: Verified trauma centers. Available at: www.facs.org/search/trauma-centers?country=United%20States. Accessed July 5, 2021.
- Carr BG, Bowman AJ, Wolff CS, et al. Disparities in access to trauma care in the United States: A population-based analysis. Injury. 2017;48(2):332-338.
- Coupet E Jr., Huang Y, Delgado MK. U.S. emergency department encounters for firearm injuries according to presentation at trauma vs nontrauma centers. JAMA Surg. 2019;154(4):360-362.
- MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378.
- Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. J Trauma. 2006;61(3):534-537.
- Smith R, Dobbins S, Evans A, Balhotra K, Dicker RA. Hospital-based violence intervention: Risk reduction resources that are essential for success. J Trauma Acute Care Surg. 2013;74(4):976-980.
- The Health Alliance for Violence Intervention. Community violence initiatives: What is a hospital-based violence intervention program (HVIP)? 2021. Available at: www.thehavi.org/what-is-an-hvip. Accessed July 5, 2021.
- Affinati S, Patton D, Hansen L, et al. Hospital-based violence intervention programs targeting adult populations: An Eastern Association for the Surgery of Trauma evidence-based review. Trauma Surg Acute Care Open. 2016;1(1):e000024.
- Dicker R, Gaines B, Bonne S, et al. Violence intervention programs: A primer for developing a comprehensive program within trauma centers. American College of Surgeons. Committee on Trauma. Available at: www.facs.org/quality-programs/trauma/advocacy/ipc/firearm-injury/hvip-primer. Accessed July 5, 2021.
- Raza S, Thiruchelvam D, Redelmeier DA. Death and long-term disability after gun injury: A cohort analysis. CMAJ Open. 2020;8(3):E469-E478.
- Vella MA, Warshauer A, Tortorello G, et al. Long-term functional, psychological, emotional, and social outcomes in survivors of firearm injuries. JAMA Surg. 2019;155(1):51-59.
- Englum BR, Villegas C, Bolorunduro O, et al. Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma. J Am Coll Surg. 2011;213(6):699-708.
- Marshall WA, Egger ME, Pike A, et al. Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database. J Trauma Acute Care Surg. 2020;89(2):371-376.
- Armstead TL, Wilkins N, Nation M. Structural and social determinants of inequities in violence risk: A review of indicators. J Community Psychol. 2021;49(4):878-906.
- Emergency Medical Treatment and Active Labor Act (EMTALA)—Examination and treatment for emergency medical conditions and women in labor. Available at: www.govinfo.gov/app/details/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXVIII-partE-sec1395dd. Accessed July 5, 2021.
- Terp S, Seabury SA, Arora S, Eads A, Lam CN, Menchine M. Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014. Ann Emerg Med. 2017;69(2):155-162.
- Akande M, Minneci PC, Deans KJ, Xiang H, Cooper JN. Association of Medicaid Expansion under the Affordable Care Act with outcomes and access to rehabilitation in young adult trauma patients. JAMA Surg. 2018;153(8):e181630.
- Henry J. Kaiser Family Foundation. Status of state Medicaid expansion decisions: Interactive map. Available at: www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. Accessed July 5, 2021.
- Artiga S, Orgera K, Damico A. Changes in health coverage by race and ethnicity since the ACA, 2010–2018. Henry J. Kaiser Family Foundation. March 5, 2020. Available at: www.kff.org/racial-equity-and-health-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/. Accessed July 5, 2021.
- American College of Surgeons. Dateline DC—Democrat leaders shift focus to preserving Affordable Care Act protections. March 1, 2019. Available at: https://bulletin.facs.org/2019/03/dateline-dc-democratic-leaders-shift-focus-to-preserving-affordable-care-act-protections/. Accessed July 5, 2021.
- American College of Surgeons. ACS Advocacy efforts focus on unanticipated medical billing issues. In the News. May 31, 2019. Available at: www.facs.org/advocacy/surgeonsvoice/news/053119-unanticipated. Accessed July 5, 2021.
- Kim D. Social determinants of health in relation to firearm-related homicides in the United States: A nationwide multilevel cross-sectional study. PLoS Med. 2019;16(12):e1002978.
- Crooks N, Donenberg G, Matthews A. Ethics of research at the intersection of COVID-19 and Black Lives Matter: A call to action. J Med Ethics. February 5, 2021 [Epub ahead of print].