State-Based Surgical Implications of Gunshot Wound Related Traumatic Injuries Stratified by Gun Law Strength

PURPOSE: Gun-related violence and safety has garnered national attention in the U.S. Gunshot wound (GSW) injuries pose the healthcare system an economic burden as high as $126 billion per year. Previous investigations at the national level have implicated the largest surgical burden to fall onto orthopedic and plastic surgeons costing nearly $77 billion worth in reconstructive care. Orthopedic and plastic surgery intervention was required in 99.7% of surgically treated GSW injuries and associated with 9% of these surgically treated mortalities. In the context of increased variation among state-based approaches to gun safety laws, we sought to understand the tricorollary relationship between state-specific gun laws, incidence of various GSW etiologies and their subsequent burden on reconstructive surgery. METHODS: Twelve states were selected based on available data under the Healthcare Cost and Utilization Project - State Inpatient Database (HCUP-SID) and stratified by their gun law grade ranking validated by the Giffords Law Center to Present Gun Violence. HCUP-SID was then queried for GSW type and injuries and subsequent surgical interventions indexed under the ICD-10 coding system for the following specialties: neurosurgery, head and neck surgery, thoracic surgery, cardiac surgery, vascular surgery, gastrointestinal surgery, genitourinary surgery, and reconstructive (orthopedic and plastic) surgery. These numbers were then normalized to the respective populations of each state. Cochran-Armitage statistical modeling was then employed to determine correlations between gun law grade, incidence of GSW events, and number of subsequent surgical proceedings. RESULTS: Increased gun law grade was negatively correlated with overall GSW events as well as those stemming from self-harm, unintentional, assault-related deaths (p<0.005). Similar trends were revealed between gun law grade and mortalities caused by GSWs (p<0.005). Regarding the surgical burden of GSW treatment, there was a significant association between gun law grade and interventions within head/neck, thoracic, cardiac, vascular, GI, as well as orthoplastic reconstructive surgery. Orthoplastic surgeries accounted for the largest surgical burden in the treatment of GSWs in ten of twelve included states. CONCLUSIONS: Our study is the first to characterize the interrelated correlation between state-based differences in gun law legislation, GSW etiological incidence, and their respective surgical burden. The implications of our data suggest that states with a lower gun law grade (ie. weaker gun safety measures) experience higher overall GSW injuries (particularly stemming from assault, self-harm, and accidental categories) as well as mortality. Such states are also saddled with a higher burden in surgical treatment of GSW events, which in most states (similar to national trends) often falls onto reconstructive surgeons. Our work will contribute to the ongoing policy debate on how to best address the GSW epidemic and the rising costs associated with its surgical treatment - a topic that is clearly relevant to the practice of reconstructive surgeons.