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Introduction1
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.
At the suggestion of officials at Kaiser Permanente, and with the support of both Kaiser Permanente and the American Hospital Association, the Board on Population Health and Public Health Practice of the National Academies of Sciences, Engineering, and Medicine convened a workshop that examined the roles that health systems can play in addressing the epidemic of firearm violence in the United States. The board convened an ad hoc committee and charged it with the following Statement of Task2:
An ad hoc committee will plan a 2-day public workshop that addresses the research needed to enable health care systems to be more effective in
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1 This section is based on the introductory presentations at the workshop. Speaker statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
2 The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.
preventing firearm injury and death. The workshop will focus on the evidence and best practices by health systems and health care professionals in preventing gun injuries.
The workshop would include speakers and discussion panels that:
- define the current state of evidence on health care–based interventions
- present current evidence-informed practices from selected health systems
- define foundations for best approaches to disseminate and implement evidence-based practices
- identify community linkages that may help empower health systems to be more effective with interventions
- frame the scope and programming of potential future research that can be carried out by Kaiser Permanente and others to fill identified research gaps
Panel discussions should consider the many facets of the health system3 that may be touch points for gun injury prevention strategies, such as primary care, specialty care, behavioral health, and emergency departments. Furthermore, prevention strategies to be discussed should include a focus on high-risk individuals who, through a combination of environmental and behavioral risk factors, are at highest risk of a firearm injury or death.
Panel discussions should not focus on regulatory or other public policy approaches or interventions related to firearm sales, manufacture, or ownership of firearms. The workshop will focus on primary prevention and not the acute care or rehabilitation services for firearm injury victims.
The committee will plan and organize the workshop, select and invite speakers and discussants, and moderate the discussions. A proceedings of the presentations and discussions at the workshop will be prepared by a designated rapporteur in accordance with institutional guidelines.
In his introductory remarks to the workshop, Victor Dzau, the National Academy of Medicine president, characterized gun violence as an issue that those involved with the health of the nation must recognize as “a defining public health challenge of our time.” He noted that in 2016 firearms had accounted for more than 38,500 deaths and more than 85,000 injuries and that three of the deadliest mass shootings in modern U.S. history occurred in a span of less than 6 months. “These events have only heightened the focus that we all need to have on gun violence and the need to take actions
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3 In the context of the workshop, “health systems” were broadly considered as an organization that consists of at least one hospital and at least one group of physicians that provides comprehensive care, who are connected with each other and with the hospital through common ownership or joint management. See https://www.ahrq.gov/chsp/chsp-reports/resources-for-understanding-health-systems/defining-health-systems.html for more information (accessed December 20, 2018).
to prevent it,” said Dzau, who added that it takes a village to solve an issue as complex as firearm violence. “That is where we all come in, because you need everything from prevention to intervention, and you need a range of stakeholders including health providers, health systems, researchers, and policy makers.”
Dzau said that in his opinion a multi-sector engagement with a focus on public health and prevention will be critical to reducing firearm injuries and death on a meaningful scale. Achieving that focus will require evidence-based policy to promote public health and prevention. While crafting and enacting such policies will not be easy, he said, evidence-based policies have been effective in reducing motor vehicle injury, tobacco use, drownings, and other causes of injury and death. The challenge with firearm violence, Dzau said, is that the research needed to understand the causes of firearm injury and death and to develop intervention and prevention strategies is currently in short supply.
In 2013, following the Sandy Hook tragedy, President Obama directed the Centers for Disease Control and Prevention (CDC) to mount a research initiative, and CDC in turn requested the Institute of Medicine (IOM), now the Health and Medicine Division, and the National Research Council (NRC) to conduct a study.4 The resulting report, Priorities for Research to Reduce the Threat of Firearm-Related Violence (IOM and NRC, 2013), laid out the priorities for a 3- to 5-year research effort. “And you know what?” Dzau said. “Nothing happened because the politics of the issue have prohibited CDC and others to support research in this area.” However, he added, thanks in part to the efforts of members of the committee that authored the IOM and NRC report, the 2018 Omnibus Funding Bill includes explicit language that federal support of research on firearm violence is allowable, which clarified a longstanding misinterpretation of the 1996 Dickey Amendment which was thought to prohibit the federal government from funding such research. “Unfortunately, no money has come this way as of yet, so we need to work harder on this issue,” Dzau said.
Health systems, said George Isham, a senior fellow at HealthPartners Institute, can make a difference in preventing gun violence. Health systems, he explained, see millions of patients each year, not just in emergency departments and hospitals but in primary care and specialty practices. Health systems conduct research and engage in quality improvement work to translate research findings into the best possible day-to-day care for people they serve. In addition, there is a strong precedent for health systems
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4 As of March 2016, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to publications issued prior to July 2015.
and the community of health care providers to address issues such as the prevention of firearm injury and death. “Health systems do have a track record in terms of making an impact,” Isham said. “They have developed this track record by implementing best practices based on good science, and, as a result, they have had a substantial impact by contributing to many public health issues.” As examples, he cited the role that health systems played in reducing tobacco use by including tobacco use as a vital sign and connecting every patient who smoked with advice on quitting, as well as in promoting cancer screening and early detection and childhood immunizations.
On a final note before introducing the first speaker of the day, Isham acknowledged that the controversy surrounding firearms in the United States makes it difficult to have any discussion about firearm violence without evoking strong feelings. However, he added, there is no controversy in what this workshop sought to address. “Trying to figure out the best way to keep people alive and healthy is what health care providers and health care systems do,” he said, “and that is what we are here to focus on over the next 2 days.”
ORGANIZATION OF THE PROCEEDINGS
The workshop (see Appendix A for the agenda) was organized by an independent planning committee in accordance with the procedures of the National Academies. This publication summarizes the discussions that occurred throughout the workshop and highlights the lessons and practical strategies that were suggested and the opportunities identified by the speakers for preventing firearm injury and death. In accordance with the policies of the National Academies, the workshop did not attempt to establish any conclusions or develop recommendations about needs or future directions, focusing instead on issues identified by the speakers and workshop participants. Furthermore, the organizing committee’s role was limited to planning the workshop. This workshop proceedings was prepared by workshop rapporteurs Joe Alper, Melissa French, and Alexis Wojtowicz as a factual summary of what occurred at the workshop.