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ED screening tool may predict future firearm violence risk

In urban EDs, a short, clinical screening tool may help identify youths at high risk for future firearm violence and help determine where to focus firearm violence prevention and intervention efforts, according to findings published in Annals of Internal Medicine.

“Firearm violence has been identified by health and legal professionals as a critical public health problem,” Jason E. Goldstick, PhD, of University of Michigan School of Medicine, and colleagues wrote.

“Although previous ED-based research has identified risk factors associated with firearm violence involvement among high-risk youth, the field of hospital and ED-based youth violence prevention programs lacks a short, clinically relevant screening tool that can be applied as part of routine clinical care in urban settings,” they added.

To develop a clinically feasible risk index for firearm violence, Goldstick and colleagues conducted the Flint Youth Injury Study, which included 599 substance-using youths aged 14 to 24 years recruited between September 2009 and December 2011. Among those, 349 visited the ED for an assault-related injury and 250 were non-assault-related. A total of 483 participants indicated the presence or absence of future firearm violence during follow-up: 52.2% were involved in firearm violence. Participants were randomly assigned into two sets: training (75%) and post-score-construction validation (25%). The researchers jointly assessed 118 baseline predictors using elastic-net penalized logistic regression and found that the most predictive variable domains were violence victimization, community exposure, peer influences and fighting.

Goldstick and colleagues developed the SaFETy — Serious fighting, Friend weapon carrying, community Environment and firearm Threats — score, consisting of 10 points derived by selecting one item from each domain. Results showed that there was an association between SaFETy and firearm violence in the validation set (OR = 1.47; 95% CI, 1.23-1.79), which remained after the researchers adjusted for reason for ED visit (OR = 1.44; CI, 1.2-1.76). Five risk strata were indicated within the training data — SaFETy scores of 0, 1 to 2, 3 to 5, 6 to 8, and 9 to 10. Each of these levels were associated with future firearm violence rates of 18.2%, 40%, 55.8%, 81.3% and 100%, respectively.

The SaFETy screening tool can be administered in 1 to 2 minutes, defined an accurate gradient of future firearm violence risk and can be adapted to a variety of settings, according to the researchers.

“We used machine learning methods to determine the most important predictors of future firearm violence in a high-risk ED sample,” Goldstick and colleagues concluded. “This is the first scale to provide risk stratification for firearm violence and the first developed in and specifically for an ED setting (rather than primary care). Previous risk scores were developed to predict related but distinct behaviors, such as nonspecific violent injury and firearm carrying. The common thread between SaFETy and previous scales is the importance of fighting and received threats as prognostic factors.

“EDs have been previously used as opportunities for identifying high-risk individuals for other types of violence, but the current lack of an easily administered screening tool for firearm violence has limited our ability to harness the same opportunity for firearm violence,” they added. “Our results suggest that SaFETy fills this gap.”

This study adds to a growing body of research trying to better understand how to predict gun violence in the United States. Another study previously published in JAMA Internal Medicine suggested that a social contagion model can explain and predict gun violence. – by Alaina Tedesco

Disclosure: The researchers report receiving primary funding from the National Institute on Drug Abuse.