Violence is a large and costly public health problem in the United States. Violent injury is the second leading cause of death for all young people aged 10–24 years and the leading cause of death for black males aged 15–24 years.1 Additionally, the Centers for Disease Control and Prevention (CDC) estimates 115 non-fatal injuries for every violent death.2 Firearm injuries constitute a large component of all violent injuries.3 In 2019, firearms were one of the leading causes of injury deaths resulting in 12.1 deaths per 100,000 population and also the means for 75 percent of all homicides.4 In 2012, the estimated cost of firearm injury to the American society exceeded $229 billion (about 1.4 percent of US GDP).5 Like many urban centers across the country, St. Louis has witnessed pervasive violence. From 2011 to 2014, the City of St. Louis experienced an average homicide rate of 40.3 per 100,000 population which is more than six times larger than the global rate of 6.2 per 100,000 population.6 In fact, St. Louis’ homicide rate is almost double the rate for Southern Africa and Central America, which are considered to have the highest rates (24 per 100,000 population) on record in the world.7

Patients who present to a hospital with violent injury are often caught in a vicious cycle of violence. Nearly 50 percent of these patients suffer violent reinjury.8 Being the prime location where violently injured individuals seek care, hospitals are uniquely positioned to break this cycle of violence for these high-risk individuals. Studies have noted that the physical and psychological vulnerability caused by suffering a violent injury can spur a mental shift wherein patients begin to see the harms imposed by their unhealthy environments and the benefit of engaging in more advantageous behaviors.9,10 Hospital-based violence intervention programs (HVIPs) seek to capitalize on this “teachable moment” to help patients turn their life around.

Led by the Institute for Public Health at Washington University in St. Louis, BJC HealthCare, Saint Louis University, and SSM Health, together initiated an HVIP called Life Outside Violence (LOV) in 2018 to break the cycle of violence in St. Louis. Such a regional approach is a first in the country. The program recruits victims of community violence from the four Level 1 trauma and emergency centers in the St. Louis region: Barnes-Jewish Hospital, Cardinal Glennon Children’s Hospital, St. Louis Children’s Hospital, and Saint Louis University Hospital. Patients and their families are connected with licensed social workers serving as program mentors who deliver evidence-based interventions, including needs assessment, brief motivational intervention, and detailed case management services to lay out a path to positive alternatives to violence. Through these interventions, LOV aims to reduce the risk factors for violence such as underlying aggression, mental health illnesses, poor coping skills, drug and alcohol addiction, and increase protective factors against violence like educational attainment and employment. Ultimately, LOV seeks to reduce recidivism for violent injury and criminal involvement for its participants.

The LOV program has achieved initial success; however, leaders of the program seek to conduct evaluations to inform and modify the program so as to best serve those affected by community violence. In this vein, the Cordell Institute has taken on two projects. The first project pursues to identify barriers to enrolling victims of community violence in the LOV program by empirically analyzing the program’s enrollment data combined with the patients’ demographics and interviews with the patients. Already, preliminary analysis of the enrollment data has led to an improved collection of the patient data by the program, which will better serve future researchers seeking evidence-based analysis of the project. Ultimately, the project aims to help the program’s outreach strategy, the enrollment practices used, the program delivery, and to ameliorate its low enrollment rate.

Second, through a systematic review of firearm injury recidivism in the United States, the Institute aims to gather best practices that will inform evaluations of not only of the LOV program, but also firearm injury recidivism more broadly. Reducing firearm injury recidivism, which represents a large portion of all violent injury recidivism, is a primary goal of the LOV program. This recidivism-review project was initiated after discussions with the LOV program leadership wherein they highlighted the need for rigorous, data-driven evaluations of the program and the lack of consensus in the current literature on the methodologies and data sources used to calculate and predict firearm injury recidivism. HVIPs implemented to date in the United States report wide ranging rates of injury recidivism and employ different data sources and methodologies to calculate these recidivism rates.

Rigorous evaluations will help the LOV program demonstrate its return on investment and make a case for sustained internal funding from the collaborating hospitals, along with requesting additional funding from the local, state, and federal authorities. The Cordell Institute’s projects will provide a benefit by informing the LOV program’s data collection and analysis methodologies. A growing body of literature shows that HVIPs produce considerable return on investment in the form of savings in health care costs, incarceration costs, and population burden of injury and death from violence. A Baltimore-based HVIP with an injury recidivism rate of five percent for the intervention group compared to 36 percent for the control group saved approximately $1.25 million in criminal justice and $598,000 in hospital costs, with the average cost of hospitalization for management of a victim of violent injury set at $46,000.11 Another cost-benefit analysis showed that healthcare cost savings alone can render an HVIP cost-neutral if it prevents 3.5 injuries per year.12


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  7. United Nations Office on Drugs and Crime. Global Study on homicide 2013. United Nations; 2014. 163 p. (Publication, Sales No. 14.IV.1).
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  9. Lawson PJ, Flocke SA. Teachable moments for health behavior change: a concept analysis. Patient Educ Couns. 2009 Jul;76(1):25–30.
  10. Longabaugh R, Minugh PA, Nirenberg TD, Clifford PR, Becker B, Woolard R. Injury as a motivator to reduce drinking. Acad Emerg Med. 1995 Sep;2(9):817–25.
  11. Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. J. Trauma Acute Care Surg. 2006 Sep; 61(3):534–40.
  12. 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 Apr; 74 (4):976–82.

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