Individuals who present to the hospital for care of a firearm injury are often caught in a cycle of violence and return for care of a recurrent firearm or other violent injury.1,2 A robust evaluation of this cycle is necessary to inform prevention strategies for recurrent injuries.3 Such public health strategies may include hospital and community-based violence intervention programs.4–6 By accurately identifying who suffers from repeat firearm injuries, violence prevention programs can preferentially target services to high-risk individuals. 

A nationwide comprehensive public health database that provides accurate surveillance of both fatal and nonfatal firearm injuries does not exist in the United States.7,8 Similarly, there are no extant guidelines regarding uniform data tracking and methodology for defining and evaluating recurrent firearm injury. Methodological differences make it difficult to compare recurrent injury rates across studies and hamper efforts to build a comprehensive database on the epidemiology of firearm injury, ultimately resulting in a lack of consensus on effective strategies to reduce firearm injuries.9–12 Developing a uniform data collection and analysis process for recurrent firearm injury will allow for better understanding of the influence of various risk and protective factors on recurrent injury across communities. This will improve methodologic rigor, implementation, and evaluation of interventions designed to interrupt the cycle of violence.

To address this need, a team of researchers affiliated with the Cordell Institute fellowship program conducted a systematic review of the available peer-reviewed literature to review methodologies, data sources, and best practices in identification, calculation, and reporting of recurrent firearm injury rates in the general United States population. Of the 918 unique articles identified, 14 were selected for inclusion in the systematic review.13–26 In our analysis, the reported recurrent firearm injury rates in the United States varied from 1% to 9.5%. 

The team observed heterogeneity in data sources and study methodologies. Firearm injury data were extracted from sources such as single-site hospital medical records to comprehensive statewide records comprising medical, law enforcement, and social security death index data. Repeat firearm-related hospital admissions were either those occurring one to 90 days from the first injury or all repeat firearm-related hospital admissions were classified as a new firearm injury by default.13,15,17–23,25,26 One study24 applied machine learning algorithms to electronic health records to identify new firearm injuries24 and one study16 allowed reinjured persons to self-identify via surveys. Studies13,14,17–20 included either firearm injuries regardless of intent,  only intentional injuries,15,22 or only assault-related injuries.16,21,23–26 Follow-up time, defined as the period the individual was surveilled after their first injury, also varied across studies. Seven studies required a minimum follow-up time which ranged from one to five years after the index injury while the others did not.13,15,17,19–21,26 

Recurrent injury rates for firearm injuries of all intents ranged from less than 1% to 8.8%13,14,17–20 whereas those for assault related firearm injuries ranged from 2.7% to 9.5%.16,21,23,25–27 Cumulative incidence rates ranged from approximately 1.5% after 5.5 years to 15.8% after 10 years, demonstrating that the risk of recurrent injury increases with time from the first injury.17,24–26 Studies that evaluated the risk of reinjury showed significantly increased risk of recurrent injury among individuals with initial firearm-related injuries as compared to other types of violent injury.17,26 Studies identified that males, individuals of Black race, and younger individuals have significantly higher risk of recurrent injury than their counterparts.24,25 There is a growing body of research over the past decade in the realm of firearm injury,14–26 which bodes well for firearm injury prevention. 

Violence intervention programs can have positive spill-over effects in the society.28,29 Population-based evaluations can identify program effects. Our systematic review highlights the need for development, dissemination, and implementation of standard practices for evaluating recurrent firearm injury across populations. As these methods become more uniform, any difference in recurrent injury rates is more likely to be attributed to the influence of risk and protective factors. Ultimately, this information will help us better target local interventions and prevention strategies such as community and hospital-based violence intervention programs.

Our systematic review identified best practices for conducting studies and reporting on recurrent firearm injuries. If implemented, these strategies can be used to inform appropriate data sources and methodologies for extracting information from databases and identifying subsequent firearm injuries, and how to report transparent, reproducible results in a manner that increases comparability across studies. A more standardized approach for assessing firearm injury and reinjury can help inform violence intervention programs and public policies like firearm legislation.


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Muhammad Shayan, Cordell Institute for Policy in Medicine & Law, Washington University in St. Louis; Daphne Lew, Division of Biostatistics, Washington University in St. Louis; Michael Mancini, College for Public Health and Social Justice, Saint Louis University; Randi Foraker, Division of General Medical Sciences, School of Medicine, Washington University in St. Louis; Michelle Doering, Bernard Becker Medical Library, Washington University in St. Louis; Kristen Mueller, Department of Emergency Medicine, School of Medicine, Washington University in St. Louis