Analysis of social determinants of health on emergency department utilization by gunshot wound survivors after level 1 trauma center discharge (2024)

Abstract

Background This project analyzed risk factors for emergency department (ED) utilization without readmission within 2 weeks post-discharge for survivors of gun violence.

Methods A hundred gun violence survivors admitted to a Level 1 trauma center were surveyed. Descriptive analyses and group comparisons were conducted between patients who did and did not use the ED. Factors analyzed are rooted in social determinants of health and clinical care related to the index hospitalization.

Results Of the 100 patients, 31 had an ED visit within 6 weeks, although most (87.1%) returned within 2 weeks of discharge. Factors significantly associated (p≤0.05) with a return ED visit included: not having an identified primary care provider, not having friends or family to count on for help, not having enough money to support themselves before return to work, and not feeling able to read discharge instructions.

Conclusion Lack of a primary care provider, low health literacy and social support were associated with increased ED visits without readmission post-discharge.

Level of Evidence Level III, Prognostic and Epidemiological

Data availability statement

No data are available. Data are not available.

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Introduction

The USA has seen a steady rise in firearm violence in the last several years, with Milwaukee, Wisconsin experiencing a 70% increase in non-fatal shootings since 2019.1 As a result, the city’s only adult Level 1 trauma center has worked to address the needs of this unique patient population. Gunshot wound (GSW) survivors are predominantly young, Black males from lower socioeconomic status—a population that has been historically marginalized by society as well as the healthcare system.2–5 These patients present to the hospital with wounds that may require operative management. However, outpatient management becomes more complex due to the potential for adverse mental health outcomes such as risk of post-traumatic stress disorder, financial insecurities, or unsafe housing. These social determinants of health (SDOH) in turn influence outcomes after injury.

The outpatient setting is optimal to address clinical recovery in the context of social determinants. However, scheduled follow-up attendance post-discharge is historically low and post-discharge emergency department (ED) utilization high among trauma patients of any mechanism of injury. Furthermore, patients with penetrating injuries such as a GSW or a stabbing are more than twice as likely to visit the ED within 30 days of discharge when compared with other trauma patients.6 Moreover, socioeconomic disadvantage has been associated with increased rates of non-urgent ED utilization.7 Non-urgent ED utilization additionally contributes to significant resource utilization.8 Prior to this review, there had been no published reports on the SDOH and needs of GSW survivors as it relates to post-discharge ED care.

Thus, this project analyzed factors associated with ED visits that did not result in a readmission within 2 weeks post-discharge for survivors of gun violence. Although not all ED visits after firearm injury are preventable, firearm-injured patients have unique social and structural determinants of health which may influence how they engage with the healthcare system after hospital discharge. We sought to identify if any specific self-reported SDOH were associated with ED utilization that did not result in a readmission within 6 weeks after hospital discharge. The aims of this project were to better understand the immediate SDOH needs of GSW survivors, and to identify areas of intervention to promote engagement with optimal outpatient care resources.

Methods

This quality improvement project surveyed GSW survivors admitted to an urban Midwest Level 1 trauma center.

Results

Discussion

The purpose of this study was to evaluate factors influencing ED visit without readmission after an admission for GSW. The demographics of our patient population were comparable with other studies evaluating victims of gun violence.4 10 A primary factor associated with ED visit without readmission was a lack of a primary care provider (PCP). Although this is a barrier that is addressable in the discharge process, it is important to identify underlying reasons that contribute to patients not having a PCP, one of which is having public insurance. Close to one-third of physicians do not accept new patients who are insured through Medicaid.11 Given that the majority of our sample (>75%) reported public insurance, this ought to be a special consideration for interventions aiming to increase primary care access for GSW survivors.12 In addition to insurance status, not having a PCP may indicate a lack of engagement in the healthcare system prior to injury. This may be due to issues of access due to insurance but may also indicate other barriers such as a de-prioritization of personal health, a mistrust of the healthcare system, or a lack of understanding of the potential benefits of routine medical care. This is supported by Chapman et al13 who indicated that there are several barriers that contribute to primary care visit non-attendance among low-income patients. These include appointment disinterest, competing demands and system insufficiency, such as transportation and appointment reminder systems.

Reduced health literacy indicates an inability to read at a level to understand one’s own medical care and, unsurprisingly, was also significantly associated with ED visit without readmission in this sample. Only 12% of adults in the USA have the proficiency to understand or effectively use health information.14 In general, patients with low health literacy have an increased rate of returning to the hospital or ED within 30 days of discharge.15 Two instruments are available for clinicians to quickly assess a patient’s health literacy: the Rapid Estimate of Adult Literacy in Medicine and the Newest Vital Sign.16 Beyond assessing health literacy, trauma care teams must then include intervention techniques such as simplifying written materials, incorporating more effective communication techniques, and providing alternatives to written materials, such as picture-based instructions.17–19 At the systems level, hospitals can create standardized templates tailored to this patient population to improve comprehension.

Social support was the final factor significantly associated with ED visit without readmission. Those who live alone were 60% more likely to visit the ED than those living with a spouse.20 Perceived poor social support is also a risk factor for other outcomes, such as post-traumatic stress disorder and pain. Increasing engagement with follow-up care may have broad positive impact through increased engagement with people in general.

Finally, all other SDOH examined were not significantly associated with post-discharge ED utilization. These findings suggest that the reasons behind ED visit without readmission were multifactorial and not due to SDOH alone. Although this study presents pilot data, the findings support several opportunities for improvement to standard of care for patients with a GSW and the racial health disparities this patient population experiences. For instance, a PCP ought to be identified prior to discharge. Then, after discharge, a post-discharge navigator could facilitate patient engagement in follow-up care. By demystifying the complexities of care coordination and building trust with the patient and their family, the navigator may offer critical support in parallel with the challenges of returning home, often the location of the index injury. The latter is currently being investigated by this research team.

A limitation of this study was uncertainty of discharge timing. This made it challenging at times for patients to clearly answer questions regarding their anticipated discharge. An additional limitation is that this was a single-site investigation, so visits to other EDs are not accounted for in the present study. It is possible that our study underestimates true post-discharge ED utilization in this population.

In our study, PCP access, health literacy, and social support were significantly associated with post-discharge ED visit without readmission and are barriers that clinicians should address in the discharge process. When supported, these are also indicators of a healthy socioecological environment that facilitates engagement in one’s health and well-being.21 Overall, this study highlights the opportunity for systems-level change in hospital processes and individualized education to better prepare patients for discharge, thereby decreasing non-essential ED utilization.

Data availability statement

No data are available. Data are not available.

Ethics statements

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