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CONTEXT: Surveillance data on nonfatal weapon-related injuries--particularly those treated only in the emergency department (ED)--have been largely unavailable. OBJECTIVE: To develop a surveillance system for fatal and nonfatal gunshot wounds and sharp instrument assaults. DESIGN: The Massachusetts Department of Public Health (DPH) developed an ED-based reporting system for weapon-related injuries. Inpatient discharges and mortality data were linked to ED data, and police data sources were evaluated. SETTING: Statewide. PARTICIPANTS: All 84 acute care hospital emergency departments. Uniform Hospital Discharge Data Set (UHDDS), mortality, and police data were obtained from existing systems. MAIN OUTCOME MEASURES: System sensitivity, predictive value positive (PVP), representativeness, flexibility, usefulness, acceptability, and sustainability. RESULTS: The ED reporting system captured 82% of firearm-related injuries and 74% of reportable sharp instrument wounds from 1994 to 1996. Case reporting by demographic characteristics of the victim was representative and largely complete. Reporting by characteristics of the incident (e.g., type of gun) was less reliable. Police data were used to augment the system. From 1994 to 1996, ED-treated gunshot wounds dropped 41%, from 662 in 1994 to 393 in 1996. Unintentional and self-inflicted gunshot wounds showed no declines. For every firearm-related homicide, 4.7 nonfatal firearm assaults were treated; 85% of self-inflicted gunshot wounds were fatal. CONCLUSIONS: The system has proven timely (1996 ED data were available for release in March 1997), flexible (the reporting form has been revised several times), useful (DPH responds to 150 weapon injury data requests annually), acceptable (reporting is voluntary and no hospital declined participation), and sustainable (state funding is currently supporting the ED reporting system).

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The Massachusetts Department of Public Health has created the first statewide surveillance system in the nation that tracks both fatal and nonfatal weapon injuries. The authors summarize findings for 1994 and discuss their public health implication. Suicides were the leading cause of firearm fatality, while self-inflicted injuries accounted for only 3% of nonfatal firearm injuries. Risk of violence-related injuries varied dramatically across the state. In Boston, one in 38 black male teenagers ages 15 to 19 was shot or stabbed in 1994, in contrast to one in 56,000 for white females of any age living in suburban communities. In Boston, non-Hispanic black male teenagers were at 41 times higher risk than white male teenagers for gun injuries. Shooting homicides increased sixfold during the late 1980s among black Boston males, while homicides by other means remained stable. In other Massachusetts cities, injury rates were higher among 20 to 24-year-olds than among teenagers, and, in some areas, incidence rates were as high or higher among Hispanic males than among non-Hispanic black males. Between 1985 and 1994, the proportion of firearm injuries caused by semiautomatic pistols increased from 23% to 52%, according to police ballistics data.

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Massachusetts has developed the first State profile of the causes and costs of injury based on the national study, "Cost of Injury in the United States: A Report to Congress." Incidence of fatal injuries is based on Massachusetts data; nonfatal hospitalized injuries, on Massachusetts age and sex rates and U.S. cause data; and nonhospitalized injuries, on U.S. rates applied to Massachusetts census data. Lifetime costs per injured person are based on national data adjusted for higher personal health care expenditures and for higher mean annual earnings in Massachusetts. The estimated total lifetime cost for the 1.4 million injuries that occurred in 1989 is $4.4 billion--$1.7 billion for health care and $2.7 billion for lost earnings. Injuries attributed to motor vehicles and falls account for more than half of the total cost. The other cause categories are poisonings, fire-burns, firearms, drowings-near drownings, and other. For every person who dies from an injury, 17 people are hospitalized, and an estimated 535 people require outpatient treatment, consultation, or restricted activity. Development of a State-based cost report can be useful in monitoring the contribution of injuries to health status and in planning effective injury prevention strategies in a community-based health care system. The methodology described in this paper can be replicated by other States through accessing their State-specific mortality and hospital discharge data bases.

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Hospital discharge data are a potentially useful information resource for documenting the epidemiology of nonfatal injuries. However, hospitals often do not include E-codes that identify external causes of injury in discharge abstracts. One barrier has been assumed to be the cost of assigning E-codes to medical records. Directors of medical records at hospitals in Massachusetts were surveyed to assess the validity of a cost-assessment study by Rivara and coworkers and to determine what resources they would need to E-code all injury discharges. According to Rivara's estimates, injury coding an additional 500 hospital discharges would entail a continuing cost to each hospital of about $600 a year. More than half of the survey's 101 respondents believed that the estimates were accurate, 16 percent believed that the estimates were inaccurate, and 27 percent were unable to assess the potential costs. Among the resources needed to E-code all injury-related discharges, respondents most often cited training for those who assign the codes and the approval of the hospital administration. Only 20 percent of the respondents cited needs directly related to ongoing costs. The perception by hospitals of the cost of E-coding, frequently cited as a major barrier to the use of hospital discharge data as an injury surveillance source, did not emerge in this survey as an overriding concern.

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