Evaluating the Impact of Florida's "Stand Your Ground" Self-defense Law on Homicide and Suicide by Firearm: An Interrupted Time Series Study.

Importance: In 2005, Florida amended its self-defense laws to provide legal immunity to individuals using lethal force in self-defense. The enactment of "stand your ground" laws in the United States has been controversial and their effect on rates of homicide and homicide by firearm is uncertain. Objective: To estimate the impact of Florida's stand your ground law on rates of homicide and homicide by firearm. Design, Setting, and Participants: Using an interrupted time series design, we analyzed monthly rates of homicide and homicide by firearm in Florida between 1999 and 2014. Data were collected from the Wide-ranging Online Data for Epidemiologic Research (WONDER) web portal at the Centers for Disease Control and Prevention. We used seasonally adjusted segmented Poisson regression models to assess whether the onset of the law was associated with changes in the underlying trends for homicide and homicide by firearm in Florida. We also assessed the association using comparison states without stand your ground laws (New York, New Jersey, Ohio, and Virginia) and control outcomes (all suicides and suicides by firearm in Florida). October 1, 2005, the effective date of the law, was used to define homicides before and after the change. Main Outcomes and Measures: Monthly rates of homicide, firearm-related homicide, suicide, and suicide by firearm in Florida and the 4 comparison states. Results: Prior to the stand your ground law, the mean monthly homicide rate in Florida was 0.49 deaths per 100 000 (mean monthly count, 81.93), and the rate of homicide by firearm was 0.29 deaths per 100 000 (mean monthly count, 49.06). Both rates had an underlying trend of 0.1% decrease per month. After accounting for underlying trends, these results estimate that after the law took effect there was an abrupt and sustained increase in the monthly homicide rate of 24.4% (relative risk [RR], 1.24; 95%CI, 1.16-1.33) and in the rate of homicide by firearm of 31.6% (RR, 1.32; 95% CI, 1.21-1.44). No evidence of change was found in the analyses of comparison states for either homicide (RR, 1.06; 95% CI, 0.98-1.13) or homicide by firearm (RR, 1.08; 95% CI, 0.99-1.17). Furthermore, no changes were observed in control outcomes such as suicide (RR, 0.99; 95% CI, 0.94-1.05) and suicide by firearm (RR, 0.98; 95% CI, 0.91-1.06) in Florida between 2005 and 2014. Conclusions and Relevance: The implementation of Florida's stand your ground self-defense law was associated with a significant increase in homicides and homicides by firearm but no change in rates of suicide or suicide by firearm

Recurrent violent injury: magnitude, risk factors, and opportunities for intervention from a statewide analysis.

INTRODUCTION: Although preventing recurrent violent injury is an important component of a public health approach to interpersonal violence and a common focus of violence intervention programs, the true incidence of recurrent violent injury is unknown. Prior studies have reported recurrence rates from 0.8% to 44%, and risk factors for recurrence are not well established. METHODS: We used a statewide, all-payer database to perform a retrospective cohort study of emergency department visits for injury due to interpersonal violence in Florida, following up patients injured in 2010 for recurrence through 2012. We assessed risk factors for recurrence with multivariable logistic regression and estimated time to recurrence with the Kaplan-Meier method. We tabulated hospital charges and costs for index and recurrent visits. RESULTS: Of 53 908 patients presenting for violent injury in 2010, 11.1% had a recurrent violent injury during the study period. Trauma centers treated 31.8%, including 55.9% of severe injuries. Among recurrers, 58.9% went to a different hospital for their second injury. Low income, homelessness, Medicaid or uninsurance, and black race were associated with increased odds of recurrence. Patients with visits for mental and behavioral health and unintentional injury also had increased odds of recurrence. Index injuries accounted for $105 million in costs, and recurrent injuries accounted for another$25.3 million. CONCLUSIONS: Recurrent violent injury is a common and costly phenomenon, and effective violence prevention programs are needed. Prevention must include the nontrauma centers where many patients seek care

Legalized Abortion and the Homicide of Young Children: An Empirical Investigation

Recent research has drawn a link, sometimes a causal link, between the legalization of abortion in the late 1960s and early 1970s and the precipitous decline in crime in the 1990s. Abortion is posited to have reduced the number of potential victims and potential perpetrators, and the potential effect is examined when these individuals would be reaching their high-crime years. We examined a more proximal potential association between legalized abortion and homicide, specifically, the homicide of young children. Assuming that abortions occurred when the family had insufficient resources for the birth, one could hypothesize that children would have been at higher risk of homicide if born into these circumstances. We examined 1960-1998 U.S. mortality data for children under 5 years of age using an interrupted time series design. The legalization of abortion was not associated with a sudden change in child homicide trends. It was, however, associated with a steady decrease in the homicides of toddlers (i.e., 1- to 4-year-olds) in subsequent years. Although in the predicted direction, the decrease in homicides of children under 1 year of age was not statistically significant. Competing explanations that could be examined in the data (e.g., changes in mortality classification) do not account for the findings

Evaluating the impact of flexible alcohol trading hours on violence: an interrupted time series analysis.

BACKGROUND: On November 24(th) 2005, the Government of England and Wales removed regulatory restrictions on the times at which licensed premises could sell alcohol. This study tests availability theory by treating the implementation of Licensing Act (2003) as a natural experiment in alcohol policy. METHODS: An interrupted time series design was employed to estimate the Act's immediate and delayed impact on violence in the City of Manchester (Population 464,200). We collected police recorded rates of violence, robbery, and total crime between the 1st of February 2004 and the 31st of December 2007. Events were aggregated by week, yielding a total of 204 observations (95 pre-, and 109 post-intervention). Secondary analysis examined changes in daily patterns of violence. Pre- and post-intervention events were separated into four three-hour segments 18∶00-20∶59, 21∶00-23.59, 00∶00-02∶59, 03∶00-05∶59. RESULTS: Analysis found no evidence that the Licensing Act (2003) affected the overall volume of violence. However, analyses of night-time violence found a gradual and permanent shift of weekend violence into later parts of the night. The results estimated an initial increase of 27.5% between 03∶00 to 06∶00 (ω = 0.2433, 95% CI = 0.06, 0.42), which increased to 36% by the end of the study period (δ = -0.897, 95% CI = -1.02, -0.77). CONCLUSIONS: This study found no evidence that a national policy increasing the physical availability of alcohol affected the overall volume of violence. There was, however, evidence suggesting that the policy may be associated with changes to patterns of violence in the early morning (3 a.m. to 6 a.m.)

State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-Sectional Analysis of Data by County

In a cross-sectional analysis of deaths from 2010 through 2014, states with strong gun laws had lower rates of firearm-related homicide and suicide than states with less regulation. Counties in states with less restrictive firearms laws had relatively lower rates of firearm-related homicide when they bordered states with strict gun laws. In contrast, rates of gun violence in areas with strong gun laws were unaffected by lenient laws in neighboring states. Restrictions on the sale and ownership of firearms may have measurable effects on rates of firearm deaths, with potential spillover across state lines

Factors associated with post-arrest withdrawal of life-sustaining therapy.

INTRODUCTION: Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown. METHODS: Utilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables. RESULTS: In our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26-0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91-0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07-1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05-1.25 per 10min), more likely to be female (OR: 1.41; 95% CI: 1.01-1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42-0.98). CONCLUSION: Patients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research

Inter-rater reliability of post-arrest cerebral performance category (CPC) scores.

PURPOSE: Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification. MATERIALS AND METHODS: We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently - in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability and stratified based on whether the score was concordant or discordant among reviewers to determine factors related to discordance. RESULTS: Thirty-nine CPC scores (22.8%) were discordant (kappa: 0.66), indicating substantial agreement. When dichotomized into favorable neurologic outcome (CPC 1-2)/ unfavorable neurologic outcome (CPC 3-5), 20 (11.7%) scores were discordant (kappa: 0.70), also indicating substantial agreement. Patients discharged home (as opposed to nursing/other care facility) and patients with suspected cardiac etiology of arrest were statistically more likely to have concordant scores. For the quality improvement database, patients with discordant scores had a statistically higher median CPC score than those with concordant scores. The registry had statistically lower median CPC score (CPC 1) than the quality improvement database (CPC 2); p\u3c0.01 for statistical significance. CONCLUSIONS: CPC scores have substantial inter-rater reliability, which is reduced in patients who have worse outcomes, have a non-cardiac etiology of arrest, and are discharged to a location other than home

Association Between Enactment of a "Stand Your Ground" Self-defense Law and Unlawful Homicides in Florida.

Results from our study of the influence of Florida’s “Stand Your Ground” self-defense law on homicide and suicide by firearm1 have been questioned for not distinguishing between “unlawful” homicide (ie, murder) and “justifiable” homicide (ie, lawful use of lethal force).2,3 Using an interrupted time series design, we found “an abrupt and sustained increase in the monthly homicide rate of 24.4%” (31.6% for homicide by firearm) following the effective date of the law.1 Readers have suggested that if the increase in homicide rates resulted from an increase in homicides that were justifiable, the law may be working as intended. We investigated this possibility by acquiring additional data and conducting new analyses