Original ResearchPrevious emergency department use among homicide victims and offenders: A case-control study
Introduction
Homicide is now the number 2 cause of death for people aged 15 to 24 years, making it a major public health priority.1 Several factors are associated with homicide, including alcohol and drug use,2., 3. ethnicity,4., 5. gang participation,2., 5. firearms,2., 5., 6., 7., 8. poverty,5 and mental illness.9 Most attempts to decrease homicide have been conducted through the criminal justice system and have emphasized punishment and other deterrents, including the death penalty, to prevent homicide.2 Public health agencies nationally and worldwide, however, increasingly view violence as a problem that demands a public health response.1 Most previous public health research on homicide prevention has focused on victims of abuse. In one study, 44% of intimate partner violence homicide victims had previous emergency department (ED) visits, and 93% of these were injury-related visits.10 Additionally, a significant proportion of intimate partner violence homicide victims have evidence of recent previous injury on autopsy.10., 11. If these patterns hold for other types of homicide, then efforts such as those aimed at early recognition and referral of intimate partner violence victims by health care workers can serve as a model for reducing all forms of homicide.
Despite much scientific investigation of homicide victimization and offending, there has been little investigation of ED utilization before the homicide event. Such an investigation could demonstrate the usefulness of health care data to identify future homicide victims and offenders by identifying risk factors associated with homicide and examining patterns of ED use in the weeks and months leading up to the homicide event. Additionally, this analysis would allow for a comparison of health-related characteristics of victims and offenders of homicide, a group that has been suggested to be similar.12., 13. The information obtained could be useful in the development of risk profiles and target individuals, both potential victims and offenders, for intervention before the homicide event.
We identified homicide victims and offenders and compared them with controls to characterize ED and other health care system utilization before the violent incident. Our goal was to identify patterns and factors that might prospectively identify individuals at increased risk of future violence.
Section snippets
Theoretical model of the problem
There is a growing body of criminological theory and research to suggest that violent victimization and offending are intricately linked. This work is framed by lifestyle/routine activities theory.12., 13. According to this theory, a criminal event occurs when a motivated offender, a suitable target or victim, and the absence of capable guardianship converge. The theory further argues that certain individuals are more likely than others to experience this convergence. The likelihood of violence
Results
The demographic characteristics of the homicide victims and offenders, separately and together (cases), and their matched controls are presented in Table 2. Offenders were more likely men (victims 73.4%; offenders 86.2%; difference 12.8%; 95% CI 3.1% to 22.5%) and were slightly younger (2.7 years; 95% CI 0.03 to 5.5 years) compared with victims. Because of matching, age and sex characteristics of cases and controls were similar. The year of the homicide, weapon use, and incident location are
Limitations
Our data are limited by the use of billing records to characterize visit diagnoses and not actual medical record abstraction. It is possible that some subjects had diagnoses that were apparent in reading the record but were not entered as diagnoses in the billing codes. We are performing medical record abstractions on the cases to determine whether more specific and discriminative information about their visits can be obtained.
We examined the health care use at only 1 of Bernalillo County's
Discussion
Our study identifies health care usage patterns by victims and offenders that differ significantly from those of a similar age and sex group. A careful examination and combination of these factors may lead to the prospective identification of individuals during an ED visit who are at increased risk of future violence.
Victims and offenders tended to use the ED more than any other health care resource, suggesting that the ED is a good place to identify and refer cases. The accelerating pattern of
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Author contributions: CSC, PFJ, LMB, GD, and DPS conceived the study. CSC and LMB developed the design. CSC coordinated the health care data collection; LMB and GD coordinated the criminal justice data collection. CSC conducted the statistical analysis. CSC, PFJ, LMB, and GD contributed to the writing the manuscript. DPS reviewed the manuscript for content and clarity. CSC takes responsibility for the paper as a whole.
Presented in part at the American College of Emergency Physicians Research Forum, Seattle, WA, October 2002, and the American Public Health Association annual meeting, San Francisco, CA, November 2003.
The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.