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Analysis of social determinants of health on emergency department utilization by gunshot wound survivors after level 1 trauma center discharge
  1. Jonelle T Campbell1,
  2. Amber Brandolino2,3,
  3. Jessica L Prom1,
  4. Hamsitha Karra1,
  5. Nana Danso1,
  6. Elise A Biesboer3,
  7. Colleen M Trevino3,
  8. Susan E Cronn3,
  9. Terri A deRoon-Cassini2,3,
  10. Mary E Schroeder3
  1. 1Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  2. 2Comprehensive Injury Center, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
  3. 3Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  1. Correspondence to Dr Mary E Schroeder; meschroeder{at}; Ms Amber Brandolino; abrandolino{at}


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

  • Healthcare disparities
  • Health Care Quality, Access, And Evaluation
  • Surveys And Questionnaires
  • violence
  • gunshot wound
  • needs assessment
  • social determinants of health
  • emergency department

Data availability statement

No data are available. Data are not available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Social determinants of health (SDOH) influence outcomes after gunshot wound injury (GSW).

  • The optimal setting to address recovery-related SDOH is in the outpatient setting, rather than the emergency department (ED).

  • Historically, clinic attendance after any injury is low and ED utilization within 30 days of discharge is high.


  • This study describes self-reported SDOH-based post-discharge needs for patients after GSW at an urban, Midwest, Level 1 trauma center.

  • SDOH-based post-discharge needs were compared between patients with GSW who did and who did not visit the ED within 6 weeks of hospital discharge.


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

  • Identifying a primary care provider at time of discharge, leveraging picture-based or simpler language discharge instructions, and increasing engagement with other people are opportunities for intervention.


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.


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


Patients were identified daily using the trauma census available through the electronic medical record (EMR) system and surveyed close to the time of their projected discharge. Patients were approached in their hospital room. Project staff described the purpose of the survey, that participation was entirely voluntary and that no personal identifiers would be tied to their responses. Patients could verbally agree to participate or decline. If patients were not available, project staff would only try one or two more times to reach them at a more convenient time that did not interfere with clinical care. This convenience sampling was used until a total of 100 patients with a GSW responded. The survey was first administered in October 2021 and the last response was collected in September 2022.

Survey design

The survey was created and managed using REDCap (Research Electronic Data Capture) hosted at the Medical College of Wisconsin. A total of 38 questions focused on SDOH, including access to a communication device (e.g., cell phone, reliable cell service, computer with Wi-Fi, MyChart), healthcare access (e.g., established with a primary care provider, health insurance), mental healthcare for the patient and their family, safe housing, social support, transportation, personal finances, employment, and health literacy. Health literacy was operationally defined as the patient’s perception of their own ability to read at a level that allows them to understand their medical care. Surveys were conducted in-person in the patient’s hospital room. The EMR was used to obtain demographic information including age, gender, race, and insurance status, in addition to ED visits and readmissions within 6 weeks of discharge and reason for that visit. Injury severity score, length of stay and discharge disposition were obtained from the local trauma registry.

Statistical analysis

Statistical analyses were performed using STATA Ver.17.9 Descriptive analyses were conducted to describe demographic characteristics and hospital course. Age and index hospital length of stay were reported as means with standard deviation, whereas number of patients who visited the ED and other demographic characteristics including gender, race, and type of insurance were reported as percentages. Survey results were compared between patients who had an ED post-discharge within 6 weeks versus those who did not. Each survey question was examined with a Χ2 test. The primary outcome was ED visit without readmission within 2 weeks post-discharge from initial admission. A p value of 0.05 or less indicated statistical significance.



Descriptive analyses of demographic characteristics, hospital course, and baseline resources are displayed in table 1. The majority of participants were male (81%), Black or African American (83%), and publicly insured through Medicaid (75%) or Medicare (6%) (table 1). The mean age of participants was 32.8 (±12.1) years. The mean length of stay in the hospital was 12.1 (±21.8) days. Most (n=27 of 31, 87.1%) of the patients who used the ED did so within 2 weeks of discharge.

Table 1

Descriptive frequencies of demographics, index hospital course, and baseline resources (N=100)

Most patients anticipated returning to their living situation after discharge (63.6%). However, for those who were not returning to the same situation, most (n=30 of 35; 85.7%) reported having a safe place to go. Prior to injury, most patients reported using a private vehicle for transportation (81%) (table 1). Similarly, for patients who anticipated being able to return for follow-up care after discharge, most anticipated that they would still use a private vehicle (88.2%). Most patients did not know about the Crime Victim Compensation (CVC) Program (85.9%), but most reported planning on applying for it after it was explained to them (90.8%).

Self-reported survey factors associated with a post-discharge ED visit

Several SDOH factors were significantly associated with an ED visit; however, most were not (table 2). These included: not having an identified primary care provider (p=0.05), not having friends or family to count on for help (p=0.05), not having enough money to support themselves until they can return to work (p=0.02), and not feeling able to read discharge instructions (p=0.03). Two patients identified not having the literacy required to understand their discharge instructions, and both (100%) returned to the ED (p=0.03).

Table 2

Patient social determinants of health survey responses comparing ED versus no ED visit within 6 weeks post-discharge

Healthcare-related factors from the index hospitalization and anticipated post-discharge follow-up care needs were not significantly associated with whether a patient had a subsequent ED visit (table 3). Most patients had met with trauma psychology during hospitalization (70%). Similarly, near the time of discharge, most patients felt ready to go home (75%), but not all.

Table 3

Healthcare-related survey responses comparing ED versus no ED visit within 6 weeks post-discharge


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

Patient consent for publication

Ethics approval

This project was conducted as an approved quality improvement project and was exempt from review by the Institutional Review Board at the primary author’s institution.



  • X @jo_camp7, @AmberBrandolino, @ColleenMTrevino, @susanercronn, @MKETraumaDocs, @LibbyMD823

  • Contributors MES, Td-C, CT, and SEC conceptualized the project design. JTC, JLP, HK, ND, and EAB interviewed patients and collected data. MES conducted the statistical analysis presented. JTC, MES, and AB drafted the article. All authors provided critical revisions and aided in the interpretation of results. All authors approve the final article. The guarantor of this project is MES and in this role they accept full responsibility for the finished work and the conduct of the project, had access to the data, and controlled the decision to publish.

  • Funding This work was not supported by any grants from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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