Survivors of police shootings in Canada have significantly higher long-term healthcare costs than they had before the shooting, new research suggests. They also have higher healthcare costs than do individuals who sustain other forms of police-related injuries.

In a 20-year study that included more than 13,000 adults in Ontario, Canada, a patient’s annual medical costs were three times more per year after a shooting ($16,223 CAD), compared with before a shooting ($5384 CAD). They also were three times higher than those of patients injured by other police-related tactics ($16,223 CAD vs $5412 CAD). The increased costs mainly resulted from increased psychiatric care.

“I noticed these patients are nothing like what’s in movies. None of the defiance, belligerence, or anger,” principal investigator Donald A. Redelmeier, MD, director of clinical epidemiology at Sunnybrook Health Sciences Centre in Toronto, told Medscape Medical News. “Instead, they come across as deeply defeated, emotionally hopeless, and severely depressed.

“Almost all patients (more than 98%) survived, yet about 1 in 5 became permanently disabled within 5 years — before age 40, on average,” he added. “The long-term healthcare costs were substantial…and averaged an extra $10,000 annually.”

The study was published online September 28 in JAMA Network Open.

Differences in Disability

The investigators analyzed data from 13,545 adults (mean age, 35 years; 86% men) who were injured by police and required emergency medical care between 2002 and 2022 in Ontario.

Police shootings were defined as injuries involving a firearm discharge by law enforcement agents while on duty, compared with other mechanisms of injury involving police. Among the 13,520 individuals who survived acute injury, long-term financial data were available for 8755 persons (88 had survived a firearm injury, and 8667 had survived a nonfirearm injury).

Participants who were injured in police shootings were relatively more likely to be male, to live in a rural region, and to have been diagnosed with a mental health disorder. There was no significant difference in mean healthcare costs during the year before injury between patients in the two groups ($5384 CAD vs $5179 CAD).

Injury severity was likely greater after a police shooting than after a nonfirearm injury. Injuries from police shootings were more likely to be associated with higher frequencies of ambulance involvement, hospital admissions, surgical procedures, critical care admissions, and blood product transfusions. In addition, the mean hospital length of stay was 1 week longer after a police shooting (13.5 days vs 5.8 days).

Twenty-five patients died during the initial hospitalization, and mortality was higher after a police shooting (9% vs 0.1%).

Patients who survived a police shooting accounted for 28 subsequent cases of disability over 525 patient-years of follow-up, which is equal to an incidence of 53 per 1000 patients annually. Patients who survived nonfirearm injuries accounted for 2181 subsequent cases of disability over 51,577 patient-years of follow-up (42 per 1000 patients annually).

Adjusted analyses matching annual costs before and after injury for each patient showed a 3.96 relative increase for survivors of police shootings and a 2.06 relative increase for survivors of nonfirearm injuries.

In secondary analyses, the largest single contributor to the differences in long-term healthcare costs was inpatient psychiatric care, which cost a mean $10,573 CAD annually after a police shooting, vs a mean of $1348 CAD after a nonfirearm injury.

Older age, weekday occurrence of the incident, and prior healthcare costs were each associated with higher long-term healthcare costs, as were a previous diagnosis of mental illness or substance misuse.

Mental Healthcare Indicated

Study limitations included a lack of data on costs that are not covered by Canada’s universal health insurance plan and a lack of data on patients with minor injuries that did not require medical attention. Moreover, for some patients, follow-up was insufficient.

Economic analyses were limited by lags in the billing system and other accounting delays, and with the 5-year follow-up period, it is likely that longer-term healthcare costs were underestimated.

“Our study suggests early mental healthcare interventions might be indicated for survivors of police shootings,” said Rademeyer. “This might include social workers in the community and other allied professionals if the goal is to return productive members to society.

“Clinicians should realize that mortality statistics underestimate the losses from a police shooting, since many individuals do not survive intact,” he added. “The study is not a commentary on police training, staffing, supervision, funding, or whether the use of force was justified.”

Sunnybrook has a new initiative called the BRAVE program, “which is intended to break the cycle of violence with empathy,” he said. “This is an early effort to support survivors of gun violence and includes patients injured by police.”

Questions Remain

Commenting on the study for Medscape, Adam Abba-Aji, MD, clinical professor of psychiatry at the University of Alberta and facility medical director at Alberta Hospital in Edmonton, said, “Though the study has the strength of a large sample size, there are pertinent factors that may have influenced the results.” Abba-Aji did not participate in the study.

“It is difficult to conclude that the 88 survivors of firearm injuries had three times higher healthcare costs, compared with 8667 nonfirearm injuries,” he said. “This is a fundamental bias [comparing a small sample to a considerably larger group] that could show a disproportionately higher per capita cost among the 88 with firearm injury, compared to a larger sample of 8667 victims of nonfirearm injury.”

The authors did not report indirect costs of the injury, such as leaves of absence from work for the victims and those who care for them, he said. Furthermore, “they did not include other potential confounding factors, such as healthcare costs covered by private insurance, any pending legal case against the police that may affect chronicity, and whether there was any difference regarding family support in the two groups.”

Additional research could include analyses of national data to identify provincial variability, he suggested, and “to understand the resilience of firearm survivors and what factors determine the chronicity of clinical outcomes.”

Surviving a firearm or nonfirearm injury can lead to mental health problems, such as anxiety, depression, and posttraumatic stress disorder, Abba-Aji noted. “I hope the results of this study will not be used to negatively judge the victims of police firearm injury but rather identify the factors that directly or indirectly contributed to poor clinical outcomes.”

This project was supported by a Canada Research Chair in Medical Decision Sciences, the Canadian Institutes of Health Research, and the PSI Foundation. This study also was supported by Institute of Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and the Ontario Ministry of Long-Term Care. No conflicts of interest were reported. Abba-Aji had no relevant conflicts.

JAMA Netw Open. Published online September 28, 2023. Full text


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