Closing Data Gaps: Tracking Firearm Violence in North Carolina

A version of this blog post will be published as a Letter to the Editor in the North Carolina Medical Journal in the summer of 2023.    

Over 1,600 North Carolinians lost their lives to firearm violence in 2020, an 18% rate increase from the year prior (CDC WISQARS). Firearm injuries are entirely preventable; however, one key to prevention is identifying and responding to the circumstances that precipitate a fatal or nonfatal firearm injury.

How can we understand these circumstances in time to intervene and protect the lives of North Carolinians? These decisions require accurate data. Fortunately, North Carolina leaders have access to comprehensive data on firearm fatalities. Researchers have been effective in compiling data through the National Violent Death Reporting System (NVDRS), which links data from death certificates, law enforcement reports, and medical examiner reports, and provides circumstance and context that can give insights into the nature of events that result in firearm deaths. North Carolina was an early contributor to NVDRS and has become a leader in data excellence. Data from NC-VDRS have frequently been used to describe the prevalence of circumstances preceding homicides and suicides for specific vulnerable populations (veterans, Native Americans, pregnant women, and others) to identify touchpoints for interventions. At the national level, NVDRS data have been used to inform priorities such as the 2012 National Strategy for Suicide Prevention.

The nonfatal part of the firearm injury equation, however, is not well-described in a single data source. Medical records data are commonly used for this purpose, though these data mostly capture events that result in severe injury, and researchers frequently note that intent and other characteristics about the incident itself may not be accurately captured.

Data from emergency departments show that nonfatal firearm injuries are at least twice as common as fatal firearm injuries. Kauffman et al. (2021) contextualized this ratio by merging death data with nonfatal firearm injury data from the Healthcare Cost and Utilization Project National Emergency Department Sample. They found that firearm assault injuries occurred at double the rate of self-inflicted firearm injuries, and that firearm assault injuries were less likely to result in death (the case fatality rate was 25.9% for assaults and 89.4% for self-injury). Thus, we see that while most firearm deaths are due to suicide, most firearm injuries—combining fatal and nonfatal events—are due to assault.

The fact that death data sources such as NVDRS do not fully reflect the role of assault in firearm injuries is problematic in part because firearm assault victimization is much more common among racial and ethnic minority populations. Kauffman et al. demonstrated that 56.6% of firearm assault victims were Black, compared to just 5.5% of self-harm victims. Unfortunately, in the absence of a reliable national data source to describe fatal and nonfatal firearm injuries, we are overly reliant on death data alone to inform policy decisions and priorities, and we remain under-informed of the basic surveillance and circumstance information that could reveal and help to prioritize prevention activities to reduce the firearm injury burden on racial and ethnic minorities.

Fortunately, North Carolina is well-equipped with the necessary data assets to address this challenge, and RTI is working with state government and academic partners to specifically focus on developing a more complete data source on nonfatal firearm injury in this state. With funding from the CDC’s FASTER program, researchers affiliated with the University of North Carolina Injury Prevention Center have achieved an individual-level linkage between NC-VDRS data and state-wide emergency department data collected by NC DETECT.

For its part, RTI has developed unparalleled expertise in the use of the FBI’s National Incident Based Reporting System (NIBRS), which collects law enforcement data on crimes. NIBRS recently achieved near-complete coverage in North Carolina, and plans are in place to add data fields that will capture and identify gunshot injuries. These data can provide a complement to emergency department data to help establish intent and other characteristics of the incident, leading to better capture and understanding of nonfatal events within the larger context of gun violence.

To advance this and other efforts that can meaningfully reduce gun violence in North Carolina, RTI and other key partners throughout the state have joined forces to develop a firearms research agenda. We plan for this to be under development throughout the summer and fall of 2023, culminating in a gathering of stakeholders to identify and define research priorities. This will result in a whitepaper that aims to facilitate knowledge of firearms research and interventions being conducted in the state, and to provide direction for future efforts. We believe that these efforts and the rich data assets available in North Carolina will continue to make this state—and RTI—leaders in evidence-based strategies for gun violence prevention. Additionally, the data available in North Carolina is also present in a growing number of states, meaning that the work that is underway here can set a national standard for the future of evidence-based strategies.