Socioeconomic disparities and severity of gunshot injuries in Israel: a retrospective review of National Trauma Registry data from public hospitals 2019-2022

Abstract

Background: Socioeconomic status (SES) is correlated with gunshot violence. This study examined the associations between SES and the severity of gunshot injuries in Israel.

Methods: The Israel National Trauma Registry was reviewed for all violence-related gunshot wound patients who were admitted to all public hospitals in Israel from 2019 to 2022. Self-inflicted injuries were excluded. This time frame preceded the regional military conflict that began in October 2023 and did not include any military-related activity. The registry records patient demographics including ethnicity. Severity was assessed on the Injury Severity Score (ISS), and SES was categorized into 10 clusters based on the patients' home addresses using the Israel Central Bureau of Statistics index.

Results: A total of 1,848 patients who sustained a gunshot injury were extracted from the database for the period in question, and their SES was identified. Patients from lower SES areas (1-5) were typically young (mean age 30.87 vs. 31.33 in the higher SES group; p = 0.4059) and were almost all from the Arab sector (94.53% vs. 46.94% in the higher SES group; p < 0.0001). Males were injured more frequently, regardless of SES (1825 vs. 82 females). While most patients came from lower SES backgrounds (92% SES levels 1-5), severe injuries were more prevalent in those with higher SES levels (6-10), and had higher ISS scores (p < 0.0001), more admissions to the intensive care unit (p = 0.04), injuries to internal organs (p = 0.0026), and referrals to rehabilitation facilities (p = 0.04). No differences were found for mode of transport to the hospital or likelihood to undergo surgery as a function of SES.

Conclusions: The rate of gunshot-related injuries in Israel is significantly affected by socioeconomic status and ethnicity. The lower SES cohorts, with an ethnic majority of Arabs, experienced more frequent gunshot injuries, but these tended to be less severe. This discrepancy suggests a potential difference in the underlying injury mechanism between social and ethnic groups. Local authorities as well as community leaders would benefit from a clearer understanding of these differences in injury mechanisms, which can contribute to better management of this growing societal issue.

Keywords: Ethnicity; Gunshot injuries; Gunshot wound; Socioeconomic status; Trauma; Violence.

Fig. 1

Distribution of patients by socioeconomic status (SES) cluster. The 1,848 patients with gunshot injuries are grouped into low SES (clusters 1–5) and high SES (clusters 6+), and by age

Fig. 2

Ethnic distribution by SES. Ethnic background differed significantly across SES clusters. Patients in the lower SES cluster were predominantly of Arab ethnicity (94.53%), while higher SES groups included more Jewish patients, with 46.94% identifying as Arab, thus illustrating the disparity in injury based on both SES and ethnicity

Fig. 3

Injury Severity Score (ISS) by ethnicity and SES. ISS was analyzed by SES cluster and ethnic group. While the overall ISS did not differ significantly by ethnicity, among patients in the higher SES clusters (6+), Jewish ethnicity was significantly associated with higher ISS scores (p = 0.0351), indicating more severe injuries compared to patients with Arab ethnicity in the same SES clusters

Fig. 4

Injury Severity Score (ISS) by SES. In patients in SES cluster 6+, Jewish patients had a significantly higher proportion of severe injuries (ISS ≥ 16) at 44.93%, as compared to 28.21% among Arab patients. This supports the association between ethnicity and injury severity within high SES populations

Fig. 5

ICU admission rate by SES. Comparison of ICU admissions across SES clusters. ICU admission was more frequent in higher SES clusters (26.5%) than in lower SES clusters (18.1%) (p = 0.04). This difference reflects the higher clinical severity of patients in higher SES clusters

Fig. 6

Injury site distribution by SES group. Internal organ injuries were significantly more frequent in patients in the higher SES cluster (p = 0.0026), suggesting a difference in the mechanism or impact of trauma. No significant differences were found for other types of injury, such as extremity, spine, vascular, or nerve injuries

Fig. 7

Percentage of surgical operations as a function of Injury. Severity Score (ISS) Injury severity was correlated with the number of operations performed. Patients with higher ISS scores underwent significantly more surgical interventions, irrespective of SES (p < 0.0001)