Intentional Injuries in Allegheny County

Our Mission: To protect, promote, and preserve the health and well-being of all Allegheny County residents, particularly the most vulnerable.

In 2022, the Allegheny County Health Department (ACHD) released the  Plan for a Healthier Allegheny (PHA) , which was informed by the   Community Health Assessment (CHA) . The PHA established goals and objectives for improving health outcomes in three priority areas: physical health, behavioral health, and environmental health. The following goals contain objectives for reducing intentional injuries in Allegheny County, including specific metrics related to self-harm and violence:

This data supports the first step in The Public Health Approach Process: Define the Problem, by identifying intentional injuries (fatal and nonfatal) among Allegheny County residents from 2017-2021. Injuries can be classified as unintentional or intentional, depending on the intent of the injury. Unintentional injuries are not done on purpose (occur without intent), while intentional injuries are inflicted purposefully on oneself or others. The focus of this initial report is intentional injuries.

Intentional injury is a serious public health concern that impacts people in all stages of life. Understanding potential underlying factors, identifying patterns, and examining the consequences of intentional injury is necessary for developing effective prevention and intervention strategies. Intentional injury includes violence toward others or self-harm. Violence toward others includes nonfatal assaults, domestic violence, abuse, and deaths by homicide. Self-harm includes nonfatal actions a person takes to harm themselves on purpose and death by suicide.

Multiple factors contribute to intentional injury; understanding these interconnections can help develop targeted interventions and policies aimed at breaking the cycle of intentional injury and promoting healthier, safer communities.

• The standardized CSTE ICD-10-CM Injury Surveillance Toolkit was used to identify ICD-10 injury codes relating to diagnosis or external cause of intentional injury
• County resident data from 2017 - 2021 with relevant ICD-10 codes were obtained from:
  • Emergency department (ED) visits
  • Inpatient hospitalizations
  • Death data from vital statistics registry
• Data were compared by year, demographics, and ZIP Code using Age-adjusted rates
• Results were censored for rates with underlying counts less than 10

•  Violence 
  • Intentional injury ED visit rates peaked in 2019 (391 per 100k) and significantly decreased in 2021 (202 per 100k); however, there were no statistically significant changes in hospitalization and death rates from 2017 to 2021.
  • Black residents had a higher rate of assault-related ED visits, hospitalizations, and deaths compared to White residents.
  • Female residents had a higher rate of assault-related ED visits, but male residents had a higher rate of hospitalizations and death.
  • Children were more likely to be seen in the ED or hospitalized due to abuse.
•  Self-harm 
  • Self-harm by drug or biological substance was the most common mechanism for nonfatal events, and death by suicide caused by physical mechanisms, particularly firearms, was the most common for fatal events.
  • Female residents experience higher rates of nonfatal self-harm, and males experience higher rates of death by suicide.
  • Black residents had higher rates of nonfatal self-harm compared to White residents, but rates were similar for deaths by suicide.
  • Nonfatal self-harm was more common among the younger population, whereas death by suicide was more common among middle-aged and older adults.

Intentional injury surveillance is the first step in The Public Health Approach Process and is necessary for monitoring the progress of established goals in the Plan for a Healthier Allegheny. Time trends for acute care interactions and mortality rates have decreased (likely influenced by the pandemic) or remain unchanged. Ongoing annual analysis is necessary for understanding the burden of intentional injury in Allegheny County. Disparities in annual rates by race, sex, age, and geography should be carefully examined by injury recipient and mechanism for programmatic utility. The next step in the public health approach process is to explore additional risk and protective factors influencing or contributing to disparities associated with intentional injury. 

Actions done deliberately to another person that can cause injury, including death.

National data for 2021 identified 1.4 million emergency department (ED) visits for assaults, and assaults were the 8th leading cause of nonfatal ED visits. There were 26,031 (7.8 per 100,000 residents) homicides in the United States; 80% (20,958) were caused by a firearm. Homicides were the 2nd leading cause of death among people 15 to 24 years old and the 3rd leading cause of death among children 1 to 9 years old and adults 25 to 34 years old.  ^1,2  

Homicide was the 18th leading cause of death for Allegheny County residents in 2020. Between 2017-2021, Black residents had a higher rate of assault-related ED visits, hospitalizations, and deaths when compared to White residents. Female residents had a higher rate of assault-related ED visits compared to males, but male residents had a higher rate of assault-related hospitalizations and deaths. Additionally, all age groups experienced events of violence; however, people aged 15 to 24 were the most impacted.

Local violence data from emergency department visits, inpatient hospitalizations, and death records were divided into the following surveillance groups:

•  All Assaults 
•  All Physical Assaults 
•  Firearms 
•  All Abuse and Neglect 
•  Child Abuse and Neglect 
•  Adult Abuse and Neglect 

Actions done deliberately that can cause injury to oneself, including death.

In 2021, there were 660,000 ED visits for self-harm injury in the United States; self-harm was the 8th leading cause of nonfatal ED visits among 10-14 year-olds and the 9th leading cause for 15-24 year-olds. Death by suicide was the 11th leading cause of death in 2021 with 48,183 (14.5 per 100,000 residents) suicides in the United States. Firearms (55%), suffocation (26%), and poisoning (12%) were the three leading mechanisms of death by suicide. Likewise, self-harm death by suicide was the 8th leading cause of death among 15-24-year-olds and the 3rd leading cause of death among 1-9-year-olds and 25-34-year-olds.  ^1,4   

In 2019 and 2020, suicide was the 11th and 14th leading cause of death among Allegheny County residents. Overall, from 2017 to 2021, nonfatal self-harm was more common among the younger population, whereas death by suicide was more common among middle-aged and older adults. Self-harm by drug or biological substance was the most common mechanism for nonfatal events, and suicide by external mechanisms, particularly firearms was the most common for fatal events. Female residents experience higher rates of nonfatal self-harm, and males experience higher rates of death by suicide. In comparison to White residents, Black residents had higher rates of nonfatal self-harm, however, rates were similar for suicide.

Local violence data from emergency department visits, inpatient hospitalizations, and death records were divided into the following surveillance groups:

•  All Self-Harm/Suicide 
•  All Physical Self-Harm/Suicide 
•  Firearms 
•  All Biological Self-Ham/Suicide 
•  All Chemical Self-Harm/Suicide 
•  Hanging, Asphyxiation, and Suffocation 
•  Suicidal Ideation 
•  Suicide Attempt  

• The  Office of Violence Prevention  aims to reduce violence throughout Allegheny County. Specifically, efforts to reduce gun violence through a variety of strategies. To do this, they partner with the  Allegheny County Department of Human Services  and the  City of Pittsburgh , as well as other governmental, non-profit, neighborhood, and faith-based organizations.

• The  Office of Family and Child Health  coordinates two fatality review programs dedicated to preventing future fatalities of those 21 years of age and younger: the Fetal and Infant Mortality Review (FIMR) and the Child Death Review (CDR).

• Contact the  National Domestic Violence Hotline  at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY for the Deaf) or Text "Start" to 88788 or  chat live .
• Contact the  Pennsylvania Coalition Against Domestic Violence  at 1-800-932-4632 to find a local domestic violence program near you.
• To report child abuse or neglect call the national ChildLine at 1-800-932-0313 or the local Allegheny County number at 412-473-2000
• To report elder abuse or abuse of an adult with a disability call the Protective Services Hotline at 1-800-490-8505
• Contact the Suicide and Crisis Lifeline by calling or texting 988 or chatting at  988lifeline.org  if you are experiencing mental health-related distress or are worried about a loved one who may need crisis support

• Estimates produced in this analysis depend upon the accuracy and completeness of the ICD-10 codes in the patient's record.
• Injuries that result in hospitalization only represent a portion of the overall burden of injury. These injuries should be considered in the context of both less- and more severe injuries.
• ED, hospital, and death records only have the home address of the patient, not where the incident happened.
• People who live in Allegheny County (e.g. college students) but use a permanent address outside of Allegheny County are not captured in this data.

The  CSTE ICD-10-CM Injury Surveillance Framework  used in this analysis provides standardized guidance for using ED and hospitalization ICD-10-CM medical administrative discharge data for assessing rates of nonfatal injury. This framework was adopted for fatal injury causes associated with death records for consistency. Guidance and surveillance definitions provided by CSTE may differ from surveillance reporting requirements associated with federal funding.

The rates in this analysis were calculated as  age-adjusted rates.  Age adjustment allows us to compare rates by adjusting for the bias different age distributions can cause. The age-adjusted rates in this analysis were calculated using the direct standardization method. The direct standardization method involves calculating an age-specific rate, which means dividing the number of ED visits, hospitalizations, and deaths in specific age groups by the total population in that specific age group. That rate is then weighted with a standard population, the U.S. 2000 Standard population, for each age group. Age-adjusted rates in any group with fewer than 10 records were censored, or not included in this analysis.

The first step in  The Public Health Approach to Violence Prevention  is to understand the “who,” “what,” “when,” “where,” and “how” associated with it. Grasping the magnitude of the problem involves analyzing data such as the number of violence-related behaviors, injuries, and deaths. Data can demonstrate how frequently violence occurs, where it occurs, trends, and who the victims and perpetrators are. These data can be obtained from police reports, medical examiner files, vital records, hospital charts, registries, population-based surveys, and other sources.

It is not enough to know the magnitude of a public health problem. It is important to understand what factors protect people or put them at risk for experiencing or perpetrating violence. Risk and protective factors are useful because they help identify where prevention efforts need to be focused. Risk factors do not cause violence. The presence of a risk factor does not mean that a person will always experience violence. Victims are never responsible for the harm inflicted upon them.

• Risk Factor – Characteristic that increases the likelihood of a person becoming a victim or perpetrator of violence.
• Protective Factor – Characteristic that decreases the likelihood of a person becoming a victim or perpetrator of violence or provides a buffer against risk.

Findings from the research literature and data from needs assessments, community surveys, key collaborator interviews, and focus groups are useful for designing prevention strategies. Using these data and findings is known as an evidence-based approach to program planning. Once prevention strategies are developed or existing strategies are identified, they are then evaluated rigorously to determine their effectiveness.

The strategies shown to be effective in Step 3 are then implemented and adopted more broadly. Communities are encouraged to implement strategies based on the best available evidence and to continuously assess whether the strategy is a good fit with the community context and achieving its goal of preventing violence. Dissemination techniques to promote widespread adoption include training, networking, technical assistance, and evaluation.

 The Social-Ecological Model  considers the complex interplay between individual, relationship, community, and societal factors. It is important to understand the range of factors that put people at risk for violence or protect them from experiencing or perpetrating violence. This includes violence against others ( adverse childhood experiences ,  child abuse and neglect ,  youth violence ,  elder abuse , and  sexual violence ) and  self-harm/suicide . The overlapping rings demonstrate how factors at one level influence factors at another.

1.  Leading Causes of Death and Injury - PDFs | Injury Center | CDC 
2.  FastStats - Homicide (cdc.gov) 
3. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. DOI:  http://dx.doi.org/10.15585/mmwr.mm6923e1external icon 
4.  FastStats - Suicide and Self-Inflicted Injury (cdc.gov)