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Residents Of U.S. States With Relaxed Consumer Firework Laws Have Increased Risk For Firework-related Traumatic Hand Amputations In The Medicare And Humana Populations
Aaron L. Wiegmann, MD1, Syed I. Khalid, MD2, Wassim Hmeidan, BS3, Alivia L. Sabatino, BS3, Thomas Q. Xu, MD4, Anuja K. Antony, MD1, Mark Grevious, MD5.
1Rush University Medical Center, Department of Surgery, Division of Plastic & Reconstructive Surgery, Chicago, IL, USA, 2Rush University Medical Center, Department of Surgery, Chicago, IL, USA, 3Rush Medical College, Chicago, IL, USA, 4Rush University Medical Center, Chicago, IL, USA, 5John H Stroger Hospital of Cook County, Department of Plastic and Reconstructive Surgery, Chicago, IL, USA.

PURPOSE The hand and fingers are commonly involved in fireworks accidents. These injuries can be disabling and costly. Consumer firework laws vary by state; however, laws can be categorized based on how strictly they regulate highly explosive consumer fireworks, such as mortar shells. Many residents of states that ban these fireworks travel to neighboring states with more relaxed laws to purchase these items. This study aims to evaluate if prohibitive consumer firework laws are protective against the most severe type of firework-related hand injury: traumatic amputation of the hand.
METHODS - Each state's consumer firework laws were reviewed using the American Pyrotechnics Association's online database and states were grouped based on the degree to which they prohibited explosive fireworks: consumer fireworks allowed, only "safe and sane" fireworks, only novelty fireworks, or fireworks prohibited. "Safe and sane" states largely prohibit highly explosive fireworks and novelty states only allow items such as sparklers, poppers, and snakes. Medicare and Humana Insurance Claims Databases were then queried, with institutional IRB approval, for patients presenting with either a partial or complete hand amputation secondary to firework accident spanning the years 2005-2014 and 2007-2015, respectively (Table 1). This population was then further analyzed to include rates of injury per firework law state group over the study period (Table 2). To control for population differences, total person-years were calculated for each state and study year per the U.S. Census Bureau estimates of yearly state populations and incidence rate ratios (IRR) were calculated to compare hand amputation risk between state groups weighted by population size over time. P-values were calculated using a Z-test.RESULTS - The total number of hand amputations per state group are shown in Table 2. In the Medicare population, residents of "safe and sane" states had a 54% less risk of traumatic hand amputation by firework compared to residents of states allowing highly explosive fireworks (IRR 0.463, P=4.3x10-12). Novelty and prohibited state populations had even less risk (Table 2). In the Humana population, residents of "safe and sane" states had a 46% less risk of traumatic hand amputation by firework compared to residents of states allowing highly explosive fireworks (IRR 0.536, P=5.5x10-6). Novelty and prohibited state populations had even less risk (Table 2). CONCLUSIONS - These data suggest that the risk for devastating firework injuries to the hand has an incredibly strong association with state firework laws in the Medicare and Humana populations. Residents of states with relaxed laws have significantly increased risk of traumatic hand amputation. These data would suggest that prohibitive firework legislation is protective against firework-related traumatic hand amputation.

Table 1: State Groupings Based on Fireworks Laws, Traumatic Hand Amputation ICD-9 Codes
Most or all consumer fireworks allowedICD-9 CodeDiagnosis
AL, AK, AZ, AR, GA, HI, KS, LA, ME, MI, MS, MO, MT, NE, NV, NH, ND, OK, SC, SD, TN, TX, UT, WA, WY8870Traumatic amputation of hand (complete) (partial)
"Safe and sane" fireworks allowed8871Traumatic amputation of hand (complete) (partial)
CA, CO, CT, FL, ID, IN, KY, MD, MN, NM, NC, OR, PA, RI, VA, DC, WV, WIE9230Accident caused by fireworks
Only novelty fireworks allowed
IL, IA, NY, OH, VT
Fireworks not permitted
DE, MA, NJ

Table 2: Hand Amputation Risk in the Medicare and Humana Populations By Consumer Firework Laws
Medicare
LawsTotal Person-YearsHand AmputationsIncidence RateIncidence Rate Ratio vs. Allowedlog(IRR)SE(IRR)zP-value
Allowed1,109,782,5022272.045E-07
Safe and Sane1,329,839,1031269.475E-080.4632-0.7695620180.111093628-6.9274.294E-12
Novelty473,457,855428.871E-080.4337-0.835423970.167972647-4.9746.573E-07
Prohibited162,138,21316.168E-090.0302-3.5014798251.002200223-3.4940.0005
Prohibited162,138,213148.635E-080.4221-0.8624224950.27537948-3.1320.0017
Humana
LawsTotal Person-YearsHand AmputationsIncidence RateIncidence Rate Ratio vs. Allowedlog(IRR)SE(IRR)zP-value
Allowed1,015,294,5961361.340E-07
Safe and Sane1,212,133,020877.177E-080.5358-0.6239495880.137285083-4.5455.496E-06
Novelty427,721,278245.611E-080.4189-0.8701387270.221403721-3.9308.491E-05
Prohibited146,914,94116.807E-090.0508-2.9795745811.003669737-2.9690.0030
Prohibited146,914,941149.529E-080.7114-0.3405172510.280680446-1.2130.2251
*Prohibited state amputation rates are shown as a range between 1 and 14 because they were coded as an unknown number less than 15 but greater than 0.


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