The cost of treating gunshot survivors is greatest in states with the highest rates of firearm ownership and the most permissive gun laws, new research shows.

More than 4 in 10 shooting victims admitted to hospitals between 2006 and 2014 were concentrated in 16 Southern states and the District of Columbia, according to a study published this week by two researchers at Stanford University School of Medicine.

Of initial hospital admissions for firearms injuries, 43 percent were in the South. The West and Midwest each had 20 percent of hospitalizations, while the Northeast claimed 16 percent. More than a third of patients treated in the South were uninsured.

Dr. Thomas Weiser, an associate professor of surgery, and Sarabeth Spitzer, a medical student, analyzed inpatient hospital records to conclude that the initial hospitalization of patients wounded by guns over the eight-year period cost Americans more than $6.6 billion. The researchers used a sample of more than 250,000 patients admitted to American hospitals with gunshot injuries.

The average cost per hospitalization was $24,746. Patients with government-funded Medicaid or Medicare were responsible for roughly 40 percent of costs in the survey period. Uninsured patients were accountable for about a quarter of the costs.

The costs attributed to the South alone were $2.7 billion.

The medical community is in near unanimous agreement that owning a gun increases the risk of being shot, whether intentionally or in an accident. As Americans continue to purchase firearms at breakneck pace, this reality has public safety implications: Every year, roughly 110,000 people are shot in the United States. This epidemic also has financial ramifications for the institutions that must treat victims: Most of the roughly 80,000 people who are wounded by a bullet annually enter the healthcare system, incurring massive costs.

“For every one person who dies from a gunshot, there are three or four people who survive,” Weiser said. “At the end of the day, injuries are associated with a cost. And that’s a cost that’s [often] borne by taxpayers.”

The study draws from a survey of 20 percent of American hospitals conducted by the Agency for Healthcare Research and Quality. The survey collects patient information and insurance trends of roughly 8 million discharges annually. The study does not offer state-by-state breakdowns, but does show costs across geographical regions. Southern states were responsible for a disproportionate amount of patients.

The study counts Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, as Southern states.

The researchers focused on financial costs, and did not attempt to account for how gun ownership and gun laws might play a role. Weiser said he wants to better understand the connection, but “we don’t really have data.”

But the finding that the South is the region with the highest number of gunshot victims roughly mirrors gun ownership statistics. According to a survey by researchers from Harvard and Northeastern universities, of America’s 55 million gun owners, nearly 37 percent live in the South, while the West and Midwest claim about 22 percent, respectively. Eighteen percent of gun owners hail from the Northeast.

The same survey found that almost three quarters of Southern gun owners said they own their firearms for self-protection.

Over the last decade, many Southern states have rolled back restrictions on carrying guns in public and relaxed requirements for obtaining a concealed weapons permit, all while strengthening laws protecting the use of deadly force. On Wednesday, Governor Asa Hutchinson of Arkansas signed a bill that would allow people to carry concealed handguns on the campuses of the state’s public colleges and universities.

The Stanford study emerged from Spitzer’s interest in gun violence. When she arrived at Stanford two years ago, she was surprised to learn just how little research had been published about firearms injuries, she said. She hopes that the success of this study will inform researchers more down the road, potentially with a focus on how often gunshot survivors return to the healthcare system for care after their initial injury.

“A motivating factor is filling this [research] gap,” she said.

The study only focused on a patient’s first trip to the hospital with a gunshot wound. It does not include the subsequent hospitalizations, rehabilitation, or patients treated and released from the emergency room.

“This is a very select group of patients,” Weiser said. “And in truth we don’t know anything about patients about once they get out.”

A gunshot victim’s recovery can be an arduous and costly process, especially for those without the financial means to access services. Survivors often require long-term care, such as physical therapy or mental health treatment to deal with the aftermath of such traumatic injuries.

Past studies have included long-term rehabilitation — and a variety of other factors — when calculating the cost of gun violence, but the majority focus on specific states. In one recent analysis, published in February, Dr. Ted Miller of the Pacific Institute and First Coast News determined that gun violence costs each Florida resident $740 every year. The model included estimated costs to the criminal justice system, loss of work, extended medical treatments, and a decline in quality of life.

Miller is the same economist who worked with Mother Jones in 2015 to calculate the national cost of gun violence. The number they landed on, using the expanded criteria of costs: $229 billion per year.

Weiser stressed that such additional costs are extremely important when assessing the total impact of recovering from a gunshot. But he said that many of them can “be perceived as arbitrary.” He said it was his and Spitzer’s intent to conduct their analysis with the most iron-clad data available, to prevent the findings from being misconstrued. His objective was to “remove the emotion” from the research, he said, “and look at the actual dollar figures.”

That’s one of the reasons the authors believe their work may have an impact outside of the medical community.

“If these costs are borne by the government, it has real implications for federal and state budgets,” Weiser said. “If you’re going to argue for increased availability for firearms, you need to calculate the increase in costs.”

Uninsured patients and those with Medicaid each accounted for roughly 30 percent of the sample used in the survey. Slightly more than 20 percent of patients had private insurance, while just 6 percent had Medicare. The insurance status of an additional 14 percent of patients was “other”: individuals whom the hospital opted not to charge, and those with “alternative forms of insurance,” according to the study.

Demographics varied significantly between payer groups. The average Medicaid patient was 26, and more than 50 percent identified as black and reported a household median income in the lowest quartile, below $37,999. Individuals with private insurance were on average older, more likely to be white, and had a higher median income. Patients with Medicare had an average age of 57 and were the most likely to be transferred to another hospital for treatment, or die as a result of their injuries.

However, one factor remained the same: In every payer group, males accounted for more than 80 percent of patients.

Weiser said he is energized about continuing work on the issue of gun violence. In the operating room he interacts with shooting victims first-hand, though he’d rather not have to.

“If I as a trauma surgeon never had to take care of a young kid with a gunshot wound again, that would be fantastic,” he said.

[Photo: Flickr user Airman Magazine]