United States trends in healthcare charges for pediatric firearm injuries

Costs of Fatal and Nonfatal Firearm Injuries in the U.S., 2019 and 2020

INTRODUCTION

Firearm-related injuries are among the five leading causes of death for people aged 1-44 years in the U.S. The immediate and long-term harms of firearm injuries pose an economic burden on society. Fatal and nonfatal firearm injury costs in the U.S. were estimated providing up-to-date economic burden estimates.

METHODS

Counts of nonfatal firearm injuries were obtained from the 2019-2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Data on nonfatal injury intent were obtained from the National Electronic Injury Surveillance System - Firearm Injury Surveillance System. Counts of deaths (firearm as underlying cause) were obtained from the 2019-2020 multiple cause-of-death mortality data from the National Vital Statistics System. Analyses were conducted in 2023.

RESULTS

The total cost of firearm related injuries and deaths in the U.S. for 2020 was $493.2 billion, a 16 percent increase compared with 2019. There are significant disparities in the cost of firearm deaths in 2019-2020, with non-Hispanic Black people, males, and young and middle-aged groups being the most affected.

CONCLUSIONS

Most of the nonfatal firearm injury-related costs are attributed to hospitalization. These findings highlight the racial/ethnic differences in fatal firearm injuries and the disproportionate cost burden to urban areas. Addressing this important public health problem can help ameliorate the costs to our society from the rising rates of firearm injuries.

The Medical Costs of Firearm Injuries in the United States: A Systematic Review

BACKGROUND

Firearm injury poses a significant public health burden in the United States.

OBJECTIVES

The purpose of this systematic review was to provide a comprehensive accounting of the medical costs of firearm injuries in the United States.

METHODS

A systematic literature review was conducted to identify studies published between January 1, 2000 and July 13, 2022 that reported medical costs of firearm injuries. A search of Embase, PubMed, and the Cochrane Library databases was performed by a medical librarian. The National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate for risk of bias. Health care-related charges and costs per firearm injury were presented and trends were identified.

RESULTS

Sixty-four studies were included in the analysis. Study sample sizes ranged from 18 to 868,483 patients. Reported costs per injury ranged from $261 to $529,609. The median cost reported was $27,820 (interquartile range [IQR] $15,133-$40,124) and median charge reported was $53,832 (IQR $38,890-$98,632). Studies that divided initial hospitalization costs and follow-up medical costs identified that initial hospitalization accounts for about 60% of total costs.

CONCLUSIONS

We found a significant volume of literature about the medical costs of firearm injury, which identified a highly heterogeneous cost burden. A significant amount of cost burden occurs after the index hospitalization, which is the only cost reported in most studies. Limitations of this study include reporting bias that favors hospitalized patients as well as a large focus on hospital charges as measurements of cost identified in the literature.

Pediatric firearm injury related emergency department visits and hospitalizations: a population-based study in the United States

Background

Firearm injury (FI) is the leading cause of death in children and adolescents in the United States (US). We describe the epidemiology of pediatric FI-associated emergency department (ED) visits and hospitalizations in the US stratified by race and ethnicity.

Methods

Data on pediatric (0-17-year-olds) FI were analyzed using the 2019 Nationwide Emergency Department Sample (NEDS) and Kids' Inpatient Database (KID), the largest all-payer databases in the US for ED visits and pediatric hospitalizations, respectively. FI encounters were stratified by race and ethnicity. Poisson regression was used to identify factors associated with in-hospital mortality. Sampling weights were applied to generate nationally representative estimates.

Findings

There were 7017 pediatric ED visits with FI (NEDS); 85.0% (5961/7017) were male and 73.0% (5125/7017) were adolescents (15-17 years). Overall, 5.5% (384/7017) died in the ED; 53.1% (3727/7017) of ED encounters did not result in hospitalization. There were 2817 pediatric FI hospitalizations (KID); 84.1% (2369/2817) were male and 71.6% (2018/2817) were adolescents; 51.4% (1447/2817) of FI were unintentional, 42.8% (1207/2817) were assault-related, and 5.8% (163/2817) were self-inflicted. Black children had the highest proportion (52.6%; 1481/2817) of hospitalizations among all race and ethnicities (p < 0.0001 vs. White). White children had the highest proportion of hospitalizations for self-inflicted injuries (16.6% [91/551] vs. 4.9% [25/504; p < 0.0001] in Hispanics and 1.7% [24/1481] in Blacks; p < 0.0001). The majority (56.5%; 1591/2817) of hospitalizations were patients from low-income zip codes (median annual-household-income <$44,000); 70% (1971/2817) had Medicaid as the primary insurance payer. Overall, 8.0% (225/2817) died during FI-associated hospitalizations. Self-inflicted injuries had the highest in-hospital mortality (prevalence ratio = 8.20, 95% CI = 6.06-11.10 vs. unintentional).

Interpretation

Black children and children with lower household incomes were disproportionately impacted by FI resulting from assaults and accidents, while White children had the highest proportion of self-inflicted FI injuries. Public health and legal policy interventions are needed to prevent pediatric FI.

Funding

US National Institutes of Health.

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities

Objectives

Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies.

Patients and methods

Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths.

Results

There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%.

Conclusions

Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness.

Level of evidence

Level III; epidemiological study type.

Healthcare utilization and mental health outcomes among nonfatal shooting assault victims

Victims of nonfatal shooting (NFS) assaults suffer from emotional and physical trauma; however, little is understood about clinical care utilization patterns among victims. This study examines the healthcare utilization and mental health outcomes before and after an index NFS victimization. A longitudinal dataset of police and clinical data were linked at the individual level to define a cohort of NFS victims with one or more clinical encounter in the 24-months preceding an index NFS injury (N = 2,681) in Indianapolis, Indiana between 2005 and 2018. Mental health was defined using ICD diagnosis codes from any emergency department, inpatient, or outpatient encounter and clinical care utilization was the number of unique encounters within the 24-months preceding and following an index NFS injury. Multivariable logistic regression was conducted to examine factors associated with a mental health diagnosis in the post injury period. Analyses were conducted in October 2021-March 2022. Overall clinical care utilization (Mean: pre = 277.7 (SD 235.3) vs. post = 333.9 (SD 255.1), p < 0.001) and mental health prevalence (14.4% pre vs. 18.8% post, p < 0.001) increased in the 24-months following an index NFS compared to the prior 24-months. Preinjury mental health utilization increased the odds of receiving a mental health diagnosis in the 24-months following an index NFS injury - particularly for Black victims (Odds Ratio 1.69, 95% CI 1.01, 2.85). The findings indicate missed opportunities within the healthcare system to connect NFS victims with needed mental health services, as well as the importance of premorbid connection to mental health care.