National Trends in the Cost Burden of Pediatric Gunshot Wounds Across the United States

Epidemiology of Pediatric Firearm Injuries in the United States: The Progression of Gunshot Injury Rates Through the Coronavirus Disease 2019 Pandemic

OBJECTIVES

Ballistic injuries among pediatric populations have become a public health crisis in the United States. The surge in firearm injuries among children has outpaced other causes of death. This study aims to assess the trend in pediatric gunshot injuries (GSIs) over the last decade and investigate the impact, if any, of the pandemic on GSIs statistics.

METHODS

A comprehensive retrospective analysis was conducted using a federated, real-time national database. A total of 15,267,921 children without GSIs and 6261 children with GSIs between 2017 and 2023 were identified. The study evaluated the incidence and annual proportions of GSIs among different demographics. In addition, the incidence proportions per 100,000 for accidental, nonaccidental, fracture-related, and fatal GSIs were analyzed.

RESULTS

The incidence proportions per 100,000 for GSIs, accidental GSIs, nonaccidental GSIs, fatal GSIs, wheelchair-bound cases, and fracture-related GSIs increased significantly from 2017 to 2023, going from 9.7 to 22.8 (Relative Risk: 2.342, 95% CI: 2.041, 2.687 , P < 0.001). The overall increase was mostly a result of accidental GSI when compared with nonaccidental (incidence proportion 25.8 vs 2.1; P < 0.001) in 2021 at the height of the pandemic. In patients with an accidental GSI, the incidence proportion per 100k between 2017 and 2023 increased from 8.81 to 21.11 (Relative Risk: 2.397, 95% CI: 2.076, 2.768, P < 0.001).

CONCLUSION

The study supports the shift in the leading cause of death among children from motor vehicle accidents to GSIs, with the continued rise in rates despite the coronavirus disease 2019 pandemic. Accidental injuries constituted the majority of GSIs, indicating the need for enhanced gun safety measures, including requirements for gun storage, keeping firearms locked and unloaded, requiring child supervision in homes with guns, and enforcing stricter punishments as penalties. Comprehensive efforts are required to address this public health crisis. Pediatricians play a vital role in counseling and educating families on firearm safety.

LEVEL OF EVIDENCE

Level III.

Firearm Fatalities in the Pediatric Population: A Retrospective Study From the Cook County Medical Examiner's Office

ABSTRACT

Gunshot injuries are one of the leading causes of death from trauma in the United States. In recent years, the US has experienced an increasing number of fatal pediatric cases related to firearms.A search of the database of the Cook County Medical Examiner's Office over the period January 2016-December 2021 revealed 418 deaths by gunshot wounds (GSWs) among people aged between 0 and 18 years old. Subjects were subcategorized in infants (0 to 1 year), toddlers (≥1 to 3 years), preschool (≥3 to 6 years), preadolescents (≥6 to 12 years), and adolescents (≥12 to 18 years).Most victims were males (n = 374) and adolescents (357 males and 30 females). Homicide (n = 373) was the most common manner of death. Only 2 deaths were accidental. Single GSWs deaths (n = 232) were more common than multiple GSWs (n = 186) and preferentially directed to the head in both homicides and suicides. Gang or robbery related events in areas of readily available firearms explained 4.5% of homicides (17 out of 373 cases). Among deaths by self-inflicted GSWs (n = 36), 7 cases were linked to psychiatric disorders, 3 to family difficulties, 2 to history of playing Russian roulette, and 2 to bullying at school.Pediatric gunshot injuries and deaths are an important public health problem. Understanding and addressing individual and societal risk factors should be the first step toward prevention.

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.

Defining the Full Spectrum of Pediatric Firearm Injury and Death in the United States: It is Even Worse Than We Think

OBJECTIVE

To characterize the full spectrum of pediatric firearm injury in the United States by describing fatal and nonfatal injury data epidemiology, vulnerable populations, and temporal trends.

BACKGROUND

Firearm injury is the leading cause of death in children and adolescents in the United States. Nonfatal injury is critical to fully define the problem, yet accurate data at the national level are lacking.

METHODS

A cross-sectional study combining national firearm injury data from the Centers for Disease Control (fatal) and the National Trauma Data Bank (nonfatal) between 2008 and 2019 for ages 0 to 17 years. Data were analyzed using descriptive and χ 2 comparisons and linear regression.

RESULTS

Approximately 5000 children and adolescents are injured or killed by firearms each year. Nonfatal injuries are twice as common as fatal injuries. Assault accounts for the majority of injuries and deaths (67%), unintentional 15%, and self-harm 14%. Black youth suffer disproportionally higher injuries overall (crude rate: 49.43/million vs White, non-Hispanic: 15.76/million), but self-harm is highest in White youth. Children <12 years are most affected by nonfatal unintentional injuries, 12 to 14 years by suicide, and 15 to 17 years by assault. Nonfatal unintentional and assault injuries, homicides, and suicides have all increased significantly ( P < 0.05).

CONCLUSIONS

This study adds critical and contemporary data regarding the full spectrum and recent trends of pediatric firearm injury in the United States and identifies vulnerable populations to inform injury prevention intervention and policy. Reliable national surveillance for nonfatal pediatric firearm injury is vital to accurately define and tackle this growing public health crisis.

Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective

INTRODUCTION

Firearm-related injuries in America have been under increasing scrutiny over the last several years. Few studies have examined the burden of these injuries in the pediatric population. The objective of this study was to describe the incidence of firearm-related injuries in hospitalized pediatric patients in the United States and identify the risk factors associated with readmission in this young population.

METHODS

The Nationwide Readmission Database was examined from 2010 to 2017. Pediatric patients (aged ≤18 y) who survived their index hospitalization for any firearm injury were analyzed to determine incidence rate, case fatality rate, risk factors for 30-d readmission, and financial health care burden.

RESULTS

There were 35,753 pediatric firearm injuries (86.8% male) with an overall incidence rate of 10.49 (95% confidence interval [CI]: 9.26-11.71) per 100,000 pediatric hospitalizations. Adolescents aged >12 y had the highest incidence rate (60.51, 95% CI: 55.19-65.84). In-hospital mortality occurred in 1948 cases (5.5%), with higher case fatality rates in males. There were 1616 (5.7%) unplanned 30-d readmissions. Multivariate analysis showed abdominal firearm injuries (hazard ratio: 1.13, 95% CI: 1.03-1.24; P = 0.006) and longer length of stay (hazard ratio: 1.27, 95% CI: 1.04-1.55; P = 0.016) were associated with a greater risk of 30-d readmission. The median health care cost for firearm-related injuries was $36,535 (interquartile range: $19,802-$66,443), 22% of which was due to readmissions. Cost associated with 30-d readmissions was $7978 (interquartile range: $4305-$15,202).

CONCLUSIONS

Firearm-related injury is a major contributor to pediatric morbidity, mortality, and health care costs. Males are disproportionately affected by firearm injury, but females are more likely to require unplanned 30-d readmissions. Interventions should target female sex, injuries of suicidal intent, psychiatric comorbidities, prolonged index hospitalization, and abdominal injuries.

The American Academy of Pediatrics firearm safety infographic improves firearm safety guidance: A qualitative study

PURPOSE

Approximately 800 children annually suffer unintentional firearm injuries and deaths from unsecured firearms in the United States. These injuries are preventable, and may be avoided by providing parents with firearm safety guidance (FSG). The purpose of this study was to evaluate the experience of pediatric providers in delivering FSG following incorporation of the American Academy of Pediatrics (AAP) infographic.

METHODS

Qualitative study completed July 2019-December 2019. Community pediatricians in Houston, Texas were provided the AAP firearm safety infographic and encouraged to provide FSG routinely during well-child visits with firearm-owning parents. Efficacy, feasibility of use and barriers to FSG were assessed via focus groups. Content analysis was utilized to identify emergent themes from provider experiences.

RESULTS

Forty-four pediatricians across eight clinics delivered FSG using the AAP infographic. Of these, thirty-four participated in focus groups discussing their experience. Only 34% of those in the focus groups had routinely provided FSG prior to the study. The AAP infographic was a useful tool because of its visibility, valuable information, and assistance with broaching the topic of firearm safety with parents. Three themes were identified from qualitative analysis: methods of successful delivery of FSG (62%), patient responses to FSG (25%), and barriers to delivery of FSG (13%). Parents were generally receptive to the guidance.

CONCLUSIONS

The AAP firearm safety infographic, which is free and publicly available, can be a valuable and satisfactory tool for delivery of firearm safety guidance by pediatric providers, including surgeons. Further study is needed to assess whether the guidance changes parental storage behaviors.

LEVEL OF EVIDENCE

Level VI.