Trends in Firearm Injuries Among Children and Teenagers in the United States

A joinpoint analysis examining trends in firearm injuries at six us trauma centers from 2016 to 2022

BACKGROUND

There is an epidemic of firearm injuries in the United States since the mid-2000s. Thus, we sought to examine whether hospitalization from firearm injuries have increased over time, and to examine temporal changes in patient demographics, firearm injury intent, and injury severity.

METHODS

This was a multicenter, retrospective, observational cohort study of patients hospitalized with a traumatic injury to six US level I trauma centers between 1/1/2016 and 6/30/2022. ICD-10-CM cause codes were used to identify and describe firearm injuries. Temporal trends were compared for demographics (age, sex, race, insured status), intent (assault, unintentional, self-harm, legal intervention, and undetermined), and severity (death, ICU admission, severe injury (injury severity score ≥ 16), receipt of blood transfusion, mechanical ventilation, and hospital and ICU LOS (days). Temporal trends were examined over 13 six-month intervals (H1, January-June; H2, July-December) using joinpoint regression and reported as semi-annual percent change (SPC); significance was p < 0.05.

RESULTS

Firearm injuries accounted for 2.6% (1908 of 72,474) of trauma hospitalizations. The rate of firearm injuries initially declined from 2016-H1 to 2018-H2 (SPC = - 4.0%, p = 0.002), followed by increased rates from 2018-H2 to 2020-H1 (SPC = 9.0%, p = 0.005), before stabilizing from 2020-H1 to 2022-H1 (0.5%, p = 0.73). NH black patients had the greatest hospitalization rate from firearm injuries (14.0%) and were the only group to demonstrate a temporal increase (SPC = 6.3%, p < 0.001). The proportion of uninsured patients increased (SPC = 2.3%, p = 0.02) but there were no temporal changes by age or sex. ICU admission rates declined (SPC = - 2.2%, p < 0.001), but ICU LOS increased (SPC = 2.8%, p = 0.04). There were no significant changes over time in rates of death (SPC = 0.3%), severe injury (SPC = 1.6%), blood transfusion (SPC = 0.6%), and mechanical ventilation (SPC = 0.6%). When examined by intent, self-harm injuries declined over time (SPC = - 4.1%, p < 0.001), assaults declined through 2019-H2 (SPC = - 5.6%, p = 0.01) before increasing through 2022-H1 (SPC = 6.5%, p = 0.01), while undetermined injuries increased through 2019-H1 (SPC = 24.1%, p = 0.01) then stabilized (SPC = - 4.5%, p = 0.39); there were no temporal changes in unintentional injuries or legal intervention.

CONCLUSIONS

Hospitalizations from firearm injuries are increasing following a period of declines, driven by increases among NH Black patients. Trauma systems need to consider these changing trends to best address the needs of the injured population.

Trends in pediatric firearm-related injuries and disparities in acute outcomes

Background

Firearm-related injuries (FRI) are an increasing cause of death and injury in children. The etiology for this rise is multifactorial and includes socioeconomic factors. Despite its prevalence and documented increase over COVID-19, there is a paucity of research on disparities and the influence of social determinants of health (SDH) in pediatric FRI. This study aims to explore the epidemiology of this vulnerable population in Atlanta, trends over time and relevant dates such as COVID-19 and a state firearm law, and disparities in clinical outcomes.

Methods

Retrospective cohort of patients with FRI (0-20 years-old, x̄=9.8, Median = 11) presenting to our hospital EDs from January 2014 to April 2023 (N = 701) and eligible for the Trauma Registry. This period includes two major events, namely the COVID-19 pandemic (March 2020), and passage of state law Constitutional Carry Act (SB 319) (April 2022), allowing for permit-less concealed firearm carry. Single series interrupted time series (ITS) models were run and clinical outcome differences between race and insurance groups were calculated unadjusted and adjusted for confounders using inverse propensity treatment weights (IPTW). The primary outcome was mortality; secondary are admission and discharge.

Results

Majority of FRI involved patients who were male (76.7%), Black (74.9%), publicly insured (82.6%), ≤12 years-old (61.8%), and injured by unintentional shootings (45.6%) or assault (43.7%). During COVID-19, there was a sustained increase in FRI rate by 0.42 patients per 1,000 trauma visits per month (95% CI 0.02-0.82, p = 0.042); post-SB 319 it was 2.3 patients per 1,000 trauma visits per month (95% CI 0.23-4.31, p = 0.029). Publicly insured patients had 58% lower odds of mortality than privately insured patients (OR 0.42, 95% CI 0.18-0.99, p = 0.047). When controlled for race and mechanism of injury, among other confounding factors, this association was not significant (p = 0.652).

Conclusion

Pediatric FRI are increasing over time, with disproportionate burdens on Black patients, at our hospitals. Disparities in mortality based on insurance necessitate further study. As social and economic repercussions of COVID-19 are still present, and state firearm law SB 319 is still in effect, assessment of ongoing trends is warranted to inform preventative strategies.

Population Density and Triage of Pediatric Firearm Injuries in a Rural Trauma System

BACKGROUND

Rural pediatric firearm injuries require regional pediatric and trauma expertise. We evaluated county-level population density associations with transport, hospital interventions, and patient outcomes at a Level I pediatric trauma center serving a rural, statewide catchment area.

MATERIAL AND METHODS

The trauma registry of the only in-state pediatric trauma center was reviewed for firearm injuries in patients < 18 between 1/2013 and 3/2020. County-level population density was classified according to the United States Office of Management and Budget definitions for rural, micropolitan, and metropolitan areas.

RESULTS

364 patients were identified, including 7 patients who were re-injured. Mean age was 11.3 ± 4.5 y and patients were 79.4% male. 59.3% were transferred from a referring hospital. Median injury severity score was 5 (IQR 1-10); 88.0% required trauma center admission, and 48.2% required operative intervention. 7.4% were injured in a rural county, 46.4% in a micropolitan county, and 46.2% in a metropolitan county. Patients from rural counties were more likely to be unintentionally injured (72.0%) than those from micropolitan (54.4%) or metropolitan counties (44.0%, P = .04). While need for inpatient admission and length of stay were similar, those transported from rural counties had significantly longer transport times (P < .01) and less frequent need for operative intervention (P = .03), as well as trends toward lower injury severity (P = .08) and mortality (P = .06).

CONCLUSION

Management of pediatric firearm injury is a unique challenge with significant regional variability. Opportunities exist for outreach, telehealth, and decision support to ensure equitable distribution of resources in rural trauma systems.

LEVEL OF EVIDENCE

Epidemiological, Level III.

State Gun Regulations and Reduced Gun Ownership are Associated with Fewer Firearm-Related Suicides Among Both Juveniles and Adults in the USA

BACKGROUND

Few studies have investigated the relationship between specific gun regulations and gun ownership with the firearm-related suicide rate among juveniles and adults across U.S. states. Therefore, this study seeks to determine if gun ownership rates and gun restrictions are related to the firearm-related suicide rate in both the pediatric and adult populations.

METHODS

Fourteen measures of state gun law restrictions and gun ownership were collected. These included Giffords Center ranking, gun ownership percentages, and 12 specific firearm laws. Unadjusted linear regressions modeled the relationship between each individual variable and the rate of firearm-related suicides for adults and children across states. This was repeated using a multivariable linear regression adjusting for poverty, poor mental health, race, gun ownership, and divorce rates by state. P values of <0.004 were considered significant.

RESULTS

In the unadjusted linear regression, 9 of 14 firearm-related measures were statistically associated with fewer firearm-related suicides in adults. Similarly, 9 of 14 measures were found to be associated with fewer firearm-related suicides in the pediatric population. In the multivariable regression, 6 of 14 vs. 5 of 14 measures were statistically associated with fewer firearm-related suicides in the adult and pediatric populations, respectively.

CONCLUSIONS

Ultimately, this study found that increased state gun restrictions and lower gun ownership rates were associated with fewer firearm related suicides among juveniles and adults in the US. This paper provides objective data to help lawmakers as they create gun control legislation that can potentially decrease the rate of fire-arm related suicide.

LEVELS OF EVIDENCE

II.

Trends and Disparities in Firearm Deaths Among Children

BACKGROUND AND OBJECTIVES

In 2020, firearm injuries became the leading cause of death among US children and adolescents. This study aimed to evaluate new 2021 data on US pediatric firearm deaths and disparities to understand trends compared with previous years.

METHODS

Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research was queried for firearm mortalities in children/adolescents from 2018 to 2021. Absolute mortality, death rates, and characteristics were reported. Death rates were defined per 100 000 persons in that population per year. Death rates across states were illustrated via geographic heat maps, and correlations with state poverty levels were calculated.

RESULTS

In 2021, firearms continued to be the leading cause of death among US children. From 2018 to 2021, there was a 41.6% increase in the firearm death rate. In 2021, among children who died by firearms, 84.8% were male, 49.9% were Black, 82.6% were aged 15 to 19 years, and 64.3% died by homicide. Black children accounted for 67.3% of firearm homicides, with a death rate increase of 1.8 from 2020 to 2021. White children accounted for 78.4% of firearm suicides. From 2020 to 2021, the suicide rate increased among Black and white children, yet decreased among American Indian or Alaskan Native children. Geographically, there were worsening clusters of firearm death rates in Southern states and increasing rates in Midwestern states from 2018 to 2021. Across the United States, higher poverty levels correlated with higher firearm death rates (R = 0.76, P < .001).

CONCLUSIONS

US pediatric firearm deaths increased in 2021, above the spike in 2020, with worsening disparities. Implementation of prevention strategies and policies among communities at highest risk is critical.

Trends in Adolescent Firearm-Related Injury: A Time Series Analysis

BACKGROUND

Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019.

PURPOSE

This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified.

RESEARCH DESIGN

City-wide retrospective cohort review.

STUDY SAMPLE

Adolescent victims (age 11-21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia.

DATA ANALYSIS

Descriptive, multivariate and time series analysis.

RESULTS

There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11-14 years (43.1%) compared to 15-17 years (10.2%) and 18-21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021.

CONCLUSION

Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

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.

Health Inequities in Pediatric Trauma

This review article highlights the disparities evident in pediatric trauma care in the United States. Social determinants of health play a significant role in key aspects of trauma care including access to care, gun violence, child abuse, head trauma, burn injuries, and orthopedic trauma. We review the recent literature as it relates to these topics. The findings from these recent studies emphasize the important principle that trauma care for children should be designed with a focus on equity for all children.

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 emerging infrastructure of US firearms injury data

For every fatal shooting in the United States, detailed information from reports of coroners or medical examiners, police departments, and other sources is recorded in the National Violent Death Reporting System. There is no such system in place for nonfatal shootings, which far outnumber fatalities. Hospital data systems are in place that could, with some improvements, provide access to reliable local, state and national estimates of firearm injuries. Such estimates are possible because most firearms injuries are treated in hospitals, and hospitals routinely assign "external cause of injury" codes to all injury encounters. Federal health agencies supervise a number of data systems that centralize hospital data. Challenges currently being addressed are public access, timeliness, and accuracy of coding of intent. (Hospitals misclassify many firearm assaults as accidents.) Law enforcement agencies provide detailed data on shootings in criminal circumstances, including shootings that are not treated in a hospital. The FBI's Uniform Crime Reports (UCR) system aggregates data from agencies. The FBI instituted a radical reform of this system beginning in 2021, resulting in a sharp agency participation drop that prevents valid national estimates. The reform requires agencies to report incident-level data instead of summary counts, which is all that was required for the previous 90 years. There are ongoing efforts to increase participation in the new system and restore its former status as the leading source of national crime estimates. In the meantime, data on nonfatal gunshot cases are available from a number of police departments. We discuss additional reforms needed to generate timely, accurate, publicly accessible data from hospitals and police.

Are Children Harmed by Being Locked up at Home? The Impact of Isolation during the COVID-19 Pandemic on the Phenomenon of Domestic Violence

The phenomenon of violence against children is a very complex one. There are many types of child abuse, and they are culturally dependent to a significant degree. Although studies show that children generally only suffer from mild COVID-19 infection, some social restrictions introduced during the pandemic, such as home isolation, may have many severe consequences on the population's mental health. Studies on this topic suggest that violence against children increased during lockdown due to the COVID-10 pandemic. This narrative review summarizes this available literature on the subject and discusses the different forms of violence against children, their cultural aspects, the impact of the COVID-19 pandemic on the phenomenon of violence, the long-term consequences of the above, and forms of assistance for abused minors.

Firearm-Related Injuries and Deaths in Children and Youth

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Relationships Between Socioeconomic Deprivation and Pediatric Firearm-Related Injury at the Neighborhood Level

BACKGROUND

Disparities in pediatric injury are widely documented and partly driven by differential exposures to social determinants of health (SDH). Here, we examine associations between neighborhood-level SDH and pediatric firearm-related injury admissions as a step to defining specific targets for interventions to prevent injury.

METHODS

We conducted a retrospective review of patients ≤16 years old admitted to our level 1 pediatric trauma center (2010-2019) after a firearm-related injury. We extracted patients' demographic characteristics and intent of injury. We geocoded home addresses to enable quantification of injury-related admissions at the neighborhood (census tract) level. Our population-level exposure variable was a socioeconomic deprivation index for each census tract.

RESULTS

Out of 15,686 injury-related admissions, 140 were for firearm-related injuries (median age 14 years [IQR 11,15]). Patients with firearm-related injuries were 75% male and 64% Black; 66% had public insurance. Nearly half (47%) of firearm-related injuries were a result of assault, 32% were unintentional, and 6% were self-inflicted; 9% died. At the neighborhood level, the distribution of firearm-related injuries significantly differed by deprivation quintile (p < .05). Children from the highest deprivation quintile experienced 25% of injuries of all types, 57% of firearm-related injuries, and 70% of all firearm-related injuries from assault. They had an overall risk of firearm-related injury 30-times that of children from the lowest deprivation quintile.

CONCLUSIONS

Increased neighborhood socioeconomic deprivation is associated with more firearm-related injuries requiring hospitalization, at rates far higher than injury-related admissions overall. Addressing neighborhood-level social determinants of health may help prevent pediatric firearm-related injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological - Level III.

Pediatric firearm injury trends in the United States: A national trauma data bank (NTDB) analysis

AIM OF STUDY

Firearm injuries are the second leading cause of injury-related death in the USA in children less than 18. We compared overall and intent-specific firearm hospitalizations across age group and race to understand recent trends.

METHODS

A retrospective cohort of 20,083 children from the national trauma data bank involved in incidences of firearm discharges from 2013 to 2017 was divided by race, discharge intent, gun type, and four age groups: infants (ages 0-2), toddlers (3-6), children (7-12), and adolescents (13-18). Discharge intent and gun type were determined by ICD-9-CM and ICD-10-CM External Causes of Injury codes. Injury severity score (ISS), hospital discharge disposition, and length of stay (LOS) were used as predictors for morbidity and mortality.

RESULTS

From 2013 to 2017, there were on an average 4016 firearm injuries reported to the NTDB (n = 20,083). 71% (n = 14,313) of the incidents were assaults. Victims who identified as African American and Caucasian made up 60% (n = 11,890) and 26% (n = 5162) of the total victims, respectively, and were predominantly male (86%, n = 17,202). Victims who identified as Caucasian made up 70% of suicides (n = 819), while African Americans made up 70% of assaults (n = 9733). 87% (n = 17,525) of the patient population were adolescents. The number of accidental firearm discharges compared to firearm assaults was greater for toddlers, while the opposite was true for infants, children, and adolescents. Average LOS by age group varied each year, though children had the highest total average LOS.  Average ISS was highest for infants and adolescents (11.5 and 10.4) and American Indians and Caucasians (10.1 and 11.1). Overall mortality rate was 6% (n = 1220) and had no significant differences between years. Mortality rate was highest for infants (7%, n = 25).

CONCLUSIONS

Adolescent males and African Americans were disproportionately affected by overall and assault-specific firearm discharges. Firearm injury prevention legislation is critical to prevent these injures.

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

OBJECTIVE

To characterize hospitalization costs attributable to gun-related injuries in children across the US.

STUDY DESIGN

The 2005-2017 National Inpatient Sample was used to identify all pediatric admissions for gunshot wounds (GSW). Patients were stratified by International Classification of Diseases procedural codes for trauma-related operations. Annual trends in GSW hospitalizations and costs were analyzed with survey-weighted estimates. Multivariable regressions were used to identify factors associated with high-cost hospitalizations.

RESULTS

During the study period, an estimated 36 283 pediatric patients were admitted for a GSW, with 43.1% undergoing an operative intervention during hospitalization. Admissions for pediatric firearm injuries decreased from 3246 in 2005 to 3185 in 2017 (NPtrend < .001). The median inflation-adjusted cost was $12 408 (IQR $6253-$24 585). Median costs rose significantly from $10 749 in 2005 to $16 157 in 2017 (P < .001). Compared with those who did not undergo surgical interventions, operative patients incurred increased median costs ($18 576 vs $8942, P < .001). Assault and self-harm injuries as well as several operations were independently associated with classification in the highest cost tertile.

CONCLUSIONS

Admissions for pediatric firearm injuries were associated with a significant socioeconomic burden in the US, with increasing resource use over time. Pediatric gun violence is a major public health crisis that warrants further research and advocacy to reduce its prevalence and social impact.

United States trends in healthcare charges for pediatric firearm injuries

BACKGROUND

From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups.

METHODS

In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time.

RESULTS

Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries.

CONCLUSIONS

Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.

Penetrating Trauma in Baltimore: An Analysis of the Effect of a Rise in Localized Violence by Age Group

BACKGROUND

Incidence of firearm mortality in the United States is increasing. Baltimore, MD saw a substantial increase in violence in April 2015. We analyzed the effect of this localized surge in violence on the pediatric population.

METHODS

Using the Maryland Health Services Cost Review Commission database, initial hospital encounters for gunshot wound (GSW) or stab wound (SW) were identified. Baltimore Police Department victim-based crime data and homicide data on GSW and SW assault were used to capture those not seen at hospitals. Changes in incidence rate ratios from before/after April 2015 were analyzed using Poisson regression.

RESULTS

No change in mortality was seen in hospital-evaluated GSW patients. The pediatric population showed decreased incidence of SW (P < 0.001) and increase in GSW (P < 0.001) but no change in total penetrating trauma (tPT). The young adult population had decreased SW incidence (P < 0.001) without change in GSW or tPT. The pediatric populations saw no difference in SW/GSW deaths or homicide rate. However, in young adults, there were increased homicides (P < 0.001) and GSW deaths (P < 0.001) with unchanged SW deaths.

CONCLUSIONS

After a surge in violence, the shifted mechanism of penetrating trauma in the pediatric population did not increase mortality or tPT. By contrast, GSW incidence is increasing in young adults with more lethal injuries. Intervention could be aimed at gun control and targeted education/intervention in the at-risk younger age group.

A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality

OBJECTIVES

To perform a national analysis of pediatric firearm violence (PFV), hypothesizing that black and uninsured patients would have higher risk of mortality.

METHODS

The Trauma Quality Improvement Program (2014-2016) was queried for PFV patients ≤16 years-old. Multivariable logistic regression models on all patients and a subset excluding severe brain injuries were performed.

RESULTS

The PFV mortality rate was 11.2%. 66.5% of PFV patients were black (p < 0.001). Deceased patients were more likely to be uninsured (14.5% vs. 5.3%, p < 0.001). Black race was an associated risk factor for mortality in patients without severe brain injury (OR 5.26, CI 1.00-27.47, p = 0.049) but not for the overall population (OR 1.32, CI 0.68-2.56, p = 0.39).

CONCLUSION

Nearly two-thirds of PFV patients were black. Contrary to previous studies, black and uninsured pediatric patients did not have an increased risk of mortality overall. However, in a subset of patients without severe brain injury, black race was associated with increased mortality risk.

SUMMARY

Between 2014 and 2016 the mortality rate for pediatric firearm violence (PFV) in children 16 years and younger was 11.2%. Although two-thirds of PFV patients were black, black race and lack of insurance were not risk factors of mortality for the overall population. Once patients with severe brain injury were excluded, black race and became associated with an increased risk of mortality.

Pediatric Firearm Injuries and Fatalities: Do Racial Disparities Exist?

OBJECTIVE

To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level.

BACKGROUND

Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients.

METHODS

The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays.

RESULTS

A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (β + 4.13; P<0.001), while White race was not.

CONCLUSION

Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes.

LEVEL OF EVIDENCE

Level III Prognostic.