Firearm related injuries amongst children: estimates from the nationwide emergency department sample

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.

Upper Extremity Fractures in the Emergency Department: A Database Analysis of National Trends in the United States

BACKGROUND

Upper extremity (UE) fractures are a common reason for emergency department (ED) visits, but recent data on their epidemiology are lacking. This study aimed to describe the incidence, demographics, patient characteristics, and associated health care factors of UE fractures, hypothesizing that they would remain prevalent in the ED setting.

METHODS

Using the Nationwide ED Sample database, patients presenting to the ED with UE fractures in 2016 were identified, and population estimates were used to calculate incidence rates. Data on insurance status, trauma designation, cost, and teaching status were analyzed.

RESULTS

The study identified 2 118 568 patients with UE fractures, representing 1.5% of all ED visits in 2016. Men accounted for 54.2% of UE fractures, with phalangeal fractures being most common. Distal radius and/or ulna fractures were most common in women (30.4%). The greatest proportion of UE fractures (23.2%) occurred in patients aged 5 to 14 years (1195.5 per 100 000). Nontrauma centers were the most common treating institutions (50.4%), followed by level I (19.5%), II (15.3%), and III (12.8%) centers. The greatest proportion of fractures (38.3%) occurred in the southern United States. Emergency department cost of treatment was almost 2-fold in patients with open UE fractures compared with closed.

CONCLUSION

This study provides important epidemiological information on UE fractures in 2016. The incidence rate of UE fractures in the ED has remained high, with most occurring in the distal radius, phalanges, and clavicle. In addition, UE fractures were most common in younger patients, men, and those in the southern United States during the summer. These findings can be useful for health care providers and policymakers when evaluating and treating patients with UE fractures.

Fatal and non-fatal firearm-related injuries in Canada, 2016-2020: a population-based study using three administrative databases

BACKGROUND

Firearms are a substantial cause of injury-related morbidity and mortality in Canada and globally, though evidence from contexts other than the USA is relatively limited. We examined deaths, hospitalizations and emergency department (ED) visits due to firearm-related injuries in Canada to identify population groups at increased risk of fatal and non-fatal outcomes.

METHODS

We conducted a population-based study using three national administrative databases on deaths, hospitalizations, and ED visits. ICD-10 codes were used to identify firearm-related injuries from January 1, 2016, through December 31, 2020. Fatal and non-fatal firearm injuries were classified as suicide/self-harm, homicide/assault, unintentional, undetermined or legal intervention injuries. We analyzed the data with counts, rates and proportions, stratified by sex, age group, province/territory, and year.

RESULTS

Over the 5-year period, we identified 4005 deaths, 3169 hospitalizations, and 2847 ED visits related to firearm injuries in various jurisdictions in Canada. Males comprised the majority of fatal and non-fatal injury cases. The highest rates of fatal and non-fatal firearm injuries were among 20- to 34-year-olds. The leading cause of fatal firearm injuries was self-harm (72.3%). For non-fatal firearm hospitalizations and ED visits, assault (48.8%) and unintentional injuries (62.8%) were the leading causes of injury. Rates varied by province and territory.

CONCLUSIONS

Our results showed that males comprised the majority of fatal and non-fatal firearm injuries in Canada. The rates of both fatal and non-fatal firearm injuries were highest among the 20- to 34-year-old age group. This comprehensive overview of the epidemiology of firearm injuries in Canada provides baseline data for ongoing surveillance and policy evaluation related to public health interventions.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies

OBJECTIVE

To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC).

BACKGROUND

A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury.

METHODS

We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms.

RESULTS

We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76).

CONCLUSIONS

Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients

BACKGROUND

Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients.

METHODS

Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury.

RESULTS

Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study.

CONCLUSION

The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states.

LEVEL OF EVIDENCE

Economic and Value Based Evaluations; level III.

Pediatric Trauma Arrival Times and the Swing Shift

BACKGROUND

Trauma center staff and trainees are often assigned to a day and night shift. However, for adult trauma, the swing shift has been found to offer superior clinical exposure compared with a standard day or night shift for trainees. We characterized patterns in pediatric trauma arrival times based on the hour, weekday, and month and studied whether or not the swing shift also maximizes exposure to hands-on experiences in managing pediatric trauma.

METHODS

We performed a retrospective review of the trauma database at our urban, level 2 pediatric trauma center. We identified all the pediatric trauma activations in the last 13 years (2006-2018). A retrospective shift log was created, which included day (7:00 am to 7:00 pm), night (7:00 pm to 7:00 am), and swing (noon to midnight) shifts. The shifts were compared using the Wilcoxon match-pairs signed rank test. Weekends data were also compared with weekdays, and comparisons were also made for pediatric patients with Injury Severity Scores (ISS) >15.

RESULTS

There were 3532 pediatric patients identified for our study. The swing shift had 1.98 times more activations than the night shift, and 1.33 more than the day shift (P < 0.001). The swing shift was also superior to both the day and night shifts for exposure to patients with Injury Severity Score greater than 15 (P < 0.001). Weekend days had 1.28 times more trauma than the weekdays (P < 0.001). Peak arrival time was between the hours of 3:00 pm and 9:00 pm, and patient age did not have an effect on this trend.

CONCLUSIONS

Experience in managing pediatric trauma patients will improve for trainees who utilize the swing shift. In addition, the hours between 3:00 pm and 9:00 pm on weekends may represent a time of particularly high likelihood of pediatric trauma arrivals, which may require extra staff and hospital resources.Level of Evidence: Therapeutic Study, Level IV.

Pediatric firearm-associated fractures: Analysis of management and outcomes

BACKGROUND

Firearm-associated injuries (FAIs) are among the leading causes of morbidity and mortality in children living in the United States. Most victims of such injuries survive, but may experience compromised function related to musculoskeletal injuries. Although complex firearm-associated fractures (FAFs) often require specialized orthopaedic, vascular, and plastic surgical intervention, there is minimal research describing their management and outcomes. The purpose of this study is to describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

AIM

To describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries.

METHODS

A retrospective chart review was performed at a major, pediatric level 1 trauma center. The study included patients aged 18 or younger who presented with FAIs between 2008-2018. Additional data was collected on patients with FAFs including demographic and clinical data such as age, sex, race, payor type, fracture location, injury severity score (ISS), and radiographic and clinical outcomes. The management of FAFs was analyzed as well as need for readmission and reoperation. Descriptive statistics were used to summarize the results and univariate analyses were performed to assess differences between groups.

RESULTS

Between 2008 and 2018, there were a total of 61 patients who presented with FAIs. In this cohort, 21 patients (34%) sustained FAFs (25 fractures) with a mean age of 11 (Range: 10 mo to 18 years old) at the time of presentation. Approximately 52% (n = 11) of patients with FAFs were male, 76% (n = 8 and n = 8, respectively) identified as black or other, and 71% (n = 15) had government insurance. FAFs were most commonly noted in the upper extremity (n = 7) and lower extremity (n = 6). In patients with FAFs, the mean ISS at presentation was 11.38 (Range: 2-38), and 24% of patients (n = 5) were classified as having a major trauma. There were no significant differences in age, sex, race, and payor type in FAF patients that presented with and without major trauma (P > 0.05). When comparing FAF and non-FAF patients, there was a statistically significant difference in ISS (11.38 vs 14.45, P = 0.02). In total, 33% (n = 7) of patients with FAFs required orthopaedic surgical management, which was most commonly comprised of debridement (n = 6/7, 86%), and 14% (n = 1/7) of these patients required coordinated care with plastic and/or vascular surgery. There were no significant differences in age and payor type in patients with FAFs treated with and without orthopaedic surgery. Of the patients with FAFs, 52% (n = 11) had a minimum 90-d follow-up, and 48% (n = 10) had a minimum 2-year follow-up. Two patients were readmitted within 90-d, while one patient required a reoperation within 2-years.

CONCLUSION

Over 25% of FAIs in pediatric patients result in FAFs. FAFs often present to pediatric trauma centers and the majority of these injuries occur in non-Caucasian males with government insurance. Most FAFs do not need orthopaedic surgical management; 14% of these injuries require subspecialty care by orthopaedic surgery, vascular surgery, or plastic surgery. Patients with FAFs also have lower ISS compared to patients who sustained FAIs without fracture. Thus, these patients should be treated at pediatric trauma centers with specialty care and additional research is needed to focus prevention efforts, understand reasons for poor follow-up, and evaluate outcomes after injury.

Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

OBJECTIVE

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury.

METHODS

This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests.

RESULTS

Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury.

CONCLUSIONS

Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Sociodemographic Factors and Outcomes by Intent of Firearm Injury

BACKGROUND AND OBJECTIVES

Firearm injuries are a leading and preventable cause of morbidity and mortality among youth. We sought to explore differences in sociodemographic factors and youth firearm injury outcomes by injury intent (unintentional, assault, and self-harm).

METHODS

We conducted a repeated cross-sectional analysis of emergency department (ED) visits among youth aged 21 and younger presenting to an ED with a firearm injury between 2009 and 2016 using the Nationwide Emergency Department Sample. We performed multivariable logistic regression to measure the strength of association between (1) patient-level factors, (2) visit-level characteristics, and (3) clinical outcomes and intent of firearm injury.

RESULTS

We identified 178 299 weighted visits for firearm injuries. The mean age was 17.9 (95% confidence interval 17.8-18.0) years; 89.0% of patients were male, 43.0% were publicly insured, 28.8% were admitted, and 6.0% died. Approximately one-third of the injuries were categorized as unintentional (39.4%), another third as assault (37.7%), and a small proportion as self-harm (1.7%). Unintentional firearm injuries were associated with younger age, rural hospital location, Southern region, ED discharge, and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back, or spinal cord injury. Firearm injuries by assault were associated with lower socioeconomic status, urban hospital location, and requiring admission.

CONCLUSIONS

We identified distinct risk profiles for youth with unintentional, self-harm-, and assault-related firearm injuries. Sociodemographic factors related to intent may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

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.

Retracted Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included 1) difference in health care encounters for 1 year before and 1 year after injury, 2) difference in health care expenditures, and 3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests. Among 3,296 children, there were 47,660 health care encounters before the injury and 61,660 after. Concomitantly, there was an overall increase of $18.5 million in health expenditures ($5,612 per patient). There was a 40% increase in children qualifying for complex chronic condition status after firearm injury. Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Increases in Actual Health Care Costs and Claims After Firearm Injury

BACKGROUND

The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments.

OBJECTIVE

To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury.

DESIGN

Before-after study.

SETTING

Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana.

PARTICIPANTS

Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017.

MEASUREMENTS

Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes.

RESULTS

Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8 158 786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41 255 916 ($70 644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17 806 per member) for those discharged from the ED and 2138% (from $4118 to $92 151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized.

LIMITATION

Firearm injury intent was not specified because of misclassification concerns.

CONCLUSION

In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable.

PRIMARY FUNDING SOURCE

None.

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.

The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries

BACKGROUND

Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries.

METHODS

This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues.

RESULTS

Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue.

CONCLUSIONS

Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population.

LEVEL OF EVIDENCE

Level III, economic/decision.

Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes

BACKGROUND/PURPOSE

The U.S. has an alarming rate of firearm injuries. Racial disparities among victims and predictors of outcomes are not well established. Our objective was to assess costs, length of stay (LOS), and inpatient mortality among nonfatal and fatal pediatric firearm injuries that required hospitalization.

METHODS

Pediatric (≤18 years of age) hospitalizations with a firearm injury discharge diagnosis were identified from the national Kids' Inpatient Databases (KID) for 2006 through 2012. Firearm injury intent, weapon type, and hospitalization rates by racial groups were examined. Inpatient mortality, costs, and length of stay were examined using regression models.

RESULTS

Of 15,211 hospitalizations, the majority of injuries were due to assault (60%) and the intentions of firearm injury differed by race (p < 0.001). The median cost per hospitalization was $10,159 (interquartile range: $5071 to $20,565), totaling more than a quarter of a billion dollars. On regression analysis, Black (OR: 0.41; CI: 0.30-0.55) and Hispanic (OR: 0.47; CI: 0.34-0.66) patients were less likely to die than White patients.

CONCLUSION

Pediatric firearm injury circumstances and survival vary by race with Whites being more likely to experience unintentional injury and suicide, while Blacks and Hispanics are more likely to experience inflicted injury.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical Research Study.

Gunshot Injuries in Lebanon: Does Intent Affect Characteristics, Injury Patterns, and Outcomes in Victims?

Introduction:

Lebanon lacks a national database of gunshot injuries (GSIs), which limits injury prevention initiatives.

Objectives:

This study examines patient characteristics, injury patterns, and clinical outcomes in GSI victims and evaluates the impact of intent on clinical outcomes with the aim of improving awareness among emergency department (ED) physicians about the importance of inquiring about intent to predict prognosis.

Materials and Methods:

We conducted a retrospective cohort study of GSI victims presenting to the ED of a tertiary care center in Beirut, Lebanon. Descriptive and bivariate analyses were done to identify differences based on intent.

Results:

A total of 83 patients were included, 59% with intentional GSI, 22% with unintentional GSI, and 19% with unspecified intent. They were mostly males (89.2%), with a mean age of 31.7 years, and mostly presenting during summer seasons. Females were more commonly victims of unintentional GSI. All victims sustaining multiple GSIs were in the intentional group. When compared to unintentional GSI, intentional and unspecified GSIs were found to result in more ICU admissions (46.9%, 31.3%, and 16.7%, P = 0.096), significantly longer hospital stays (18.2, 26.3, and 5.6 days; P = 0.001) and higher mortality (11.6%, 18.2%, and 6.7%; P = 0.747). The rates of surgical procedures were similar between the three groups although more victims of intentional and unspecified GSI underwent multiple surgeries.

Conclusion:

GSIs have different features, resource utilization, and clinical outcomes depending on the intentionality of injuries. All GSI victims suffer from substantial morbidity and mortality, but intentionally harmed victims sustain more severe injuries with worse outcomes.

Firearm-associated Fractures in Children and Adolescents: Trends in the United States 2003-2012

BACKGROUND

Firearm-associated injuries are the second leading cause of death in children in the United States. Fractures are common comorbid injuries in young patients with firearm-associated injuries. The purpose of this study was to define the burden of firearm-associated fractures (FAFs) in children and adolescents in the United States.

METHODS

We analyzed the 2003-2012 Kids' Inpatient Database. Patients were grouped into 4 age groups: 0 to 4, 5 to 9, 10 to 14, and 15 to 20 years old. Sample observations with both an external cause of injury code indicating gunshot injury and a diagnosis code indicating orthopaedic fracture (extremity, pelvis, or spine) were identified as cases of FAF. Sex, age, race, cause of injury, and fracture-related operating room procedures were catalogued. Population-level incidence was calculated for each year studied.

RESULTS

From 2003 to 2012, the incidence of FAF in patients 20 years and below of age increased from 73 to 96 cases per 100,000 admissions (P=0.009). The 0 to 4 age group saw the largest increase in injury frequency (141%, P=0.08). There was a 4-fold increase in the rate of unintentional injury in this subgroup. The most common age group affected by FAFs was 15 to 20 year olds. Minorities and male individuals were disproportionately affected. Assault and unintentional causes were the most common reasons for injury.

CONCLUSIONS

The frequency of FAF in patients 20 years and below of age increased over the study period, with almost 1 case per 1000 admissions in 2012. The finding that certain subpopulations are disproportionately affected reflects the complex sociologic factors influencing gun violence in the United States.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Temporal Variations in Pediatric Trauma: Rationale for Altered Resource Utilization

Trauma is a major cause of morbidity and mortality in the pediatric population. However, temporal variations of trauma have not been well characterized and may have implications for appropriate allocation of hospital resources. Data from patients evaluated at an ACS-verified Level I pediatric trauma center between 2011 and 2015 were retrospectively analyzed. Date and time of injury, type of injury (blunt vs penetrating), and postemergency department disposition were reviewed. To assess temporal trends, heatmaps were constructed and a mixed poisson regression model was used to assess statistical significance. Pediatric trauma from blunt and penetrating injuries occurred at significantly higher rates between the hours of 1800 and 0100, on weekends compared with weekdays, and from May to August compared with November to February. These data provide useful information for hospital resource utilization. The emergency department, operating room, and intensive care unit should be prepared for increased trauma-related volume between May and August, weekends, and evening hours by appropriately increasing staff volume and resource availability.

Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base

OBJECTIVE

To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations.

METHODS

The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics.

RESULTS

Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age.

CONCLUSIONS

An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.

Cost of hospitalization for firearm injuries by firearm type, intent, and payer in the United States

Background

Firearm injuries disproportionately affect young, male, non-White populations, causing substantial individual and societal burden. Annual costs for hospitalized firearm injuries have not been widely described, as most previous cost studies have focused on lifetime costs. We examined a nationally-representative database of hospitalizations in the US to estimate per-hospital and overall hospital costs for firearm injuries by intent, type of weapon, and payer source.

Methods

We conducted a retrospective cohort study of all firearm injury hospitalizations in the National Inpatient Sample from 2003 through 2013. The National Inpatient Sample, maintained by the Healthcare Utilization Project, is a stratified and weighted national sample of more than 20% of all hospitals. All admissions for firearm injuries were identified through Ecodes, yielding a weighted total of 336,785 for the study period. Average annual per-patient and overall hospital costs were estimated using generalized linear modelling, controlling for patient and hospital variables. Costs by intent, firearm type, and payer sources were estimated.

Results

Annually from 2003 through 2013, 30,617 hospital admissions were for firearm injuries, for an annual rate of 10.1 admissions per 100,000 US population. More than 80% of hospitalizations were among individuals aged 15–44, and rates were nine times higher for males than females and nearly ten times higher for the Black than the White population. More than 60% of admissions were for assaults, and 70% of the injuries that had a known firearm type were from handguns. The average annual admission cost was $622 million. The highest per-admission costs were for injuries from assault weapons ($32,237 per admission) and for legal intervention ($33,462 per admission), but the highest total costs were for unspecific firearm type ($373 million) and assaults ($389 million). A quarter of firearm injury hospitalizations were among the uninsured, yielding average annual total costs of $155 million.

Conclusion

Hospitals can project that government insurance will be the highest source for firearm injury reimbursement, and depending on healthcare access laws, that many of their firearm injury admissions will not be covered by insurance.

The effect of gun control laws on hospital admissions for children in the United States

BACKGROUND

Gun control laws vary greatly between states within the United States. We hypothesized that states with strict gun laws have lower mortality and resource utilization rates from pediatric firearms-related injury admissions.

METHODS

Kids' Inpatient Database (1997-2012) was searched for accidental (E922), self-inflicted (E955), assault (E965), legal intervention-related (E970), or undetermined circumstance (E985) firearm injuries. Patients were younger than 20 years and admitted for their injuries. Case incidence trends were examined for the study period. Propensity score-matched analyses were performed using 38 covariates to compare outcomes between states with strict or lenient gun control laws.

RESULTS

Overall, 38,424 cases were identified, with an overall mortality of 7%. Firearm injuries were most commonly assault (64%), followed by accidental (25%), undetermined circumstance (7%), or self-inflicted (3%). A small minority involved military-grade weapons (0.2%). Most cases occurred in lenient gun control states (48%), followed by strict (47%) and neutral (6%).On 1:1 propensity score-matched analysis, in-hospital mortality by case was higher in lenient (7.5%) versus strict (6.5%) states, p = 0.013. Lenient states had a proportionally higher rate of accidental (31%) and self-inflicted injury (4%) versus strict states (17% and 1.6%, respectively), p < 0.001. Assault-related injuries were proportionally lower in lenient (54%) versus strict (75%) states, p < 0.001. Military-grade weapons were more common in lenient (0.4%) versus strict (0.1%) states, p = 0.001.

CONCLUSIONS

These findings highlight the importance of legislative measures and their role in injury prevention, as firearm injuries are entirely avoidable mechanisms of injury. Lenient gun control contributes not only to worse outcomes per case, but also to a more significant and detrimental impact on public health.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Firearm-related Musculoskeletal Injuries in Children and Adolescents

Firearm injuries are a major cause of morbidity and mortality among children and adolescents in the United States and take financial and emotional tolls on the affected children, their families, and society as a whole. Musculoskeletal injuries resulting from firearms are common and may involve bones, joints, and neurovascular structures and other soft tissues. Child-specific factors that must be considered in the setting of gunshot injuries include physeal arrest and lead toxicity. Understanding the ballistics associated with various types of weaponry is useful for guiding orthopaedic surgical treatment. Various strategies for preventing these injuries range from educational programs to the enactment of legislation focused on regulating guns and gun ownership. Several prominent medical societies whose members routinely care for children and adolescents with firearm-related injuries, including the American Academy of Pediatrics and the American Pediatric Surgical Association, have issued policy statements aimed at mitigating gun-related injuries and deaths in children. Healthcare providers for young patients with firearm-related musculoskeletal injuries must appreciate the full scope of this important public health issue.

Energy-dependent expansion of .177 caliber hollow-point air gun projectiles

Amongst hundreds of different projectiles for air guns available on the market, hollow-point air gun pellets are of special interest. These pellets are characterized by a tip or a hollowed-out shape in their tip which, when fired, makes the projectiles expand to an increased diameter upon entering the target medium. This results in an increase in release of energy which, in turn, has the potential to cause more serious injuries than non-hollow-point projectiles. To the best of the authors' knowledge, reliable data on the terminal ballistic features of hollow-point air gun projectiles compared to standard diabolo pellets have not yet been published in the forensic literature. The terminal ballistic performance (energy-dependent expansion and penetration) of four different types of .177 caliber hollow-point pellets discharged at kinetic energy levels from approximately 3 J up to 30 J into water, ordnance gelatin, and ordnance gelatin covered with natural chamois as a skin simulant was the subject of this investigation. Energy-dependent expansion of the tested hollow-point pellets was observed after being shot into all investigated target media. While some hollow-point pellets require a minimum kinetic energy of approximately 10 J for sufficient expansion, there are also hollow-point pellets which expand at kinetic energy levels of less than 5 J. The ratio of expansion (RE, calculated by the cross-sectional area (A) after impact divided by the cross-sectional area (A ₀) of the undeformed pellet) of hollow-point air gun pellets reached values up of to 2.2. The extent of expansion relates to the kinetic energy of the projectile with a peak for pellet expansion at the 15 to 20 J range. To conclude, this work demonstrates that the hollow-point principle, i.e., the design-related enlargement of the projectiles' frontal area upon impact into a medium, does work in air guns as claimed by the manufacturers.

Predictors and Outcomes of Pediatric Firearm Injuries Treated in the Emergency Department: Differences by Mechanism of Intent

OBJECTIVE

Firearm injuries among children are a major clinical and public health concern and one of the leading causes of pediatric fatalities. Our objective was to investigate differences in predictors and clinical outcomes between self-inflicted, violent, and unintentional pediatric firearm injuries for patients who present to pediatric emergency departments (EDs).

METHODS

We conducted a retrospective study of patients 0 to 21 years old treated in 37 pediatric academic EDs from 2004 to 2014. Patients were classified into the injury intent categories of self-inflicted, violent, and unintentional firearm injury using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnoses and external causes of injury codes. Multivariable multinomial regression models compared groups.

RESULTS

We identified 9,628 firearm injuries from 2004 to 2014: 109 (1%) self-inflicted, 2,394 (25%) violent, and 7,125 (74%) unintentional. Male sex, increasing age, nonwhite race, public insurance, residing in an urban zip code, and lower zip code-level median household income were all independently associated with violent firearm injuries, relative to self-inflicted and unintentional injuries. Self-inflicted injuries were at the highest risk for hospital admission, death, intensive care unit services, surgical services, and increased length of stay, followed by violent injuries with intermediate risk and unintentional injuries at the lowest risk

CONCLUSIONS

Self-inflicted, violent, and unintentional firearm injuries in children had distinct demographic risk factors and clinical and utilization outcomes. Targeted prevention and intervention efforts should be developed to reduce the incidence and severity of these injuries.

Gunshot-associated Fractures in Children and Adolescents Treated at Two Level 1 Pediatric Trauma Centers

INTRODUCTION

Gunshot injuries are a potentially significant cause of morbidity and mortality in the pediatric population. The objective of this study was to evaluate the epidemiology, fracture locations, associated injuries, types of treatment, and complications of gunshot-associated fractures in children and adolescents treated at two level 1 trauma centers.

METHODS

The clinical and radiographic records of all children and adolescents who had a gunshot-associated fracture treated at 1 of 2 level 1 pediatric trauma centers between January, 2005, and April, 2013, were reviewed. The following characteristics were recorded: patient age and sex, type of weapon, fracture location, presence of neurovascular injury or other associated injuries, antibiotic treatment, method of stabilization, duration of hospital stay, complications, and need for subsequent procedures.

RESULTS

Forty-nine patients with 58 fractures were identified; 9 patients had multiple fractures. The 41 males and 8 females had an average age of 12.2 years (range, 1 to 18 y). The tibia and femur were the most common sites of fracture (19% each), followed by the small bones of foot (4%) and the fibula (4%). Most of the fractures (71%) were treated nonoperatively. Nearly half (47%) of the patients had additional injuries, including abdominal or genitourinary injuries, neuropraxia or nerve injuries, and vascular injuries. Two patients (4%) developed infections (1 superficial and 1 deep) that required multiple irrigation and debridement procedures. Three patients developed compartment syndrome, and 4 patients had vascular injuries requiring repair. Nearly a third of patients (35%) had fractures or complications that required additional operative procedures.

CONCLUSIONS

This large retrospective study highlights the significant morbidity of fractures caused by gunshots. Although the overall infection rate was low and most of these fractures were successfully treated nonoperatively, many of the patients required an additional operative procedure and nearly half had additional nonorthopaedic injuries. This emphasizes the necessity of coordination among emergency, general surgeons, intensivist, and orthopaedic surgical teams.

LEVEL OF EVIDENCE

Level IV—retrospective case series.

Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital

PURPOSE

Firearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children's hospital to determine the most likely time for injuries to occur over 10 years.

METHODS

A retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17 years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p<0.05.

RESULTS

Mean age was 12 years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p=0.01). The incidence was lowest 2008-2010 and highest in 2006 and 2011. Mortality was 3.5%.

CONCLUSIONS

We noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months.

Epidemiology of paediatric firearm injuries in the USA, 2001-2010

OBJECTIVES

Firearm injuries to children and adolescents remain an important cause of morbidity and mortality in the USA. The objectives of this study were to describe the prevalence of and epidemiologic risk factors associated with firearm injuries to children and adolescents evaluated in a nationally representative sample of US emergency departments and ambulatory care centres.

STUDY DESIGN

We performed a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2001 to 2010. Firearm injury-related visits in patients 0-19 years old were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification firearm injury codes. The primary outcome was the prevalence of firearm-related injuries. We used multivariate logistic regression to analyse demographic risk factors associated with these injuries.

RESULTS

From 2001 to 2010, there were a total of 322 730 927 (95% CI 287 462 091 to 357 999 763) paediatric US outpatient visits; 198 969 visits (0.06%, 95% CI 120 727 to 277 211) were for firearm injuries. Fatal firearm injuries accounted for 2% of these visits; 36% were intentionally inflicted. There were increased odds of firearm injuries to men (OR 10.2, 95% CI 5.1 to 20.5), black children and adolescents (0-19 years) (OR 3.2, 95% CI 1.5 to 6.7) and adolescents 12-19 years old (all races) (OR 16.6, 95% CI 6.3 to 44.3) on multivariable analysis.

CONCLUSIONS

Firearm injuries continue to be a substantial problem for US children and adolescents, with non-fatal rates 24% higher than previously reported. Increased odds for firearm-related visits were found in men, black children and those 12-19 years old.

Cost analysis of youth violence prevention

BACKGROUND AND OBJECTIVE

Effective violence interventions are not widely implemented, and there is little information about the cost of violence interventions. Our goal is to report the cost of a brief intervention delivered in the emergency department that reduces violence among 14- to 18-year-olds.

METHODS

Primary outcomes were total costs of implementation and the cost per violent event or violence consequence averted. We used primary and secondary data sources to derive the costs to implement a brief motivational interviewing intervention and to identify the number of self-reported violent events (eg, severe peer aggression, peer victimization) or violence consequences averted. One-way and multi-way sensitivity analyses were performed.

RESULTS

Total fixed and variable annual costs were estimated at $71,784. If implemented, 4208 violent events or consequences could be prevented, costing $17.06 per event or consequence averted. Multi-way sensitivity analysis accounting for variable intervention efficacy and different cost estimates resulted in a range of $3.63 to $54.96 per event or consequence averted.

CONCLUSIONS

Our estimates show that the cost to prevent an episode of youth violence or its consequences is less than the cost of placing an intravenous line and should not present a significant barrier to implementation.

Gout-related health care utilization in US emergency departments, 2006 through 2008

OBJECTIVE

To characterize gout-related emergency department (ED) utilization using a nationally representative sample and to examine factors associated with the frequency and charges of gout-related ED visits.

METHODS

Using the National Emergency Department Sample data from 2006-2008, the weighted national frequency of gout visits was calculated along with the median ED charge and total national ED-related charges. Associations of several patient- and facility-level factors were examined with the occurrence of gout visits using multivariable logistic regression and with ED-related charges using multivariable linear regression.

RESULTS

Gout was the primary indication for 168,410 ED visits in 2006, 171,743 visits in 2007, and 174,823 visits in 2008, accounting for ∼0.2% of all visits annually and generating ED charges of more than $128 million in 2006, $144 million in 2007, and $166 million in 2008. Age, male sex, household income <$39,000, private insurance, and hospital locations in nonmetropolitan areas and the southern US were associated with an increased propensity for ED utilization in gout. Higher ED-related charges for gout were associated with female sex, age, a higher number of coded diagnoses, and a metropolitan residence.

CONCLUSION

Gout accounts for a substantial proportion of ED visits, leading to significant health care charges. Effective strategies to reduce gout burden in EDs could potentially benefit by targeting groups characterized by factors demonstrated to be related to a higher ED utilization in gout as identified by our study.