Firearm Injuries Are on the Rise, the Results of a Pediatric Trauma Center.

INTRODUCTION: Firearm injury is the leading cause of death in children. The recent rise has coincided with the COVID-19 pandemic. The purpose of this study was to evaluate the trends of pediatric firearm injury over a 6-y period, to include the COVID-19 pandemic, at our pediatric trauma center. METHODS: A retrospective review of the trauma registry at a free-standing children's hospital from January 2018 to December 2023 was performed. The variables evaluated included year of injury, age of injury, race, gender, admission requirements, need for blood products, need for operation, mortality, insurance type, and reason for injury. RESULTS: There were 397 firearm injury presentations identified over the 6-y period. The median age of injury was 13 y with an interquartile range of 6-15 y. Most were male (72.3%) and of Black race (74.6%). A majority of children who sustained a firearm injury had Medicaid (77.8%). During the years of 2018 and 2019, we evaluated 40 and 39 patients, respectively. Over the next 2 y, there was a dramatic increase in pediatric firearm injuries with an increase of 65% (N = 66) in 2020 and 102.5% (N = 81) in 2021. Although there was less of an increase above baseline in 2022, there was still an elevation of 82.5% (N = 73). By the end of 2023, there had been a 145% rise (N = 98) in pediatric firearm injuries above the baseline year of 2018. The mortality rate was 7.6% (N = 30), which is 2.5 times higher than the all-cause trauma mortality of 3.1% at our facility. CONCLUSIONS: The number of firearm injuries dramatically increased during the COVID-19 pandemic and these increases have been sustained. Most of the victims have been male, of Black race, and publicly insured. While the state population of Alabama is 26.4% Black race, Black children account for 74.6% of all firearm-injured pediatric patients in our trauma registry. The reason for this disparity is not well-understood. Through ongoing research, we hope to gain insight into the reasons behind pediatric firearm injury and the best ways to mitigate them through both the medical and public health arenas.

Firearm Injuries in Young Children: Surgical Resource Utilization and Implications for Prevention.

INTRODUCTION: Pediatric firearm injury prevention research in younger age groups is limited. This study evaluated a large multicenter cohort of younger children with firearm injuries, focusing on injury patterns and surgical resource utilization. METHODS: Children ≤15 y old sustaining firearm injuries between 2016 and 2021 and treated at 10 pediatric trauma centers in Florida were included. Individual cases were reviewed for demographics, shooting details, injury patterns, resource utilization, and outcomes. Patients were grouped by age into preschool (0-5 y), elementary school (6-10 y), middle school (11-13 y), and early high school (14-15 y). Multivariable logistic regression was used to identify predictors of death and critical resource utilization. RESULTS: A total of 489 children (80 preschool, 76 elementary school, 92 middle school, and 241 early high school) met inclusion criteria. Demographics, injury patterns, and resource utilization were similar across age groups. Assault and self-harm increased with age. Self-harm was implicated in 5% of cases but accounted for 18% of deaths. Hand surgery (i.e., below-elbow) procedures were common at 8%. Overall mortality was 10%, but markedly higher for self-harm injuries (47%). On multivariable regression, age and demographics were not predictive of death or critical resource utilization, but self-harm intent was a strong independent risk factor for both. CONCLUSIONS: This study suggests that given the age distribution and disproportionately high impact of self-harm injuries, behavioral health resources should be available to children at the middle school level or earlier. Hand surgery may represent an overlooked but frequently utilized resource to mitigate injury impact and optimize long-term function.

Urban Teen Perspectives on Gun Violence: a Mixed Methods Study.

We aimed to explore perspectives of teenagers on their exposure to gun violence (GV), their knowledge and attitudes towards firearm injury prevention (FIP) efforts, and how to counsel them about FIP. Teens from two single-sex Bronx Catholic high schools participated in videoconferencing focus groups. Participants completed an online survey collecting demographic information and Likert-scale scoring of attitudes towards GV. Quantitative data was analyzed with descriptive statistics. Focus group discussions were recorded and transcribed. Using Dedoose, two investigators independently coded data and achieved consensus using content analysis. Six focus groups (3 from each school, n = 28 participants) were held from October-November 2020. A total of 27 participants completed the survey. Eighty-one percent of respondents agreed "Doctors should talk to teens about gun safety." During focus groups, participants reported personal, community, and entertainment media exposure to GV. GV elicited many emotions, including fear and frustration. Teens identified factors contributing to GV that should be addressed, including poverty, racism, and mental illness. Most had not received prior FIP education and desired more information from trusted adults. They preferred discussions over written materials and information given over time. Teens were open to doctors counseling on FIP during healthcare visits and suggested including screening questions on surveys, conversations during healthcare maintenance visits, and classroom talks by physicians. Bronx teens are exposed to and distressed by community GV. They desired more FIP education, including physician counseling during healthcare visits. Next steps are to create and test FIP guidance for adolescents.

Community-Academic Partnership to Assess the Role of Physical Disinvestment on Firearm Violence in Toledo, OH.

Reversing physical disinvestment, e.g., by remediating abandoned buildings and vacant lots, is an evidence-based strategy to reduce urban firearm violence. However, adoption of this strategy has been inconsistent across US cities. Our community-academic partnership sought to support adoption in Toledo, OH, USA, by generating locally relevant analyses on physical disinvestment and firearm violence. We used a spatial case-control design with matching. Physical disinvestment measures were derived from a citywide parcel foot audit conducted by the Lucas County Land Bank in summer 2021. Firearm violence outcomes were incident-level shootings data from the Toledo Police Department from October 2021 through February 2023. Shooting locations were matched to controls 1:4 on poverty rate, roadway characteristics, and zoning type. Exposures were calculated by aggregating parcels within 5-min walking buffers of each case and control point. We tested multiple disinvestment measures, including a composite index. Models were logistic regressions that adjusted for the matching variables and for potential spatial autocorrelation. Our sample included N = 281 shooting locations and N = 1124 matched controls. A 1-unit increase in the disinvestment score, equal to approximately 1 additional disrepair condition for the average parcel within the walking buffer, was associated with 1.68 times (95% CI: 1.36, 2.07) higher odds of shooting incidence. Across all other measures, greater disinvestment was associated with higher odds of shooting incidence. Our finding of a strong association between physical disinvestment and firearm violence in Toledo can inform local action. Community-academic partnership could help increase adoption of violence prevention strategies focused on reversing physical disinvestment.

Predicting potential underreporting of firearm ownership in a nationally representative sample.

PURPOSE: This study utilized demographic and intrapersonal variables to identify individuals who may have falsely denied firearm ownership and determined if individuals can be divided into meaningful subgroups. METHODS: Participants were United States residents (N = 3500) recruited from January to June 2020. matched to the 2010 census data for age, race, sex, income, and education level. A Zero-Inflated Negative Binomial (ZINB) regression was utilized to determine potential underreporting of firearm ownership, and a latent class analysis was utilized to determine unique subgroups of those who were identified as underreporting firearm ownership in the ZINB. RESULTS: Participants (N = 1306) were identified as underreporting firearm ownership (excess zeros) based on a model that included demographic and intrapersonal variables. A latent class analysis indicated that among excess zeros, three unique subgroups exist. CONCLUSIONS: Determining who may be underreporting firearm ownership will allow for a more comprehensive understanding of firearm ownership in the US and more targeted safe storage messages that may reach those who own firearms and are at risk for firearm-related injury and death.

Firearms and post-separation abuse: Providing context behind the data on firearms and intimate partner violence.

AIM: The aim of this study is to provide insight from maternal survivors of intimate partner violence (IPV) describing their experiences with their ex-partners' firearm ownership, access, storage and behaviours in the context of co-parenting and separation. DESIGN: We conducted a qualitative descriptive study informed by the IPV and Coparenting Model. METHODS: The analytic sample consists of self-identified maternal survivors (n = 14) who completed semi-structured qualitative interviews between January and May 2023 describing experiences of post-separation abuse. Participants were recruited through social media and domestic violence advocacy and legal aid organizations. In the interview guide, participants were asked one item about firearm exposure: Have you or your children had any experiences with guns and your ex-partner that made you or your children feel scared? Interviews were audio-recorded and transcribed. Interview transcripts were managed and coded in ATLAS.ti using a codebook. Codes were applied using descriptive content analysis, discrepancies reconciled and themes related to firearm exposure in the context of post-separation abuse identified. RESULTS: Six themes emerged related to firearm experiences and post-separation abuse: (1) gun ownership (2) gun access; (3) unsafe storage; (4) direct and symbolic threats; (5) involving the children; (6) survivors' protective actions. CONCLUSION: This manuscript provides context on how abusive ex-partners' firearm ownership, access and threats cause terror and pervasive fear for mothers and children following separation. Analysis of qualitative data provides important insights into opportunities to address firearm injury prevention. IMPACT: Findings add to the contextual understanding of how survivors of IPV experience non-fatal firearm abuse. Existing quantitative data may not capture the full extent of fear caused by perpetrators' gun ownership access and symbolic threats. Data from this study can help inform firearm injury prevention efforts. PATIENT OR PUBLIC CONTRIBUTION: The authors would like to acknowledge and thank the individuals who helped in cognitive testing of the interview guide prior to conducting interviews with participants, including (3) survivors of post-separation abuse. The authors would also like to acknowledge domestic violence advocates and those individuals who helped with recruitment and connected us with participants. Importantly, with deep gratitude, the authors would like to thank the participants who generously shared their time and stories with us.

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.

Child Firearm Injury Circumstances and Associations With Violence Intervention Program Enrollment.

INTRODUCTION: Pediatric firearm injuries are the leading cause of death among American children. While assault is the most commonly cited cause, few studies have investigated circumstances surrounding such injuries. Violence intervention programs (VIPs) have been utilized to combat firearm violence, though a similar lack of knowledge exists regarding possible associations between firearm injury circumstances and youth VIP enrollment. METHODS: This cross-sectional study included children aged 6-17 y who presented to an urban level 1 pediatric trauma center with firearm injuries from 2014 to 2017. Victim demographics and enrollment in a VIP were obtained from medical records, as well as circumstances surrounding the injuries based on account of the victim, victim's family/friends, and/or police present at the hospital. Circumstances included location of the shooting, if the shooter was known to the victim, and if the shooting was confirmed by the victim or their contacts to have been accidental or an intentional assault. Medical record numbers were used to locate victims in our trauma registry in order to obtain their assigned international classification of disease codes. Wilcox-rank sum, Pearson's chi-squared and Fisher's exact tests were used to detect associations between demographics, VIP enrollment, and shooting circumstances. RESULTS: 156 victims of firearm injury were described, including primarily Black adolescent males. 72% of victims were shot outdoors by an unknown shooter, the motivation of which was unknown in 93% of cases. 36% of these shootings were "drive-by". The majority of victims received international classification of disease codes for assault, though shootings that were confirmed by the victim to have been intentional assaults were relatively uncommon (13.4%). Most children lived in the same zip code in which they were shot (71%), and three particular zip codes accounted for 40% of shootings. 26% of victims chose to enroll in the VIP, and those that were victims of confirmed assaults (odds ratio 3.5) as well as those admitted to the hospital (odds ratio 2.4) were significantly more likely to enroll. CONCLUSIONS: Based on victim account, children living in an urban setting are more frequently victims of unclearly motivated, outdoor neighborhood shootings rather than intentional assaults. More accurate understanding of the causes of pediatric firearm injuries should inform both recruitment into VIPs, as well as a balancing of VIPs with community-level interventions to address firearm violence.

A systematic review of recurrent firearm injury rates in the United States.

OBJECTIVES: To conduct a systematic review of methodologies, data sources, and best practices for identifying, calculating, and reporting recurrent firearm injury rates in the United States. METHODS: In accordance with PRISMA guidelines, we searched seven electronic databases on December 16, 2021, for peer-reviewed articles that calculated recurrent firearm injury in generalizable populations. Two reviewers independently assessed the risk of bias, screened the studies, extracted data, and a third resolved conflicts. FINDINGS: Of the 918 unique articles identified, 14 met our inclusion criteria and reported recurrent firearm injury rates from 1% to 9.5%. We observed heterogeneity in study methodologies, including data sources utilized, identification of subsequent injury, follow-up times, and the types of firearm injuries studied. Data sources ranged from single-site hospital medical records to comprehensive statewide records comprising medical, law enforcement, and social security death index data. Some studies applied machine learning to electronic health records to differentiate subsequent new firearm injuries from the index injury, while others classified all repeat firearm-related hospital admissions after variably defined cut-off times as a new injury. Some studies required a minimum follow-up observation period after the index injury while others did not. Four studies conducted survival analyses, albeit using different methodologies. CONCLUSIONS: Variability in both the data sources and methods used to evaluate and report recurrent firearm injury limits individual study generalizability of individual and societal factors that influence recurrent firearm injury. Our systematic review highlights the need for development, dissemination, and implementation of standard practices for calculating and reporting recurrent firearm injury.

Impact of firearm injury in children and adolescents on health care costs and use within a family.

In 2020, firearm injury became the leading cause of death in U.S. children and adolescents. This study examines sequelae of firearm injury among children and adolescents in terms of health care costs and use within a family over time using an event study design. Using data from a large U.S. commercial insurance company from 2013 to 2019, we identified 532 children and adolescents aged 1-19 years who experienced any firearm-related acute hospitalization or emergency department (ED) encounter and 1667 of their family members (833 parents and 834 siblings). Outcomes included total health care costs, any acute hospitalization and ED visits (yes/no), and number of outpatient management visits, each determined on a quarterly basis 2 years before and 3 years after the firearm injury. Among injured children and adolescents, during the first quarter after the firearm injury, quarterly total health care costs were $24,018 higher than pre-injury; probability of acute hospitalization and ED visits were 27.9% and 90.4% higher, respectively; and number of outpatient visits was 1.8 higher (p < .001 for all). Quarterly total costs continued to be elevated during the second quarter post-injury ($1878 higher than pre-injury, p < .01) and number of outpatient visits remained elevated throughout the first year post-injury (0.6, 0.4, and 0.3 higher in the second through fourth quarter, respectively; p < .05 for all). Parents' number of outpatient visits increased during the second and third years after the firearm injury (0.3 and 0.5 higher per quarter than pre-injury; p < .05). Youth firearm injury has long-lasting impact on health care within a family.