Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth.

Importance: Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking. Objective: To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race. Design, Setting, and Participants: This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024. Main Outcomes and Measures: Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent. Results: Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Conclusions and Relevance: In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.

Evaluating Firearm Violence After New Jersey's Cash Bail Reform.

Importance: Reducing the pretrial detention population has been a cornerstone of movements to end mass incarceration. Across many US cities, there are ongoing public debates on policies that would end pretrial detention due to the inability to afford bail, with some raising concerns that doing so would increase community violence. Objective: To evaluate changes in firearm violence after New Jersey's 2017 bail reform policy that eliminated financial barriers to avoiding pretrial detention. Design, Setting, and Participants: This case-control study used synthetic control methods to examine changes in firearm mortality and combined fatal and nonfatal shootings in New Jersey (2014-2019). New Jersey was chosen because it was one of the first states to systematically implement cash bail reform. Outcomes in New Jersey were compared with a weighted combination of 36 states that did not implement any kind of reform to pretrial detention during the study period. Data were analyzed from April 2023 to March 2024. Exposure: Implementation of New Jersey's cash bail reform law in 2017. Main Outcomes and Measures: Quarterly rates of fatal and nonfatal firearm assault injuries and firearm self-harm injuries per 100 000 people. Results: Although New Jersey's pretrial detention population dramatically decreased under bail reform, the study did not find evidence of increases in overall firearm mortality (average treatment effect on the treated, -0.26 deaths per 100 000) or gun violence (average treatment effect on the treated, -0.24 deaths per 100 000), or within racialized groups during the postpolicy period. Conclusions and Relevance: Incarceration and gun violence are major public health problems impacting racially and economically marginalized groups. Cash bail reform may be an important tool for reducing pretrial detention and advancing health equity without exacerbating community violence.

Exploring Firearm Access, Carriage, and Possession among Justice-Involved Youth.

Firearm carriage and possession predicts youth firearm violence victimization and perpetration. This study describes self-reported factors associated with firearm access, carriage, and possession among justice-involved youth. We conducted an exploratory, mixed-methods study. Participants were recruited from May 2022 to February 2023 from the Juvenile Justice Collaborative, a diversion program for justice-involved youth. We used online anonymous surveys to investigate exposures related to firearm access, carriage, and possession. We performed semi-structured interviews using the phenomenology framework. We used descriptive statistics to examine firearm exposures by participant demographics. We performed qualitative analyses using an iterative approach with constant comparison to identify key themes. We completed 28 surveys and 5 interviews. Most survey participants identified as male (57%) and Black (61%) with a median age of 18 years. Interview participants described the socialization and cultural normalization of firearms, most prominently among peers. Survey participants reported whether they had ever carried (25%) or possessed (21%) a firearm. Survey and interview participants endorsed protection in the context of increasing violence exposure over time as the primary motivation for firearm possession. Interview participants describe accessing firearms primarily through social networks while survey participants also reported access from strangers (25%) and licensed sellers/gun dealers (18%). In conclusion, justice-involved youth believe firearm carriage and possession may be needed for protection due to increasing violence exposure. Further investigation is necessary to determine interventions that may decrease firearm access, carriage, and possession among justice-involved youth.

Estimating Community Disruption from Nighttime Gunshots in 6 U.S. Cities, 2015 to 2021.

BACKGROUND: Gunshots affect those directly involved in an incident and those in the surrounding community. The community-level impact of nighttime gunshots, which may be particularly disruptive to the sleep of nearby community members, is unknown. OBJECTIVE: Our aim is to estimate the number of people potentially affected by nighttime gunshots and the relationship between nighttime gunshots and median household income in the USA. DESIGN: We collected publicly available data on the timing and location of gunshots in six U.S. cities (Baltimore, MD; Boston, MA; Washington, D.C.; New York, NY; Philadelphia, PA; and Portland, OR) from 2015 to 2021. We then analyzed the data by computing rate ratios (RRs) to compare the frequency of gunshots during nighttime hours (6:00 pm to 5:59 am) versus daytime hours (6:00 am to 5:59 pm). Additionally, we used geospatial mapping to create choropleth maps to visualize the variation in nighttime gunshot density across cities. We estimated, using city-wide population, person-nights potentially impacted by the sound of gunshots within areas of 0.2- (low) and 0.5-mile (high) radius. Finally, for five of six cities where data on median household income were available by census tract, we built nonlinear regression models to estimate the relationship between the number of nighttime gunshots and median household income. KEY RESULTS: We analyzed 72,236 gunshots. Gunshots were more common during the nighttime than daytime (overall RR = 2.5). Analyses demonstrated that the low estimates for the mean annual number of person-nights impacted by nighttime gunshots were 0.4 million in Baltimore and Portland, 1.3 million in Philadelphia, 1.6 million in Boston, 2.9 million in New York City, and 5.9 million in Washington. The number of nighttime gunshots was inversely related to median household income. CONCLUSIONS: Nighttime gunshots are prevalent, particularly in low-income neighborhoods, and may have under-recognized effects on the surrounding community.

Reporting and Description of Research Methodology in Studies Estimating Effects of Firearm Policies.

BACKGROUND: Evidence about which firearm policies work, to what extent, and for whom is hotly debated, perhaps partly because variation in research methodology has produced mixed and inconclusive effect estimates. We conducted a scoping review of firearm policy research in the health sciences in the United States, focusing on methodological considerations for causal inference. METHODS: We identified original, empirical articles indexed in PubMed from 1 January 2000 to 1 September 2021 that examined any of 18 prespecified firearm policies. We extracted key study components, including policy type(s) examined, policy operationalization, outcomes, study setting and population, study approach and design, causal language, and whether and how authors acknowledged potential sources of bias. RESULTS: We screened 7733 articles and included 124. A plurality of studies used a legislative score as their primary exposure (n = 39; 32%) and did not examine change in policies over time (n = 47; 38%). Most examined firearm homicide (n = 51; 41%) or firearm suicide (n = 40; 32%) as outcomes. One-third adjusted for other firearm policies (n = 41; 33%). Three studies (2%) explicitly mentioned that their goal was to estimate causal effects, but over half used language implying causality (n = 72; 58%). Most acknowledged causal identification assumptions of temporality (n = 91; 73%) and exchangeability (n = 111; 90%); other assumptions were less often acknowledged. One-third of studies included bias analyses (n = 42; 34%). CONCLUSIONS: We identified a range of methodologic approaches in firearm policy research in the health sciences. Acknowledging the imitations of data availability and quality, we identify opportunities to improve causal inferences about and reporting on the effects of firearm policies on population health.

Assessment of injuries patterns produced by a 9mm P.A.K "rubber ball" blank firing weapon: porcine model.

The use of less lethal weapons aims to mitigate civilian casualties caused by firearm use. However, due to numerous cases in which these weapons caused serious injuries, even lethal injuries, both legislation and the forensic field are interested in characterizing and regulating them better. In the forensic field, there is a lack of strong research about injury patterns of these weapons which makes it difficult to identify the type of weapon employed. In this study, the main objective was to characterize the injury pattern produced by the impact of the 9 mm P.A.K. projectile. A porcine model was used. Four different distances were studied: firm contact, 10 cm, 60 cm and 110 cm, using 3 of the more representative anatomical sites: the head, the hind leg and the ribs. The average measurement of the entrance orifice varied according to the anatomical site, being 6.67 mm wide and 6.25 mm long in the thorax, 7.3 mm wide and 8.8 mm long in the hind legs, and 7.62 mm wide and 7.54 mm long in the head. The variation in width and length measurements was not found to be directly related to the shot distance. The gunshot residues had similar characteristics to those of conventional lead projectiles, however there was more unburned powder deposit near the wounds, with a less dense soot and more dense powder tattoo. Depth varied widely regardless of tissue and firing distance, although loss of penetrating power and injury is observed as one moves away from the target.

Racial inequities in homicide rates and homicide methods among Black and White women aged 25-44 years in the USA, 1999-2020: a cross-sectional time series study.

BACKGROUND: In the USA, Black women aged 25-44 years are disproportionately murdered compared with their White counterparts. Despite ongoing efforts to reduce racial and structural inequities, the result of these efforts remains unclear, particularly in light of the COVID-19 pandemic. METHODS: This study examined a cross-sectional time series of homicide death rates, by race, from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research system. We included data for women aged 25-44 years between 1999 and 2020 among 30 states in the USA. Homicide death was classified using underlying cause and multiple cause of death codes; mortality rates were calculated per 100 000 based on US Census Bureau population sizes. Homicide methods were classified as firearm, cutting or piercing, and other. Firearm homicides were compared with other homicides with logistic regression including covariates of race, time, and their interaction. We report odds ratios and 95% CIs. FINDINGS: In 2020, the homicide rate among Black women was 11·6 per 100 000, compared with 3 per 100 000 among White women. This inequity has persisted over time and is virtually unchanged since 1999. Homicide inequities vary across US states; in 11 states, racial inequities have increased since 1999. The racial inequity was greatest in Wisconsin, where in 2019-20, Black women aged 25-44 years were 20 times more likely to die by homicide than White women. Homicide by firearm is increasing in frequency; women in the USA had 2·44 (95% CI 2·14-2·78) times the odds of homicide involving firearms in 2019-20 compared with 1999-2003. Firearm homicide deaths are disproportionately concentrated among Black women in every region in the USA. INTERPRETATION: Our findings suggest that there is an urgent need to address homicide inequities among Black and White women in the USA. Enacting federal legislation that reduces gun access is a crucial step. Policy makers must address long-standing structural factors that underpin elevated gun violence by implementing sustainable wealth-building opportunities; developing desegregated, mixed income and affordable housing; and increasing green spaces in communities where Black women largely reside. FUNDING: National Institute of Mental Health of the National Institutes of Health.

Patterns of firearm related injury in the elderly: A single institution analysis.

BACKGROUND: Firearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic. METHODS: A retrospective review of the trauma registry at a large Level I center was performed from 2016-2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18-64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition. RESULTS: 23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7-93.1] compared to 63.7 [IQR 33.2-83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in "at risk" or "distressed" communities. CONCLUSION: FRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Disparities Among Pediatric Firearm Suicides in the United States: An Analysis of the National Violent Death Reporting System, 2014 to 2018.

Suicide is a leading cause of death in the United States (U.S.), with firearms being the predominant method. This study examines the racial disparity and disproportionality of pediatric firearm suicide from 2014 to 2018 in 17 U.S. states. We used the National Violent Death Reporting System to quantify the burden of pediatric firearm suicide by race/ethnicity and gender and assessed themes among decedents aged 10 to 17 years. Racial disparity and disproportionality were measured using the Disparity Index and Disproportionality Representation Index, respectively. Decedents were primarily non-Hispanic White (NHW, 77.5%) and male (84.0%). NHW children died at a rate that was 1.3 times greater than expected based on their proportion in the general population and were 2.6 times more likely to die by firearm suicide than non-Hispanic Black (NHB) children. NHB children were less likely to disclose suicide intention, suggesting that this group may require more active screening intervention. Qualitative analysis revealed unsafe firearm storage as a common theme among these deaths. Differences in age with respect to social media use and precipitating factors such as bullying and arguments with parents were also identified as contributing factors. Results of this study support the expansion of interventions such as lethal means restriction counseling and implementation of safer firearm storage laws.

Protect and Provide: Perceptions of Manhood and Masculinities Among Disabled Violently Injured Black Men in a Hospital-Based Violence Intervention Program.

Exploring the post-injury lives of those who have survived gunshot wounds is essential to understanding the entire scope of firearm violence. The lives of Black male firearm violence survivors are transformed in various ways due to their injuries both visible and invisible. This study explored how Black men who suffer from disabilities via a firearm negotiated their masculine identities. Semi-structured, qualitative interviews were conducted with 10 violently injured Black men participating in a hospital-based violence intervention program. Survivors expressed their thoughts on how their injuries impacted their manhood and masculinities. Three themes emerged: (1) perceptions of manhood, (2) loss of independence and burden on others, and (3) and mobility. These themes highlighted and described how their lives were impacted post-injury and characterized their psychological and physical experience of recovery. The research findings suggest the need for more qualitative studies to further explore the relationship between firearm injury, Black masculinity, and perceptions of manhood. While Black men are understudied in health research and invisible in disability research, they continue to be hyper-invisible when discussing violently acquired disabilities.

Investing in family-centered early childhood education: A conceptual model for preventing firearm homicide among Black male youth in the United States.

INTRODUCTION: Firearms are now the number one killer of children and adolescents in the United States. Firearm homicides among Black male youth are the driver of this increase. Prevention requires a multi-faceted life course approach. Academic achievement has been identified as a protective factor. Early childhood education, which is linked to later achievement, is thus an intervention area of interest. Conceptualizing the potential links between early childhood education and reduced risk for youth firearm homicide is important for guiding policy advocacy and informing future research. METHODS: This paper presents a conceptual model linking early childhood education to reduced risk for firearm homicide. Each link in the model is discussed, and a corresponding review of the literature is presented. The need for anti-racist policies to strengthen the impact of early childhood education is highlighted. RESULTS: Early education and firearm homicide research are each well-established but largely disconnected. There are clear immediate benefits of early childhood education; however, these effects wane with time, particularly for youth of color. At the same time, juvenile delinquency-a major risk factor for firearm homicide-is influenced by educational inequities. CONCLUSIONS: Effective interventions to reduce firearm homicides among Black male youth in the United States are needed. Early childhood education shows promise as an intervention. However, to have an impact, this education needs to be accessible and affordable for all, particularly families of color and low income. Societal structures and policies must also better support the positive gains seen through early childhood education to avoid dissipation.

The Association Between State Minimum Wage and Firearm Homicides, 2000-2020.

INTRODUCTION: Recent research has indicated an association between both poverty and income inequality and firearm homicides. Increased minimum wages may serve as a strategy for reducing firearm violence by increasing economic security among workers earning low wages and reducing the number of families living in poverty. This study aimed to examine the association between state minimum wage and firearm homicides in the U.S. between 2000 and 2020. METHODS: State minimum wage, obtained from Temple's Law Atlas and augmented by legal research, was conceptualized using the Kaitz Index. State-level homicide counts were obtained from 2000 to 2020 multiple-cause-of death mortality data from the National Vital Statistics System. Log-linear regressions were conducted to model the associations between state minimum wage and firearm homicides, stratifying by demographic groups. Analyses were conducted in 2023. RESULTS: A 1% point increase in a state's Kaitz Index was associated with a 1.3% (95% CI: -2.1% to -0.5%) decrease in a state's firearm homicide rate. When interacted with quartile of firearm ownership, the Kaitz Index was associated with decreases in firearm homicide in all except the lowest quartile. These findings were largely consistent across stratifications. CONCLUSIONS: Changing a state's minimum wage, whereby a full-time minimum wage worker's salary is closer to a state's median income, may be an option for reducing firearm homicides.

Socioeconomic disparities based on shooting intent in pediatric firearm injury.

BACKGROUND: Pediatric firearm injury is often associated with socioeconomically disadvantaged neighborhoods. Most studies only include fatal injuries and do not differentiate by shooting intent. We hypothesized that differences in neighborhood socioeconomic disadvantage would be observed among shooting intents of fatal and nonfatal cases. METHODS: A linked integrated database of pediatric fatal and nonfatal firearm injuries was developed from trauma center and medical examiner records in Harris County, Texas (2018-2020). Geospatial analysis was utilized to map victim residence locations, stratified by shooting intent. Area Deprivation Index (ADI), a composite measure of neighborhood socioeconomic disadvantage at the census tract level was linked to shooting intent. Differences in high ADI (more deprived) versus low ADI among the shooting intents were assessed. Unadjusted and adjusted regression models assessed differences in ADI scores across shooting intent, adjusted models controlled for age, gender, and race/ethnicity. RESULTS: Of 324 pediatric firearm injuries, 28% were fatal; 77% were classified as interpersonal violence, 15% unintentional, and 8% self-harm. Differences were noted among shooting intent across the ADI quartiles; with increases in ADI score, the odds of interpersonal violence injuries compared with self-harm injuries significantly increased by 5%; however, when adjusting for individual-level variables of age, gender, and race and ethnicity, no significant differences in ADI were noted. CONCLUSION: Our results suggest that children living in disadvantaged neighborhoods are more likely to be affected by interpersonal firearm violence compared with self-harm; however, when differences in race/ethnicity are considered, the differences attributable to neighborhood-level disadvantage disappeared. Resources should be dedicated to improving structural aspects of neighborhood disadvantage, which disproportionately impact racial/ethnic minoritized populations. Furthermore, firearm self-harm injuries occurred among children living in the less disadvantaged neighborhoods. Understanding the associations among individual and neighborhood-level factors are important for developing streamlined injury prevention interventions by shooting intent. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

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.

Modeling the Relationship Between Firearm Restrictions, Medicaid Expansion, and Political Partisanship with Pediatric Firearm Mortality Costs.

INTRODUCTION: Firearms are now the leading cause of pediatric mortality in the U.S., but few studies have investigated the economic impact of these deaths. Thus, this study determined whether multiple different gun-related measures, political partisanship and Medicaid expansion were related to the costs of pediatric gun deaths. METHODS: Each states' medical costs, years of potential life lost (YPLL), and value of statistical life (VSL) lost due to pediatric gun deaths were extracted from the WISQARS database from 2015 to 2020. Seven firearm laws or restrictiveness measures (assault weapons bans, child access prevention laws, firearm registration and permit to purchase requirements, safe storage laws, Giffords Law Center ranking, and the number of firearm provisions), the Cook Partisan Voting Index (PVI), and Medicaid expansion status were determined across states. Unadjusted analyses compared each measure and (1) medical costs, (2) VSL, and (3) YPLL for each state. These were repeated using adjusted analyses, controlling for poverty, educational attainment, poor mental health, and race. RESULTS: Of the 9 variables assessed, unadjusted analyses revealed that 8 variables were significantly associated with increased medical costs, all 9 were associated with higher VSL and 8 were associated with higher YPLL due to pediatric firearm-related mortality. Multivariable analyses revealed that 7 variables were associated with medical costs, 7 were associated with VSL and 6 were associated with YPLL. CONCLUSION: States with fewer gun laws and those which have not adopted Medicaid expansion were more likely to experience a higher economic burden due to pediatric gun deaths. Quantifying the costs of these deaths can demonstrate the social toll of gun violence to policymakers and the general public. LEVEL OF EVIDENCE: III.

Impact of Medicaid Expansion and Firearm Legislation on Cost of Firearm Injuries.

INTRODUCTION: Firearm injury-related hospitalizations in the U.S. cost $900 million annually. Before the Affordable Care Act, government insurance programs covered 41% of the costs. This study describes the impact of Affordable Care Act Medicaid expansion and state-level firearm legislation on coverage and costs for firearm injuries. METHODS: This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. The impact of the Affordable Care Act expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses. RESULTS: The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted ($11,550; p=0.02) injuries; there were no state-level differences in assault or total per capita firearm-related hospitalization costs. Affordable Care Act expansion increased government coverage of costs by 15 percentage points (95% CI=3, 29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI=6, 21). In 2016, states with weak firearm legislation and no Affordable Care Act expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI=15, 34). CONCLUSIONS: Affordable Care Act expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had the highest proportion of uninsured/self-pay patients.

Modification of Firearm Law-Firearm Injury Association by Economic Disadvantage.

INTRODUCTION: Firearm-related injuries in the U.S. have risen 37% since 2015. Understanding how the association between firearm incidents and state-level firearm restrictiveness is modified by community-level distress and economic connectedness (EC) may inform upstream injury prevention efforts. METHODS: A national cross-sectional study of firearm incidents (interpersonal and unintentional firearm events) occurring between 1/2015 and 12/2021 was performed using the Gun Violence Archive. The exposures were community distress (Distressed Communities Index, DCI), EC, and year-state-level firearm restrictiveness. The primary outcome was mean annual urban firearm incidence rate per ZIP Code Tabulation Area. Generalized linear mixed models were fit to evaluate the modification of the firearm law-firearm incident association by DCI and EC. Data analyses took place in 2022. RESULTS: About 266,020 firearm incidents were included. The mean rate was higher with each DCI tertile, with a RR of 3.18 (95% CI: 3.06, 3.30) in high versus low distress communities. Low EC was associated with over 1.8 times greater rate of firearm-related injury. The least restrictive firearm laws were associated with 1.20 times higher risk of firearm incidents (95% CI: 1.12, 1.28). The association between restrictive laws and lower incidence rates was strongest in low and medium distress and high EC communities. CONCLUSIONS: Stricter firearm laws are associated with lower rate of firearm incidents. The magnitude of this association is smallest for communities experiencing the greatest economic disadvantage.

Death by the minute: Inequities in trauma care for victims of firearm violence.

BACKGROUND: Gunshot wounds (GSWs) remain a significant source of mortality in the United States. Timely delivery of trauma care is known to be critical for survival. We sought to understand the relationship of predicted transport time and death after GSW. Given large racial disparities in firearm violence, we also sought to understand disparities in transport times and death by victim race, an unstudied phenomenon. METHODS: Firearm mortality data were obtained from the Boston Police Department 2005 to 2023. Firearm incidents were mapped using ArcGIS. Predicted transport times for each incident to the closest trauma center were calculated in ArcGIS. Spatial autoregressive models were used to understand the relationship between victim race, transport time to a trauma center, and mortality associated with the shooting incidents. RESULTS: There were 4,545 shooting victims with 758 deaths. Among those who lived, the median transport time was 9.4 minutes (interquartile range, 5.8-13.8) and 10.5 minutes (interquartile range, 6.4-14.6; p = 0.003) for those who died. In the multivariable logistic regression, increased transport time to the nearest trauma center (odds ratio, 1.024; 95% confidence interval, 1.01-1.04) and age (odds ratio, 1.016; 95% confidence interval, 1.01-1.02) were associated with mortality. There was a modest difference in median transport time to the nearest trauma center by race with non-Hispanic Black at 10.1 minutes, Black Hispanic 9.2 minutes, White Hispanic 8.5 minutes, and non-Hispanic White 8.3 minutes ( p < 0.001). CONCLUSION: Our results highlight the relationship of transport time to a trauma center and death after a GSW. Non-White individuals had significantly longer transport times to a trauma center and predicted mortality would have been lower with White victim transport times. These data underscore the importance of timely trauma care for GSW victims and can be used to direct more equitable trauma systems. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

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

INTRODUCTION: Firearm-related injuries are among the five leading causes of death for people aged 1-44 years in the U.S. The immediate and long-term harms of firearm injuries pose an economic burden on society. Fatal and nonfatal firearm injury costs in the U.S. were estimated providing up-to-date economic burden estimates. METHODS: Counts of nonfatal firearm injuries were obtained from the 2019-2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Data on nonfatal injury intent were obtained from the National Electronic Injury Surveillance System - Firearm Injury Surveillance System. Counts of deaths (firearm as underlying cause) were obtained from the 2019-2020 multiple cause-of-death mortality data from the National Vital Statistics System. Analyses were conducted in 2023. RESULTS: The total cost of firearm related injuries and deaths in the U.S. for 2020 was $493.2 billion, a 16 percent increase compared with 2019. There are significant disparities in the cost of firearm deaths in 2019-2020, with non-Hispanic Black people, males, and young and middle-aged groups being the most affected. CONCLUSIONS: Most of the nonfatal firearm injury-related costs are attributed to hospitalization. These findings highlight the racial/ethnic differences in fatal firearm injuries and the disproportionate cost burden to urban areas. Addressing this important public health problem can help ameliorate the costs to our society from the rising rates of firearm injuries.

Risk and Protective Factors for Firearm Assault Injuries Among Black Men: A Scoping Review of Research.

Black men are disproportionately affected by firearm assaults in the United States, and these disparities are rooted in structural and social inequities. The objective of this scoping review of research was to identify risk and protective factors for firearm assault injuries among Black men at all levels of the social-ecological framework. The search was conducted in 2021. The initial search generated 1,122 articles. Studies were eligible if they (a) included an analysis of modifiable risk or protective factors for firearm assaults among Black men; (b) reported an estimate of correlation, association, or effect between risk or protective factors and firearm assault injuries, firearm violence, and/or firearm homicides; and (c) were published peer-reviewed articles. In all, 19 articles were identified for review. Risk factors identified at each ecological level include the following: (1) Individual: firearm possession/weapon use and criminal legal system interaction; (2) Relationships: gang membership and exposure to other people who have experienced a firearm assault; (3) Community: indicators for socioeconomic status and racial residential segregation; and (4) Societal: historical racist policy. Individual-level substance use had mixed results. Few (26%) studies examined protective factors at any ecological level, but community-level factors like neighborhood tree cover were identified. Future research needs to examine risk and protective factors at the societal level and multiple ecological levels simultaneously leading to more effective multi-level interventions that will guide policy formation. A greater diversity of study designs, research methods, and theoretical frameworks is needed to better understand factors associated with firearm assault among Black men.