A pilot project of a Post Discharge Care Team for firearm injury survivors decreases emergency department utilization, hospital readmission days, and cost.

BACKGROUND: Persons of low socioeconomic status are overrepresented in the firearm injury patient population and may experience challenges in accessing complex outpatient health systems. Consequently, outpatient care for these patients is plagued by poor follow-up and increased emergency department (ED) utilization. We developed a Post Discharge Care Team (PDCT) consisting of a dedicated trauma nurse navigator and medical social worker to bridge the gap between hospital discharge and outpatient care to improve recovery. METHODS: Adult firearm injury survivors admitted to the trauma service were randomized 1:1 to receive either PDCT services or standard of care (SOC) workflows. The PDCT nurse provided education and set expectations regarding injuries, wound care, and outpatient follow-up. The PDCT social worker performed a comprehensive assessment to identify concerns including housing and financial instability, food insecurity, or transportation issues. The primary outcome was ED utilization, with secondary outcomes including readmissions and overall health care costs compared between groups. RESULTS: In the first 6 months of the study, a total of 44 patients were randomized to PDCT and 47 to SOC. There were 10 patients who visited the ED in the PDCT group compared with 16 in the SOC group ( p = 0.23) for a total of 14 and 23 ED visits, respectively. There were 14 patients in the PDCT and 11 patients in the SOC groups who were readmitted ( p = 0.31), but the PDCT group was readmitted for 27.9 fewer hospital days. After accounting for programmatic costs, the PDCT had a hospital savings of $34,542.71. CONCLUSION: A collaborative, specialized PDCT for firearm injury survivors consisting of a dedicated trauma nurse navigator and medical social worker decreased outpatient ED utilization, readmission days, and was cost effective. Trauma centers with high volumes of penetrating trauma should consider a similar model to improve outpatient care for firearm injury survivors. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018.

INTRODUCTION: The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers. METHODS: Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018. RESULTS: A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico. CONCLUSION: States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Outcomes of Hospitalized Injured Suspects Sustaining Gunshot Wounds From Law Enforcement Action.

BACKGROUND: Although firearms are implicated in the majority of law enforcement intervention (LEI)-related deaths, scientific research is lacking. The present study sought to characterize clinical and financial outcomes between injured suspects and other gunshot wound (GSW) patients. STUDY DESIGN: The 2016-2020 National Inpatient Sample was queried for patients ≥16 years old admitted following GSW. Patients were categorized as injured suspects (ISs) if they were injured in LEI and non-IS otherwise. The primary outcome was in-hospital mortality with complications, hospitalization duration (LOS), and costs secondarily considered. Multivariable regression models were used to adjust for patient characteristics, injury burden using the Trauma Mortality Prediction Model (TMPM), and hospital factors. RESULTS: Of 143,125 hospitalizations, 1575 (1.10%) were IS. Compared to non-IS, ISs were less frequently Black (24.4% vs 54.3%) but had a higher proportion of psychiatric conditions (19.4% vs 6.4%) (P < .05). Although having a similar requirement for major operations and TMPM score, ISs more frequently underwent thoracic (11.4% vs 4.1%) and gastrointestinal operations (33.0% vs 25.7%) (P < .05). After adjustment, IS was associated with similar odds of mortality but was associated with greater odds of cardiac complications, respiratory failure, and need for intensive care. While LOS was similar, IS was associated with greater costs (ß: +$14,300, 95% CI: 6,200-22,400). CONCLUSIONS: Suspects injured during law enforcement intervention have similar in-hospital mortality but greater complication rates and costs. Through the quantification of the clinical and financial burden of IS, our findings may help inform further policy discussions regarding use of potentially lethal force in law enforcement intervention.

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.

Health Care Utilization After Nonfatal Firearm Injuries.

OBJECTIVES: Despite the high incidence of firearm injuries, little is known about health care utilization after nonfatal childhood firearm injuries. This study aimed to describe health care utilization and costs after a nonfatal firearm injury among Medicaid and commercially insured youth using a propensity score matched analysis. METHODS: We conducted a propensity score matched cohort analysis using 2015 to 2018 Medicaid and Commercial Marketscan data comparing utilization in the 12-months post firearm injury for youth aged 0 to 17. We matched youth with a nonfatal firearm injury 1:1 to comparison noninjured youth on demographic and preindex variables. Outcomes included inpatient hospitalizations, emergency department (ED) visits, and outpatient visits as well as health care costs. Following propensity score matching, regression models estimated relative risks of the health care utilization outcomes, adjusting for demographic and clinical covariates. RESULTS: We identified 2110 youth with nonfatal firearm injury. Compared with matched noninjured youth, firearm injured youth had a 5.31-fold increased risk of inpatient hospitalization (95% confidence interval [CI] 3.93-7.20), 1.49-fold increased risk of ED visit (95% CI 1.37-1.62), and 1.06-fold increased risk of outpatient visit (95% CI 1.03-1.10) 12-months postinjury. Adjusted 12-month postindex costs were $7581 (95% CI $7581-$8092) for injured youth compared with $1990 (95% CI $1862-2127) for comparison noninjured youth. CONCLUSIONS: Youth who suffer nonfatal firearm injury have a significantly increased risk of hospitalizations, ED visits, outpatient visits, and costs in the 12 months after injury when compared with matched youth. Applied to the 11 258 US youth with nonfatal firearm injuries in 2020, estimates represent potential population health care savings of $62.9 million.

The economic impact of gunshot wounds on an urban level 1 trauma center.

INTRODUCTION: Firearm-related injuries impact the healthcare system, taxpayers, and injured patients due to lost productivity and reduced quality of life. The goal was to quantify the economic costs related to hospitalization for gunshot wounds (GSWs) at a single urban level 1 trauma center. MATERIALS AND METHODS: 941 patients over 27 months were treated for GSW. Elements related to hospitalization including length of stay, surgical procedures, medications and therapies, and subsequent readmission were identified, and costs were determined, inclusive of fixed and variable direct and indirect costs of facility care. Costs were classified based on body region: abdominal, chest, soft tissue, extremity or pelvic girdle, and head/neck/face. RESULTS: Mean age was 30 years, with 94% male. Most patients (81%) were admitted, and 8% sustained fatal injuries. Overall, 12% were seen previously or subsequently for additional, unrelated GSWs. Mean costs per patient were: $66,780 for abdominal GSWs; $3,986 for chest; $3,509 for soft tissue; $19,875 for extremities; $64,533 for head or neck, and means of $25,249 for two regions and $26,638 for three regions. Over the prospective period, 941 individuals sustained GSWs (approximately 35 per month). 37% were to the extremities, 23% were within the skin/subcutaneous tissue, 7% to the abdomen, 7% to the chest, 6% to the head or neck, and 20% to two or more body regions. Total facility costs for these 941 GSWs was $18.9 million, or $698,960 per month. 55% of the patients had Medicaid, and 33% were uninsured, resulting in substantial uncompensated expenses for the trauma center. CONCLUSION: Firearm-related injuries generate considerable expense. Our data underestimated cost, as professional services and indirect costs associated with lost economic productivity of patients and caregivers were excluded. No objective assessment of the disastrous personal and social impact was projected. Moving forward, interventions to prevent initial injury and recidivism in this high-risk population are crucial. LEVEL OF EVIDENCE: Level III.

Healthcare utilization and costs following non-fatal powdered and non-powdered firearm injuries for children and youth.

Little is known about the healthcare and economic burdens of non-fatal firearm injuries for children/youth beyond the initial admission. This study sought to estimate healthcare utilization and total direct healthcare costs of non-fatal powdered and non-powdered (air gun) firearm injuries 1-year post-injury. Using administrative data from 2003 to 2018 on all children/youth 0-24 years old in Ontario, Canada, a matched 1:2 cohort study was conducted to compare children/youth who experienced powdered and non-powdered firearm injuries with those who did not. Mean and median number of healthcare encounters and costs, and respective 95% confidence intervals (CIs) and interquartile ranges (IQRs), were estimated for both weapon type groups and controls and by intent. Children/youth who experienced a powdered and non-powdered firearm injury had a higher number of healthcare encounters and costs per year than those who did not. Mean 1-year costs for those with powdered and non-powdered firearm injuries were $8825 ($8007-$9643) and $2349 ($2118-$2578), respectively, versus $812 ($567-$1058) and $753 ($594-$911), respectively, for those without. Mean 1-year costs were highest for handgun injuries ($12,875 [95% CI $9941-$15,808]), and for intentional assault-related ($13,498 [$11,843-$15,153]; $3287 [$2213-$4362]), and intentional self-injuries ($14,773 [$6893-$22,652]; $6005 [$2193-$9817]) for both powdered and non-powdered firearm injuries, respectively.   Conclusion: Firearm injuries have substantial healthcare and economic burdens beyond the initial injury-related admission; this should be accounted for when examining the overall impact of firearm injuries. What is Known: • Child/youth firearm injuries have significant health and economic burdens. • However, existing work has mainly examined healthcare utilization and costs of initial admissions and/or have been limited to single-center studies and no studies have provide cost estimates by weapon type and intent. What is New: • Children/youth who suffered powdered firearm injuries had higher mean healthcare utilization and costs than those with non-powdered firearm injuries as well as comparable healthy children/youth. • Mean 1-year costs were highest for handgun injuries ($12,875), and for intentional assault-related ($13,498; $3287), and intentional self-injuries ($14,773; $6005) for powdered and non-powdered firearm injuries, respectively.

Penetrating injuries in Germany - epidemiology, management and outcome an analysis based on the TraumaRegister DGU®.

BACKGROUND: The management of penetrating wounds is a rare challenge for trauma surgeons in Germany and Central Europe as a result of the low incidence of this type of trauma. In Germany, penetrating injuries are reported to occur in 4-5 % of the severely injured patients who are enrolled in the TraumaRegister DGU® (trauma registry of the German Trauma Society). They include gunshot injuries, knife stab injuries, which are far more common, and penetrating injuries of other origin, for example trauma caused by accidents. The objective of this study was to assess the epidemiology and outcome of penetrating injuries in Germany, with a particular focus on the level of care provided by the treating trauma centre to gain more understanding of this trauma mechanism and to anticipate the necessary steps in the initial treatment. MATERIALS AND METHODS: Since 2009, the TraumaRegister DGU® has been used to assess not only whether a trauma was penetrating but also whether it was caused by gunshot or stabbing. Data were taken from the standard documentation forms that participating German hospitals completed between 2009 and 2018. Excluded were patients with a maximum abbreviated injury scale (MAIS) score of 1 with a view to obtaining a realistic idea of this injury entity, which is rare in Germany. RESULTS: From 2009 to 2018, there were 1123 patients with gunshot wounds, corresponding to a prevalence rate of 0.5 %, and 4333 patients with stab wounds (1.8 %), which were frequently caused by violent crime. The high proportion of intentionally self-inflicted gunshot wounds to the head resulted in a cumulative mortality rate of 41 % for gunshot injuries. Stab wounds were associated with a lower mortality rate (6.8 %). Every fourth to fifth patient with a gunshot or stab wound presented with haemorrhagic shock, which is a problem that is seen during both the prehospital and the inhospital phase of patient management. Of the patients with penetrating injuries, 18.3 % required transfusions. This percentage was more than two times higher than that of the basic group of patients of the TraumaRegister DGU®, which consists of patients with a MAIS ≥ 3 and patients with a MAIS of 2 who died or were treated on the intensive care unit. CONCLUSIONS: In Germany, gunshot and stab wounds have a low incidence and are mostly caused by violent crime or attempted suicides. Depending on the site of injury, they have a high mortality and are often associated with major haemorrhage. As a result of the low incidence of these types of trauma, further data and analyses are required in order to provide the basis for evaluating the long-term quality of the management of patients with stab or gunshot wounds.

Penetrating Trauma Rapid Estimated Disability Scale: Assessing Facial Self-Inflicted Gunshot Wounds.

Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may be associated with hospital course and cost after self-inflicted facial GSWs. Methods: This is retrospective review of self-inflicted facial GSWs between January 1, 2009, and December 31, 2018, at a tertiary academic center. Patients were given a penetrating trauma rapid estimated disablity (PRED) score (1-4) based solely on radiologic imaging injury patterns. Clinicopathologic factors were then compared between groups. Results: There were 2 PRED 1 patients (15.1%), 8 PRED 2 patients (29.6%), 5 PRED 3 patients (18.5%), and 12 PRED 4 patients (44.4%). An increased PRED score was statistically associated with increasing mean days in intensive care unit (2.5 PRED 1, 4.2 PRED 2, 6 PRED 3, 11.6 PRED 4, p = 0.001), mean length of hospitalization (5.5 PRED 1, 13.1 PRED 2, 25.6 PRED 3, 39.8 PRED 4, p = 0.007), and mean cost ($) of hospitalization (22,000 PRED 1, 29,000 PRED 2, 37,000 PRED 3, 63,000 PRED 4, p = 0.01). Conclusions and Relevance: The PRED score for self-inflicted GSWs to the face is strongly associated with length of hospital stay and cost of hospitalization.

Prevalence and hospital charges from firearm injuries treated in US emergency departments from 2006 to 2016.

BACKGROUND: Age- and intent-related differences in the burden and costs of firearm injury treated in emergency departments are not well-documented. METHODS: We performed a serial cross-sectional study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey from 2006 to 2016. We used International Classification of Diseases diagnoses codes revisions 9 and 10 to identify firearm injuries. We calculated survey-weighted counts, proportions, means, and rates and confidence intervals of national, age-specific (0-4, 5-9, 10-14, 15-17, 18-44, 45-64, 65-84, >84) and intent-specific (assault, unintentional, suicide, undetermined) emergency department discharges for firearm injuries. We used survey-weighted regression to assess temporal trends. RESULTS: There was a total of 868,483 (25.5 per 100,000) emergency department visits for firearm injuries from 2006 to 2016, and 7.8% died in the emergency department. Overall, firearm injury rates remained steady (P = .78). The largest burden was among those 25 to 44 years of age, but their rates remained stable (10.8 per 100,000). Overall assault injuries declined from 39.7% to 36.4%, and overall unintentional injuries increased from 46.4% to 54.7%. Legal-intervention injuries declined from 0.6 to 0.3 per 100,000. The charges (total $4,059,070,364, $369,006,396/year) increased across time in age and intent groups. The mean predicted charges increased from $1,922 to $3,348 in those alive versus $3,741 to $6,515 among those who died. CONCLUSION: Interventions and programs to manage the consequences of firearm injury in persons who live with ongoing morbidity and economic burden are warranted.

Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment.

OBJECTIVES: (1) To determine the overall treatment costs associated with isolated low-energy gunshot wounds (GSWs) to the extremity and (2) to estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients (N = 380) with extremity-only GSW injuries from 2010 to 2015 were retrospectively reviewed. Treatment was recorded including type and duration of antibiotics, admission, and surgical intervention. MAIN OUTCOME MEASURES: Costs were calculated including facility services in the operating room and hospital. RESULTS: There were 460 GSWs in 380 patients with a mean age of 30 years old. There were 309 admissions, 273 operations performed, and 1010 days of antibiotics prescribed. The total inpatient facility cost to treat all patients was $1,701,154. Among 179 patients who could be treated by the single-dose antibiotic care pathway for simple GSWs, 132 patients (73%) received additional treatment with 108 hospital admissions, 26 debridement surgeries, and 322 days of additional oral and/or IV antibiotics. The single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses. CONCLUSIONS: The overall cost associated with isolated low-energy GSWs to the extremity is high. Limiting antibiotics to a single IV dose in the emergency room can reduce treatment expenses substantially for patients with simple GSWs. LEVEL OF EVIDENCE: Economic Level IV. See instructions for authors for a complete description of levels of evidence.

Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents.

BACKGROUND: Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado. METHODS: Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents. RESULTS: Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million. CONCLUSION: The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients. LEVEL OF EVIDENCE: Epidemiological, Level III.

Assessment of firearm injuries undergoing advanced airway management: Role II hospital experience.

BACKGROUND: Airway problems are one of the most important factors affecting mortality in firearm injuries. The present study aims to examine the data of patients who underwent advanced airway support due to explosion and bullet injuries in a Role II hospital. METHODS: Ninety three patients who underwent advanced airway support due to gunshot wounds in a Role II hospital between January 2015 and September 2016 were included in this study. The patients were divided into two groups as blast (Group A) (handmade explosives, rocket, and mine) and bullet (Group B) (rifle and pistol bullet) trauma injuries. The groups were compared regarding pre-hospital intubation, NISS (New Injury Severity Score), cardio-pulmonary resuscitation (CPR), emergency surgical intervention and mortality rates. RESULTS: There was no difference between the patient groups concerning demographic and clinical features. Thirty-six patients were included in group A, and 57 patients were included in group B. There was no statistically significant difference between the groups about emergency surgical intervention rates (p=0.42). However, a statistically significant difference was observed between the groups in terms of pre-hospital intubation (p=0.001), CPR application (p=0.001), mortality (p=0.001) rates and NISS (p=0.002) scores. CONCLUSION: Bullet injuries that require advanced airway are more destructive and more deadly than explosion injuries. This may be due to direct airway or organ damage in bullet gunshot wounds.

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.

Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

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.

Current Burden of Gunshot Wound Injuries at Two Los Angeles County Level I Trauma Centers.

BACKGROUND: Gunshot wound (GSW) injuries present a unique surgical challenge. This study explored the financial and clinical burdens of GSW patients across 2 Los Angeles County Level I trauma centers over the last 12 years, and compared them with other forms of interpersonal injury (OIPI). STUDY DESIGN: This was a retrospective study of patients presenting as those with GSW and OIPI (defined as combined stab wound or blunt assault), between January 1, 2006 and March 30, 2018, at LAC+USC Medical Center (LAC+USC) and Harbor UCLA Medical Center (HUCLA). Demographic and clinical variables were assessed for GSW patients and compared with victims of OIPI. RESULTS: There were 17,871 patients who met inclusion criteria. There was a significant difference in mortality for patients with GSW vs OIPI (11% vs 2%, p < 0.001). The odds ratio for GSW patients requiring operation was twice as high as those suffering OIPI (odds ratio [OR] 2.0, 95% CI 1.8 to 2.2). The odds ratio for GSW patients requiring ICU admission was 20% higher than that for OIPI patients (OR 1.23, 95% CI 1.11 to 1.36). Gunshot wound patients experienced a longer median length of stay vs OIPI patients (3 days vs 2 days, p < 0.001). The median hospital charge per admission for GSW was twice that of OIPI (GSW $12,612 vs OIPI $6,195; p < 0.001). CONCLUSIONS: When compared with OIPI, GSW patients arrived more severely injured and required more operations, more ICU admissions, and longer hospital stays. Patients with GSW incurred significantly higher hospital charges and had a significantly higher mortality rate. Gunshot wound injury is a unique public health concern requiring comprehensive, nation-wide, contemporary study.

Risk of 90-day readmission in patients after firearm injury hospitalization: a nationally representative retrospective cohort study.

BACKGROUND: National conversation has justifiably been concerned with firearm-related deaths and much less attention has been paid to the consequences of surviving a firearm injury. We assessed the risk of hospital readmission, length of stay (LOS) during hospitalization, and costs within 90-days after surviving an index firearm injury and compared these data with pedestrians and occupants involved in motor vehicle crash (MVC). METHODS: Nationwide Readmission Database, a nationally representative readmission database from 2013 and 2014 was used to create a retrospective cohort study. The primary outcome was time-to-first all-cause readmission within 90-days after discharge from the index hospitalization. Secondary outcomes were LOS and hospitalization costs at index events and at 90-days. RESULTS: There were 3,334 (10.5%), 3,818 (10.6%) and 24,672 (9.4%) firearm injury, pedestrian, and occupant MVC readmissions within 90-days. The risk of 90-day readmission among firearm was 20% (HR=1.20, 95%CI=1.09-1.32) and 34% (HR=1.34, 95%CI=1.26-1.44) greater than patients admitted after pedestrian and occupant MVC. The primary causes of firearm readmission were surgical complications, intestinal disorders and open wounds. The mean total costs were lower among patients after firearm injury versus occupant MVC hospitalizations ($9,357 versus $11,032, p=0.028) but mean total LOS was greater (4.48 versus 4.38 days, p=0.003). Medicaid-insured patients had longer LOS at a total lower cost during index hospitalization after firearm injury as compared to MVC occupant injury. Increased LOS and lower costs of 90-day readmissions among firearm patients versus occupant MVC were irrespective of insurance. CONCLUSIONS: The patients surviving a firearm injury have a substantial risk of subsequent hospitalizations, higher than pedestrian or occupant MVC injuries. Medicaid is disproportionately burdened by the costs of treatment of firearm injury.

Between-hospital and between-neighbourhood variance in trauma outcomes: cross-sectional observational evidence from the Detroit metropolitan area.

OBJECTIVE: Disparities in treatment outcomes for traumatic injury are an important concern for care providers and policy makers. Factors that may influence these disparities include differences in risk exposure based on neighbourhood of residence and differences in quality of care between hospitals in different areas. This study examines geographical disparities within a single region: the Detroit metropolitan area. DESIGN: Data on all trauma admissions between 2006 and 2014 were obtained from the Michigan State Inpatient Database. Admissions were grouped by patient neighbourhood of residence and admitting hospital. Generalised linear mixed modelling procedures were used to determine the extent of shared variance based on these two levels of categorisation on three outcomes. Patients with trauma due to common mechanisms (falls, firearms and motor vehicle traffic) were examined as additional subgroups. SETTING: 66 hospitals admitting patients for traumatic injury in the Detroit metropolitan area during the period from 2006 to 2014. PARTICIPANTS: 404 675 adult patients admitted for treatment of traumatic injury. OUTCOME MEASURES: In-hospital mortality, length of stay and hospital charges. RESULTS: Intraclass correlation coefficients indicated that there was substantial shared variance in outcomes based on hospital, but not based on neighbourhood of residence. Among all injury types, hospital-level differences accounted for 12.5% of variance in mortality risk, 28.5% of variance in length of stay and 32.2% of variance in hospital charges. Adjusting the results for patient age, injury severity, mechanism and comorbidities did not result in significant reduction in the estimated variance at the hospital level. CONCLUSIONS: Based on these data, geographical disparities in trauma treatment outcomes were more strongly attributable to differences in access to quality hospital care than to risk factors in the neighbourhood environment. Transfer of high-risk cases to hospitals with greater institutional experience in the relevant area may help address mortality disparities in particular.