On February 14, 2018, 19-year-old Nikolas Jacob Cruz killed 17 and wounded 17 teachers and students at his former school, Marjory Stoneman Douglas High School in Parkland, Florida. Although the aftermath of this mass shooting saw increased debate surrounding gun violence, research on firearm-related injuries in the United States—particularly among individuals younger than 18 years—continues to be limited.1 This study describes national trends in the incidence of and charges associated with the emergency department (ED) and inpatient management of firearm-related injuries among individuals younger than 18 years.
We used the International Classification of Disease, Ninth Edition, Clinical Modification, external cause of injury codes (e-codes) to identify ED visits for individuals younger than 18 years for the management of firearm-related injuries from January 2006 through December 2014 from the Nationwide Emergency Department Sample (NEDS).2,3 This study was approved by the institutional review board of The Johns Hopkins University, which waived the need for informed consent for the use of publicly available data.
As previously described, sampling weights were used to obtain nationally representative estimates. Mortality in the ED or hospital was defined as any death occurring during the visit or admission, respectively.2 Total charges for the ED visit or inpatient admission were extracted for each record, as appropriate. Data from the US Department of Labor Consumer Price Index were used to adjust for inflation to the nearest 2018 US dollar.4 Data from the US Census were used to calculate age- and sex-specific population estimates by dividing national estimates from the NEDS by the total number of individuals and reported per 100 000.5 Data were analyzed from February through April 2018 using Stata software (version 14.0; Stata Corp).
We identified a weighted sample of 75 086 ED visits (11.3 ED visits per 100 000 individuals) for patients younger than 18 years (86.2% male and 13.8% female; mean [SD] age, 14.8 [3.3] years) who presented to the ED after a firearm-related injury. Over time, ED visits for firearm-related injuries were observed to vary, decreasing initially until 2013, and then increasing from 2013 through 2014 (Figure 1). Emergency department visits for firearm-related injuries were more than 5-fold higher for male patients compared with female patients, a trend observed consistently for all years of the study; the highest incidence was among male patients aged 15 to 17 years (85.9 ED visits per 100 000 individuals). The most common intent of injury was an assault (49.0%), followed by unintentional injuries (38.7%) and suicides (2.0%).
Among all patients presenting to the ED, 35.3% were admitted to inpatient care for further management; overall mortality was 6.0% (ED, 3.6%; inpatient, 6.6%). The median ED and inpatient charges were $2445 (interquartile range, $1318-$5191) and $44 966 (interquartile range, $21 156-$91 771), respectively, and increased with time (Figure 2). Total charges associated with these injuries amounted to $2.5 billion (ED, $259 million; inpatient, $2.24 billion) or a mean of $270 million per year.
Although previous studies have sought to report on pediatric firearm-related injuries, they have been limited to single-center reports or statewide analyses. The present study represents, to our knowledge, the first and largest nationally representative study characterizing ED visits for firearm-related injuries among patients younger than 18 years. Our results are subject to limitations inherent to the use of NEDS.6 First, misclassification or miscoding of variables may have occurred. Second, because we were unable to follow up patients after discharge, we may have underestimated the mortality and charges associated with firearm-related injuries. Last, because NEDS does not report on hospital costs, payments, or out-of-pocket expenses, these data could not be evaluated.
Notwithstanding these limitations, our study demonstrated a substantial clinical and financial burden associated with firearm-related injuries among pediatric patients. Moving forward, additional resources and funds should be allocated to the study of firearm-related injuries. Only through further understanding of the social, political, and health-related risk factors for these injuries can we develop and implement effective policies to address this public health concern.
Accepted for Publication: July 9, 2018.
Corresponding Author: Faiz Gani, MBBS, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Blalock Room 1202, Baltimore, MD 21287 (firstname.lastname@example.org).
Published Online: October 29, 2018. doi:10.1001/jamapediatrics.2018.3091
Author Contributions: Dr Gani had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Gani.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Gani.
Administrative, technical, or material support: Both authors.
Conflict of Interest Disclosures: None reported.