Abstract
OBJECTIVE
Firearm injuries are the leading cause of death for children in the United States. Child access prevention (CAP) laws have been passed in some states. This study examines characteristics of children with firearm injuries in states with different types of CAP laws.
METHODS
The Pediatric Health Information System database was reviewed to identify all pediatric firearm injury patients between 2016 and 2021. Hospital data were categorized based on state laws as (1) no CAP laws (2) some CAP laws or (3) strict CAP laws. CAP laws that specifically outlined criminal liability for the negligent storage of firearms were considered a strict restriction, whereas any other form of CAP law was considered some restriction. χ-squared and independent-samples median testing were performed to compare restriction levels.
RESULTS
Between 2016 and 2021, 12 853 firearm injuries were recorded in the Pediatric Health Information System database. In states with strict CAP laws, patients were significantly older (P < .001) and had a significantly higher household income (P < .001) compared with patients in states with no CAP laws. Gender, race, and the number of firearm injuries differed between the 3 restriction levels. There were less firearm injuries observed than expected in cities with strict CAP laws.
CONCLUSIONS
CAP laws are associated with a higher age and household income of pediatric firearm injury patients. Given the disparities seen between cities, a federal CAP law may best protect children nationwide.
Firearm injuries are currently the leading cause of death for children in the United States. Firearm injury became the leading cause of death of children in the United States in 2020, surpassing motor vehicle crashes.1 Over 5000 children were injured or died secondary to firearm injuries in 2021.2 A dramatic increase in firearm purchasing occurred during the coronavirus disease 2019 pandemic.3–7 Gun ownership has never been more prevalent in the United States. An estimated 393 347 000 guns are owned in the United States, or approximately 120.5 guns for every 100 people in the United States; this is likely a gross underestimate given many guns are not registered.8 Between January 1, 2019 and April 26, 2021, 7.5 million Americans purchased their first firearm.4 In contrast, the rate of gun ownership in Japan is 0.3 guns for every 100 people.8
Secure storage of firearms is thought to be an important means of decreasing pediatric firearm injuries, both unintentional and intentional. In 2015, an estimated 7% of US children (4.6 million) lived in homes in which at least 1 firearm was stored loaded and unlocked, twice as high as estimates reported in 2002.9 In more than three-fourths of child suicides where storage practices could be identified, the gun used by the child had been stored loaded and unlocked.10 Unintentional firearm-related injury or death were less likely to occur in households where guns were stored unloaded or locked or where guns and ammunition were stored separately.10
Thirty-one states and the District of Columbia have passed child access prevention (CAP) laws.11 Previous studies have defined strong CAP laws as imposing criminal liability for the negligent storage of a firearm and weak CAP laws as imposing criminal liability only when an adult provides a firearm to a child intentionally, knowingly, or recklessly.12 Twenty two states currently have CAP laws that specifically outline criminal liability for the negligent storage of firearms.11 A 30% reduction in firearm injuries in states with strong CAP laws was seen between 2006 and 2009 utilizing the Kid’s Inpatient Database.12 CAP laws have been associated with decreased pediatric firearm-related homicides and suicides.13,14 Conversely, many gun owners may not be aware of the CAP law in their state, suggesting firearm storage practices may not change with the passage of CAP laws.15 The purpose of this study is to describe differences in characteristics of children admitted to the Pediatric Health Information System (PHIS) hospitals with firearm related injuries between 2016 and 2021 in states with 3 different types of CAP laws. We hypothesize that strict CAP laws that specifically result in criminal charges for unsafe storage of a weapon will be associated with fewer firearm injuries than some CAP laws or no CAP laws.
Methods
PHIS is a database created by the Children’s Hospital Association that collects data from children’s hospitals across the United States.16 PHIS was queried for inpatient, emergency department, and observation unit encounters with International Classification of Diseases codes related to firearm injury between 2016 and 2021. International Classification of Diseases codes included were Y24.9XXA: X93, X94, X72, X73, X74, X95, W32, W33, W34, Y22, Y23, Y24 and U01.4. Injuries caused by air, spring-operated, and paintball guns were excluded.
Pediatric hospitals in 41 cities representing 26 states had complete datasets. Laws that specifically outlined criminal liability for the negligent storage of firearms were considered strict CAP laws, whereas any other form of CAP law was considered some restriction. Current CAP laws for each state were determined from Gifford’s Law Center.11 Each city was classified based on its state CAP law. Washington and New York enacted strict CAP laws during the study period.17,18 Data from Washington and New York were placed into the no CAP laws and strict CAP laws group based on the date of admission and the CAP laws at that time.
IBM SPSS for Windows v28 was used to perform statistical analysis. Univariate descriptive medians and interquartile ranges were calculated for quantitative data, and the 3 groups were compared using independent-samples median testing (Kruskal-Wallis test) with Bonferroni post hoc testing. Quantitative data included age at admission, length of stay, and median household income. PHIS reports a median household income based on the patient’s zip code, and frequency of median household income quartiles were calculated. A χ-squared test for independence was used to determine if gender, race, and the number of firearm injury encounters differed between restriction groups. A P value < .05 was considered significant for all statistical tests.
This study underwent Institutional Review Board approval and was cleared under “exempt review.”
Results
Over the 6-year period of interest, 12 853 incidences of firearm injury were recorded in the PHIS database. The median age of children presenting with a firearm injury was 14 years (interquartile range [IQR] = 6 years). The median household income of the families of firearm injury patients was $34 555 (IQR = $15 853). Quartile 1 was $27 501 and Quartile 3 was $43 354. The frequency data for quartiles was Q1 N = 2888, Q2 N = 3271, Q3 N = 3210, and Q4 N = 3224. Gender, race, and ethnicity demographics of the firearm injury patients are outlined in Table 1 below. Most notable are the high proportions of male (80.0%) and Black (53.4%) patients. Of the 12 853 reported injuries, 3103 occurred in states with no CAP laws, 3783 occurred in states with some CAP laws, and 5967 occurred in states with strict CAP laws. Forty five total hospitals from 41 cities were included in this study. Twelve were in states with no CAP laws, 9 were in states with some CAP laws, and 21 were in states with strict CAP laws. Three were in states that enacted CAP laws during the study period, splitting their patient classification by time period.
TABLE 1.
Demographics of Firearm Injury Patients in 2016 to 2021
| Overall Cohort (N = 12 853) | No CAP Laws (N = 3103) | Some CAP Laws (N = 3783) | Strict CAP Laws (N = 5967) | P | |
|---|---|---|---|---|---|
| Gender | |||||
| °Male % (N) | 80 (10 287) | 78.3 (2430) | 78.2 (2959) | 82.1 (4898) | P < .001 |
| °Female % (N) | 19 (2442) | 20.1 (624) | 21.3 (805) | 17.0 (1013) | |
| °Unknown % (N) | 1.0 (124) | 1.6 (49) | 0.5 (19) | 0.9 (56) | |
| Race | |||||
| °Black % (N) | 53.3 (6857) | 63.1 (1959) | 62.3 (2356) | 42.6 (2542) | P < .001 |
| °White % (N) | 30.0 (3858) | 29.5 (915) | 28.3 (1072) | 31.4 (1871) | |
| °Other % (N) | 16.7 (2138) | 7.4 (229) | 9.4 (355) | 26.0 (1554) | |
| Median admit age and IQR (years) | 14.0 (6.0) | 14.0 (6.0) | 14.0 (7.0) | 15.0 (6.0) | P < .001 |
| Median household income and IQR | $34 555 ($15 853) | $31 397 ($12 748) | $32 618 ($15 405) | $37 221 ($17 463) | P < .001 |
| Median length of stay and IQR | 1.0 (1.0) | 1.0 (1.0) | 1.0 (1.0) | 1.0 (1.0) | P = .488 |
The age at admission of the firearm injury patients, median household income of the patients’ families, and median length of stay of the patient in the hospital were compared across the 3 restriction levels (Table 1). Because of deviation from normality (ie, significant Kolmogorov-Smirnov results), independent samples median test with Bonferroni adjustment for multiple comparisons was used. Kruskal-Wallis testing found a significant difference in age of patients between the restriction levels (P < .001). Bonferroni testing found that with strict CAP laws, firearm injury patients were significantly older when compared with some CAP laws (P < .001) and no CAP laws (P < .001). With no CAP laws, firearm injury patients were significantly older when compared with some CAP laws (P < .001). Independent-samples median testing found a significant difference in household income between the restriction levels (P < .001). Bonferroni testing found the median household income of patients’ families was significantly increased in states with strict CAP laws compared with states with no CAP laws (P < .001) and with states with some CAP laws (P < .001). No CAP laws were associated with a significantly lower median household income of patients’ families compared with some CAP laws (P < .001). Independent-samples median testing found no significant difference in length of stay between the restriction levels (P = .488). These results are summarized in Table 1.
A χ-squared test found that gender differed between the 3 restriction levels (no CAP laws: 20.1% female, 78.3% male, 1.6% unknown; some CAP laws: 21.3% female, 78.2% male, 0.5% unknown; strict CAP laws: 17% female, 82.1% male, 0.9% unknown, P < .001). A χ2 test found that race differed between the 3 restriction levels (no CAP laws: 63.1% Black, 29.5% white, 7.4% other; some CAP laws: 62.3% Black, 28.3% white, 9.4% other; strict CAP laws: 42.6% Black, 31.4% white, 26.0% other, P < .001). A χ2 test found that the number of firearm injuries differed between the 3 restriction levels, χ2 (2, N = 18 257 401) = 619.34, P < .001.
Discussion
One-third of American households have at least 1 firearm; 21% of households with children self-report that they have unlocked and loaded firearms in their home.9 Previous studies have found CAP laws were associated with a reduction in the number of homicides committed by juveniles with firearms by 17%.13 CAP laws requiring safe firearm storage were associated with a reduction in the number of suicides committed by juveniles with firearms by 13.1%.14 Recklessness CAP laws imposing liability for directly supplying a firearm to a child had no effect on pediatric firearm fatality, whereas negligence CAP laws were associated with a 13% reduction in firearm fatality.19 Our finding that cities with strict CAP laws had a lower number of firearm injuries than expected supports the enactment of laws that impose criminal liability for the negligent storage of firearms.
Results from a study of the National Vital Statistics System and National Electronic Injury Surveillance system between 2002 and 2014 found that males comprised 82% of the cases of pediatric firearm mortality and 84% of the cases of nonfatal firearm injuries.20 This is similar to our finding that males comprised 80% of firearm injury patients between 2016 and 2021. A study of the Kid’s Inpatient Database between 2006 and 2009 also found a high proportion of male victims, 88.4%, but found that victims of firearm injuries caused by self-harm were more likely to be female.21 We found the number of female firearm injury patients to be lower than expected in cities with strict CAP laws and higher than expected in cities with no and some CAP laws.
Results from our study demonstrates the disparities in pediatric firearm injuries, with Black children and children from lower income homes being disproportionately affected. We also saw cities with no and some CAP laws had a higher number of Black patients than expected, whereas cities with strict CAP laws had a lower number of Black patients than expected. A study of the Nationwide Emergency Department Sample between the years 2009 and 2016 found that lower income was associated with firearm injury by assault, whereas higher income was associated with firearm injury by self-harm in youths aged 21 and under.22 We found that patients in states with strict CAP laws had household incomes that were up to 20% higher than those in states with no CAP laws. This finding supports the idea that the enactment of strict CAP laws could reduce some economic disparity in pediatric firearm injuries.
This study demonstrates a significant increase in patient age in cities with strict CAP laws when compared with cities with no CAP laws or cities with some CAP laws. A study of pediatric firearm injuries in Los Angeles found that younger age was associated with unintentional firearm injuries.23 These unintentional firearm injuries were also associated with a firearm from the home and involving a friend or family member.24 Unintentional firearm injuries have been associated with a younger age, whereas self-harm firearm injuries were associated with an older age.22 It is possible that the increase in age seen in cities with strict CAP laws could be because of a decrease in unintentional injuries as a result of safe firearm storage.
The financial burdens of pediatric firearm injury to both the healthcare system and families are great.24 Pediatric firearm injury hospitalizations cost $95.5 million yearly with another estimated $38 million of yearly productivity losses because of parents missing work.25 The median hospitalization cost of a pediatric firearm injury has recently been estimated to be $12 984.25 CAP laws were not found to decrease the average cost or length of stay of individual hospitalizations for children injured by firearms. However, by decreasing the total number of hospitalizations, strict CAP laws have the potential to substantially decrease overall healthcare costs and utilization in the United States.
There are limitations to this study. Because of the nature of the PHIS database, data from all states and cities was not included. This data came exclusively from children’s hospitals, potentially excluding pediatric firearm injury patients who were seen at adult hospitals and emergency rooms. It is also important to note that not all pediatric hospitals report to PHIS. Not all pediatric firearm injuries are captured by the PHIS database. The length of stay may be longer for pediatric firearm injury patients in children’s hospitals when compared with other hospitals.26 Median household income was determined based on zip code rather than patient-level data. In addition, we are unable to determine the directionality of the relationship between median household income and CAP laws – that is, if stricter CAP laws can lead to a decrease in economic disparities. There are other state-based factors that may contribute to pediatric firearm injuries beyond CAP laws, such as legislation regarding background checks and ammunition sales. Although our study only took CAP laws into account, there is a need for further research into these other regulations that may influence pediatric firearm injuries.
The current state of pediatric firearm injuries has been described as a “national public health crisis.”27 Current literature urges physicians to advocate, educate, and research methods to combat pediatric firearm injury and death.28 Based on our results, we urge physicians to support strict CAP laws to protect their pediatric patients. Given the disparities seen between cities, a federal CAP law is needed to protect all children nationwide.
Conclusions
Firearm injuries are the leading cause of death for children in the United States, and there is an urgent need to evaluate methods for reducing pediatric firearm injuries. In the PHIS database, differences in race, gender, age, and income of pediatric firearm injury patients were seen based on the presence and strength of child access prevention laws. Given the disparities seen between cities, a federal CAP law may best protect children nationwide.
Footnotes
Ms Wilson, Dow, and Dr Oddo provided substantial contributions to the conception and design of the study, the acquisition of data, and drafting; Drs Gregoski, Barfield provided substantial contributions to the acquisition, analysis, and interpretation of data, and drafting; Dr Murphy provided substantial contributions to the conception and design of the study; Dr Van Nortwick, provided substantial contributions to the conception and design, interpretation of data; and all authors provided contributions to drafting or revising critically for important intellectual content, gave final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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