Addressing Data Deficiencies to Prevent Pediatric Firearm Injuries: Insights From the American College of Surgeons (ACS) Firearm Study

Since 2020, firearm injury has been the leading cause of death among children and adolescents in the United States.¹ Flynn-O’Brien et al. analyzed data from nearly 3000 children injured with a firearm across 128 trauma centers collected from the Trauma Quality Improvement Project (TQIP) database.² The study, which covered the period from March 2021 through February 2022, found that roughly two thirds of the children were shot during an assault, and the remainder were injured unintentionally or by self-inflicted means. The authors analyzed how the context of pediatric firearm injury differs by intent and identified the factors that contribute to missing data across key contextual variables. The findings highlight clear demographic and racial disparities in risk for pediatric firearm injury, which echo prior studies.³ The majority of youths in the study across injury intent were Black, male, non-Hispanic children living in urban areas characterized as distressed or at risk. Yet the results also shine a light onto crucial blind spots regarding the context of pediatric firearm injuries due to high levels of missing data in the TQIP database.

The national data infrastructure for nonfatal firearm injury is not currently comprehensive, accessible, or granular enough to provide the information necessary to inform policy and practice, despite the fact that gun violence is a leading national public health problem.⁴ The TQIP database is designed to enhance data transparency and provide best-practice guidelines to improve trauma care, offering an opportunity to better understand nonfatal firearm injuries, particularly among children. Yet the data suffer from extensive missingness, which hinders these efforts. For example, using the TQIP data, Flynn-O’Brien et al. found that only about 19% of the injured children had an adverse childhood experience (ACE), despite emerging evidence that ACEs increase risk for firearms exposure.⁵ However, most cases in the study (56%) were missing data regarding ACEs, making it difficult to confidently interpret the findings. Roughly half of all cases had missing data on experiences of prior trauma separate from ACEs, past violent assaults and injuries, and prior suicide attempt and self-harm. In cases of assault, the data showed that most children are shot by a stranger, although data were missing for more than one third of all cases. Data were also missing for more than half of all cases concerning the type of firearm used in the injury, largely because of missingness for assault-related injuries. Further, about 64% of the cases had missing data regarding firearm ownership and access in the home, whereas nearly 90% of the data were missing method of firearm storage.

The amount of missing data in the article by Flynn-O’Brien et al. is concerning and makes it challenging to draw strong conclusions about how preinjury and event context influence pediatric firearm injury. Similar problems with missing data have been documented in TQIP data for firearm injuries among adults.⁶ As the authors note, “Missingness imposes significant challenges to data interpretability and generalizability, and hampers the ability of researchers to make meaningful and valid conclusions.”^2(p1107) Missingness in the data was found to differ by factors such as intent and designation of the trauma center reporting data. The authors interpreted their findings about these inconsistencies to reflect differences in available resources for data collection and a care team’s level of comfort at asking questions, particularly in the case of assault, where those injured or their families may lack trust in the health care system or have concerns about information being used against them.

How can we fully address gun violence as the leading cause of death among children if we do not have a clear understanding of the problem in the first place? Data fidelity has been a long-standing issue in gun violence research, and this study helps us to know what we don’t know.⁷ The study underscores data deficiencies in health care settings that influence knowledge about pediatric firearm injury, but it is imperative to consider that incomplete data can also lead to less effective policymaking. For instance, the high level of missing data on ACEs and other contextual factors in the TQIP database could cause policymakers to underestimate the true prevalence of these risk factors among children injured by firearms. This could result in an insufficient allocation of resources for preventive measures to adequately address ACEs, thereby failing to mitigate a root cause of firearm injuries among children.

Collection of data on preinjury and event-level factors related to pediatric firearm injury must be improved to enhance knowledge about the ecological context and proximate firearm behaviors that heighten the risk of children being shot. The present data landscape remains insufficient and disjointed, even as dozens of children are shot with a firearm every day.⁸ General surveillance of nonfatal firearm injuries in the United States only began in 2020 and remains limited to 12 states with coarse data granularity. In the absence of accessible public systems, some gun violence researchers who study nonfatal shootings have turned to databases created by nonprofit organizations such as the Gun Violence Archive and newsrooms like The Trace.⁹ In light of the concerns highlighted by Flynn-O’Brien et al. about missing data in the trauma center database, researchers should continue to utilize valid data from alternative sources, such as interviews with parents who are firearm owners and national surveys.

However, concurrent efforts should also be made to reduce missingness in the TQIP database. Trauma centers can adopt standardized data collection protocols that include mandatory fields for key variables related to firearm injuries and automated data collection systems that prompt providers to complete missing fields before submission to enhance data completeness. Health care providers must also be trained on the importance of collecting detailed and accurate information, particularly in sensitive cases involving assault. Drawing upon successful models in active public health surveillance, such as the National Violent Death Reporting System, can provide insights into effective strategies for comprehensive data capture and monitoring.

Better data on the risk and protective factors for pediatric firearm injury can inform broader public health efforts to reduce these injuries. For example, child access prevention (CAP) or safe storage laws are designed to prevent children from accessing firearms in the home by requiring firearm owners to lock up their firearms, with penalties for failing to do so. Only 26 states have adopted some type of CAP law, despite strong evidence that they reduce firearm injuries among children.¹⁰ Comprehensive data on the relationship between firearm storage methods and pediatric firearm injury by intent can provide additional evidence to support broadening CAP law coverage around the country. Additionally, recent research shows that people often store firearms insecurely but most are open to considering secure storage to prevent child access.¹¹ Continued research on why firearm owners store their firearms unsafely and their openness to alternative storage methods can inform tailored messaging and public outreach that reinforces safe storage as a critical means for saving children’s lives and preventing injury.¹² The safety of our children should be the nation’s top priority, and firearm injuries are preventable. It is our collective responsibility to implement the necessary systems, starting with high-quality data and effective research, to protect them.