Key Points
Question
What is the total health care cost for initial firearm-related emergency department (ED) visits and inpatient hospitalizations in the US?
Findings
In this economic evaluation study including data from 6 states, using a Monte Carlo simulation, firearm injuries led to an estimated 298 721 ED visits and 185 846 hospital admissions from 2016 through 2021. The total estimated firearm injury health care cost was $7.7 billion over the 6 years (in base year 2024 dollars); inpatient admissions accounted for 93% of the cost.
Meaning
Child and adult firearm injury is a substantial source of health care cost in the US and has risen over time.
This economic evaluation study estimates the total health care cost of new firearm injury hospital visits from 2016 to 2021 in the US.
Abstract
Importance
Firearm injury is a leading cause of mortality in the US. Contemporary firearm injury health care costs and characteristics of hospital visits can inform investment decisions on treatment and prevention strategies.
Objective
To estimate the total health care cost of new firearm injury hospital visits from 2016 to 2021 in the US.
Design, Setting, and Participants
This economic evaluation study via Monte Carlo simulation included data from the Arkansas, Florida, Maryland, Massachusetts, New York, and Wisconsin Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases from 2016 to 2021. Children and adults with an inpatient or emergency department (ED) hospital visit for new firearm injuries were included. Data were analyzed from June 2023 to May 2025.
Exposures
Firearm-related inpatient or ED visits with new firearm injury International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes.
Main Outcomes and Measures
A Monte Carlo simulation used new inpatient and ED firearm injury visits in 6 sample states to estimate the national health care cost for the treatment of initial firearm injuries from 2016 to 2021. The simulation also used national inpatient data from the RAND Corporation for nonsample states. Costs were adjusted for inflation to 2024 US dollars. Costs to each body region were derived from the Injury Mortality Diagnosis Matrix classification scheme.
Results
The Monte Carlo analysis included 2400 simulations. Firearm injuries in the US led to an estimated 298 721 ED visits and 185 846 inpatient visits, with a total health care cost of $7.7 billion from 2016 to 2021. Inpatient admissions accounted for 93% of the cost, or $7.2 billion. Treatment for children younger than 18 years accounted for 9% of the cost, or $684 million. Annual ED and inpatient visits were both approximately stable from 2016 to 2019, at which point they grew by 42% and 40%, respectively, from 2019 to 2021. Annual total health care cost was also stable at approximately $1.2 billion until 2019, when cost began to grow to a peak of $1.6 billion in 2021. The mean (SE) ED visit cost was $1743 (4.5), and the mean (SE) inpatient admission cost was $38 879 (138.9). These costs remained stable annually over the sample period.
Conclusions and Relevance
In this economic evaluation study, an increase in firearm injuries in the last 6 years paralleled an increase in costs from 2016 to 2021.
Introduction
Firearm injury is a leading cause of disability and premature death in the US.1 The US Surgeon General recently described firearm injury as a public health crisis.2 Although costs are largest for patients with firearm injuries, the health care system also incurs financial costs in the treatment of firearm injuries.3 In 1990, the cost of direct expenditures for firearm injury health care and related services was $1.6 billion.4 Another study over 2006 to 2014 estimated combined emergency department (ED) and inpatient charges at nearly $2.8 billion annually.5
Contemporary cost estimates of ED and inpatient hospital firearm injury treatment can inform investment decisions on prevention strategies, such as safe storage for suicide prevention, hospital-based violence intervention programs, and trauma recovery centers, which traditionally support the population affected by intimate partner violence.6,7,8,9,10 Additionally, public insurance has been the most frequent source of hospital reimbursement for firearm injury health care cost. Many hospitals are reimbursed below the cost of health care provision.11 Hospital financial strain can threaten hospitals’ ability to provide care for all medical conditions.12,13,14
This study estimated mean and total health care costs of ED and inpatient visits for new firearm injuries in the US from 2016 to 2021. These costs were stratified by year, visit type, patient age, injury body location, payer, hospital bed size, and trauma center level designation, among other factors, to understand where hospitals account for the greatest health care cost.
Methods
Study Design
This economic analysis used observational administrative data from 2016 to 2021 to estimate total firearm injury ED and inpatient visit costs in the US. The study followed both the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline for economic evaluations.15,16 This research was deemed exempt by the Northwestern University Institutional Review Board because it was not human subjects research.
Data Sources
Primary data sources were the Arkansas, Florida, Maryland, Massachusetts, New York, and Wisconsin Statewide Inpatient Databases (SID) and State Emergency Department Databases (SEDD) maintained by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project.17 Data from SEDD/SID for the 6 sample states were linked via hospital identifiers to American Hospital Association (AHA) Annual Survey data.17,18 The RAND Corporation state-level database provided estimates of inpatient firearm injury hospitalization rates for nonsample states via personal communication.
Inclusion Criteria
The sample included any ED and inpatient visits in SEDD/SID with a new firearm injury identified by an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code in eTable 1 in Supplement 1 with a final character A to indicate a new visit in Arkansas, Florida, Maryland, Massachusetts, New York, and Wisconsin from 2016 to 2021. Patients of all ages and injuries of any intent were included. Cost estimates were derived from 74 619 cases with nonmissing charge values. Visits with a missing charge value were excluded (n = 15 193). Costs across variable categories may not sum to total cost due to missing values.
Cost Perspective
This study adopted a hospital cost perspective. Hospitals bear a large financial cost of initial firearm injury because many patients with firearm injuries are uninsured or underinsured. Furthermore, hospitals face increased calls to address social drivers of health.19
Main Outcome Measurement
The primary outcome was total health care visit cost, obtained through the product of the total visit charge and the hospital-specific, year-specific cost to charge ratio. Costs were converted to 2024 US dollar values with Consumer Price Index data from the Federal Reserve Bank of Minneapolis.20
Patient demographic characteristics included age, sex, race and ethnicity, payer type, home zip code income quartile, and discharge disposition. Age was grouped into categories of age 0 to 17 years, age 18 to 24 years, age 25 to 44 years, age 45 to 64 years, and 65 years or older. Sex was categorized as male or female. Race and ethnicity categories in this database were abstracted from the medical record from Healthcare Cost and Utilization Project categories and included Asian or Pacific Islander, Black, Hispanic, Native American, White, and other race. Payer included Medicaid, Medicare, private, self-pay, no charge, and other (workers’ compensation, TRICARE, Civilian Health and Medical Program of the Department of Veterans Affairs, Title V, and other government programs). Home zip code income quartiles were defined by yearly national median income thresholds in SID/SEDD. Discharge disposition included routine home, transfer to acute care hospital, transfer to other facility (hospice, rehabilitation, long-term care hospital, psychiatric hospital, skilled nursing facility, or intermediate care facility), home health care, against medical advice, and died.
Injury variables included intent, body region, severity, comorbidities, and reinjury. Intent was obtained from ICD-10 codes and included assault, self-inflicted, unintentional injury, undetermined, and legal intervention. Injury body region was derived from ICD-10 codes with the Injury Mortality Diagnosis Matrix.21 Injury severity score (ISS) was defined as the squared and summed Abbreviated Injury Scale score using the ICD Programs for Injury Categorization.22 ISS was categorized as mild (score of 0 to 8), serious (score of 9 to 25), and severe (score of 26 to 75). Patient comorbidities were derived with the Weighted Elixhauser Index of Comorbidity, then categorized as none, 1, 2, and 3 or more.23,24 Reinjury was defined as patients who presented for 2 new firearm injuries to an acute care hospital in the same calendar year.25 Reinjury was classified as either no reinjury or at least 1 reinjury.
Hospital AHA variables included number of inpatient beds, the ratio of Medicaid discharges to all-payer discharges, core-based statistical area (CBSA) designation, trauma center level designation, rural hospital designation, total inpatient admissions, total ED visits, and medical school affiliation. The inpatient hospital beds category was grouped into 1 to 99, 100 to 499, and 500 or more beds. Hospitals’ percentage of Medicaid discharges were divided into ascending quartiles from total hospital discharges for all conditions (calculated from the sample in each simulation). Hospitals’ CBSA was categorized as metropolitan, micropolitan, and rural. Hospitals’ trauma center level designation was categorized as regional resource (level I), community (level II), rural (level III), and greater (level IV). Hospitals’ total inpatient admissions were categorized into ascending quartiles based on all hospital admissions. Hospitals’ total ED visits were categorized into ascending quartiles based on all ED visits. Rural hospital status and medical school affiliation were binary variables in the AHA dataset.
Statistical Analysis
A Monte Carlo simulation estimated the national cost of ED visits and inpatient admissions for new firearm injuries based on patient claims data from Arkansas, Florida, Maryland, Massachusetts, New York, and Wisconsin. The simulation used RAND Corporation yearly state-level firearm injury inpatient admissions estimates for other states.26 The Monte Carlo procedure (1) drew a pure random sample, with replacement, of inpatient admissions from the 6 sample states in each year equal to the size of inpatient admissions in nonsample states; (2) drew an analogous sample for ED visits, with the number of ED visits determined by the product of RAND inpatient admission estimates and the ratio of ED visits to inpatient hospitalizations in the 6 sample states; and (3) combined the resampled data with original data to create a national, annual sample from 2016 to 2021.
While previous national studies used stratified and weighted samples of approximately 20% of hospitals nationwide,27,28,29 the National Inpatient Sample,11,30,31,32 or Nationwide Emergency Department Sample5 to estimate firearm injury health care costs, the Monte Carlo simulation offers 2 benefits.33 First, the state data contained a VisitLink identifier to track individuals across visits. Second, the AHA linkage contained additional hospital variables, such as trauma center designation and admissions by payer type, which are unavailable in the national sample. Cost estimates were derived as mean values across the simulations. All analysis was conducted in SAS Studio version 9.4 (SAS Institute) and R version 4.4.1 (The R Foundation). Simulation R code is available in the eMethods in Supplement 1. Data were analyzed from June 2023 to May 2025.
Results
From 2016 to 2021, an estimated 484 567 initial firearm injury hospital visits occurred nationally (Table 1).34 Of them, 298 721 were ED visits, and 185 846 involved an inpatient hospital admission. Using a Monte Carlo analysis including 2400 simulations, these visits incurred an estimated $7.7 billion total cost, 93% of which was attributable to inpatient admissions. The mean (SE) cost per inpatient visit was $38 879 (138.9), and the mean (SE) cost per ED visit was $1743 (4.5) (Table 2).
Table 1. Monte Carlo Estimates for Total Cost of Emergency Department and Inpatient Visits for New Firearm Injuries in the US from 2016 to 2021.
| Characteristic | Total cost, $ (SE)a | ||
|---|---|---|---|
| Overall (N = 484 567) | Emergency department (n = 298 721) | Inpatient (n = 185 846) | |
| Overall | 7746.3 (25.9) | 520.7 (1.3) | 7225.0 (25.8) |
| Age, y | |||
| 0-17 | 684.4 (10.1) | 44.7 (0.5) | 639.8 (10.1) |
| 18-24 | 2083.1 (14.3) | 154.2 (0.8) | 1928.9 (14.3) |
| 25-44 | 3668.6 (19.6) | 237.1 (1.0) | 3431.5 (19.6) |
| 45-64 | 1014.5 (10.3) | 62.8 (0.6) | 951.6 (10.3) |
| ≥65 | 286.7 (5.4) | 18.5 (0.3) | 268.2 (5.4) |
| Sex | |||
| Female | 855.6 (9.2) | 66.4 (0.6) | 789.2 (9.1) |
| Male | 6889.7 (25.2) | 454.0 (1.3) | 6435.7 (25.2) |
| Race and ethnicityb | |||
| Asian or Pacific Islander | 37.1 (1.8) | 2.7 (0.1) | 34.4 (1.8) |
| Black | 4513.7 (21.2) | 321.7 (1.2) | 4191.9 (21.2) |
| Hispanic | 888.2 (10.8) | 54.8 (0.5) | 833.4 (10.8) |
| Native American | 11.8 (2.0) | 0.9 (0.1) | 11.0 (2.0) |
| White | 1737.2 (13.2) | 108.9 (0.6) | 1628.3 (13.2) |
| Other race | 317.6 (7.2) | 14.4 (0.3) | 303.2 (7.1) |
| Payer | |||
| Medicaid | 4004.3 (23.2) | 203.2 (1.0) | 3801.1 (23.2) |
| Medicare | 446.0 (6.5) | 23.3 (0.3) | 422.6 (6.4) |
| Private | 1514.5 (12.7) | 93.8 (0.7) | 1420.7 (12.7) |
| Self-pay | 1057.5 (7.6) | 163.1 (0.8) | 894.4 (7.6) |
| No chargec | 196.0 (3.3) | 7.0 (0.1) | 189.0 (3.3) |
| Otherd | 512.4 (6.9) | 28.4 (0.4) | 484.0 (6.9) |
| Home zip code income quartilee | |||
| 1 | 4021.0 (20.5) | 267.7 (1.0) | 3753.3 (20.4) |
| 2 | 1718.7 (13.1) | 111.3 (0.7) | 1607.4 (13.1) |
| 3 | 1147.8 (12.0) | 80.9 (0.6) | 1066.9 (12.0) |
| 4 | 609.3 (9.4) | 39.7 (0.5) | 596.6 (9.4) |
| Discharge disposition | |||
| Routine home | 3919.3 (14.7) | 356.1 (1.0) | 3563.2 (14.7) |
| Transfer to acute care hospital | 286.8 (6.7) | 41.9 (0.3) | 244.9 (6.7) |
| Transfer to other facilityf | 1759.7 (19.2) | 16.4 (0.3) | 1743.3 (19.2) |
| Home health care | 998.1 (11.6) | 2.6 (0.1) | 995.6 (11.6) |
| Against medical advice | 128.9 (2.8) | 10.2 (0.2) | 118.7 (2.8) |
| Died | 642.3 (8.6) | 91.0 (1.0) | 551.4 (8.6) |
| Injury intent | |||
| Assault | 3695.2 (21.2) | 203.3 (1.0) | 3149.9 (21.1) |
| Self-inflicted | 618.9 (8.4) | 16.5 (0.3) | 602.5 (8.4) |
| Unintentional | 3145.4 (16.9) | 276.3 (1.0) | 2869.0 (16.8) |
| Undetermined | 178.3 (3.8) | 20.2 (0.3) | 158.1 (3.8) |
| Legal intervention | 108.5 (3.5) | 4.5 (0.2) | 104 (3.5) |
| Body region | |||
| Head and neck | 327.0 (5.6) | 38.8 (0.4) | 288.2 (5.6) |
| Face | 112.1 (3.1) | 7.7 (0.2) | 104.4 (3.1) |
| Chest | 285.7 (5.0) | 37.2 (0.5) | 248.5 (5.0) |
| Abdomen | 785.8 (9.8) | 46.3 (0.5) | 739.5 (9.8) |
| Extremities | 1426.3 (7.1) | 227.2 (0.8) | 1199.1 (7.1) |
| Multiple regions | 4724.4 (25.2) | 155.2 (1.0) | 4569.2 (25.2) |
| Otherg | 11.7 (0.6) | 2.3 (0.1) | 9.5 (0.6) |
| Injury severity score | |||
| 0-8 | 1414.9 (6.6) | 315.7 (0.9) | 1099.2 (6.6) |
| 9-25 | 3618.2 (17.6) | 164.9 (1.0) | 3453.3 (1735.0) |
| 26-75 | 2713.1 (22.2) | 40.0 (0.6) | 2673.1 (22.2) |
| Elixhauser Comorbidity Score | |||
| 0 | 1852.1 (7.6) | 379.3 (1.1) | 1472.8 (7.5) |
| 1 | 1646.8 (10.1) | 96.9 (0.8) | 1549.9 (10.1) |
| 2 | 1476.8 (12.4) | 31.3 (0.5) | 1445.4 (12.4) |
| ≥3 | 2770.6 (23.5) | 13.1 (0.3) | 2757.5 (23.5) |
| Reinjuryh | |||
| 0 | 7052.9 (25.5) | 463.1 (1.3) | 6589.8 (25.5) |
| ≥1 | 693.4 (7.5) | 57.5 (0.5) | 635.8 (7.5) |
| Hospital beds | |||
| 1-99 | 47.7 (1.1) | 23.2 (0.2) | 24.5 (1.1) |
| 100-499 | 2491.0 (15.1) | 207.6 (0.9) | 2283.4 (15.0) |
| ≥500 | 5208.1 (23.5) | 289.5 (1.1) | 4918.6 (23.5) |
| Percentage of hospital Medicaid discharges quartilei,j | |||
| 1 | 1422.6 (30.0) | 107.7 (1.3) | 1314.9 (29.0) |
| 2 | 1638.5 (29.9) | 130.3 (1.3) | 1508.2 (28.9) |
| 3 | 2523.3 (44.0) | 135.3 (0.8) | 2388.0 (44.1) |
| 4 | 2162.4 (43.1) | 146.9 (0.8) | 2015.4 (43.1) |
| Core-based statistical area | |||
| Metro | 7690.5 (25.6) | 500.2 (1.3) | 7190.3 (25.5) |
| Micro | 44.8 (1.3) | 11.9 (0.2) | 32.9 (1.3) |
| Rural | 11.5 (0.3) | 8.2 (0.1) | 3.3 (0.3) |
| Level of trauma center | |||
| Regional resource (level I) | 4737.5 (23.5) | 260.3 (1.1) | 4477.2 (23.4) |
| Community (level II) | 1818.8 (13.1) | 108.8 (0.7) | 1709.9 (13.1) |
| Rural (level III) | 178.4 (2.7) | 32.2 (0.3) | 146.2 (2.7) |
| Greater (level IV) | 12.5 (0.4) | 8.6 (0.1) | 3.8 (0.3) |
| Rural hospital | |||
| No | 6597.7 (25.3) | 441.9 (1.3) | 6155.8 (25.2) |
| Yes | 405.6 (6.3) | 27.5 (0.3) | 378.1 (6.3) |
| Total inpatient admissions quartilej | |||
| 1 | 861.8 (32.3) | 127.1 (1.7) | 734.7 (30.8) |
| 2 | 1817.3 (29.9) | 103.7 (1.4) | 1713.7 (28.8) |
| 3 | 2346.6 (47.7) | 156.4 (2.1) | 2190.3 (54.8) |
| 4 | 2721.0 (51.4) | 133.1 (2.3) | 2587.9 (49.4) |
| Total emergency department visits quartilej | |||
| 1 | 1203.2 (34.2) | 105.3 (1.0) | 1097.9 (33.3) |
| 2 | 1906.9 (34.4) | 143.9 (1.1) | 1763.0 (33.8) |
| 3 | 2097.5 (32.1) | 138.3 (1.5) | 1959.2 (31.2) |
| 4 | 2539.1 (33.2) | 132.7 (1.3) | 2406.4 (32.3) |
| Medical school affiliation | |||
| No | 1455.5 (10.2) | 120.4 (0.6) | 1335.2 (10.2) |
| Yes | 6291.2 (25.1) | 399.9 (1.3) | 5891.3 (25) |
Dollars are inflation adjusted to base year 2024.
Race and ethnicity categories in this database were abstracted from the medical record from Healthcare Cost and Utilization Project categories and included Asian or Pacific Islander, Black, Hispanic, Native American, White, and other race.
Arkansas and Wisconsin classify no charge as self-pay.
Other insurance includes worker’s compensation, TRICARE, Civilian Health and Medical Program of the Department of Veterans Affairs, Title V, and other government programs.
Zip code income quartile is a quartile classification of the estimated median household income of residents in the patient’s zip code and was defined yearly.34
Other type of facility includes discharge to hospice, rehabilitation, long-term care hospital, psychiatric hospital, skilled nursing facility, or intermediate care facility.
Other includes those unclassifiable by body site using the Barell Matrix.
Reinjury is defined as the number of times a patient presented during the year for a new firearm injury.
Hospital Medicaid percentage is calculated as the ratio of Medicaid discharges to total discharges in ascending order.
Threshold values for the quartiles were calculated in each simulation.
Table 2. Monte Carlo Estimates for Mean Hospital Cost per Emergency Department and Inpatient Visits for New Firearm Injuries in the US from 2016 to 2021.
| Characteristic | Cost, mean (SE), $a | |
|---|---|---|
| Emergency department (n = 298 721) | Inpatient (n = 185 846) | |
| Overall | 1743.0 (4.5) | 38 879.0 (138.9) |
| Age, y | ||
| 0-17 | 1623.0 (14.7) | 42 116.0 (574.1) |
| 18-24 | 1739.0 (7.3) | 36 996.0 (240.4) |
| 25-44 | 1791.0 (7.0) | 40 185.0 (209.7) |
| 45-64 | 1700.0 (12.3) | 38 449.0 (355.6) |
| ≥65 | 1552.0 (18.1) | 32 741.0 (544.3) |
| Sex | ||
| Female | 1651.0 (12.3) | 35 052.0 (341.3) |
| Male | 1757.0 (4.8) | 39 408.0 (149.9) |
| Race and ethnicityb | ||
| Asian or Pacific Island | 1650.0 (48.7) | 39 343.0 (1579.8) |
| Black | 1853.0 (6.2) | 39 961.0 (185.3) |
| Hispanic | 1741.0 (13.2) | 39 960.0 (438.1) |
| Native American | 1825.0 (117.7) | 37 634.0 (6452.0) |
| White | 1418.0 (6.9) | 35 240.0 (244.6) |
| Other race | 1909.0 (25.2) | 44 049.0 (910.9) |
| Payer | ||
| Medicaid | 1889.0 (7.6) | 46 515.0 (252.5) |
| Medicare | 1470.0 (14.1) | 34 031.0 (423.6) |
| Private | 1613.0 (10.2) | 37 442.0 (285.8) |
| Self-pay | 1713.0 (7.4) | 26 949.0 (182.8) |
| No chargec | 1370.0 (21.2) | 26 771.0 (343.4) |
| Otherd | 1804.0 (23.2) | 37 214.0 (425.4) |
| Home zip code income quartilee | ||
| 1 | 1734.0 (5.6) | 38 915.0 (191.4) |
| 2 | 1654.0 (8.4) | 36 756.0 (263.3) |
| 3 | 1825.0 (10.9) | 39 423.0 (377.0) |
| 4 | 1742.0 (19.4) | 43 935.0 (614.9) |
| Discharge disposition | ||
| Routine home | 1636.0 (4.3) | 28 674.0 (109.6) |
| Transfer to acute care hospital | 1398.0 (8.5) | 58 058.0 (1334.1) |
| Transfer to other facilityf | 1649.0 (20.4) | 87 113.0 (757.6) |
| Home health care | 3646.0 (155.0) | 56 209.0 (519.0) |
| Against medical advice | 1609.0 (24.5) | 24 078.0 (465.0) |
| Died | 2752.0 (25.0) | 37 898.0 (508.1) |
| Injury intent | ||
| Assault | 2192.0 (8.8) | 43 392.0 (236.7) |
| Self-inflicted | 2067.0 (25.4) | 40 159.0 (458.8) |
| Unintentional | 1504.0 (5.2) | 34 444.0 (183.4) |
| Undetermined | 1828.0 (17.7) | 31 112.0 (617.4) |
| Legal intervention | 1390.0 (41.5) | 52 196.0 (1311.6) |
| Body region | ||
| Head and neck | 1659.0 (11.5) | 32 062.0 (519.6) |
| Face | 1511.0 (30.5) | 35 935.0 (825.2) |
| Chest | 2065.0 (22.8) | 30 871.0 (516.4) |
| Abdomen | 2345.0 (23.4) | 38 911.0 (439.5) |
| Extremities | 1375.0 (4.5) | 20 944.0 (99.6) |
| Multiple regions | 2668.0 (13.3) | 53 856.0 (259.2) |
| Otherg | 1049.0 (39.0) | 11 746.0 (632.8) |
| Injury severity score | ||
| 0-8 | 1508.0 (4.2) | 18 513.0 (91.3) |
| 9-25 | 2156.0 (10.6) | 38 270.0 (170.9) |
| 26-75 | 3114.0 (38.4) | 73 772.0 (496.3) |
| Elixhauser Comorbidity Score | ||
| 0 | 1616.0 (4.5) | 21 919.0 (92.1) |
| 1 | 2104.0 (13.9) | 31 382.0 (165.1) |
| 2 | 2395.0 (31.0) | 44 730.0 (310.1) |
| ≥3 | 2694.0 (47.2) | 74 626.0 (521.0) |
| Reinjuryh | ||
| 0 | 1764.0 (4.8) | 39 586.0 (147.9) |
| ≥1 | 1594.0 (10.9) | 32 808.0 (325.9) |
| Hospital beds | ||
| 1-99 | 1010.0 (7.3) | 20 093.0 (653.5) |
| 100-499 | 1393.0 (5.1) | 31 562.0 (183.9) |
| ≥500 | 2294.0 (7.8) | 43 815.0 (193.0) |
| Percentage of hospital Medicaid discharges quartilei,j | ||
| 1 | 1342.0 (7.9) | 32 271.0 (243.5) |
| 2 | 1703.0 (9.8) | 33 894.0 (234.0) |
| 3 | 2061.0 (11.3) | 43 163.0 (305.5) |
| 4 | 1940.0 (8.4) | 44 540.0 (358.4) |
| Core-based statistical area | ||
| Metro | 1797.0 (4.5) | 39 080.0 (138.8) |
| Micro | 963.0 (9.3) | 20 184.0 (637.9) |
| Rural | 1084.0 (12.4) | 15 919.0 (932.7) |
| Level of trauma center | ||
| Regional resource (level I) | 2484.0 (9.1) | 45 658.0 (215.6) |
| Community (level II) | 1840.0 (9.5) | 35 053.0 (229.6) |
| Rural (level III) | 1136.0 (8.5) | 20 802.0 (291.0) |
| Greater (level IV) | 1040.0 (11.2) | 14 416.0 (1002.5) |
| Rural hospital | ||
| No | 1824.0 (5.0) | 40 077.0 (157.8) |
| Yes | 1493.0 (11.9) | 35 518.0 (489.9) |
| Total inpatient admissions quartilej | ||
| 1 | 1292.0 (7.1) | 32 440.0 (383.3) |
| 2 | 1494.0 (10.5) | 33 200.0 (233.4) |
| 3 | 2338.0 (21.9) | 40 474.0 (333.4) |
| 4 | 2095.0 (15.2) | 45 047.0 (295.2) |
| Total emergency department visits quartilej | ||
| 1 | 1262.0 (6.4) | 29 205.0 (238.0) |
| 2 | 1907.0 (9.7) | 38 726.0 (299.3) |
| 3 | 1885.0 (14.2) | 41 145.0 (331.9) |
| 4 | 2014.0 (14.3) | 43 688.0 (350.8) |
| Medical school affiliation | ||
| No | 1138.0 (4.4) | 27 422.0 (149.1) |
| Yes | 2079.0 (6.0) | 42 960.0 (173.5) |
Dollars are inflation adjusted to base year 2024.
Race and ethnicity categories in this database were abstracted from the medical record from Healthcare Cost and Utilization Project categories and included Asian or Pacific Islander, Black, Hispanic, Native American, White, and other race.
Arkansas and Wisconsin classify no charge as self-pay.
Other insurance includes worker’s compensation, TRICARE, Civilian Health and Medical Program of the Department of Veterans Affairs, Title V, and other government programs.
Zip code income quartile is a quartile classification of the estimated median household income of residents in the patient’s zip code and was defined yearly.34
Other type of facility includes discharge to hospice, rehabilitation, long-term care hospital, psychiatric hospital, skilled nursing facility, or intermediate care facility.
Other includes those unclassifiable by body site using the Barell Matrix.
Reinjury is defined as the number of times a patient presented during the year for a new firearm injury.
Hospital Medicaid percentage is calculated as the ratio of Medicaid discharges to total discharges in ascending order.
Threshold values for the quartiles were calculated in each simulation.
Temporal Trends
Figure 1A shows annual trends in total costs for inpatient and ED visits. The annual aggregate cost remained at approximately $1.2 billion until 2020, at which point cost rose to a peak of $1.6 billion in 2021. Figure 1B presents annual trends in the mean costs of inpatient and ED visits, which were approximately constant across the sample period.
Figure 1. National Monte Carlo Estimates of Total Cost and Mean Cost per Visit for Firearm Injury Emergency Department (ED) Visits and Inpatient Hospitalizations by Visit Type from 2016 to 2021.
Figure 2A shows annual trends in total health care costs by age group. For children aged 0 to 17 years, costs declined by 28% from 2016 to 2017, remained roughly constant from 2017 to 2019, then increased by 54% from 2019 to 2021. Costs for patients aged 18 to 24 years and aged 25 to 44 years remained stable until 2019, rising 72% and 56%, respectively, by 2021. Total costs for patients aged 45 to 64 years or 65 years or older remained largely flat over the sample period. Figure 2B presents cost trends by race and ethnicity, which were approximately flat for each group until 2019. From 2019 to 2021, Asian or Pacific Islander patients experienced an increase of 73%; Black patients, an increase of 64%; Hispanic patients, an increase of 39%; and White patients, an increase of 23%.
Figure 2. National Monte Carlo Estimates of Total Cost for Firearm Injury Emergency Department Visits and Inpatient Hospitalizations by Age Group and Race and Ethnicity from 2016 to 2021.
Patient Variables
Total Cost
Nationally, firearm injury health care costs were most heavily concentrated among male children and adults who were Black, had Medicaid as payer, and had residence in lower-income zip codes. From 2016 to 2021, initial firearm injury treatment incurred an estimated $6.9 billion in cost for male patients. Total hospital costs for caring for Black patients were $4.5 billion. Hospital costs for White patients were the next highest at $1.7 billion, followed by Hispanic patients at $0.9 billion, non-Hispanic patients of another race at $0.3 billion, and Asian or Pacific Islander patients and Native American patients at $0.04 billion and $0.01 billion, respectively. Hospital costs of care were $4.0 billion for patients with Medicaid as payer, $1.5 billion for those with private insurance, $1.1 billion for those who self-paid, $0.5 billion for those with other insurance, $0.4 billion for those with Medicare, and $0.2 billion for those who were not charged. Hospitals costs of care for patients from a home zip code in the lowest income quartile was $4.0 billion, followed by $1.7 billion for those from a home in the second quartile, $1.1 billion for those from a home in the third quartile, and $0.6 billion for those from a home in the fourth quartile.
Injuries categorized as assaults or unintentional accounted for the largest proportion of firearm injury health care cost. Assaults accounted for $3.7 billion, while injuries categorized as unintentional accounted for $3.1 billion. Injuries to multiple body regions totaled $4.7 billion and accounted for 31.6% of ED costs and 64.4% of inpatient costs (eFigure in Supplement 1). Injuries to isolated extremities totaled $1.4 billion and accounted for 40.4% of ED costs and 15.4% of inpatient costs. Lastly, serious injuries with an ISS from 9 to 25 accounted for $3.6 billion, followed by severe injuries with an ISS from 26 to 75 at $2.7 billion.
Mean Cost
Mean (SE) inpatient admission cost for assaults was $43 392 (236.7), followed by $40 159 (458.8) for self-inflicted injuries and $34 444 (183.4) for injuries categorized as unintentional. Mean (SE) inpatient cost was highest for firearm injury to multiple body regions at $53 856 (259.2). The second highest body region cost category was abdominal injuries at $38 911 (439.5). Mean (SE) inpatient cost was highest for severe firearm injuries with an ISS of 26 to 75 at $73 772 (496.3) compared with serious firearm injuries with an ISS of 9 to 25 at $38 270 (170.9) and minor injuries with an ISS of 0 to 8 at $18 513 (91.3). Because the cost distribution can be skewed by a small number of relatively expensive visits, median values may provide a better sense of cost for typical visits than mean values (eTable 2 in Supplement 1).
Hospital Variables
Total Cost
Over the sample period, hospitals with 500 or more beds saw a total cost of $5.2 billion, and hospitals with 100 to 499 beds saw a cost of $2.5 billion. Costs ranged from a high of $2.1 billion for hospitals in the upper quartile of percentage of Medicaid discharges to a low of $1.4 billion for those in the lowest quartile. Almost all costs were concentrated in hospitals in a metro CBSA. Regional resource hospitals (level I trauma center) accounted for the highest total of new firearm injury costs at $4.7 billion, followed by community hospitals (level II trauma center) at $1.8 billion. Lastly, hospitals affiliated with a medical school accounted for $6.3 billion new firearm injury cost.
Mean Cost
Mean (SE) cost ranged from a high of $43 815 (193.0) for hospitals with 500 or more beds to a low of $20 093 (653.5) for hospitals with 1 to 99 beds. Mean (SE) cost ranged from a high of $44 540 (358.4) for hospitals in the upper quartile of percentage of Medicaid discharges to a low of $32 271 (243.5) for hospitals in the first quartile. The mean (SE) cost ranged from a high of $45 648 (215.6) for regional resource hospitals (level I) to a low of $14 416 (1002.5) for greater nontrauma hospitals (level IV). See eTable 2 in Supplement 1 for median costs.
Mean Inpatient Cost and Percentage of Contribution to Total Cost
Figure 3 summarizes the highest contributions to overall cost via a scatter plot with the mean inpatient treatment cost for the highest 10 categories of percentage contributions to total cost. Figure 3A displays patient characteristics and Figure 3B displays hospital characteristics. For example, injuries to multiple body regions accounted for 63% of total cost, and admissions for these injuries incurred a mean (SE) cost of $53 856 (259.2).
Figure 3. Mean Cost per Inpatient Admission of New Firearm Injury for Patient and Hospital Characteristics With Top Percentage Contributions to National Inpatient Cost from 2016 to 2021.
CBSA indicates core-based statistical area; ED, emergency department; ISS, injury severity score.
Discussion
US hospital health care costs for new firearm injuries were an estimated $7.7 billion from 2016 to 2021. Annual costs increased from $1.2 billion to $1.6 billion from 2019 to 2021. The increase coincided with a rise in violent crime during the COVID-19 pandemic.35,36 Although total costs increased, mean cost per visit remained largely constant from 2016 to 2021. Firearm injury incidence therefore appears to be a primary driver of the rise in costs.
Another contribution of this study is the estimation of costs in pediatric populations, as the incidence and mortality from pediatric firearm injuries have increased in recent years.37,38 From 2016 to 2021, firearm injuries incurred approximately $684 million in hospital costs for patients younger than 18 years. The annual cost of treatment for pediatric patients also grew by an estimated 54% from 2019 to 2021. Additionally, the proportion of all costs caused by injuries categorized as unintentional grew from 40% in 2016 to 52% in 2021. Future research should explore explanations for the rise.
Black male children and adults with a home zip code in the lowest income quartile with multiple assault injuries presenting to large, urban regional resource hospitals (level I trauma centers) serving the largest proportion of Medicaid patients accounted for the largest proportion of firearm health care costs. Assault injuries accounted for most costs. However, intent is often coded inaccurately in hospital systems, and many injuries coded as unintentional were likely intentional in reality.27,39
Firearm reinjury has been found to occur in up to 40% of firearm injury survivors.40,41 In this study, reinjury estimates were biased downward because the ability to track the same patient ends at each calendar year. Despite the bias, subsequent visits accounted for 9% of the national cost estimate. Reinjury may offer a prevention point for injury and cost reduction if risk factors for violence can be modified through hospital-based violence intervention programs. These programs appear to be cost-effective.8,10,42,43 These programs may also be a potential focal point for cost reduction because average costs of treatment did not rise over the sample period. Rather, changes in incidence appear to explain the increase in cost.
Across hospital characteristics, firearm injury health care costs were borne primarily by hospitals with 500 or more beds and in the upper quartile of percentage of Medicaid discharges. These results are consistent with a separate study by Okeke et al,31 who used the Nationwide Inpatient Sample and found that moderate to high safety net mixed hospitals bore the highest costs across a longer period from 2003 to 2020. Payer type is an important consideration for hospitals and policymakers. Because hospitals are on average reimbursed below cost by most Medicaid programs, high rates of Medicaid and uninsurance can put hospitals under financial strain and threaten the ability to provide care.44,45,46,47,48 Notably, however, Medicaid expansion can promote financial viability through the conversion of uninsurance to Medicaid.49
Okeke et al31 offer perhaps the most closely related study. The authors estimated $1.4 billion in total inpatient costs for the year 2020, which matches our own estimate in Figure 1. While our study used a Monte Carlo simulation with state data, Okeke et al31 used the national inpatient sample. The concordance in estimates across the 2 approaches offers encouragement for the accuracy in addition to the rigor and reproducibility of our results.
Although $7.7 billion in total costs over the sample period conveys a substantial source of US health care cost, the complete financial cost of firearm injury treatment is certainly larger. The administrative data do not include physician professional fees, which increases cost by approximately 20%.50 Likewise, these data omit prehospital transportation cost, such as the ambulance or helicopter costs, nor do they include trauma activation fees.51 Additionally, the cost of readmission or a subsequent visit for the same firearm injury can be high. These visits were not included in this study. One study estimated a national cost of $54.2 million for readmission among adults.52 Another study found nonfatal firearm injury survivors experienced increased health care use.53 Furthermore, only acute care hospital costs were included, not postacute care, such as long-term nursing care, rehabilitation, and physical therapy. Initial hospitalization costs only account for 60% of total costs in the first year of a firearm injury.54 Finally, indirect costs, such as caregiver expenses and lost wages, were also not included but are known to be substantial.54
Limitations
This study was subject to several limitations. First, the sample states with SEDD/SID data may not perfectly represent the demographic composition of the US. Bias was mitigated through the use of geographically and demographically diverse states as well as inpatient data for nonsample states in the simulation. Second, the VisitLink identifier used to estimate reinjury was restricted by calendar year, so censored values create underestimates of reinjury. Third, acute care hospital costs are only a portion of firearm injury cost to the health care system, which also include prehospital health care professional costs, professional fees, postacute care costs, and other direct care costs. Fourth, this study adopted the perspective of health care cost and does not estimate firearm injury costs borne by survivors, their caregivers, or their communities.
Conclusions
In this economic evaluation study, new firearm injuries created an estimated $7.7 billion in ED-only and inpatient hospital health care costs from 2016 to 2021. These data can inform decision-makers who prioritize firearm injury prevention strategies at the patient level. The data can also inform policies to support the hospitals disproportionally affected by firearm injury costs. As mean costs per visit have remained approximately constant over time, efforts to prevent firearm injury may hold potential as cost-saving measures to reduce uncompensated care for health systems and costs to government-sponsored health care plans.
eMethods. Monte Carlo Simulation R Code
eTable 1. List of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Codes to Identify Firearm Injury Patients
eTable 2. Monte Carlo Estimates for Median Hospital Cost per Emergency Department and Inpatient Visits for New Firearm Injuries in the US from 2016 to 2021
eFigure. National Monte Carlo Estimates of Mean Cost for Firearm Injury Emergency Department Visits and Inpatient Hospitalizations by Body Region
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods. Monte Carlo Simulation R Code
eTable 1. List of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Codes to Identify Firearm Injury Patients
eTable 2. Monte Carlo Estimates for Median Hospital Cost per Emergency Department and Inpatient Visits for New Firearm Injuries in the US from 2016 to 2021
eFigure. National Monte Carlo Estimates of Mean Cost for Firearm Injury Emergency Department Visits and Inpatient Hospitalizations by Body Region
Data Sharing Statement