Pediatric Non-Fatal Firearm Injury Healthcare Utilization

Abstract

Firearm injury is a leading cause of death among children in the United States. For every one child killed by a firearm, approximately two to four more are injured and survive. An emerging literature characterizes changes in healthcare utilization and costs attributable to survivors of pediatric firearm injuries. We provide a summary that may guide intervention efforts focused on both injury prevention and post-injury care. Among 15 studies, we found that multiple categories of healthcare use increased after firearm injury, including hospitalizations and readmissions, compared both to pre-injury patterns and to non-firearm injured controls. Mental health diagnoses also increased after firearm injury. Healthcare spending increased considerably in the first-year post injury among both injured children and their families. There are few data addressing longer-term healthcare outcomes and expenditures. To quantify the continuing economic and societal impact of firearm injury, as well as the cost effectiveness of prevention efforts, longitudinal research is needed addressing the health impacts on firearm-injured children, families, and communities.

Article Summary

A recent increase in research focused on non-fatal pediatric firearm injuries, has broadened our understanding about utilization and expenditures after injury, but significant gaps remain.

BACKGROUND

In 2017, firearm injuries surpassed motor vehicle injuries as the leading cause of death among children and young adults 1-24 years of age in the United States (US).^1,2 For every child who dies by firearm injury, approximately two to four more suffer a non-fatal firearm injury.^3,4 There are an estimated 58,000 healthcare encounters annually for children who are injured by a firearm and survive.⁵ The health consequences of both fatal and non-fatal firearm injury in the US, especially among children, have resulted in the broad recognition of firearm injury as a public health epidemic, including by the US Surgeon General in 2024.^6-9

Non-fatal firearm injuries contribute to substantial physical, psychological, and economic consequences, and underscore the important need to address both immediate and long-term outcomes at the individual and community level. Quantifying healthcare utilization and cost can provide benchmarks for the evaluation of the effectiveness of prevention and intervention efforts and informs resource allocation and policy development. Furthermore, a deeper understanding of these health harms and associated expenditures is vital for the identification of gaps in care and mitigation of the enduring effects of firearm injuries on individuals and communities.

Several recent studies highlight the health consequences of pediatric non-fatal firearm injuries, addressing short- and longer-term health impacts, healthcare utilization and costs. In this review, we summarize and provide a synthesis of this literature with the goal of guiding efforts aimed at both post-injury care and injury prevention.

APPROACH

To provide a comprehensive review of the literature focused on pediatric healthcare utilization and expenditures after non-fatal firearm injuries, we utilized a structured approach. Two medical research librarians at the University of Vermont Dana Health Library with experience in diverse review methodologies assisted the team, including selection of data sources based on the goals of a state-of-the-art review.

Data Sources and Article Selection

We searched the MEDLINE database for peer-reviewed English-language articles with Medical Subject Headings related to four conceptual groups: (1) pediatric and (2) nonfatal firearm injury, with either (3) healthcare utilization or (4) expenditure data published between January 2010-September 2024. The search results were uploaded into Covidence software, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews.¹⁰ Titles and abstracts were independently screened by JD and CP using a structured protocol. Articles were included if they provided quantitative data on children and young adults (ages 0-24) non-fatal firearm injuries in the US and included specific measures of healthcare utilization and/or costs. Discrepancies were resolved through discussion and consensus, and EF provided final arbitration when necessary. Full-text review followed the same process, with additional articles identified through bibliographic analysis of selected studies.

Data Extraction and Summary

Data were extracted on healthcare utilization and expenditures associated with a pediatric non-fatal firearm injury. Given the heterogeneity in study approaches, we summarized the following elements: publication year, database, geographic region of focus, age ranges, outcome variables, and main findings. For the healthcare utilization articles we extracted any variables associated with healthcare utilization (e.g., healthcare encounters (including mental health), readmissions), and for expenditures articles we extracted the total estimated expenditures. Most articles estimated expenditures over multiple years; therefore we report the original amount without a conversion to current value.

FINDINGS

Search Results

Our search yielded 358 articles. Of those, 326 articles were deemed not applicable to the review by title and abstract information. Thirty-two articles underwent full-text review, and of those, 21 were excluded. ^11-21 Additional review of the references in the remaining 11 articles identified four more articles for full-text review, for a total of 15 articles.^22-25 (Figure 1)

Figure 1.

PRISMA Diagram

Healthcare Utilization

Thirteen studies described healthcare utilization after non-fatal firearm injuries among children, and twelve of these were published between 2019 and 2024 (Table 1).^12-24 The articles were heterogeneous in terms of their sources of data and outcome measures. Healthcare encounters after the index encounter was the most common utilization outcome measure. All articles reported increases in pediatric healthcare utilization after an index firearm injury compared to either children who did not sustain a firearm injury or compared to a child’s own prior utilization. (Table 1)

Table 1.

Healthcare Expenditures Following Non-Fatal Firearm Injury Among Youth

Study	Authors	Year	Database / Region	Age Ranges Used	Outcome Variables	Highlighted Findings (Utilization with units)
Guns and states: Pediatric firearm injury	Lee et al.	2013	The Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) 2006-2009	0-18 years old	Median Lenth of Stay (LOS), Mean Total Hospital Charge (THC)	LOS (Median): 3 days Discharge to rehabilitation: 8.4%, THC total (mean): $56,844.
Readmission and reinjury patterns in pediatric assault victims	Cortolillo et al.	2019	National readmissions database 2010-2014	0-18 years old	Hospitalization, Readmissions	Hospitalizations due to a firearm injury: 7,638 Readmission within 1 year; 772 Odds of readmission: 2.5 [95% CI 2.10,2.97])
Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents	Phillips et al.	2020	Trauma registries of Children’s Hospital Colorado from 2008 to 2018, Denver Health from 2013 to 2018, Universal of Colorado Health Memorial Hospital Central Trauma Center from 2012 to 2018	0-18 years old	Transportation mode, diagnostic imaging, surgical/radiological intervention, blood transfusions, length of ventilator time, psychiatric treatments, outpatient operations	Transport: 64% ambulance, 24% personal vehicle, 11% helicopter, 1% other. Transfusions: 21% require packed red blood cells (PRBCs), 38% require two or more PRBCs, 12% require PRBC and plasma, 7% on massive transfusion protocol. Surgical intervention: 52%, craniotomy: 15% of children and 2% of adolescents, thoracotomy: 2% of adolescents, any surgical procedure within 30 days and 1 year: 11%, 14% Ventilator time (mean): 0.8 days. Psychiatry evaluation and treatment: 14% at 30 days 30 day readmission rate: 11.6%
Human and Economic Costs of Pediatric Firearm Injury	Quiroz et al.	2020	National readmissions database 2010-2014	0-18 years old	Hospitalizations, major operative procedures, readmissions, total hospital days accumulated, median LOS	Total hospitalizations: 13,596 Patients surviving index injury: 12,799 30-day readmission percentage: 6% 1 year readmission percentage: 11% Children that underwent a major operation are more likely to be readmitted Total hospitalization days accumulated: 101,000 Median LOS: 3 days.
Nonfatal firearm injuries: Utilization and expenditures for children pre- and post-injury	Pulcini et al.	2021	Medicaid MarketScan 2010−2016 claims database	0-18 years old	Outpatient and inpatient encounters including index visit, CCC status	Increase in total encounters: 28.7% Average increase of total encounters per patient: 2.6 Increase in children with CCC post-injury: 100%
Mental Health Utilization and Expenditures for Children Pre–Post Firearm Injury	Pulcini et al.	2021	Medicaid MarketScan 2010−2016 claims database	0-18 years old	Total mental health encounters	Decrease in mental health expenditures: 7.8% Healthy subgroup prior to injury: increase in mental health encounters: 131% High prior mental health utilization: decrease in utilization: 18%.
Two-Year Utilization and Expenditures for Children After a Firearm Injury	Pulcini et al.	2022	Medicaid MarketScan 2010−2016 claims database	0-18 years old	Outpatient and inpatient encounters (including index visit)	Change in healthcare encounters in 1 year: 22% increase Change in healthcare encounters in 2 years: 20% decrease Low expenditure group: Low expenditure group: increase in encounters in year 1: 112%; increase in encounters in year 0-2: 35%
Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective	Simpson et al.	2022	NRD from 2010 to 2017; 28 states	12 and under were classified as toddlers and children, 12-18 were classified as adolescents	Days to readmission, cost of services, hospitalization incidence, 30-day risk of readmission, LOS, cost of services	Patients require readmission: 10.49 per 1000 Unplanned 30-day readmission: 5.7% Median time to unplanned readmission: 8 days Suicide median readmission time: 5 days Unplanned readmission incidence rate: 57.3 per 1000 Median index injury LOS: 7 days Median readmission LOS: 4 days
Mental healthcare following firearm and motor vehicle related injuries: differences impacting our treatment strategies	Ehrlich et al.	2022	Medicaid MarketScan 2010−2016 claims database	3-17 years old	New mental health diagnosis (NMHD) post-index injury comparing firearm injuries and motor vehicle accident cohorts	Firearm injured children are less likely to be discharged from ED (71.7% vs 93.4%) Percentage of firearm injured children developing NMDH: 34.8% Likely classifications of NMDH: substance abuse, ADHD, trauma, and stress disorders Increased NMDH odds for firearm injured children: 1.55 aOR [95% CI 1.33,1.80] Increased NMDH odds in patients admitted for inpatient treatment: 1.8 aOR [95% CI 1.47,2.22] Increased NMDH odds for ICU patients: 1.78 aOR [95% CI 1.22,2.59]
Burden of unintentional pediatric firearm injury: An examination of the Nationwide Readmission Database	Lumbard et al.	2023	Nationwide Readmission Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2019; 30 geographically dispersed states	0-12 and 13-17 age groups	LOS Mean and median, total charges mean and median, readmission for initial diagnosis, readmission to other hospital	Mean LOS for primary admission: 8.2 days Median LOS for primary admission: 4 days Mean LOS for readmission: 5.2 Median LOS for readmission: 3 days 90 day unplanned readmissions percentage: 8.9%
Mental Health Care Utilization Among Children and Adolescents With a Firearm Injury	Oddo et al.	2023	Truven Health AnalyticsMarketScan (now IBM Watson Health, IBM MarketScan Research Databases) Multi-State Commercial and Medicaid Claims databases from January 1, 2015, to December 31, 2018	0-17 years old	Mental healthcare utilization 12 mo post-index: therapy use, substance use, and medication prescription	Patients having at least 1 mental healthcare service encounter within 1 year: 23.7% Patients having at least 1 psychotherapy session: 14% Patients having a substance use encounter: 12.6% Patients having a prescription claim for psychotropics: 18.9% Increased risk of utilizing mental health services post firearm injury: 1.4 (95% CI 1.25,1.56) Increased risk of utilizing psychotherapy: 1.23 (95% CI 1.06,1.43) Increased risk of substance use treatment: 1.4 (95% CI 1.19,1.64)
Firearm Injuries In Children And Adolescents: Health And Economic Consequences Among Survivors And Family Members	Song et al.	2023	2007–21 MarketScan commercial claims data	0-19 years old	Hospitalizations, procedures, visits, ED visits, mental health visits, imaging, labs, prescriptions	Increase hospitalizations per 1000 per month: 37.1 (95% CI 33.1,41.0) Increased office visits per 1000 per month: 183.5 (95% CI 152.7-214.4) Increased ED visits per 1,000 per month 94.5 (95% CI 88.3-100.6) Increase in procedures: 245% Increase in imaging studies: 423% Increase in laboratory studies: 147% Increase in pain medication prescriptions: 411% Increase in psychiatric medication prescription: 35%
Health Care Utilization After Nonfatal Firearm Injuries	Gastineau et al.	2024	MarketScan Multi-State Commercial and Medicaid data from January 1, 2015 to December 31, 2018; multi state	0-17 years old	Patient hospitalization, ED visits, outpatient visits within 12 months of index visit; Total healthcare cost within 12 months ($ for total care payments)	Difference in hospitalization claims: 11.6% Difference in ED visits: 13.7% Difference experiencing either an ED visit or hospitalization: 17.6% Difference for outpatient visits: 50.2% Increased risk of inpatient hospitalization 12 mo after index: 5.31 (95% CI 3.93,7.20) Increased risk of ED visits: 1.49 (95% CI 1.37,1.62) Increased risk of outpatient visits: 1.06 (95% CI 1.03,1.10)

Overall, the studies consistently demonstrated increased healthcare utilization after non-fatal firearm injury. There was significant heterogeneity in study design, outcome measurement, and study population. For example, one retrospective cohort study utilized the Medicaid Marketscan database published in 2021 and compared the year before and after (i.e. pre- post) the index non-fatal firearm injury among children ages 0-18 years. This population experienced a 28.7% increase in total healthcare encounters. Additionally, this study reported a greater than 154% increase in children with a complex chronic condition (CCC) status (a commonly utilized metric to estimate disability and medical complexity among children defined as conditions expected to last longer than 12 months with involvement of one or more organ system(s) and expected high health utilization) among those who have a CCC before the firearm injury to those after (11 children before (5.6% of total), 28 children after (14.7%)).^14,26

A 2024 article used the expanded Medicaid Marketscan database (Medicaid plus commercial claims). This study utilized a propensity score matched cohort analysis from 2015-2018 to compare children ages 0-17 years who experienced a non-fatal firearm injury vs. matched non-injured children. They measured hospitalization, ED visits, and outpatient visits as primary outcomes. The authors reported an adjusted relative risk of 5.31 (95% confidence interval [CI] 3.93,7.18) for hospitalization, 1.49 (95% CI 1.37,1.62) for an ED visit, and 1.06 (95% CI 1.03,1.10) for an outpatient visit for up to one year after the index injury when comparing children with a firearm injury vs. those who did not.²⁰

Another 2023 study utilizing the Medicaid Marketscan database focused solely on commercial claims and reported a 245% increase in surgical procedures, a 423% increase in imaging, and a 147% increase in laboratory tests after a children ages 0-19 years suffered a non-fatal firearm injury from 2007-2021 when compared to matched individuals without a firearm injury.¹⁹ Despite the utilization of similar databases and reported overall increases in utilization, the heterogeneity in outcome selection, measurement, and study populations is apparent.

Other studies focused on hospitalizations, encounters, readmissions, procedures, transfers, and testing following non-fatal firearm injuries among children but utilized different databases. For example, one study queried the National Readmissions database from 2010-2014 and found 13,596 hospital admissions attributed to children ages 0-18 years who experienced a non-fatal firearm injury. Further, as many as 101,000 hospital-days were attributed to such injuries within a single year.²⁴

Multiple reports found increases in hospital readmissions attributed to pediatric non-fatal firearm injury.^{12,16,17,22,24} One study found that older children (13-17 years) discharged from the ED experienced a 90-day unplanned readmission rate of 80.5%.¹⁶ Another study used trauma registries in Colorado and found 64% of children ages 0-18 years were transported to the emergency department via ambulance, 78% required some form of blood product transfusion, and 52% of patients required some form of surgical intervention..¹²

Mental Healthcare Utilization

Mental healthcare utilization after pediatric non-fatal firearm injury was directly addressed in four studies (Table 1).^15,18,19,23 Three studies found an increase in pediatric mental healthcare utilization after a non-fatal firearm injury,^18,19,23 while another demonstrated an increase only among those with little to no mental health utilization prior to the non-fatal firearm injury.¹⁵ These studies were notable for a consistent finding of increased mental health care utilization, but varied in study design, outcome measurement, and study populations.

A propensity score-matched cohort analysis utilized the Medicaid Marketscan database, comparing children ages 0-17 years with non-fatal firearm injury to matched non-firearm injured children. Those injured by firearm had increases in total mental health encounters 8(23.7%), psychotherapy usage (11.1%), encounters for treatment of substance use (12.6%), and prescription of psychotropic medications (8.7%).¹⁸ Another study utilizing the Medicaid Marketscan database compared children age 3-17 years injured by firearms to those involved in a motor vehicle collision, and found increased odds of a new mental health diagnosis among those with firearm injury (adjusted odds ratio (aOR) 1.55, 95% CI 1.33,1.80).²³ Using this same database, other investigators observed a 32% increase in usage of mental health services/1,000 children ages 0-19 years who experienced a non-fatal firearm injury compared to age matched controls.¹⁹ In addition, this study found 117% increase in pain disorders, 68% increase in psychiatric disorders, and 144% increase in substance use disorders among those firearm-injured. This study also described family members’ mental healthcare utilization, finding that parents of firearm-injured children experienced a 31% increase in psychiatric disorders in the 12 months after the injury.¹⁹

Expenditures

We identified twelve studies which examined healthcare expenditures after pediatric non-fatal firearm injuries (Table 2).^{11-17,19-21,24,25} Healthcare expenditures increased in all studies following pediatric non-fatal firearm injury, but heterogeneity existed with respect to study design, outcomes, and populations. One of the common differences was outcome measurement. Many studies focused only on the first healthcare visit (index visit) after the firearm injury,^11,12,25 while others captured readmission expenditures and/or longitudinal measurement of healthcare expenditures.^{13-17,19-21,24} The studies which focused on the index visit unsurprisingly demonstrated a significant expenditure burden generated from those encounters. One study utilized the 2006-2009 Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) and estimated a median total expenditure per index non-fatal firearm injury as $36,535-$56,844 per child ages 0-18 years.¹¹ Another study utilized trauma registries in Colorado and estimated total costs at $84,176 per child ages 0-18 years.¹² A study utilized the KID from 2003-2012 and found the average cost to the US healthcare system for initial hospitalizations alone was $109 million annually.²⁵ A few studies measured unplanned readmission rates attributable to the index encounter at 30 days and 1 year, and reported $7,978 for unplanned 30 day readmissions when compared to non-injured children,¹⁶ and $66,581 in unplanned readmissions in the first year post-injury.¹⁷ One study provided a broad estimate of total expenditures associated with national readmissions after pediatric non-fatal firearm injury, and estimated a total annual cost of $40 million.²⁴

Table 2.

Healthcare Expenditures Following Non-Fatal Firearm Injury Among Youth

Study	Authors	Year	Database / Region	Age Ranges Used	Outcome Variables	Findings (Expenditure with units)
Guns and states: Pediatric firearm injury	Lee et al.	2013	The Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) 2006-2009; States with SYG and CAP	0-18 years old	Mean total hospital charge	Mean total hospital charge: $56,844 Total hospital charge $1.09 billion
Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents	Phillips et al.	2020	Trauma registries of Children’s Hospital Colorado from 2008 to 2018, Denver Health from 2013 to 2018, UCHealth Memorial Hospital Central Trauma Center from 2012 to 2018; Colorado, Iowa, Kansas, Missouri, Nebraska, South Dakota, and Wyoming	0-18 years old	Transportation mode, diagnostic imaging, surgical/radiological intervention, blood transfusions, length of ventilator time, psychiatric treatments, outpatient operations	Helicopter costs: $40,000 per trip Total helicopter expenses in study: $1.4 million Total cost of care in US: $26 million Total cost per patient: $84,176 Hospitals loss during study period: $3 million
Human and Economic Costs of Pediatric Firearm Injury	Quiroz et al.	2020	National readmissions database 2010-2014; national level	0-18 years old	Total overall cost of admission, cost of readmission, total USD spent on pediatric firearm injury, annual productivity loss assuming parent takes leave to be with child	Total cost of admissions $382 million Total cost of readmissions: $40 million Total spent annually on hospitalizations: $95.5 million Assumed productivity loss: $38 million
Financial burden of pediatric firearm-related injury admissions in the United States	Taylor et al.	2021	Kids’ Inpatient Database 2003, 2006, 2009, 2012; national	0-18 years old	Initial hospitalization cost per year to the US Healthcare System, trends associated with increased costs, factors associated with higher cost	Average initial cost per year: $109 million Increasing trend annually Higher costs association factors: High injury severity score, higher LOS, high patient income bracket, Asian patient
Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury	Pulcini et al.	2021	Medicaid MarketScan 2010−2016 claims database; 10-12 states with varying locations	0-18 years old	Outpatient and inpatient encounters including index visit, CCC status	Increase in expenditure: $16.6 million Increased expenditure in previously healthy patients: $13.9 million
Mental Health Utilization and Expenditures for Children Pre–Post Firearm Injury	Pulcini et al.	2021	Medicaid MarketScan 2010−2016 claims database; 10-12 states with varying locations	0–18-year-olds	Expenditure on mental health services	Overall: Decreased expenditure: $346,029 Healthy: Increased expenditure: $804,024 High prior mental health expenditures: Decreased expenditure: $1,074,905 High non-mental health expenditure: Decrease expenditure: $75,149
Two-Year Utilization and Expenditures for Children After a Firearm Injury	Pulcini et al.	2022	Medicaid MarketScan 2010−2016 claims database; national level	0-18 years old	Outpatient and inpatient encounters including index visit	Overall Increase in expenditure in 1 year: 253% Decrease expenditure in 2 years: 14%
Trends and Burden of Firearm-Related Injuries Among Children and Adolescents: A National Perspective	Simpson et al.	2022	NRD from 2010 to 2017; 28 states	12 and under were classified as toddlers and children, 12-18 were classified as adolescents	Days to readmission, cost of services, hospitalization incidence, 30-day risk of readmission, LOS, cost of services	Median total hospital care cost per case: $36,535 30-day readmission cost per case: $7,978
Burden of unintentional pediatric firearm injury: An examination of the Nationwide Readmission Database	Lumbard et al.	2023	Nationwide Readmission Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2019; 30 geographically dispersed states	0-12 and 13-17 age groups	Total charges mean and median, readmission for initial diagnosis, readmission to other hospital	For primary Mean total charge: $119,932 Median total charge: $62,859 For no readmission: Mean total charge: $111,870 Median total charge: $58,857 For readmission: Mean total charge: $66,581 Median total charges: $36,164
Firearm Injuries in Children And Adolescents: Health And Economic Consequences Among Survivors And Family Members	Song et al.	2023	2007–21 MarketScan commercial claims data; national level	0-19 years old	Paid amounts between insurance and hospitals	Post injury per survivor per month spending increase: $2,907 Per survivor per month cost sharing increase: $132 Increased in spending: $26,809 Cost sharing increase: $1,281
Health Care Utilization After Nonfatal Firearm Injuries	Gastineau et al.	2024	MarketScan Multi-State Commercial and Medicaid data from January 1, 2015 to December 31, 2018; multi state	0-17 years old	Total healthcare cost within 12 months ($ for total care payments)	Mean costs 12 months post index encounter: $8,288 Difference vs. non-injured patients: $6,108 Increased cost per injured youth: $5,591
The Health and Economic Impact of Youth Violence by Injury Mechanism	Parker et al.	2024	WISQARS 2020, HCUP-NEDS 2018-2020; NEISS-FISS 2018-2020, National Electronic Injury Surveillance System-All Injury Program, MarketScan Commercial Claims and Encounters Databases; national level	10–24-year-olds	Average cost of ED visit treated and released vs hospitalization	Total economic burden caused by firearm injury: $3 billion dollars

For longitudinal expenditure calculation, the Medicaid Marketscan database was used most frequently. One study utilized this database without commercial Medicaid insurance data and reported a total increase of $16.6 million in healthcare expenditures among 1,821 children ages 0-18 years comparing 1 year pre- and post-injury.¹⁴ Another study compared a sample of 2,110 children ages 0-17 years injured by firearms to 2,110 non-injured children, and found the total cost per child increased by $5,591 within 1 year of the index injury with an estimated $17.5 million in total care payments.²⁰ One study used the Marketscan database with commercial Medicaid insurance data and characterized both the individual and familial costs of non-fatal firearm injury among children ages 0-19 years. This study found that spending increased $2,907 per individual patient per month post-injury when matched to children without a non-fatal firearm injury.¹⁹ We found only one other study which examined data from the National Readmission database to that similarly evaluated expenditures relative to the family. This study included a cohort of 13,596 patients and reported an estimated $38 million loss in productivity for family members after a non-fatal firearm injury in a child age 0-18 years of age..²⁴

It is important to note that all studies recognized that cost estimation was difficult, given the profound and broad individual, familial, community, and societal impact of pediatric non-fatal firearm injuries. One study attempted to address this gap and capture a more global estimate of expenditures among persons ages 10-24 years after non-fatal firearm injuries. For this estimate, the authors combined data from multiple databases (web-based Injury Statistics Query and Reporting, Healthcare Cost and Utilization Project-Nationwide Emergency Department Sample, National Electronic Injury Surveillance System – Firearm Injury Surveillance Study, National Electronic Injury Surveillance System-All Injury Program, Marketscan Commercial) with previous study estimates of expected medical and non-medical expenditures after non-fatal injury for both the individual and families. They estimated an annual total cost burden of $3 billion for youth non-fatal firearm injuries in the US.²¹

DISCUSSION

This state-of-the-art review presents a synthesis of recent efforts to quantify some of the individual, familial, societal, and economic consequences and impact of pediatric non-fatal firearm injury in the US. Overall, the articles demonstrated a high healthcare burden of pediatric non-fatal firearm injury in terms of healthcare encounters (including mental health) and associated expenditures at the individual and family levels. There were increases in every measured outcome focused on healthcare utilization included in this review, compared to both pre-injury levels and non-injured controls. Similarly, nearly all measures of spending increased (with a single exception of mental health spending over two years), even amongst family members of injured children.

Studies across both pediatric and adult populations show similar patterns of increased healthcare use, which highlights the broad burden of firearm injuries in the US.^27,28 National estimates for 2022 from the Centers for Disease Control and Injury Prevention’s Web-based Injury Statistics Query and Reporting System indicated that individuals aged 0-24 experienced 31,778 hospitalizations, with medical costs estimated at $3.58 billion, work lost costs at $307.7 million, and quality of life costs at $3.3 billion.⁵ Further, for the same age group, there are an estimated 26,266 treated in the ED and discharged, with $429.5 million in medical costs, $41.8 million in work loss costs, and $385.3 million in quality of life costs associated with these “treat and release” visits.⁵ These findings reinforce the need to address the firearm injury crisis holistically and leverage prevention efforts that benefit all age groups while tailoring interventions to meet the unique needs of children.^29-31

For example, the reduction of access to firearms by children has demonstrated promising results.^32-34 Secure firearm storage practices, which involve keeping firearms unloaded, locked, and storing ammunition separately, have been associated with reductions in unintentional injuries and suicides among children and adolescents.^32,33 Thus, secure storage efforts to limit access to firearms by children could be one viable path to decrease the high burden of healthcare utilization and expenditures demonstrated through this review.³³ Similarly, community and school-based violence prevention programs, which include hospital-linked interventions, have demonstrated promise in reducing violence and its broader societal impacts by addressing underlying risk factors and the provision of support to at-risk children.^34,35 Enhanced access to mental health services, when counseling on lethal means safety is included, has been linked to reduced suicide rates and may play an important role in the prevention of firearm-related injuries.³⁵ However, more research is needed to inform evidence-based prevention initiatives and subsequent reductions of firearm injuries among children.^34-36

While these strategies are not yet widely implemented or fully evaluated for their impact on healthcare costs, our review provides an estimate of the range of costs associated with non-fatal firearm injuries and emphasizes the economic case for prevention efforts. These findings offer an additional driver for prevention and serve as a critical benchmark against which the effects of future interventions can be measured. National data parallels our findings and consistently demonstrate that firearm injuries result in substantial healthcare utilization and expenditures, and that adults also incur substantial costs related to emergency care, hospitalizations, mental health services and long-term rehabilitation.^{28,37 27,28} Beyond direct medical costs, national estimates also capture lost productivity, family economic strain, and broader societal costs, which underscore the extensive ripple effects of firearm injuries. These findings reinforce the need to address the firearm injury crisis holistically, to address shared risks and leverage prevention efforts that benefit all age groups while tailoring interventions to meet the unique needs of children.^29-31

Given the substantial impacts in healthcare utilization and related costs for children with non-fatal firearm injuries and their family members, this review can also inform important policy considerations. At the institutional level, hospitals should support hospital and community-based violence intervention and prevention programs.^9,38 At the state level, it is essential to advocate for state-level laws that would decrease unauthorized access of firearms by children. This includes child access prevention laws and secure storage laws, which provide resources to health care professionals to provide firearm safety education as well as locks and lockboxes to patients and families.^39,40 On the federal level, continued advocacy to increase funding for firearm injury prevention research will be critical to continue to build the necessary research infrastructure with appropriate databases and researchers.^2,9,41 Funding is also essential to advance the science of firearm injury prevention.⁴² This includes engagement with health insurers and health systems to dedicate resources for the improvement of data systems and linkages for firearm injury prevention research. Advocacy for these policy approaches to advance the research for firearm injury prevention as well as to directly decrease firearm injuries is essential to mitigate healthcare utilization and expenditures for firearm injuries and deaths.⁴³ A summary of recommendations for further research and intervention aligning with our findings in this state-of-the-art review can be found in Figure 2.

Figure 2.

Recommended Research and Potential Interventions for Pediatric Non-Fatal Firearm Injury

Although the articles included in our review consistently demonstrated an increase in healthcare utilization and expenditures after a pediatric non-fatal firearm injury, due to heterogeneity in the currently published studies, it is difficult to provide a comprehensive estimate of the utilization and expenditures which result from non-fatal firearm injuries on the individual, family, community, and national level. For example, differences in outcome measurement, study design (ex. case-control vs. pre-post), and a paucity of data on healthcare utilization and expenditures beyond the children affected by firearm injury makes comprehensive and accurate estimates somewhat elusive. Many of the articles included in the review build towards this goal, however, more research is needed to better understand the collective healthcare and expenditure consequences of pediatric non-fatal firearm injury. Notably, minimal data is available on the longer-term impact of children injured by firearm beyond one year or on the impact of a non-fatal firearm injury on family members, communities, etc., which is a limitation of current databases. Advocating for and establishing more robust and comprehensive data sources for research that allows more accuracy in estimating the burden of non-fatal firearm injury among children, families, communities, and beyond is needed. Lastly, none of the current studies we reviewed examined potential disparities in healthcare utilization and expenditures among individuals or communities.^9,44 This is of particular importance when measuring the impact of childhood firearm injury given that known disparities exist.^9,43-45 Youth injured by firearms are most likely to live in specific geographic regions (southern and midwestern US, urban areas), identify as Black, male, adolescents/young adults, and are often live in areas of higher concentrated poverty.^44-46 From a health equity standpoint, we need to expand the current literature to better understand these potential differences in healthcare utilization and expenditures.^9,47

CONCLUSION

Our review provides a comprehensive synthesis of emerging evidence that consistently demonstrates significant increases in healthcare utilization and expenditures following pediatric non-fatal firearm injuries and underscores the importance to implement evidence-informed policies to address this burden. Despite differences in study design and outcome measurement, the findings reveal a clear and substantial burden on individuals, their families, and the healthcare system. Current policy discussions on firearm safety and injury prevention must prioritize addressing this burden through funding, legislative action, and public health initiatives.

Abbreviations:

Emergency Department

ED