In a recently released article in Pediatrics, Dr. Kelsey Gastineau and colleagues sought to determine if healthcare utilization was increased in the 12 months following a non-fatal firearm injury among youth ages 0–17 years (10.1542/peds.2022-059648). They used the MarketScan Multi-State Medicaid and Commercial Claims databases (January 1, 2015–December 31, 2018). This large data repository contains individual-level de-identified claims data for both publicly and privately insured youth, thus providing a broad view not limited to a specific youth demographic profile. Primary outcomes at the 12-month mark included healthcare use, defined by inpatient hospitalizations, emergency room visits, and outpatient visits; the secondary outcome of healthcare costs was also examined.
The authors conducted a “propensity score matched cohort analysis” in which youth with firearm injury were matched 1:1 with youth without firearm injury to compare outcomes in the 12 months following the injury (those with injury) or an equivalent period (those without injury). Propensity score matching is a statistical technique that has advantages over the more commonly used multivariable regression: propensity matching has the ability to more closely approximate a randomized clinical trial because important characteristics of participants (in this case those with and without firearm injury) can be examined and matched ahead of time (ie, before the outcome is known), unlike multivariable regression, in which key participant characteristics are added linearly and in which an outcome variable is needed. The authors were able to account for multiple demographic descriptors such as age, sex, and insurance type; for prior medical conditions and mental health diagnoses; and for healthcare utilization in the 12 months preceding the research comparison.
The authors found that healthcare utilization was indeed increased in the 12 months after a non-fatal firearm injury (compared to those without an injury), with:
- a 5.31-fold increased risk for hospitalization,
- a 1.49-fold increased risk for emergency room visits,
- a 1.06-fold increased risk of outpatient encounters; and
- almost 4x higher healthcare costs ($7,581 versus $1,990 per youth)
The authors note that Black adolescent males who are publicly insured have born the greatest burden of firearm violence and injury, and they consider this equity problem through the lens of historical and current structural racism in our society. The discussion section thoughtfully considers the implications of each of their findings, as well as potential paths forward.
This research adds meaningfully to the growing body of evidence about the risks and societal burdens of firearm injuries. While the authors have chosen to focus on healthcare encounters and expenditures, other possible outcomes of firearm injury that haunt youth and their families that could be studied using the analytic techniques employed here include: (1) school absenteeism and school achievement, (2) housing instability due to ongoing gang and/or retaliatory threats, (3) reinjury rates, and (4) further exploration of mental health consequences.
There is much each of us can do in our own practices to help prevent firearm injury, from utilizing resources in the AAP toolkit to joining state-based Safe Storage initiatives. Let us know what you are doing!
