255 Long-Term Mortality in Pediatric Firearm Assault Survivors: A Retrospective, Multi-Center, Comparative Cohort Study

Children and youth in the United States face an inordinately high risk of firearm violence, but the long-term mortality risk of pediatric survivors of firearm assault is poorly understood. Therefore, we aimed to determine whether children surviving to hospital discharge after firearm assault are at increased risk of mortality and to elucidate the factors associated with later mortality. We performed a retrospective triple cohort study of pediatric patients aged 0 to 16 years seen at three trauma centers in Oakland and San Francisco, California between 2000 and 2009. By consecutively sampling from the trauma registries using International Classification of Diseases, Ninth Revision (ICD-9) E-codes, we constructed three cohorts comprised of all patients who presented for (1) firearm assault, (2) assault without firearm and (3) unintentional trauma. We excluded patients who were seen for suspected child abuse or suicide attempt. Additional demographic and clinical information was obtained from the medical record, including subsequent emergency department visits for trauma and gunshot wound. We queried the Social Security Death Master File and the California Department of Public Health Vital Statistics (2000-2014) to identify those who died after surviving their initial hospitalization and to determine cause of death. Cox proportional hazards regression was employed to determine hazard ratios, adjusting for demographic and clinical covariates. The trauma registry query yielded 413 firearm assault, 405 non-firearm assault, and 7062 non-assault-based trauma patients who survived their index emergency department visit and hospitalization. During a median follow-up of 8.2 years (inter-quartile range [IQR] 6.6-9.9 years), 9.0 years (IQR 7.1-11.6 years) and 9.3 years (IQR 7.1-11.8 years), a total of 75 deaths occurred, including 3.9% (n= 16), 3.2% (n= 13), and 0.7% (n= 46) of the three cohorts, respectively. Deaths occurred at a median age of 19.7 years and a median of 5.4 years after index injury. Two-thirds of all deaths following index visit (n= 50) were due to homicide. Adolescent age (adjusted hazard ratio [AHR] 2.9; 95% confidence interval [CI] 1.3-6.6), male sex (AHR 3.0; 95% CI 1.3-7.1), black race (AHR 3.3; 95% CI 1.2-9.4), and public insurance (AHR 2.5; 95% CI 1.2-5.2) were independent risk factors for long-term mortality. Firearm assault (AHR 1.8; 95% CI, 0.82-4.0) and non-firearm assault (AHR 1.9; 95% CI, 0.93-3.9) patients experienced increased risk of long-term mortality compared to non-assault trauma patients, although these differences did not reach statistical significance. Among adolescents aged 12 to 16 years, being assaulted (either with or without a firearm) was an independent risk factor for long-term mortality (AHR 1.9; 95% CI 1.01-3.6). Severe injury severity score, location of injury, and violent crime index by city of residence were not significant predictors of mortality. Among children seen in urban trauma centers, young adolescents who survive after exposure to assault, either with or without a firearm, have increased long-term mortality compared to those who survive unintentional, non-violent trauma. Given that most of these deaths are due to homicide, further studies are needed to identify effective methods of secondary prevention for this high-risk population.