 |
|
The Rural-Urban Continuum
Variability in Statewide Serious Firearm Injuries in Children and Adolescents
Michael L. Nance, MD;
Lex Denysenko, BS;
Dennis R. Durbin, MD, MSCE;
Charles C. Branas, PhD;
Perry W. Stafford, MD;
C. William Schwab, MD
Arch Pediatr Adolesc Med. 2002;156:781-785.
ABSTRACT
| |
Objective To compare rates of serious firearm injuries among children and adolescents
treated in a statewide trauma system.
Materials and Methods We reviewed the Pennsylvania Trauma Systems Foundation (Mechanicsburg)
registry from January 1, 1987, through December 31, 2000, for all pediatric
and adolescent patients (age 0-19 years) who sustained a serious firearm injury.
Data included age, sex, weapon, geographic region, injury circumstance, and
outcome.
Results During the 14-year period, 3781 children and adolescents sustained a
serious firearm injury and were treated at a participating Pennsylvania trauma
center. The population was 90.7% male, with a mean age of 16.5 years. Adolescents
(age 15-19 years) represented more than 85% of the study population. There
were 744 deaths (19.7%). The urban counties had an average annual population-based
rate of serious firearm injury of 28.3/100 000; suburban counties, 2.8/100 000;
metropolitan counties, 2.4/100 000; and nonmetropolitan counties, 2.4/100 000.
Urban counties had a higher rate for all injury circumstances (unintentional,
assault, and self-inflicted) than all nonurban counties. Assault was the most
common overall injury circumstance (78.7%), and was the most common circumstance
in urban counties (88.5%) and among adolescents (age 15-19 years [84.2 %]).
Unintentional injuries predominated in nonmetropolitan counties (56.7%) and
in young children (aged <5 years [50.6%] and 5-9 years [61.4%]). Handguns
were the most common weapon type in all age groups, geographic regions, and
injury circumstances.
Conclusions Rates of serious firearm injuries among children and adolescents are
10-fold higher in urban than nonurban regions. Assaultive injury mechanisms
predominated in urban areas, unintentional injuries in the nonurban counties.
Firearm injury statistics are heavily influenced by events in the urban counties.
Intervention and prevention strategies need to account for these regional
discordances to optimize efficacy.
INTRODUCTION
AT THE PEAK of the firearm injury epidemic in the mid-1990s, an estimated
16 children and adolescents (age 0-19 years) died each day from a firearm
injury.1 Despite declining overall national
trends in fatal firearm injuries, such injuries still represent the second
leading cause of death in Americans aged between 1 and 19 years.2
Most reports in the pediatric population focus solely on fatal firearm injuries
and have documented this high rate of firearm mortality.3-4
Other reports of pediatric firearm injury have been limited to a single locale,
typically an urban center and, thus, characterize only a subset of the overall
problem.5-6 The objective of this
study was to investigate the variability in firearm injury that exists across
the rural-urban continuum in a statewide trauma system. In addition, we focused
on children and adolescents with serious firearm injuries (both fatal and
nonfatal) as they required hospitalization and/or significant use of hospital
resources in treatment.
MATERIALS AND METHODS
From January 1, 1987, through December31, 2000, the Pennsylvania Trauma
Systems Foundation (PTSF), Mechanicsburg, registry was reviewed for firearm
injuries in pediatric and adolescent patients (age 0-19 years). The PTSF is
a statewide registry of 26 participating trauma centers (adult and pediatric)
within Pennsylvania. For 51 of Pennsylvania's 67 counties, a trauma center
is located within the county or in an adjoining county. These 51 counties
include 84% of Pennsylvania's population.7
By comparison to National Vital Statistics data, the PTSF database captured
64% of the children and adolescents who were fatally injuried by a firearm.8 The remaining 36% were either treated at a nonparticipating
trauma center or transported directly to the medical examiner's office. For
inclusion in the PTSF, registry patients must satisfy 1 of the following criteria:
length of hospital stay of 72 hours or longer, transfer from another institution,
intensive care unit admission, or emergency department or in-hospital death.
Patients treated and released from the emergency department, those treated
at a nonparticipating hospital, or patients who died in the field were not
captured in the PTSF database. Data were collected by trained trauma registrars
in individual institutions and submitted to a central database. To minimize
data errors, registrars attend mandatory training sessions semiannually, one
of which focuses on interabstractor reliability. Audits are also performed
regularly to monitor coding accuracy of the data submitted. In addition to
standard comprehensive demographic, clinical, and outcome information, a written
description of the injury and circumstances was also included. For this study,
we reviewed patient age at the time of injury, sex, county in which injury
occurred, injury circumstance (E-code), firearm used, and patient outcome.
The state was divided into geographic regions based on rural-urban continuum
(RUC) codes, a classification scheme devised by the US Department of Agriculture
as a measurement of rurality.9 The RUC codes
contain 10 distinct categories and characterize metropolitan counties by size,
and nonmetropolitan counties by degree of urbanization and proximity to metropolitan
areas (Table 1). The RUC codes
were available for all counties in the state.9
Metropolitan counties (n = 33) included RUC codes 0 through 3 and nonmetropolitan
counties (n = 34) RUC codes 4 through 9. The RUC code 0 includes counties
constituting a metropolitan statistical area exceeding 1 million population.
For example, Philadelphia county (urban county) and surrounding counties (Delaware,
Chester, and Montgomery: suburban counties) all receive a RUC code of 0. To
separate the effect of the urban county from the suburban county, the 2 urban
counties in the state (Philadelphia and Allegheny) were considered as a separate
category—urban. The remaining RUC code 0 counties were categorized as
suburban. Those counties in RUC code 1 through 3 counties were considered
metropolitan. All nonmetropolitan counties (RUC codes 4-9) were considered
collectively as nonmetropolitan.
|
|
|
|
Table 1. Definitions of Rural-Urban Continuum Codes*
|
|
|
Firearm injury rates were determined for the various geographic regions
based on population statistics for individual counties. The population-based
rate of events was calculated as the average annual number of cases per 100 000
children for the study period. The population statistics were based on the
population estimates for July 1993, the midpoint of the study. Estimates were
obtained for each county within the state for children and adolescents age
0 through 19 years.10
Injury circumstances were determined by the reported E-code and were
compared with and supplemented by the written description provided to the
PTSF. Circumstances were categorized as unintentional, assault, self-inflicted,
or unknown. Assaults included those injuries in which a weapon was discharged
with an inherent intent-to-injure and included drive-by shootings, cross-fire,homicides,
and assaults without further specification. Self-inflicted injuries included
suicide and suicide attempts. Self-inflicted cases in which intent could not
clearly be identified were categorized as unintentional.
Identification of the weapon type was based on the E-code reported and
the written description of the incident provided to the PTSF. Categories of
firearms included handgun, rifle, shotgun, nonpowder firearm, and unknown.
Specific information regarding the weapon, such as caliber or make or model
was not routinely available for review.
RESULTS
From January 1, 1987, to December 31, 2000, there were 3781 pediatric
and adolescent firearm victims reported to the PTSF for whom a complete data
set was available. Children and adolescents (age 0-19 years) represented 26.5%
of the statewide population (3 179 980 of 12 022 128 Pennsylvania
citizens). Characteristics of the study sample are provided in Table 2. The average annual rate of serious firearm injuries statewide
was 8.5 cases per 100 000 children. The annual number of firearm injuries
over the 14-year period varied from a low of 97 cases in 1987 to a peak of
365 cases for 1993-1994. There were 744 deaths [19.7%] of the sample studied.
The case-fatality rate for in-hospital, trauma center–treated patients
showed little variation between regions, ranging from 19.5% in the urban counties
to 21.4% in the nonmetropolitan counties.
|
|
|
|
Table 2. Characteristics of the Study Sample by Geographic Region,
1987-2000
|
|
|
GEOGRAPHIC REGION
Most firearm injuries (77.4%) occurred in urban counties, with 7.9%
in suburban counties, 10.2% in metropolitan counties, and 4.5% in nonmetropolitan
counties. The annual rate in the urban counties was 10-fold greater than in
the next highest region (28.3/100 000 vs 2.8/100 000) (Table 3). Nonurban counties had similar
overall annual rates of firearm injury (range, 2.4/100 000 to 2.8/100 000).
The distribution of injury circumstances across geographic regions differed
(Figure 1). Assaults, by far, accounted
for the greatest proportion (88.5%) of firearm injuries in the urban regions.
Assaults were also predominant in the suburban (57.0%) and metropolitan (48.1%)
regions but to a lesser degree. In the nonmetropolitan counties, unintentional
injuries were most frequent (56.7%).
|
|
|
|
Table 3. Rate of Firearm Injury by Geographic Region
|
|
|
|
|
|
|
Figure 1. Circumstances of injury based
on geographic region in which injury occurred.
|
|
|
The overall rate of firearm injury varied substantially over time. This
variation is almost completely due to changes in the rate of firearm injury
in the urban counties (Figure 2).
The rate of injury peaked in 1993-1994 and gradually receded to levels approximately
twice the rate noted at the commencement of this study. Firearm injuries in
the suburban, metropolitan, and nonmetropolitan counties had far less variation
over time.
|
|
|
|
Figure 2. Trends in firearm injury by geographic
region over the period of the retrospective review.
|
|
|
AGE
The study sample was divided into 4 age groups: younger than 5 years
(n = 93), 5 to 9 years (n = 83), 10 to 14 years (n = 381), and 15 to 19 years
(n = 3224). The average annual rate of firearm injury differed by age. Adolescents
had the highest rate of firearm injury (30.2/100 000). The average annual
rate of injury was significantly lower in the nonadolescent age groups (10-14
years, 3.4/100 000; 5-9 years, 0.7/100 000; and <5 years, 0.8/100 000).
Age affected the distribution of injury circumstances as well (Figure 3). Younger children (0-9 years) were more likely to be involved
in unintentional shootings than any other injury circumstance. Assault was
the most common injury circumstance for older children (age 10-19 years) including
adolescents (age 15-19 years) in whom assaults accounted for 84.2% of injuries.
|
|
|
|
Figure 3. Circumstances of injury based
on age of patient in whom injury occurred.
|
|
|
INJURY CIRCUMSTANCE
The rate of assaultive injuries varied over time (Figure 4). Coincident with the peak in firearm injuries in the urban
regions in the mid-1990s was the rise in assaultive injuries. All other injury
circumstances remained relatively stable over the period of review. The urban
counties had a greater average annual rate for all injury circumstances than
any other region (Table 3). Assaults
were 6-fold more common than unintentional injuries across the statewide population.
After assaults in the urban counties, unintentional injuries in the urban
counties had the highest annual rate.
|
|
|
|
Figure 4. Trends in firearm injury circumstance
over the period of the retrospective review.
|
|
|
WEAPON
The weapon type was identified in only 55.3% of shootings. Interpretation
of weapon data is thus limited. The handgun was the most common weapon type
identified for all age groups and in all geographic regions. However, there
were notable differences in the distribution of firearm types by geographic
region. In the urban setting, when a weapon was identified, it was a handgun
in 89.4% of cases. In the nonurban setting, the handgun again was the single
most common weapon type identified (suburban, 78.8%; metropolitan, 61.0%;
and nonmetropolitan, 36.4%); however, there was a greater proportion of other
weapons noted. Long guns (shotguns and rifles) were documented with greater
frequency in the nonurban counties (suburban, 15.9%; metropolitan, 33.6%;
and nonmetropolitan, 57.6%) than in urban counties (8.3%).
COMMENTS
Results of this study demonstrate notable differences in serious fatal
and nonfatal pediatric firearm injury characteristics based on the degree
of urbanization of a community. Application of the RUC codes to the study
of firearm injuries has previously been reported.11-12
In those studies, the population was limited to teenagers and young adults
and looked at all causes of homicide (ie, firearm and nonfirearm).11-12 In those studies, RUC code 0 was
considered a single group, the core metropolitan area. The core metropolitan
region included both the central urban county as well as surrounding suburban
counties that constituted the metropolitan statistical area. In the current
study, the RUC 0 counties were subdivided into central, urban counties (Philadelphia
and Allegheny counties) and surrounding, suburban counties. It is apparent
that such discrimination is necessary as the urban counties had a different
firearm injury profile than the adjacent suburban counties. Thus, intervention
and prevention programs designed for use in the urban counties of Pennsylvania
might not be as effective in the surrounding suburban counties despite geographic
proximity.
Regional variation in firearm injuries has previously been examined
in Pennsylvania for nonfatal shootings for all age groups.13
Firearm injury figures are heavily influenced by the urban shootings and,
thus, may not reflect the injury patterns of surrounding or distant communities.
In this study, despite the proximity to the urban counties, the suburban counties
had firearm injury rates approximating the metropolitan and nonmetropolitan
counties, all significantly lower than the urban counties. Our rate of serious
firearm injuries (28.3/100 000) in the urban counties was similar to
that previously reported for Northern Manhattan (New York) (including Harlem,
31.13/100 000) for children 0 to 16 years old.14
Knowledge of the injury circumstances in a region is important to direct community-specific
interventions. Again, programs designed to reduce the occurrence of urban
assaultive gun violence may not be as effective for unintentional shootings,
which are more prevalent in the nonurban regions. A similar approach has been
suggested from a public policy viewpoint.15
As firearm mortality rates vary by regions within a state, uniform gun laws
throughout a state may not be necessary nor optimal. Legislation designed
and implemented within a specific locality may be more effective.
In our statewide population, older children (age 10-19 years) were typically
injured by assaultive shootings (80.5%), while younger children (age 0-9 years)
were more likely to be involved in unintentional shootings (55.7%). Variation
in firearm injury circumstance based on age differences was also reported
by Li et al16 in their population of children
14 years and younger. Children in the 0 through 4-years and 10 through 14-year
age groups had an increased likelihood of assaultive injuries. Thus, firearm
injury prevention initiatives should also be tailored to the age of the target
population.
In a review of 10 years of pediatric gunshot wounds at an urban trauma
center, a 30% increase in the number of firearm injuries was noted in the
second half of the study (early 1990s). The upward trend was a reflection
of an increase in assaultive injuries.17 A
similar trend was noted in national statistics documenting a peak in firearm
mortality in 1993-1994.18 Since that report,
the incidence of fatal firearm injuries has declined across the country.18 We noted a similar trend in our serious pediatric
and adolescent firearm injured population. The urban counties were responsible
for most of the firearm injury cases with a peak in 1994. The yearly count
has declined significantly since that peak but remains higher than those levels
noted in the late 1980s when this review commenced. In the suburban, metropolitan,
and nonmetropolitan counties, there has been less variation; in general, the
rate remains higher than the levels documented in the late 1980s.
The handgun was the most common weapon type identified in this study
and was responsible for 80% of all shootings in which a weapon type was identified
in the PTSF registry. This is likely an underestimation of the role of the
handgun as many of the undetermined cases such as cross-fire or drive-by shootings
were probably handgun related. This preponderance of handgun-related injury
represents an increase from reports of prior decades when handguns accounted
for 45% to 60% of firearm injuries.19-22
Firearm injury prevention efforts likely need to shift from elimination of
the weapon to adapting and living in a world replete with firearms.
This study is confined by several limitations inherent to a review of
trauma registry data. It is best used as a descriptor of trends within the
groups studied. This review likely underestimates the burden of firearm injuries
on children in Pennsylvania as not all firearm injuries (fatal or nonfatal)
in this population are captured in the PTSF registry. However, given the inclusion
criteria of the PTSF registry, it is likely that most of the serious nonfatal
and treated but fatal firearm injuries were included. Given the criteria for
inclusion in the PTSF registry (ie, hospital length of stay >72 hours, intensive
care unit admission, or death), there is a selection bias toward the most
serious firearm injuries. This also affords a unique window on those injuries
that are resource intensive. Pennsylvania has a large number of registered
hunters. This may effect the distribution and weapon type within the state
compared with other states. Thus, results of this study may not be generalizeable
to other geographic regions of the country. However, Pennsylvania includes
2 large urban regions—Philadelphia and Pittsburgh—as well as several
additional large metropolitan areas and nonmetropolitan regions, making it
an ideal state in which to study variations in firearm injury circumstances
by geographic location.
| What This Study Adds
This study provides information about the rate of serious firearm injuries
among children and adolescents based on degree of urbanization of the geographical
region in which the injury occurred. Our results suggest that in Pennsylvania,
multifaceted intervention and prevention strategies designed for individual
communities will likely be necessary to most effectively combat firearm injuries
in children within a respective geographic region.
|
|
AUTHOR INFORMATION
Accepted for publication April 19, 2002.
These data were provided by the PTSF registry as part of the Pennsylvania
Trauma Outcome Study.
The PTSF specifically disclaims responsibility for any analysis, interpretations,
or conclusions as the source of data.
Corresponding author: Michael L. Nance, MD, Department of Pediatric
Surgery, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard,
Philadelphia, PA 19104 (e-mail: nance{at}email.chop.edu).
From the Departments of Pediatric Surgery (Drs Nance and Stafford)
and Pediatrics (Dr Durbin), Children's Hospital of Philadelphia, Division
of Trauma and Surgical Critical Care, Hospital of the University of Pennsylvania
(Mr Denysenko and Dr Schwab), and the Center for Clinical Epidemiology and
Biostatistics, University of Pennsylvania (Dr Branas), Philadelphia.
REFERENCES
| |
1. Centers for Disease Control and Prevention resources page. National Center for Injury Prevention & Control. Fatal injuries: leading causes of death reports. Available at: http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html. Accessed February
1, 2002.
2. Centers for Disease Control and Prevention resources page. National Center for Injury Prevention & Control. Fatal injuries: mortality (fatal injury) reports. Available at: http://webapp.cdc.gov/sasweb/ncipc/mortrate.html. Accessed February
1, 2002.
3. Beaver BL, Moore VL, Peclet M, Haller JA Jr, Smialek J, Hill JL. Characteristics of pediatric firearm fatalities. J Pediatr Surg. 1990;25:97-99.
ISI
| PUBMED
4. Svenson JE, Spurlock C, Nypaver M. Pediatric firearm-related fatalities: not just an urban problem. Arch Pediatr Adolesc Med. 1996;150:583-587.
FREE FULL TEXT
5. Nance ML, Stafford PW, Schwab CW. Firearm injury among urban youth during the last decade: an escalation
in violence. J Pediatr Surg. 1997;32:949-952.
FULL TEXT
|
ISI
| PUBMED
6. Dowd MD, Knapp JF, Fitzmaurice LS. Pediatric firearm injuries, Kansas City, 1992: a population-based study. Pediatrics. 1994;94(pt 1):867-873.
7. Pennsylvania Department of Health and the Pennsylvania Trauma Systems
Foundation, sponsors. Injury Care in Pennsylvania. Harrisburg: Pennsylvania Department of Health, 1996.
8. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at: http://www.cdc.gov/ncipc/wisqars/. Accessed
February 1, 2002.
9. Economic Research Service US Department of Agriculture briefing room. Measuring rurality: rural-urban continuum codes. Available at: http://www.ers.usda.gov/briefing/rurality/RuralUrbCon/. Accessed February 1, 2002.
10. Behney M, Uroda R, Copella S. 1993 State and County Detailed Population Estimates:
Pennsylvania. Middletown: Pennsylvania State Data Center; 1995.
11. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of
age: differences by level of urbanization, United States, 1979 through 1989. JAMA. 1992;267:3048-3053.
FREE FULL TEXT
12. Fingerhut LA, Ingram DD, Feldman JJ. Homicide rates among US teenagers and young adults: differences by
mechanism, level of urbanization, race, and sex, 1987 through 1995. JAMA. 1998;280:423-427.
FREE FULL TEXT
13. Sing RF, Branas CC, MacKenzie EJ, Schwab CW. Geographic variation in serious nonfatal firearm injuries in Pennsylvania. J Trauma. 1997;43:825-830.
ISI
| PUBMED
14. Durkin MS, Kuhn L, Davidson LL, Laraque D, Barlow B. Epidemiology and prevention of severe assault and gun injuries to children
in an urban community. J Trauma. 1996;41:667-673.
ISI
| PUBMED
15. Teret SP, DeFrancesco SD, Bailey LA. Gun deaths and home rule: a case for local regulation of a local public
health problem. Am J Prev Med. 1993;9(suppl 1):44-46.
16. Li G, Baker SP, DiScala C, Fowler C, Ling J, Kelen GD. Factors associated with the intent of firearm-related injuries in pediatric
trauma patients. Arch Pediatr Adolesc Med. 1996;150:1160-1165.
FREE FULL TEXT
17. Nance ML, Templeton JM Jr, O'Neill JA Jr. Socioeconomic impact of gunshot wounds in an urban pediatric population. J Pediatr Surg. 1994;29:39-43.
FULL TEXT
|
ISI
| PUBMED
18. Anonymous. Nonfatal and fatal firearm-related injuries—United States, 1993-1997. MMWR Morb Mortal Wkly Rep. 1999;48:1029-1034.
PUBMED
19. Powell EC, Tanz RR. Child and adolescent injury and death from urban firearm assaults:
association with age, race, and poverty. Inj Prev. 1999;5:41-47.
FREE FULL TEXT
20. Heins M, Kahn R, Bjordnal J. Gunshot wounds in children. Am J Public Health. 1974;64:326-330.
FREE FULL TEXT
21. Ordog GJ, Wasserberger J, Schatz I, et al. Gunshot wounds in children under 10 years of age: a new epidemic. AJDC. 1988;142:618-622.
22. Valentine J, Blocker S, Chang JH. Gunshot injuries in children. J Trauma. 1984;24:952-956.
ISI
| PUBMED
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Firearm Ownership and Storage Patterns Among Families With Children Who Receive Well-Child Care in Pediatric Offices
DuRant et al.
Pediatrics 2007;119:e1271-e1279.
ABSTRACT
| FULL TEXT
Determining objective injury prevention priorities.
Wiebe et al.
Inj. Prev. 2006;12:347-350.
ABSTRACT
| FULL TEXT
Recreational Gun Use by California Adolescents
Vittes and Sorenson
Health Educ Behav 2005;32:751-766.
ABSTRACT
The Association Between Presence of Children in the Home and Firearm-Ownership and -Storage Practices
Connor
Pediatrics 2005;115:e38-e43.
ABSTRACT
| FULL TEXT
Acute Traumatic Injuries in Rural Populations
Peek-Asa et al.
AJPH 2004;94:1689-1693.
ABSTRACT
| FULL TEXT
Urban-Rural Shifts in Intentional Firearm Death: Different Causes, Same Results
Branas et al.
AJPH 2004;94:1750-1755.
ABSTRACT
| FULL TEXT
Understanding and Preventing Violence in Children and Adolescents
Rivara
Arch Pediatr Adolesc Med 2002;156:746-747.
FULL TEXT
|
