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Christian D. Pulcini, MD, MEd, MPH
Sreejata Dutta, PhD
Sofia Chaudhary, MD, MPH
Elizabeth R. Alpern, MD, MSCE
Peter F. Ehrlich, MD, MSc
Joel A. Fein, MD, MPH
Kelsey Gastineau, MD, MPH
Monika Goyal, MD, MSCE
Matt Hall, PhD
Maya Haasz, MD
Stephen Hargarten, MD, MPH
Jennifer A. Hoffmann, MD, MS
Samaa Kemal, MD, MPH
Rachel K. Myers, PhD, MS
Karen M. Sheehan, MD, MPH
Bonnie T. Zima, MD, MPH
Eric Fleegler, MD, MPH

Most children survive common injuries, yet the longer-term health and financial consequences of non-fatal pediatric trauma are not well defined. Complex chronic condition status (CCCs) represents chronic morbidity associated with high healthcare utilization. The development of CCCs and related expenditures across injury mechanisms is understudied. Therefore, we sought to identify and compare development of CCCs and healthcare expenditures after pediatric injury from four common mechanisms: falls, firearm injuries, motor vehicle collisions (MVCs), and struck by/against events.

We conducted a retrospective cohort study of children aged 0–17 years in the Medicaid MarketScan database (2019–2023) with injuries due to falls, firearm injuries, motor vehicle collisions (MVCs), or struck-by/against events. Children required ≥6 months of enrollment before and after injury and had no preexisting CCC. New CCCs within 6 months were identified using the validated CCC v3 algorithm. Multivariable logistic regression (adjusted for age, sex, race and ethnicity) estimated odds of CCC development by mechanism. The primary expenditure outcome was total healthcare spending at the time of and the 6 months following injury, stratified by mechanism and number of new CCCs developed. Expenditures are reported as median with IQR. To compare median expenditures across injury types, we used a quantile regression model adjusting for the number of CCCs with falls serving as the reference category.

Among 374,604 injured children, 7,121 (1.9%) developed ≥1 new CCC within 6 months. Firearm injuries carried the highest risk, with 5.3% developing ≥1 CCC compared with approximately 2% for other mechanisms. Compared with falls, firearm injuries were associated with greater odds of ≥1 CCC (aOR 2.22, 95% CI 1.80–2.75) and ≥2 CCCs (aOR 5.91, 95% CI 2.88–12.16) (Table 1). Healthcare expenditures differed substantially by injury type and CCC burden. Median 6-month expenditures were highest following firearm injuries ($18,976) compared with falls ($13,176), MVCs ($10,240), and struck-by/against events ($12,696) (p<0.0001). For children with 0 CCCs (reference group), median expenditures were $12,474. This increased significantly for children developing 1 CCC ($23,178) and 2+ CCCs ($38,684) (p<0.0001). (Figure 1) Total 6-month expenditures across all subjects who developed CCCs after injury exceeded US $560 million.

A clinically meaningful proportion of injured children develop new chronic conditions that drive substantial healthcare expenditures. Firearm injuries were associated with the greatest financial burden over the 6-month study period. These findings highlight pediatric injury, particularly firearm injury, as a critical and preventable driver of downstream chronic disease and healthcare costs. Investment in evidence-based pediatric injury prevention interventions and policies, along with strengthened post injury care coordination and rehabilitation services, may reduce long-term morbidity while lowering downstream healthcare costs.

1. Firearm injuries impose a disproportionately large chronic disease burden on children compared to other common injury mechanisms: children with firearm injuries were more than twice as likely to develop a new complex chronic condition within six months, and nearly six times as likely to develop two or more, compared to children injured by falls.
2. The development of new complex chronic conditions after pediatric injury dramatically escalates healthcare costs. Median six-month expenditures more than tripled for children who developed two or more new chronic conditions ($38,684) compared to those who developed none ($12,474), with total expenditures across all affected children exceeding $560 million.
3. Pediatric injury (particularly firearm injury) is a significant and preventable driver of downstream chronic disease and long-term healthcare spending, underscoring the need for investment in evidence-based injury prevention, post-injury care coordination, and rehabilitation services to reduce both morbidity and costs.

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Ashley Hollo, MD MPH
Sivani Manchu, MPH
Carisa Bergner, PhD
Kaitlyn McQuistion, MD MSHS
Katherine Flynn-O’Brien, MD MPH
Michael Levas, MD, MS

Injury is the leading cause of death among US children aged 1-18. Where a child lives influences their risk of injury. The Child Opportunity Index (COI) measures neighborhood resources and has been linked to poor pediatric health outcomes, including risk of violent death. This study examined whether improvements in COI quintile over time were associated with reductions in pediatric injuries.

This retrospective cross-sectional study included children ages 0-18 presenting to emergency departments with injury-related ICD-10 codes between 2018 and 2022 identified through the state hospital association database. Neighborhood resources were quantified using COI. Injury-related ICD-10 codes were defined using the 2025 National Trauma Data Standard (NTDS). Additional injuries excluded from NTDS, including burns, drownings, hangings/asphyxiation, and late effects of injury, were included to better capture pediatric injury burden. Kruskal-Wallis testing evaluated differences in median injury rates among census tracts with increased, decreased, or unchanged COI quintiles from 2018 to 2022. Sub-analyses stratified injuries by mechanism and intent using ICD-10 external cause codes.

Fifty (17%) of 287 census tracts had a change in COI quintile from 2018 to 2022. Of these, 34 (11%) increased and 16 (6%) decreased. During this period, 238 (73%) of 328 census tracts experienced changes in injury rates, with 174 (53%) increasing and 64 (20%) decreasing. Kruskal-Wallis testing demonstrated a significant relationship between change in COI quintile and change in injury rates (p=.011, Figure 1). Post hoc pairwise comparisons showed that census tracts with increasing COI quintiles had higher median injury rates compared to tracts without COI change (p=.0042). When stratified by injury mechanism and intent, significant relationships were observed for “struck by” (p=.007) and “unintentional” injuries (p=.0051). No statistically significant associations were identified for cut/pierce, fall, burn, nature/environmental, overexertion, pedal/cycle, firearm, motor vehicle traffic/transport, pedestrian, or assault injuries. Analysis was limited by the small number of census tracts with COI change.

Census tracts with improvement in COI over time were associated with increased median rates of “struck by” and “unintentional” injuries. No association was observed for other mechanisms or intents. These findings suggest that factors beyond the educational, health, environmental, social, and economic indicators included within COI contribute to pediatric injury risk. Interventions focused solely on COI-related factors may therefore be insufficient. Additional longitudinal data are needed to better understand the relationship between COI and pediatric injury over time.

• Understand the relationship between neighborhood conditions and pediatric injury risk
• Differentiate between place-based social resource indices such as COI, SVI, and ADI
• Recognize limitations of relying solely on place-based social resource measures to address child injury

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Michael Levas, MD, MS
Maria Beyer, BA, MPH
Kersten Bartelt, BSN, RN
Joe Deckert, MS, PhD
Eric Barkley
Dave Little, MD, MS

Motor vehicle crashes (MVCs) and firearm injuries are leading causes of injury-related morbidity among adolescents and young adults in the United States. Patterns of traumatic injury, risk-taking behaviors, and exposure to violence often cluster during adolescence and early adulthood; however, little is known about whether an emergency department (ED) presentation for one traumatic exposure may identify patients at increased risk for subsequent firearm injury. We sought to determine whether an ED visit for an MVC is associated with elevated risk of future firearm injury.

We conducted a retrospective matched cohort study using Cosmos, a multi-institutional Epic database representing over 300 million patient records from more than 1,800 hospitals and 41,000 clinics. Patients with an ED visit for an MVC between 2017 and 2025 and no documented prior firearm injury, MVC, or fall history were identified. MVC patients (>2 million) were matched 1:1 with patients presenting for falls (>2 million) based on age, sex, race/ethnicity, census region, and encounter month. Models additionally adjusted for rurality, social vulnerability index, ED acuity, smoking history, healthcare utilization, and comorbidities including mental health conditions, traumatic brain injury, developmental disorders, and lead exposure. Analyses were stratified by age, sex, and census region.

Among male patients, ED visits for MVCs were associated with increased subsequent firearm injury risk, particularly among adolescents and young adults. Male patients aged 10–15 years demonstrated the largest effect, with up to a three-fold increase in firearm injury risk following an MVA compared with matched fall patients across several census regions. Among males aged 16–25 years, elevated risk persisted but with smaller effect sizes, with up to an 81% increase depending on region. Associations were not consistently observed among females, and adults older than 25 years generally showed no meaningful increase in firearm injury risk. Negative-control outcomes including type 1 diabetes, eczema, and Crohn disease demonstrated no significant associations.

An ED visit for an MVC may identify adolescent and young adult males at elevated risk for future firearm injury. These findings suggest acute traumatic encounters may represent an opportunity for targeted injury prevention efforts, risk screening, and early linkage to community or hospital-based violence intervention resources. Future work should evaluate mechanisms underlying this association and determine whether ED-based interventions can reduce downstream firearm injury risk.

1. Motor Vehicle Crashes across the US may be markers for future firearm injury risk in young adolescent males.
2. Opportunities to screen for interconnected injury patterns may allow for earlier prevention and youth development efforts.
3. Large Electronic Medical Records offer a unique opportunity for injury prevention surveillance and raising the data infrastructure