Healthcare Expenditures and Complex Chronic Conditions Following Pediatric Injury

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.