Journal of Adolescent Health 72 (2023) 972e976

www.jahonline.org

Original article

Violent Injury as a Predictor of Subsequent Assault-Related

Emergency Department Visits Among Adolescents
Marci J. Fornari, M.D. a, *, Gia M. Badolato, M.P.H. b, Krithika Rao c, Monika K. Goyal, M.D., M.S.C.E. a,
Robert McCarter, Sc.D. d, and Katie A. Donnelly, M.D., M.P.H. a
a
Children’s National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
b
Children’s National Hospital, Division of Emergency Medicine, Washington, District of Columbia
c
George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
d
Children’s National Hospital, Division of Translational Science, George Washington University School of Medicine and Health Sciences (retired), Washington, District of
Columbia

Article history: Received July 19, 2022; Accepted December 22, 2022
Keywords: Adolescent violence; Recidivism; Assault injury; Hospital-based violence intervention program

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: To measure the risk of a subsequent assault-related emergency department (ED) visit in
assault injured adolescents as compared to those who initially presented for non-assault related
These findings support
injuries. that assault injury among
Methods: This was a historical cohort study of youth (ages 10e18 years) seen at two pediatric EDs adolescents is a re-
between 2016 and 2019. Participants were included if their visit had an International Classification occurring problem and
of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and demonstrate the need for
sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and pediatric emergency de-
then used survival analysis to compare time to subsequent ED visit with an assault-related injury partments to implement
between study and comparison groups. violence prevention ini-
Results: A total of 6125 adolescents met inclusion criteria (Assault: n ¼ 2782, 45.4%; MVC: tiatives that target ado-
n ¼ 1834, 29.9%; Sports n ¼ 1509, 24.6%). The overall rate per 100 person years of a subsequent lescents at high-risk for
assault-related ED visit was 5.6 (n ¼ 344). Patients who initially presented with an assault-related future assaultive injury.
injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an
assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier
time to event analysis found that patients in the assault injury group have a higher probability of a
subsequent ED visit for an assault-related injury compared to patients in the MVC injury group
(adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42]).
Discussion: Adolescents injured by assault are more likely to return to the ED for a subsequent
assault-related injury compared to adolescents who initially present with non-assault-related
injuries.
Ó 2023 Society for Adolescent Health and Medicine. All rights reserved.

Conflicts of interest: The authors have no conflict of interest to disclose.
* Address correspondence to: Marci J. Fornari M.D., Children’s National Hos-
pital, Department of Pediatrics, George Washington University School of Medi-
cine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010.
E-mail address: MFornari@childrensnational.org (M.J. Fornari).
In 1996 the World Health Organization declared violence a
major public health issue [1]. More than two decades later, the
American Public Health Association continues to recognize
violence as a leading cause of morbidity and mortality in the

1054-139X/Ó 2023 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2022.12.014
 M.J. Fornari et al. / Journal of Adolescent Health 72 (2023) 972e976
United States among those 1e45 years of age, and specifically
among Black male youths between 10 and 25 years old [2]. Despite
the American Academy of Pediatrics emphasis on youth violence
prevention [3], assault among those aged 10e18 years accounts
for 15% of deaths per annum and remains the third leading cause
of death behind only unintentional injury and suicide [4]. Mor-
tality from violent injury represents only a fraction of the total
burden of violent injuries in adolescents. Assault accounts for
more than 200,000 emergency department (ED) visits annually
among children ages 10-18, and costs more than $15 billion
annually in medical, quality of life, and work-losses [4].
Assault-related injury in youth is a recurring problem; as
many as 40% of assault injured patients return to the ED for
repeat violent injuries within 5 years [5e7]. In the absence of
social worker intervention, about one-third of these reoccur
within the first post-assault year [8,9]. Risk factors associated
with repeat assault-related injury include male sex, Black race,
urban living, alcohol/drug use, weapon-carrying, and history of
involvement with the justice system [10e13].
Improved understanding of the risk and risk profile of
repeated assault-related injuries compared to repeat visits for
non-violent injuries, including sports and motor vehicle related
injury, would help to inform more targeted violence prevention
initiatives within pediatric EDs.
Therefore, the objectives of this study are to: (1) measure the risk
of a subsequent assault-related ED visit in assault injured youth
as compared to those who initially presented for non-assault
related injuries; and (2) describe the socio-demographics of
patients presenting to the ED for assault-related injury and
non-assault related injuries.
Methods
This was a historical cohort study of youth (ages 10e18 years)
seen at one of two pediatric EDs between January 1, 2016 and
December 31, 2019. The main ED is located within a children’s
hospital and has an annual ED volume of 90,000 visits, including
w19,000 adolescent visits. The satellite ED is located within a
community hospital in a historically under-served area, and has
an annual volume of 37,000 visits, including w6,000 adolescent
visits. Participants were included if their initial ED visit had an
International Classification of Diseases 10th Revision (ICD-10)
code for assault-related injury [codes: X92-X99, Y00-Y04, Y08,
Y09, and T7] or a comparison group with accidental injury. We
defined accidental injury as an injury due to a motor vehicle
collision (MVC) [codes: V30-V79, V83-V87, and V89] or a sports-
related injury [codes: W21, Y93.22, Y92.310, Y92.32, Y92.838,
Y93.4,-Y93.6, Y93.7, W18.01], two clearly defined and common
injuries among adolescents who present to the ED for care. MVC
injuries and sports injuries were chosen as comparison groups
with injury due to violence because they have a similar range in
severity. In addition, all injuries requiring medical care, regardless
of mechanism or intentionality, have the potential for negative
psychological impact on adolescents [14e17]. Once patients were
placed into their initial cohorts, only subsequent ED visits for an
assault-related injury were counted as a return visit.
Patients were excluded from the cohort if they were trans-
ferred from an outside hospital as they would be more likely to
seek care for subsequent injuries at a local hospital, were injured
due to child abuse or sexual assault, had a mechanism of injury
that could not be clearly defined, or died at the index visit. We
extracted patient and visit level data from the electronic health
973
record (EHR). Data collected on each patient included, age, sex,
race, ethnicity, insurance type, date of initial ED visit, and dates of
subsequent ED visits related to assault. Twenty percent of charts
from each cohort were manually reviewed by the research team
to validate the accuracy of electronic data.
Relative frequencies were used to describe and compare
study groups. Poisson regression analyses were used to calculate
the adjusted relative risks (aRR) of recidivism by type of injury,
adjusting for age, sex, and insurance type [18]. Insurance type
was used as a marker of socioeconomic status [19], which has
also been associated with experiencing assault-related injuries
[20]. We did not adjust for race because almost all of the return
visits were in Black, non-Hispanic patients, and therefore we
were unable to perform this analysis due to lack of events in the
comparator group. We also implemented time to event analysis,
including unadjusted Kaplan-Meier and adjusted Cox Regression,
using the aforementioned covariates, to estimate the hazard ratio
of return visits for an assault-related injury by type of initial visit.
Adjusted hazard ratios (aHR) with 95% CI were estimated to test
the hypothesis that recidivism for assault in the study group was
more likely than recidivism of the same type in the comparison
groups (lower confidence limit > 1). All statistical analyses were
performed using Stata 16 (StataCorp, College Station, TX). This
study was approved by our institutional review board.
Results
During the study period, 6125 adolescents presented to the ED
for an initial visit. Among those, 3876 (63.3%) were seen for their
initial visit at the main ED. Initial visits for an assault-related
injury were less likely to present to the main ED compared to an
MVC-related injury (OR: 0.8 [95% CI: 0.7, 0.9]) and initial visits for a
sports-related injury were more likely to present to the main ED
compared to an MVC-related injury (OR: 1.4 [95% CI: 1.2, 1.6]).
Of those visits, 45.4% were for assault, 29.9% were for MVC, and
24.6% were for sports-related injury. The majority of patients were
Black (76.5%), male (53.1%), between the ages of 10e14 (53.7%),
and publicly insured (72.6%) (Table 1).
Within the study population, there are prominent differences
in age, sex, race/ethnicity, and payor status between study
groups. Adolescents presenting for an initial assault-related
injury were older (15e18 years old), more likely to identify as
Black, and use public insurance as compared to the adolescents
presenting for an initial MVC or sports-related injury (p < .0001)
(Table 1).
The overall rate per 100 person years of a subsequent assault-
related ED visit was 5.6 (n ¼ 344). This rate varied by initial di-
agnoses: 11.8 (n ¼ 329) for the assault injury group, 0.6 (n ¼ 11)
for the MVC injury group, and 0.3 (n ¼ 4) for the sports injury
group. Patients who initially presented with an assault-related
injury had an increased aRR of return for a subsequent ED visit
for an assault-related injury when compared to MVC patients
(aRR 17.6 [95% CI: 9.6, 32.2]) and when compared to sports injury
patients (aRR 36.5 [95% CI: 13.6, 98.1]) (Figure 1). There was no
difference in rate of subsequent ED visit for assault-related injury
between the two comparison groups, sports-related injury and
MVC-related injury (aRR 0.50 [95% CI: 0.12,1.5]). Over 75% of the
subsequent visits were in our Black, non-Hispanic population,
and no white, non-Hispanic patients returned.
In our Kaplan-Meier time to event analysis, we modeled the
probability of returning to our EDs for an assault-related visit.
Patients were followed from their index visit until a subsequent
974 M.J. Fornari et al. / Journal of Adolescent Health 72 (2023) 972e976

Table 1
Select characteristics of study population at initial ED visit. p-value < .05 is considered statistical significance

Characteristic Study Pop (N, %) Assault (N,%) MVC (N, %) Sports Injury (N, %) Assault versus MVC p-valucs Assault versus Sports Injury p-valucs

Total 6125 (100%) 2782 (45.4%) 1834 (29.9%) 1509 (24.6%) .0001 .0001
Main ED 3876 (63.3%) 1634 (58.7%) 1174 (64.0%) 1068 (70.8%)
Satellite ED 2249 (36.7%) 1148 (41.3%) 660 (36.0%) 441 (29.2%)
Age (years) .0001 .0001
10e14 3286 (53.7%) 1104 (39.7%) 1179 (64.3%) 1003 (66.5%)
15e18 2839 (46.4%) 1678 (60.3%) 665 (35.7%) 506 (33%)
Sex .0001 .0001
Female 2873 (46.9%) 1328 (47.7%) 996 (54.3%) 549 (36.4%)
Male 3252 (53.1%) 1454 (52.3%) 838 (45.7%) 960 (63.6%)
Race/Ethnidty .0001 .0001
White. NH 299 (4.9%) 41 (1.5%) 110 (6.0%) 148 (9.8%)
Black, NH 4684 (76.5%) 2536 (84.7%) 1314 (71.7%) 1014 (67.2%)
Hispanic 887 (14.5%) 298 (10.7%) 319 (17.4%) 270 (17.9%)
Othera 255 (4.2%) 87 (3.1%) 91 (4.9%) 77 (5.1%)
Insurance .0001 .0001
Private 1057 (17.3%) 299 (10.8%) 359 (19.6%) 399 (26.4%)
Public 4444 (72.6%) 2184 (78.5%) 1251 (68.2%) 1009 (66.7%)
Self-Pay 624 (10.2%) 299 (10.8%) 224 (12.2%) 101 (6.7%)
a
Other: Asian, Multiple Races, Not Documented.

assault visit or the end of the study period. The median length of
time in the study period was 730 days (IQR 320, 1,128). Based on
Cox regression controlling for the aforementioned covariates,
patients in the assault injury group have a higher probability of a
subsequent assault-related ED visit compared to patients in the
MVC injury group (aHR: 17.7 [95% CI: 9.67, 32.42]) or in the sports
injury group (aHR: 36.0 [95% CI: 14.0, 97.0]). There was no dif-
ference when we compared sports-related injury to MVC-related
injury (aHR 0.49 [95% CI 0.16-1.54]) (Figure 2).
Discussion
This study found that adolescents who present to the ED with
an initial assault-related injury have a higher risk of returning to
Figure 1. Rate and aRR of subsequent ED visits for assault-related injury among
adolescents, by initial reason for ED visit. *adjusted for age, sex, and insurance
status.
the ED for the same reason than adolescents who initially pre-
sent for non-violent injuries. This is consistent with prior studies
suggesting that previous episodes of violent injury are the
strongest predictor of future violent injuries [21]. Adolescents
who experience an assault injury, have a history of a prior assault
visit, or who have witnessed an assault are four times more likely
to experience another assault-related episode than adolescents
with no history of assault [22,23].
It is well established that traumatic stressors, regardless of
intentionality, are risk factors for anger, behavioral problems,
mental illness, and substance use in youth [14]. In addition, all
injuries requiring medical care can cause long-term psycholog-
ical stress [15e17]. The findings of this study highlight the
importance of the understanding the injury context for assessing
the risk and consequences of ED recidivism for subsequent
injuries.
In our study population, adolescents who presented to the ED
with an initial assault-related injury were older than adolescents
who presented with sports or MVC-related injuries. As adoles-
cents age, they are less likely to seek care at a pediatric hospital
[24]. The accidently injured adolescents entered the study at a
younger age and were therefore more likely to continue to seek
care at a pediatric hospital for injuries during the study period,
and thus had more time and opportunity to return for subse-
quent injuries, nevertheless repeat injuries of the same type
were rare. Despite being older at initial presentation, the assault-
injured adolescents were significantly more likely to return for a
subsequent injury, especially an assault-related injury. Therefore,
our study likely underestimates the risk of a subsequent assault
injury visit in violently injured adolescents, as it is increasingly
likely that they sought care in, or were transported to, a general
ED rather than our pediatric ED.
Consistent with previous studies [23], adolescents presenting
for assault-related injuries were more likely to be Black, non-
Hispanic and have public medical insurance. This was particu-
larly evident when compared to the predominately white, pri-
vately insured adolescents who presented for an initial sports-
related injury. This difference highlights the contrasts in oppor-
tunity afforded these two groups as well as the consequences of
these resource disparities, a likely product of systemic racism
 M.J. Fornari et al. / Journal of Adolescent Health 72 (2023) 972e976
Figure 2. Kaplan-Meier survival estimates of the probability of not returning for an assault-related ED visit among adolescents, by initial reason for ED visit. *adjusted
for age, sex, and insurance status.
[25]. Children from high socioeconomic status and white chil-
dren are more likely to participate in sports than children from
lower socioeconomic status and Black and Hispanic children
[26,27]. Moreover, participation in sports is protective against
drug use and physical fighting, improves mental health, in-
creases educational achievement and helps athletes develop life
skills like teamwork, goal setting and self-control [28,29]. Our
study supports prior studies which showed no substantial
difference in sex of patients who present to the ED for
assault-related injuries [12]. There was a male predominance in
sports-related injuries, but this is likely because more males
participate in sports than females in the adolescent years [30].
While addressing issues of systemic racism on a macro-level
is necessary to reduce rates of adolescent morbidity and mor-
tality from violence, these changes will take significant time,
effort, and money. This is because adolescents from lower so-
cioeconomic status are more likely to be involved in violence due
to residential segregation, which is associated with lack of
institutional resources, less political power, inequities in policing
and difficulties in controlling crime, lower quality schools, and
gang networks [31]. Adolescents would benefit from joint efforts
between governmental agencies, community organizations, and
healthcare systems to interrupt the cycle of violence. Specifically,
our study findings support the need for micro-level point-of-care
interventions specifically for adolescents who present to the ED
for injuries related to an assault to reduce rates of re-
victimization. ED providers have a unique opportunity to capi-
talize on a potentially reachable event that could decrease future
morbidity and mortality for this young and vulnerable popula-
tion. Hospital-based violence intervention programs (HVIPs), for
example, have been shown to reduce repeat violent injury and to
be cost effective [32,33]. Our research supports the need for
expansion of these programs and other innovative violence
975
intervention efforts within the pediatric ED setting to curtail the
cycle of violence for adolescent survivors of assault.
This study has some limitations that merit discussion. Pa-
tients were identified using ICD-10 codes, and often mechanism
of injury is not properly coded [12]. Thus, there are likely patients
in both the assault and comparison groups who were injured by
the stated mechanisms but were not included in this study due to
incorrect or missing ICD-10 codes. Also, our level one pediatric
trauma center only accepts trauma activations for children
younger than age 15. Therefore, severe assault or accidental in-
juries in children older than 14 would be less likely to be
captured in our data set, as they would likely be transported to a
general trauma center instead. Thus, it is likely that we are
missing data from both index and subsequent assault-related
visits as violence escalates in severity over time [6,34]. In the
future, we hope to collaborate with the local general trauma
centers, so we gain a deeper understanding of what happens to
adolescents who presents to a pediatric ED with an initial
assault-related injury, and how best we can support these pa-
tients in preventing subsequent injuries. Lastly, results of this
study at linked tertiary care pediatric EDs in a large city, are
generalizable to other large cities, but may not be generalizable
to other geographic locations or populations.
In conclusion, adolescents who present to the ED for an initial
injury due to an assault are much more likely to return to the ED
for a similar repeat injury, specifically an assault-related injury,
than repeat injuries of the same type in adolescents who present
for an initial accidental injury. On an individual level, providers in
pediatric EDs have a responsibility to assess how the injury
occurred, so that they can provide proper care and support to
these patients who have a high risk of a subsequent violent
injury. On a systems level, it is critical for pediatric EDs to put
processes in place to provide assault-injured adolescents with
976 M.J. Fornari et al. / Journal of Adolescent Health 72 (2023) 972e976
violence intervention resources. Many EDs have successfully
adopted H-VIPs to address risk factors that make adolescents
prone to repeated violent injuries [21,35e37], and our study
supports the need to continue widespread implementation of
these programs within pediatric EDs.
Acknowledgments
All authors have made significant contributions to this work,
and all contributors to this work have been acknowledged. The
findings from this study have been previously presented in
poster format at the Pediatric Academic Society 2021 meeting
and at the American Academy of Pediatrics 2021 meeting.
Funding Sources
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
References
[1] 49th World Health Assembly. Prevention of violence: A public health Pri-
ority. 1996. Available at: http://www.who.int/violence_injury_prevention/
resources/publications/en/WHA4925_eng.pdf?ua¼1. Accessed January 7,
2022.
[2] American Public Health Association. Violence is a public health issue:
Public health is Essential to understanding and Treating violence in the U.S.
2018. Available at: https://www.apha.org/policies-and-advocacy/public-
health-policy-statements/policy-database/2019/01/28/violence-is-a-public
-health-issue. Accessed January 7, 2022.
[3] Joint policy StatementdGuidelines for care of children in the emergency
department. Pediatrics 2009;124:1233e43.
[4] Web-based injury Statistics Query and Reporting system (WISQARS).
Centers for Disease control and prevention, National center for injury
prevention and control. Available at: www.cdc.gov/injury/wisqars.
Accessed February 1, 2022.
[5] Sims DW, Bivins BA, Obeid FN, et al. Urban trauma: A Chronic recurrent
Disease. J Trauma 1989;29:940e7.
[6] Cunningham RM, Carter PM, Ranney M, et al. Violent reinjury and mortality
among youth seeking emergency department care for assault-related
injury: A 2-year prospective cohort study. JAMA Pediatr 2015;169:63e70.
[7] McCoy AM, Como JJ, Greene G, et al. A novel prospective approach to
evaluate trauma recidivism: The concept of the past trauma history.
J Trauma Acute Care Surg 2013;75:116e21.
[8] Cortolillo N, Moeller E, Parreco J, et al. Readmission and reinjury patterns in
pediatric assault victims. Pediatr Surg Int 2020;36:191e9.
[9] Kwan K, Wiebe D, Cerdá M, Goldman-Mellor S. Repeat assault injury
among adolescents Utilizing emergency care: A Statewide Longitudinal
study. J Emerg Med 2019;57:254e62.
[10] Ballesteros MF, Williams DD, Mack KA, et al. The Epidemiology of unin-
tentional and violence-related injury morbidity and mortality among
children and adolescents in the United States. Int J Environ Res Public
Health 2018;15:1e19.
[11] Copeland-Linder N, Johnson S, Haynie D, et al. Retaliatory attitudes and violent
behaviors among assault-injured youth. J Adolesc Heal 2013;50:215e20.
[12] Ranney ML, Mello MJ. A comparison of female and male adolescent victims of
violence seen in the emergency department. J Emerg Med 2011;41:701e6.
[13] Carter PM, Dora-Laskey AD, Goldstick JE, et al. Arrests among high-risk
youth following emergency department Treatment for an assault injury.
Am J Prev Med 2018;55:812e21.
[14] Copeland W, Keeler G, Angold A, Costello J. Traumatic events and Post-
traumatic stress in childhood. Arch Gen Psychiatry 2007;64:577e84.
[15] Sanders MB, Starr AJ, Frawley WH, et al. Posttraumatic stress Symptoms in
children Recovering from Minor Orthopaedic injury and Treatment.
J Orthop Trauma 2005;19:623e8.
[16] Mehta S, Ameratunga SN. Prevalence of post-traumatic stress disorder
among children and adolescents who survive road traffic crashes: A sys-
tematic review of the international literature. J Paediatr Child Health 2012;
48:876e85.
[17] Wallace M, Puryear A, Cannada LK. An Evaluation of Posttraumatic stress
disorder and parent stress in children with Orthopaedic injuries. J Orthop
Trauma 2013;27:e38e41.
[18] Purtle J, Carter PM, Cunningham R, Fein JA. Treating youth violence in
hospital and emergency department settings. Adolesc Med State Art Rev
2016;27:351e63.
[19] Casey JA, Pollak J, Glymour MM, et al. Measures of SES for electronic health
record-based research. Am J Prev Med 2018;54:430e9.
[20] Singh TK, Khan M, Tansley G, et al. Neighborhood socioeconomic Depri-
vation and youth assault injuries in Vancouver, Canada. J Pediatr 2022;240:
199e205.e13.
[21] Cunningham RM, Ranney M, Newton M, et al. Characteristics of youth
seeking emergency care for assault injuries. Pediatrics 2014;133:e96e105.
[22] Cheng TL, Schwarz D, Brenner RA, et al. Adolescent assault injury: Risk and
protective factors and locations of Contact for intervention. Pediatrics
2003;112:931e8.
[23] Lim H, McCart M, Davies H, et al. Risk for repeat emergency department
visits for violent injuries in youth Firearm victims. Clin Med Trauma
Intensive Med 2008;2:1e7:CMTIM.S2141.
[24] Marsh RH, Mollen CJ, Shofer FS, Baren JM. Characteristics that Distinguish
adolescents who present to a children’s hospital emergency department
from those presenting to a general emergency department. Pediatr Emerg
Care 2009;25:376e9.
[25] Johnston LD, Delva J, O’Malley PM. Sports participation and physical edu-
cation in American Secondary schools. Current levels and Racial/Ethnic and
socioeconomic disparities. Am J Prev Med 2007;33:S195e208.
[26] The Aspen Institute. State of Play - Trends and Developments in youth
sports. Washington, DC: The Aspen Institute; 2019. Available at: https://
www.aspeninstitute.org/publications/state-of-play-2019-trends-and-develo
pments/. Accessed January 25, 2023.
[27] Wijtzes AI, Jansen W, Bouthoorn SH, et al. Social inequalities in young
children’s sports participation and outdoor play. Int J Behav Nutr Phys Act
2014;11:155.
[28] Harrison PA, Narayan G. Differences in behavior, psychological factors, and
Environmental factors associated with participation in school sports and
other Activities in adolescence. J Sch Health 2003;73:113e20.
[29] President’s Council on Sports Fitness & Nutrition Science Board. PCSFN
Science Board Report on Youth Sports, Proceedings from the 2020 Annual
Meeting of the President’s Council on Sports, Fitness & Nutrition. 2020.
Available at: www.health.gov/our-work/pcsfn/about-pcsfn/science-board.
Accessed September 17, 2022.
[30] Deaner RO, Geary DC, Puts DA, et al. A sex difference in the Predisposition
for physical Competition: Males play sports much more than females even
in the Contemporary U.S. PLoS One 2012;7:e49168.
[31] Cheon C, Lin Y, Harding DJ, et al. Neighborhood racial Composition and Gun
Homicides. JAMA Netw Open 2020;3:e2027591.
[32] Brice JM, Boyle AA. Are ED-based violence intervention programmes
effective in reducing revictimisation and perpetration in victims of
violence? A systematic review. Emerg Med J 2020;37:489e95.
[33] Purtle J, Dicker R, Cooper C, et al. Hospital-based violence
intervention programs save lives and money. J Trauma Acute Care Surg
2013;75:331e3.
[34] Carter PM, Walton MA, Roehler DR, Goldstick J. Firearm violence among
high-risk emergency department youth after an assault injury. Pediatrics
2015;135:805e15.
[35] Cheng TL, Johnson S, Wright JL, et al. Assault-injured adolescents pre-
senting to the emergency department: Causes and Circumstances. Acad
Emerg Med 2006;13:610e6.
[36] De Vos E, Stone D, Goetz M, Dahlberg L. Evaluation of a hospital-based
youth violence intervention. Am J Prev Med 1996;12:101e8.
[37] Ranney ML, Whiteside L, Walton MA, et al. Sex differences in character-
istics of adolescents pPresenting to the emergency department with acute
assault-related injury. Acad Emerg Med 2011;18:1027e35.