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PEDIATRICS Vol. 101 No. 5 May 1998, pp. 817-824

Intervention to Improve Physician Documentation and Knowledge of Child Sexual Abuse: A Randomized, Controlled Trial

Received Apr 3, 1997; accepted Sep 2, 1997.

Rebecca R. S. Socolar*, Dagger , Byron Raines§, Mario Chen-Mok§, Desmond K. Runyan*, Dagger , Cynthia Green*, Dagger , and Steven Paterno*, Dagger

From the * Departments of Pediatrics, the § Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina; and the Dagger  Child Medical Evaluation Program, State of North Carolina, Chapel Hill, North Carolina.

Objective.  To determine if written feedback improves the chart documentation and knowledge of physicians doing evaluations for child sexual abuse and to learn what other factors are associated with better documentation and knowledge.

Design.  Randomized, controlled trial.

Setting.  A statewide network of physicians performing child abuse evaluations.

Participants.  All physicians who performed evaluations for sexual abuse during 1991 to 1992. One hundred forty-seven physicians were randomized to control (n = 75) and intervention (n = 72) groups, 122 (83%) remained at follow-up, and 87 of the 122 (71%) had done evaluations for child sexual abuse.

Interventions.  Tailored written feedback based on chart reviews and relevant articles were sent to a randomly selected one-half of the physicians during a 3-month period.

Main Outcome Measures.  The quality of documentation and physician knowledge before and after the intervention.

Results.  Documentation by chart review of up to five randomly chosen records per physician (preintervention, n = 552; postintervention, n = 259) by reviewers blinded to intervention status and physician knowledge was assessed by survey (78% completion). Change in documentation and knowledge for physicians in the intervention group was not statistically significant compared with the control group. The risk ratio for a mean overall history rating of excellent/good was 0.89 (0.63, 1.25) and for a mean overall physical examination rating of excellent/good was 1.03 (0.73, 1.45). Both groups improved significantly during the time period. The largest improvements in the time period were in documenting the history of where abuse occurred, in the physical examination position, hymenal description, penile findings, and knowing that chlamydia infection should be assessed by culture. A structured medical record, female physicians, and credits in continuing medical education were associated with better documentation.

Conclusions.  Tailored feedback to the physician with directed educational materials did not seem to improve most aspects of documentation and knowledge of child sexual abuse, although notable improvement was seen during the time period studied. This study suggests that chart audits may not be the best use of resources for trying to improve physician behavior; credits in continuing medical education and use of structured records may be more likely to be beneficial.

Key words: child abuse and neglect, continuing medical education, documentation, physician knowledge, randomized trial.




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