PEDIATRICS Vol. 117 No. 3 March 2006, pp. 722-728 (doi:10.1542/peds.2004-2731)
ARTICLE |
Variation in the Diagnosis of Child Abuse in Severely Injured Infants
a Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
b Department of Public Health, Boston University, Boston, Massachusetts
c Biostatistics Research Center
d Pediatric and Adolescent Health Research Center, Floating Hospital for Children, TuftsNew England Medical Center, Boston, Massachusetts
OBJECTIVE. Diagnosis of child abuse is difficult and may reflect patient, practitioner, and system factors. Previous studies have demonstrated potential lethal consequences if cases of abuse are missed and suggested a role for continuing medical education in improving the accuracy of diagnosis of suspected abuse. Although the majority of injured American children are treated at general hospitals, most published studies of severe injury resulting from child abuse have been conducted at childrens hospitals. The objective of this study was to evaluate the role of hospital type in observed variations in the frequency of diagnosis of child physical abuse among children with high-risk injuries.
METHODS. Hospital discharge data were evaluated, and adjusted rates of abuse diagnosis were reported according to hospital type. A regression model estimated the number of cases of abuse that would have been diagnosed if all hospitals identified abuse as frequently as observed at pediatric specialty hospitals. This study consisted of children who were <1 year old and admitted to US hospitals in 1997 for treatment of traumatic brain injury or femur fracture, excluding penetrating trauma or motor-vehiclerelated injury. A total of 2253 weighted cases were analyzed.
RESULTS. The proportion of patients with a medical diagnosis of child abuse varied widely between hospital types: 29% of the cases were diagnosed as abuse at childrens hospitals compared with 13% at general hospitals. An estimated 178 infants (39% of total) with these specific injuries would have been identified as abused had they been treated at childrens rather than general hospitals.
CONCLUSIONS. Hospital type was associated with large variations in the frequency of diagnosis of child abuse. This variation was not related to observed differences in the patients or their injuries and may result from systematic underdiagnosis in general hospitals. This result has implications for quality-improvement programs at general hospitals, where the majority of injured children in the United States receive emergent medical care.
Key Words: medical error hospital discharge data child abuse femur fracture traumatic brain injury medical error
Abbreviations: TBItraumatic brain injury HCUPHealthcare Cost and Utilization Project ICD-9-CMInternational Classification of Diseases, Ninth Revision, Clinical Modification NACHRINational Association of Childrens Hospitals and Related Institutions ISSinjury severity score CIconfidence interval ORodds ratio
Accepted Jun 30, 2005.
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