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Epidemiology of Pediatric Injury—Related Primary Care Office Visits in the United States

Simon J. Hambidge, MD, PhD^*,, Arthur J. Davidson, MD, MSPH^*,,||, Ralph Gonzales, MD, MSPH^,¶ and John F. Steiner, MD, MPH^,¶

^* Department of Community Health, Denver Health and Hospital Authority, Denver, Colorado
Department of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado
Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, Colorado
^|| Department of Family Medicine, University of Colorado Health Sciences Center, Denver, Colorado
^¶ Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, Colorado

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	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objectives. Unintentional injuries are a major cause of childhood mortality and morbidity in the United States. However, there is little epidemiologic information about pediatric injuries seen in primary care settings. The objective of this study was to characterize types and external causes of childhood injuries seen by primary care physicians and to compare the demographic and visit characteristics of children with injury-related visits (IRVs) and non-IRVs.

Methods. A stratified random sample survey of office-based practicing physicians in the National Ambulatory Medical Care Survey (1997 and 1998) was conducted. Injury-related primary care office visits were measured for patients who were <19 years (number of patient visits = 6358).

Results. Visits for childhood injuries composed >10 million primary care office visits per year (a rate of 13.8 visits per 100 person-years). The most common diagnoses assigned to these injuries were open wounds, sprains and strains, contusions, and superficial injuries such as abrasions and splinters. Leading external causes of these injuries were sports and overexertion, accidental falls, natural factors such as bites and stings, and cutting instruments. The single most common cause of pediatric injuries was sports/overexertion. Children who had IRVs were more likely to be older (odds ratio [OR]: 1.10/year of age; 95% confidence interval [CI]: 1.08–1.12), to be male (OR: 1.5; 95% CI: 1.2–1.9), and to reside in the West (OR: 1.9; 95% CI: 1.4–2.6) or in a rural area (OR: 1.4; 95% CI: 1.1–1.9). They were less likely to be Asian (OR: 0.2; 95% CI: 0.1–0.5) or Hispanic (OR: 0.5; 95% CI: 0.3–0.8). At the visit, children with IRVs were more likely to see a physician who was not their primary care physician (OR: 1.8; 95% CI: 1.4–2.3) and to see a family physician rather than a pediatrician (OR: 2.3; 95% CI: 1.8–2.9).

Conclusions. IRVs account for a significant portion of primary care for children in the United States. Identifying potentially preventable external causes of injury and characteristics of children who are more likely to be injured is important both for injury prevention programs and for the education of physicians who care for children.

Key Words: pediatric injury • primary care • sports injuries • NAMCS

Abbreviations: ED, emergency department • IRV, injury-related visit • NAMCS, National Ambulatory Medical Care Survey • PCP, primary care physician • NCHS, National Center for Health Statistics • PRF, patient record form • PSU, primary sampling unit • RSE, relative standard error • SE, standard error • CI, confidence interval • OR, odds ratio

	INTRODUCTION

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Since the 1940s, unintentional injuries have caused more deaths per capita in children aged 1 to 19 years than all infectious diseases and now account for 44% of all childhood deaths.¹ Indeed, unintentional injuries in this age group result in more deaths than the next 9 causes of death combined.² Although unintentional injury deaths have declined by >40% during the past 2 decades,³ the rate of childhood injury deaths in the United States remains more than twice the rate in other developed countries.⁴ Furthermore, it has been estimated that 18 hospitalizations and 233 emergency department (ED) visits occur for every injury death⁵ and that 20.6 million children in the United States are injured each year, resulting in a nonfatal injury rate of 25 per 100 children.⁶ The costs of unintentional childhood injury, both for the children involved and society at large, exceed $80 billion per year when future work losses are included.⁷

During the past 30 years, research in public health has helped to better the understanding of the incidence and risk factors of childhood injuries, in designing interventions to prevent those injuries, and in evaluating the impact of the interventions. The resultant decrease in childhood injury rates has highlighted that childhood injuries are not simply accidents but events that in many cases can be prevented with a better understanding of their cause and appropriate interventional strategies.^8,9 However, a recent comprehensive review of the science of childhood injury epidemiology and prevention¹⁰ highlighted deficiencies in a number of areas. These deficiencies include the absence of detailed and reliable data on nonfatal injuries and the lack of detailed information on the external causes of nonfatal injuries.

Virtually all studies of childhood injuries have focused on the subset of injured children who receive medical care in the hospital or ED setting.¹¹ However, approximately two thirds of injury-related visits (IRVs) to physicians in the United States are made to physician offices,¹² and roughly 10% of pediatric ambulatory office visits are injury related.¹³ Little is known about the majority of injured children who receive evaluation and treatment for injuries in primary care practices. Although the injuries sustained by these children may be less severe than those that present to the ED, the aggregate burden of these injuries may be substantial for the children, the families, the health care system, and society at large.

On the basis of the need for more detailed information about nonfatal childhood injuries, we used the National Ambulatory Medical Care Survey (NAMCS) to characterize pediatric IRVs to primary care physician (PCP) offices in a nationally representative sample. In particular, we examined the types of injuries diagnosed and the external causes of those injuries, and we compared the demographic characteristics of injured children with noninjured children.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The NAMCS
The NAMCS, conducted annually by the National Center for Health Statistics (NCHS), is a national survey designed to provide reliable information about the use of ambulatory medical care services in the United States. It samples nonfederally employed office-based physicians who are primarily engaged in direct patient care. Through the use of a patient record form (PRF),¹⁴ this survey describes office visit characteristics for the US civilian, noninstitutionalized population who seek medical care from 1 of the study physicians. The results presented here use data from the 1997 and 1998 NAMCS.

To derive representative national estimates, the NAMCS uses a multistage probability sample design. This design involves probability samples of primary sampling units (PSUs) within geographic areas, physician practices within PSUs, and finally patient visits within practices. A sample of approximately 2500 nonfederally employed physicians, identified from the master files of the American Medical Association and the American Osteopathic Association, is screened annually; approximately 700 physicians are ineligible because of retirement or employment primarily in teaching, research, or administration. Of the eligible physicians, 1247 participated in 1997 (69% response rate)¹⁴ and 1226 participated in 1998 (68% response rate).¹⁵ Participating physicians complete the survey instrument (the PRF) for a systematic random sample of office visits during a randomly assigned 1-week reporting period. Before this week, NAMCS study personnel meet with participating physicians and their staff to explain proper completion of the survey instrument. The final database contained 24 715 patient visits in 1997 and 23 339 in 1998.

Data Extraction
To evaluate pediatric IRVs to primary care physician offices in 1997 and 1998, we excluded all patients aged 19 years and older and limited visits to primary care specialties (general and family practice, pediatrics, adolescent medicine, and general internal medicine). The resultant data set contained 6358 patient visits.

We used the NCHS definition of an IRV.¹² The NAMCS survey form denotes an IRV by a box that the physician checks if appropriate: "Is this visit related to an injury?" To identify additional IRVs that might not be identified by this question alone, the Centers for Disease Control and Prevention uses 4 supplemental diagnostic criteria to define an IRV: a reason for visit or injury diagnosis that is injury related, or specification of a cause or location of injury on the PRF. The use of these additional diagnostic criteria expanded the number of IRVs in the 1997 NAMCS for all ages by approximately 20% to 30%.¹³ However, for the pediatric patients in the 1997 and 1998 NAMCS, the use of these additional diagnostic criteria increased the number of IRVs in the sample from 445 to 447. Thus, at least for pediatric patients seen in primary care office settings, the injury box on the NAMCS survey form had a 99.5% sensitivity for IRVs compared with use of all 5 IRV criteria.

We evaluated patient, source of payment, physician, practice, and visit characteristics for all IRVs and non-IRVs. Most items in the NAMCS had a >95% response rate.^14,15 Two exceptions were the ethnicity box, which had a 19% nonresponse rate for patients <19 years old, and the place of occurrence of injury. We imputed all blank entries in the ethnicity box as not Hispanic. A practice was considered to be rural if it was not located within a metropolitan statistical area, as defined by the US census bureau.¹⁶ To examine the external cause of pediatric IRVs, we examined both external cause codes (E-codes, as entered by the NCHS) and the actual verbatim text as entered by the physician who filled out the PRF. Seventy-three percent of the IRVs in this sample had a transcribed external cause of injury in the database. In contrast to the NCHS coders, who coded a fall in any context as an accidental fall (E880–E888), we considered a fall that occurred during a sporting event to be a sports/recreation injury. Using NCHS recodes resulted in falls being the most common cause of pediatric IRVs, whereas using the actual text entered by physicians resulted in sports being the most common cause. There were no significant differences between NCHS codes and physician text for other causes of injury.

Calculation of Injury Visit Rates
The denominators for injury visit rates are calculated from estimated US population data from the Census Bureau (www.census.gov/population/estimates/nation/e90s/e9797rmp.txt and e9898rmp.txt) for July 1, 1997, and July 1, 1998. For the analyses in this article, the average of the populations on these 2 dates was calculated to give estimated population figures for January 1, 1998, the midpoint of this study. The Census Bureau also provided denominators for the 4 regions of the country, as well as for metropolitan and nonmetropolitan areas. For calculating percentages for place of injury occurrence and for sports-related injury rates by race, adjustment was made for nonresponse.

Statistical Analysis
National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NAMCS database. These weights are derived from the probability of being sampled (as a PSU, as a physician practice, and as a patient visit) and are adjusted for nonresponse.¹⁴ For aggregate national estimates, the approximate relative standard error (RSE), expressed as a percentage of the estimate, was calculated using the formula RSE = [square root {(b/x) + a}] x 100, where a and b are the coefficients equivalent to the design effect of the NAMCS averaged for physician specialty estimates and x is the number of patient visits in thousands.¹² For the calculations in this article, we used 1997 visits to pediatricians as the reference for a and b. Because the data presented are an average of 2 years rather than a single year, actual RSEs will be approximately 20% lower than those we present (Dr Kathy Burt, Ambulatory Statistics Branch, NCHS, personal communication). The standard error (SE) and 95% confidence interval (CI) for each aggregate national estimate were then calculated using the formulas SE = (RSE) (x) and 95% CI = (1.96) (SE).

To measure the unadjusted association between predictor variables (patient, payment, physician, and practice characteristics) and whether a child had an IRV, we performed ² tests using the SAS Statistical Application Program (Release 6.12; SAS Institute Inc, Cary, NC). Independence of associations was tested further using multivariate logistic regression analysis and is presented as adjusted odds ratios (ORs) with 95% CIs. All measures of association were performed using modified sample weights recommended by the NCHS, which were calculated as follows: modified Weight (mWt) = (Wts)/(Wts²). With this modification, the point estimate of the number of visits is adjusted by the inverse of its variance.¹⁷

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Extrapolating from the NAMCS samples for 1997 and 1998, children younger than 19 years account for approximately 136 million pediatric primary care office visits per year in the United States. Of these, >10 million (7.5%) were for an IRV. Injuries were the fourth most common reason for primary care office visits, behind well-child care (31 million visits per year, 23% of visits), otitis media (9%), and upper respiratory infections (9%).

Table 1 illustrates injury visit rates to PCP offices by children, with an overall visit rate of 13.8 per 100 person-years. Injury visit rates seem to be similar across the age spectrum of children (range: 12.1–15.0 visits per 100 person-years). Native American children have the highest injury visit rate among the 4 main racial groups used by the US census, whereas children of Asian or Pacific Island descent have the lowest. Hispanic children have a 2.4-fold lower injury visit rate compared with non-Hispanic children. In young children up to 5 years of age, the home is almost always (79%) the site of injury that leads to a visit to a PCP office, whereas by adolescence, school (26%) and sports areas (25%) are the 2 main sites of injury (data not shown).

The physician diagnoses for IRVs in this sample are shown in Table 3. The most common diagnostic categories were open wounds, sprains and strains, contusions, and superficial injuries (including abrasions, blisters, insect bites, and splinters). The underlying cause of these injuries is shown in Table 4. The most common causes were sports and overexertion (19% of IRVs), followed by accidental falls (16%), natural factors such as bites and stings (15%), accidents caused by cutting instruments (8%), motor vehicle accidents (5%), intentional injury (4%), and burns (2%). The 4% of IRVs for intentional injuries included child abuse, fights, and sexual assault.

A multivariate analysis of the child and physician characteristics for IRVs versus non-IRVs is shown in Table 5. Children at IRVs were older (OR: 1.1 per year of age; 95% CI: 1.08–1.12) and more likely to be seen in a practice in the West (OR: 1.9; 95% CI: 1.4–2.6) and in a nonmetropolitan area (OR: 1.4; 95% CI: 1.1–1.9). They were less likely to be Asian or Pacific Islanders (OR: 0.2; 95% CI: 0.1–0.5) or of Hispanic ethnicity (OR: 0.5; 95% CI: 0.3–0.8). Although children at IRVs were more likely to be American Indian in crude analysis, this was not significant after adjustment for region of country and rural residence (OR: 1.9; 95% CI: 0.8–4.6). Children at IRVs were more likely than those at non—IRVs to see a family physician (OR: 2.2; 95% CI: 1.8–2.9) or an internist (OR: 2.5; 95% CI: 1.7–3.8) than a pediatrician. They were more likely to see a physician who was not their PCP (OR: 1.8; 95% CI: 1.3–2.3).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

Children with an IRV differed from children who had visits for noninjury reasons. They were more likely to be male, in agreement with past findings.^20,22,23 They were more likely to be older, although this difference was primarily attributable to the number of preventive care visits that younger children made to PCP offices. When examined at the population level, there were no major differences in injury visit rates across the pediatric age spectrum (Table 1). Children with IRVs were less likely to be Asian or Hispanic, although these findings may not represent an actual difference in injury rates per se but rather different rates of access to PCPs across different racial and ethnic groups. In addition, children with IRVs to PCP offices were more likely to be from the West or a nonurban area. The most common physician diagnoses for children with IRVs to PCP offices were open wounds, sprains and strains, contusions, and superficial injuries such as abrasions and splinters, cumulatively accounting for 50% of all IRV diagnoses. However, the leading causes of those injuries were sports and overexertion, accidental falls, natural factors such as animal bites, and accidents caused by cutting instruments. Consistent with recently reported data from Canada, we found falls to be the most common cause of injury in younger children but sports-related activities to be the most common cause in older children and adolescents.²⁴

Interpretation of the results of this study should take into account several limitations. We cannot assess the uniformity of diagnostic coding across physicians. In addition, the potential for sampling bias exists with any survey. Measures taken by NAMCS to decrease this possibility include the stratified sampling of practice sites, random selection of visits within a practice, and distribution of the sampling frame evenly throughout the year. Although most of the response forms on the NAMCS survey instrument have less than a 5% nonresponse rate, the items within the injury box were left blank more frequently. For instance, the external cause of injury item, which required the physician to write in a cause on the survey instrument, was blank 23% of the time.¹⁴ Therefore, national estimates of cause-specific IRVs (Table 5) are likely to underestimate the true number of visits by approximately one fourth. Although this omission could introduce a bias into the results, the NAMCS still provides a rich source of information on this important variable. In addition, the ethnicity box had an 81% response rate, for which all missing entries were imputed as not Hispanic. Although this may also introduce bias, a subanalysis of other demographic variables revealed that patients with imputed ethnicity were more similar to non-Hispanic patients than to Hispanics. Because of the sampling frame of the NAMCS, it is possible to make national estimates only if the sample of interest contains more than approximately 30 patient visits. Thus it is not possible to calculate pediatric injury visit rates to PCP offices for specific sports-related injuries; we estimate that 10 years of NAMCS data would be necessary to do this. It is also not possible, with the NAMCS database for 1997 and 1998, to calculate what percentage of visits were repeat visits by the same patient or how many patients were referred to an ED from the office visit. However, our analysis of the text of the external causes would suggest that only 2 pediatric IRVs in our data set were clearly for the same patient. Finally, this study examines injury visit rates to physician offices, not actual injury rates. Thus, the lower PCP visit rate seen in Asian and Hispanic populations may reflect a lack of access to PCPs rather than a lower injury rate. If this were indeed the case, then one would expect the injury visit rate for these populations to be proportionally higher to EDs and hospital outpatient departments.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
IRVs account for a significant percentage of visits to PCP offices that care for children. Given that recently trained pediatricians identify orthopedics as the single most important area in which they lacked adequate preparation after residency²⁵ and that sports-related injuries are the single most common reason for an IRV to a PCP office, it seems judicious to introduce more formal training in sports medicine and orthopedics, as well as management of overuse syndromes, into pediatric residency programs. Because physicians with different training care for injured children in the office setting, all primary care specialties need to provide adequate training in childhood injury management. In addition, as the field of injury prevention moves toward cause-specific prevention trials, this report emphasizes how the cause of injury varies with age. Thus, young children are more likely to be injured in falls at home, a setting in which office-based interventions may well be beneficial (avoidance of walkers, use of stair gates, etc.). Older children, conversely, are more likely to be injured during sports activities, and community-wide or policy-based interventions in this arena are more likely to be successful (use of break-away bases and chest protectors in baseball games, use of correct helmets and pads in football, etc.). Therefore, prevention efforts should focus on these settings.

The findings reported here highlight the quantity and variety of pediatric injuries that are seen in the primary care office setting. One objective of Healthy People 2010 is the reduction of nonfatal unintentional injuries.²⁶ Our findings emphasize the importance of considering the universe of physician offices, especially PCP offices, in any effort to understand the epidemiology of nonfatal childhood injuries.

	ACKNOWLEDGMENTS

 
This project was supported in part by a grant for Faculty Development in General Internal Medicine and General Pediatrics from the Health Resources and Services Administration (5 DOB HP 50019).

We thank Judith H. Maselli for her technical expertise in the data analysis of this work.

	FOOTNOTES

 
Received for publication Jun 6, 2001; Accepted Oct 10, 2001.

Reprint requests to (S.J.H.) Mailcode 0132, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204. E-mail: shambidg{at}dhha.org

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TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 

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