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Patterns of Health Care Use That May Identify Young Children Who Are at Risk for Maltreatment

Eron Y. Friedlaender, MD^*,, David M. Rubin, MD, MSCE^,, Elizabeth R. Alpern, MD, MSCE^*,, David S. Mandell, ScD^,||, Cindy W. Christian, MD and Evaline A. Alessandrini, MD, MSCE^*,

^* Emergency Medicine
General Pediatrics
Pediatric Generalist Research Group, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
^|| Departments of Pediatrics and Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Objectives. Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children.

Methods. We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non–emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child’s primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities.

Results. We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40–4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96–24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints.

Conclusions. Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.

Key Words: child abuse • health service use • Medicaid

Abbreviations: SMRF, State Medicaid Research Files • ED, emergency department • CPT, Current Procedural Terminology • OR, odds ratio • CI, confidence interval

Child maltreatment is a medical and public health concern that affects nearly 12 of every 1000 children annually.¹ Victimization rates are highest among children from birth to 3 years of age.¹ The National Child Abuse and Neglect Data System, developed by the Children’s Bureau of the US Department of Health and Human Services, identified 896000 victims of child maltreatment in 2002. Fatalities resulted from 1400 of these events, 76% of which occurred in children who were younger than 4 years.¹

Early identification of serious maltreatment, including physical abuse and neglect, remains a significant challenge to the medical community. Cases of physical abuse are particularly difficult to diagnose because their clinical presentations often overlap with those of other, more common childhood illnesses and syndromes (eg, cyanotic spells, vomiting).² In addition, the anecdotal, although unstudied, observation that abuse victims often receive care in multiple settings may effectively hide a multiplicity of suspicious injuries from health care providers. Given these potential pitfalls in the timely recognition of maltreatment and the increase in substantiated reports of abuse over the past 2 decades, increased attention has been paid to primary prevention and early recognition of abuse.^3–5

The most promising of these preventive interventions, home visitation programs, target high-risk families who are identified in the prenatal and perinatal periods.^6,7 The success of these programs is mitigated by their high costs, which limit widespread implementation, and enrollment based solely on sociodemographic characteristics, which is neither a sensitive nor a specific way to identify at-risk families. Methods are still needed to identify accurately at-risk children during health care visits after the neonatal period.

Children who are at risk for maltreatment, defined as serious physical abuse and neglect for the purposes of this study, may have characteristic patterns of health care use before their diagnosis that distinguish them from other children. To date, no published studies exist regarding the use of health services by maltreated children during a period of time before their maltreatment was detected. Such a study is challenging to pursue, because the families of at-risk children may seek care in multiple health care settings. Therefore, a review of individual hospital or practice-based records might fail to account for all health care visits. However, system-level administrative data, such as those generated through the Medicaid program, offer a unique opportunity to conduct a thorough review of all relevant health care visits and may permit such an analysis. We thus attempted to characterize the health service use patterns of maltreated children in the year before their first reported serious abuse or neglect episode using Medicaid data from a large urban municipality. We hypothesized that in the year before those reports, there would be discernible patterns of health care use that might have identified those children as being at "higher risk" for maltreatment and offered earlier opportunities for prevention strategies to reduce cumulative maltreatment.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We performed a case-control study to compare patterns of health service use in a subset of abused and neglected children in the year before their first serious report of maltreatment or neglect accompanied by foster care placement with patterns of health service use among matched control subjects. The source population included children who were enrolled in fee-for-service Medicaid in the county of Philadelphia in fiscal years 1994–1996. Our study period was restricted to this time period because of the ability to capture all health care visits that were paid as "fee-for service" visits; since 1997, the penetration of managed care providers in this municipality has significantly increased, and the reporting of ambulatory data from such encounters has been incomplete because capitation failed to provide a fee-for-service incentive to report all claims. Our case population was limited to children who were 6 months to 5 years of age and (1) were enrolled in the Medicaid fee-for-service insurance program in the year before their identification as a victim of abuse or neglect, (2) were placed in foster care within 2 weeks of a report for child maltreatment, and (3) remained in foster care for >30 days. This case definition attempted to identify incident cases of serious maltreatment, defined in this study as either physical abuse or neglect warranting transfer of care to an alternative primary caregiver outside the home. As such, our method of case selection reflected reports that were substantiated, were the first record of children’s contact with the child welfare system, and resulted in swift out-of-home foster care placement. Restricting these children further to those who remained in foster care for >30 days provided additional evidence that the maltreatment was substantiated. Finally, children who were Medicaid eligible because of a disability, as indicated by their participation in the Supplemental Security Income program, were excluded because of the potential that they had complex medical needs and required foster care solely for medical reasons.

Two independent data sources were linked to perform this study: State Medicaid Research Files (SMRF) and the Foster Child Tracking System. After identifying potential cases from foster care records, we linked these children to the unique Medicaid identification numbers from their SMRF using a sequential linkage algorithm used in previous studies of children in foster care.⁸ Figure 1 demonstrates our subject identification process. First, data were linked using social security numbers; these matches accounted for 38% of potential cases. When a match by social security number failed, a unique identifier in the foster care data was created from each child’s name, date of birth, and gender; this process accounted for an additional 34% of potential cases. When these data were not available, a combination of first placement date and date of birth were used to create a match to the starting date of Medicaid eligibility and date of birth in the Medicaid claims data; this process accounted for an additional 2% of potential cases. This latter merge capitalized on the common practice of retroactively making foster children eligible for Medicaid from their placement date. Therefore, 74% of children who entered foster care within 14 days of a first maltreatment report were linked to Medicaid data.

View larger version (24K): [in this window] [in a new window]   Fig 1. Identification of study population.

Control subjects were randomly chosen from a population of nearly 170000 fee-for-service Medicaid-enrolled children between 1994 and 1996 who had no claims generated for maltreatment and were not placed in out-of-home foster care. Each case was matched to 4 control subjects by age (within 4 weeks of the case date of birth), gender, and the number of months of Medicaid eligibility in the year before study enrollment. On identifying all potential control subjects for each case, a computer-generated random numbers ranking approach was used to randomly select the 4 control subjects per case.

Exposure Variables
All children were linked to their Medicaid claims found in the SMRF to identify the patterns of service use during a 1-year look-back period before their enrollment in the study. A 1-year look back period was possible for all children who were older than 1 year and was shortened to include lifetime service use for the small minority who were younger than 1 year. We excluded any visit that occurred on the day of the report among the case patients to prevent the inclusion of a sentinel visit for maltreatment in our analysis. In addition, birth records were not included in the analysis as a provider visit. Exposure variables included the total number of non–emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have previously been linked to abuse,² and the number of changes in a child’s primary care provider. Ambulatory care claims for physician visits were identified using the "place of service" variable in the Medicaid claims. Claims were considered indicative of ambulatory care when place of service was coded as occurring in a physician’s office or outpatient hospital and the Current Procedural Terminology (CPT)¹⁰ code fell within a range indicating an ambulatory visit to a primary provider or consultant. ED claims were identified as those that occurred within a place of service indicating the ED and for which the CPT codes were specific for care rendered by an ED physician. The numbers of ambulatory visits were categorized as 0, 1 to 2, 3 to 4, or >4 during the study period. The number of ED visits was categorized as 0, 1, or >1.

All visits for any reason were included in the analysis, followed by an additional concentration on 2 specific subsets of diagnoses that were encountered in any ambulatory setting: injury-related and nonspecific somatic complaints previously linked to abuse. Medical diagnoses from each physician visit were categorized as either injury-related or nonspecific complaints using ICD-9 codes. Injury diagnoses included all ICD-9 diagnoses between 800 and 899.99.¹¹ The list of nonspecific complaints, derived through consultation with a panel of experts in the field of child abuse and a literature review, included the following: cyanosis, choking, colic, fussy infant, excessive crying, nausea and vomiting, syncope, alopecia, vomiting blood, hemoptysis, esophagitis, dental caries, respiratory conditions not otherwise specified, failure to thrive, and encopresis.² The number of provider changes in the ambulatory care setting was categorized as 0, 1, or 2. This variable was created using CPT codes that are specific to the ambulatory setting and identify a new patient visit to an outpatient practice (CPT codes 99201–99205 and 99381–99385)¹⁰ and does not include patients who change providers within a practice.

Our covariates included age group, whether the child’s family was receiving cash assistance through the welfare program (cash assistance eligibility), and medical comorbidities. Cash assistance eligibility (versus medical assistance only) was included as a proxy for socioeconomic status. Cash assistance is a shared federal and state entitlement provided to families with children when available resources do not fully support the family’s basic material needs. Distinguishing those families who received cash assistance from those who did not receive this assistance is one way of identifying relative poverty within the Medicaid program. Comorbid disease states were identified in all patients to allow for risk adjustment using a method developed by Silber et al.¹² Children who were classified as being immunocompromised and those with the following chronic physical health conditions were considered to have comorbid conditions: diabetes, sickle cell anemia, cerebral palsy, seizures, trisomy 21, cancer, autoimmune disease, major organ disease (cystic fibrosis, chronic liver disease, and chronic kidney disease), mental retardation, congenital anomalies, asthma, and congenital heart disease. Patients were identified as having a specific chronic disease on the basis of ICD-9 codes in Medicaid claims that were recorded at any time during the study period.

Analysis
Data were described using frequencies for categorical variables and means (with SD) and medians (with interquartile ranges) for continuous variables. To test the unadjusted association between the exposures of interest and maltreatment, we performed matched conditional logit analyses for binary outcomes. For the multivariable models, we added each independent variable in a separate model adjusting for race, receipt of cash assistance, and presence of a comorbid disease diagnosis. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Sample Size
With the sample size, we had sufficient power to detect an OR of >2 if the prevalence of our predictor variable in the control population was at least 15%. This estimate included a conservative assumption of the effectiveness of our matching (intra-class correlation coefficient = 0.3). A less conservative assumption of over-matching (intra-class correlation coefficient = 0.1) reduced the necessary prevalence in the control population to 10% to detect an OR of >2.¹³

This study was reviewed and approved by the Institutional Review Board at the Children’s Hospital of Philadelphia and by the Office of Regulatory Affairs at the University of Pennsylvania. Data Sources included SMRF, used with the permission of the Center for Medicare and Medicaid Services, and data from the Foster Child Tracking System provided by the Philadelphia Department of Human Services.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We identified 157 cases of serious child maltreatment that were matched to 628 control subjects. Three quarters of all subjects were between 3 and 5 years of age, and more than half were male. Case patients were less likely to be eligible for cash assistance (OR: 0.05; 95% CI: 0.03–0.09) and were more likely than control subjects to be black (OR: 2.63; 95% CI: 1.16–6.02) and to have a chronic disease (OR: 2.47; 95% CI: 1.40–4.35; Table 1).

There were no differences between case patients and control subjects in the frequency of ED visits (OR: 0.8; 95% CI: 0.53–1.16). The mean number of ED visits for victims of abuse was 0.45, the median was 0, and the interquartile range was 0 to 1 visits. Similarly, the mean number of ED visits for control subjects was 0.52, the median was 0, and the interquartile range was 0 to 1 visits.

Case patients showed a modest increase over control subjects in the number of non-ED outpatient visits. Case patients were 1.87 times (95% CI: 1.24–2.80) as likely as control subjects to have at least 1 non-ED outpatient visit. The increased use of non-ED outpatient services by case patients remained a significant finding for all categories of visit frequencies (1–2 vs 0 visits, 3–4 vs 0 visits, and >4 vs 0 visits; Table 2). The mean number of non-ED outpatient visits for victims of maltreatment was 2.82, the median was 2.0, and the interquartile range was 0 to 5 visits. Among control subjects, the mean number of non-ED outpatient visits was 2.95, the median was 2.0, and the interquartile range was 0 to 4 visits.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The results of this study have implications for the early identification and outpatient care of maltreated children. Our findings suggest that victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children after controlling for socioeconomic status, race, and health status. We also found that the maltreated children in our study were more likely to have greater numbers of provider changes in the preceding year, reaching a nearly sevenfold risk for 2 or more provider changes compared with control subjects. Although maltreated children tended to change providers more frequently, this feature was not specific to them, as nearly 10% of control subjects, compared with 16% of case patients, had at least 1 provider change. Despite this lack of specificity, the strong relationship between provider changes and maltreatment can provide primary care practitioners with an associated, although not causative, patient characteristic that may help to identify the at-risk child. Active investigation into the reasons that a family leaves the care of a given practitioner or increased sensitivity to potential psychosocial stressors among these cases may identify potentially worrisome home environments among those screened.

Other findings of this study included the lack of association of ED visits or specific diagnoses with the likelihood of a future diagnosis of maltreatment. Although this work demonstrated modest increases in ambulatory visits among maltreatment cases compared with controls, case patients had similar numbers of ED visits and visits for injury or nonspecific somatic complaints. These similarities, particularly regarding ED visits, were unexpected but may reflect an overall predisposition among Medicaid-enrolled families in general to seek care in EDs.^14–16 In addition, the lack of meaningful differences in visits for injuries or nonspecific complaints may represent the heterogeneity of abuse-related injuries and their sequelae and likewise the difficulty of differentiating abuse-related complaints from the signs and symptoms of other health conditions. This latter concern reinforces the need for better appreciation among health care professionals of subtle risk factors for maltreatment, such as characteristic patterns of health service use, because physical signs and symptoms of abuse and neglect have proved largely unreliable for timely diagnosis. Ultimately, improved screening measures will allow providers to apply prevention measures more effectively.

A particular strength of the study is the use of foster care administrative data for identification of maltreated children. Reliance on ICD-9 codes for abuse in the Medicaid data would likely have confused incident with prevalent cases and also have resulted in considerable underreporting. The reliability of diagnostic coding of maltreatment from ED and non-ED outpatient visits also remains questionable as many practitioners code for types of injuries rather than mechanism of injury, thus avoiding labeling an injury as abusive in nature until an in-depth investigation substantiates provider concerns. Thus, we propose this alternative method as a means to identify incident cases of serious abuse and neglect.

Despite its promise, this method for identifying incident cases does have its limitations. In the process of maximizing the validity for identifying incident cases using child welfare data, we made the assumption that a first report that resulted in immediate placement into foster care would signify a serious first report of substantiated maltreatment (particularly if the placement period were longer than the average 30-day investigation period). Restricting this definition, however, led to the exclusion of many other children whose maltreatment report did not result in immediate placement and for whom we could not determine whether a substantiated report had occurred. In fact, <1 in 5 suspected child abuse victims are placed into foster care after a report.¹⁷ Furthermore, we were unable to distinguish with our data the type of maltreatment (physical abuse or neglect) that led to the report, although the restriction of continuous eligibility before the report likely reduced the numbers of neglected children among the cases. Overall, though, the effect of both of these limitations would likely have been to increase the likelihood of misclassifying children with abuse or neglect into our control group or even to underestimate service use among our cases if there were a significant number of neglected children. As a result, these limitations would have made it more difficult to observe the effect of provider changes on likelihood of maltreatment and suggests that we might have observed a much larger effect had we identified a more inclusive sample.

One additional finding was that children who were maltreated were less likely to be receiving cash assistance. Previous investigation has demonstrated an association between poverty and higher rates of maltreatment.^1,18,19 Our findings suggest that within the Medicaid population, there is not a simple explanation for the lack of cash assistance among families who ultimately maltreated their children, and there is likely to be multiple reasons for why these families, many of whom may have been eligible, were not receiving cash assistance. It is also unknown whether the lack of that cash assistance may have contributed to the maltreatment cases, and this clearly warrants future investigation.

This project had several limitations other than those related to sample selection described above. First, administrative data provide few covariates. We accepted this limitation because of the perceived strength of these data in tracking all health care visits, which allowed us to account for families who may seek care for their children in multiple settings to avoid detection. Second, the strict inclusion criteria limited the sample size. Finally, use of administrative data also precluded us from using more recent information. A study period of 1994–1996 was chosen for this project because of the completeness of the data set over this time. However, the relationships that we observed are unlikely to have been affected dramatically by emergence of managed care, as previous investigation has demonstrated that enrollment in Medicaid managed care does not alter patterns of ED use or other ambulatory service use from those observed in fee-for-service Medicaid in our community.²⁰

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We believe that we have identified a characteristic pattern of health service use that may identify at-risk children before a maltreatment report and therefore may permit the opportunity to provide assistance to these children and their families to prevent cumulative maltreatment. Children who are at risk for serious maltreatment are almost 3 times as likely than their peers to change primary care providers even once in a 1-year period, and this association doubles for children who change their providers more than once during that period. We encourage primary care providers to participate in the earlier diagnosis and possible primary prevention of child maltreatment by paying special attention to new patients, particularly those with multiple provider changes, taking a detailed social history, and maintaining a heightened awareness of the potential for abuse or other precipitant problems, such as substance abuse or domestic violence, for which intervention may reduce the likelihood of subsequent maltreatment to the child.

	ACKNOWLEDGMENTS

 
This work was supported by a University of Pennsylvania Research Foundation Award.

We thank Xianquan Luan for statistical support and expert assistance in database design and management and Jennifer Loftus for assistance in manuscript preparation.

	FOOTNOTES

 
Accepted Feb 15, 2005.

Address correspondence to Eron Y. Friedlaender, MD, Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104. E-mail: friedlaender{at}email.chop.edu

No conflict of interest declared.

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Child Maltreatment 2002: Summary of Key Findings. National Clearinghouse on Child Abuse and Neglect Information: US Department of Health and Human Services Administration for Children and Families. Available at: nccanch.acf.hhs.gov/pubs/factsheets/canstats.cfm. Accessed June 1, 2004
2. Jenny C, Hymel K, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281 :621 –626[Abstract/Free Full Text]
3. US Department of Health and Human Services. Executive Summary of the Third National Incidence Study of Child Abuse and Neglect. Washington, DC: Westat, Inc; 1996
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6. Leventhal J. The prevention of child abuse and neglect: successfully out of the blocks. Child Abuse Negl. 2001;25 :432 –439
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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Friedlaender, E. Y. Articles by Alessandrini, E. A. Search for Related Content PubMed PubMed Citation Articles by Friedlaender, E. Y. Articles by Alessandrini, E. A. Related Collections Office Practice

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