Maltreatment-Related Emergency Department Visits Among Children 0 to 3 Years Old in the United States

Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018

The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.

Operational Definitions of Poly-Victimization: A Scoping Review

Throughout the last two decades, research on poly-victimization (PV) has evolved from examinations of a core set of past-year victimization types in youth samples to investigations of a broad range of victimization types experienced during variable time intervals in diverse samples of varying ages. As the concept of PV expands, greater clarity regarding the definition and measurement of PV is needed to advance understanding of its risk and protective factors as well as its associated outcomes. This scoping review aimed to (a) identify approaches used to operationally define and measure PV across studies and (b) synthesize empirical findings concerning risk factors and outcomes associated with PV. A systematic search of peer-reviewed research published before 2022 across 12 databases yielded 98 studies that met inclusion criteria. Study characteristics including the research design, sample type, victimization timeframe, operational definition(s) of PV, measurement of PV, analytic methods, and key findings were synthesized across studies. Findings indicated that the majority of reviewed studies were cross-sectional investigations that utilized categorical measures of lifetime PV in samples of youth. Results also demonstrated that PV is robustly associated with a broad range of predictors, including mental health symptoms and diagnoses as well as family- and community-level factors. PV is also associated with numerous adverse outcomes including depression, anxiety, suicidality, substance use, and delinquency across diverse study types and populations. Future research that examines the conditional effects of PV is needed to identify subgroups of individuals at higher risk of adverse outcomes following PV and modifiable targets for interventions.

Pilot study using machine learning to improve estimation of physical abuse prevalence

BACKGROUND

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes have been shown to underestimate physical abuse prevalence. Machine learning models are capable of efficiently processing a wide variety of data and may provide better estimates of abuse.

OBJECTIVE

To achieve proof of concept applying machine learning to identify codes associated with abuse.

PARTICIPANTS AND SETTING

Children <5 years, presenting to the emergency department with an injury or abuse-specific ICD-10-CM code and evaluated by the child protection team (CPT) from 2016 to 2020 at a large Midwestern children's hospital.

METHODS

The Pediatric Health Information System (PHIS) and the CPT administrative databases were used to identify the study sample and injury and abuse-specific ICD-10-CM codes. Subjects were divided into abused and non-abused groups based on the CPT's evaluation. A LASSO logistic regression model was constructed using ICD-10-CM codes and patient age to identify children likely to be diagnosed by the CPT as abused. Performance was evaluated using repeated cross-validation (CV) and Reciever Operator Characteristic curve.

RESULTS

We identified 2028 patients evaluated by the CPT with 512 diagnosed as abused. Using diagnosis codes and patient age, our model was able to accurately identify patients with confirmed PA (mean CV AUC = 0.87). Performance was still weaker for patients without existing ICD codes for abuse (mean CV AUC = 0.81).

CONCLUSIONS

We built a model that employs injury ICD-10-CM codes and age to improve accuracy of distinguishing abusive from non-abusive injuries. This pilot modelling endeavor is a steppingstone towards improving population-level estimates of abuse.

The Impact of COVID-19 on Infant Maltreatment Emergency Department and Inpatient Medical Encounters

OBJECTIVE

To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic.

METHODS

Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters.

RESULTS

Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed that the count of maltreatment encounters increased 64% with the onset of COVID-19.

CONCLUSIONS

We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment.

Diagnosis codes dramatically underestimate the burden of abuse

BACKGROUND

International Classification of Diseases (ICD) billing codes are not well-suited to estimate physical abuse prevalence among hospitalized patients and may be even less accurate in emergency departments (EDs). The Centers for Disease Control and Prevention (CDC) has recently published a child abuse and neglect syndromic surveillance definition to more accurately examine national abuse trends among ED visits.

OBJECTIVE

To retrospectively apply the CDC syndromic definition to a population of physically abused children and determine its sensitivity for abuse in an ED and at hospital discharge.

PARTICIPANTS AND SETTING

All physically abused children <5 years seen in the ED and evaluated by the child protection team from 2016 to 2020 at a large Midwestern children's hospital.

METHODS

Retrospective cross-sectional study utilizing the hospital's child protection team administrative database, the Pediatric Health Information System and the electronic health record to identify the study sample, chief complaint, and abuse-specific codes assigned in the ED and at hospital discharge. Abuse-specific codes were defined as all ICD-10-CM and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes included in the CDC syndromic definition, which was applied to the sample and its sensitivity determined.

RESULTS

Among the 550 abused patients identified, most were male (58.4 %), white (65.1 %), <2 years old (80.4 %), and had public insurance (81.6 %). When applying the CDC syndromic definition, only 11.6 % were identified as abused in the ED and 65.3 % were identified at hospital discharge.

CONCLUSIONS

The CDC syndrome surveillance definition lacks sensitivity in identifying abuse in the ED or at hospital discharge.

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

BACKGROUND

Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic.

OBJECTIVE

To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three.

PARTICIPANTS AND SETTING

Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231).

METHODS

We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed.

RESULTS

Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3).

CONCLUSION

This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

Judgements of physicians, nurses, and social workers regarding suspected Child maltreatment in community health care services

This study investigated how physicians, nurses, and social workers in community health care services make judgements about possible child maltreatment in ambiguous situations. We examined the influences of social biases (i.e., perceptions linking ethnicity, gender, and family socioeconomic status to child maltreatment) and belonging to distinctive occupational groups (i.e., physicians, nurses, and social workers) on professionals' assessment of suspected child maltreatment, intention to consult with others, and reporting. We used an experimental survey design including vignettes presenting a child's history inspired by real-life clinical cases. Data were collected from 397 health care professionals-170 physicians, 179 nurses, and 48 social workers-employed at community health care clinics in northern Israel. Findings show that the child's gender and family socioeconomic status had significant effects on assessment of possible child maltreatment. Also, professionals' occupational group had significant effects on assessment of child maltreatment and intention to pursue consultation. Another key finding was the significant effects of judgements about child maltreatment assessment, consultation, and reporting on one another. The study reinforces efforts to improve health care professionals' management of suspected child maltreatment that include the development of clinical decision support systems that use routinely collected electronic medical record data.

The CAPNET multi-center data set for child physical abuse: Rationale, methods and scope

BACKGROUND

The pediatric subspecialty of Child Abuse Pediatrics (CAP) was certified by the American Board of Medical Subspecialties in 2006. Relative to its impact on pediatric health, CAP-focused research has been relatively under-funded. Multi-center networks related to CAP-focused research have made important advances, but have been limited in scope and duration. CAPNET is multi-center network whose mission is to support CAP-focused research.

OBJECTIVE

To describe the rationale, development, and scope of the CAPNET research network infrastructure, the CAPNET data registry and associated data resources.

METHODS

Based on existing priorities for CAP-focused research, we used consensus building and iterative testing to establish inclusion criteria, common data elements, data quality assurance, and data sharing processes for children with concerns of physical abuse.

RESULTS

We describe the rationale, methods and intended scope for the development of the CAPNET research network and data registry. CAPNET is currently abstracting data for children <10 years (120 months) old who undergo sub-specialty evaluation for physical abuse at 10 US pediatric centers (approximately 4000 evaluations/year total) using an online data capture form. Data domains include: demographics; visit timing and providers, medical/social history, presentation, examination findings, laboratory and radiographic testing, diagnoses, outcomes, and data for contact children. We describe the methods and criteria for collecting and validating data which are broadly available to CAP investigators.

CONCLUSIONS

CAPNET represents a new data resource for the CAP research community and will increase the quantity and quality of CAP-focused research.

Emergency Department Admissions for Physical Child Abuse: Evidence from the 2006-2017 Nationwide Emergency Department Sample

Physical child abuse continues to be a serious public health issue in the United States. This study expands on previous research by exploring trends in physical child abuse diagnoses among children admitted to emergency departments (EDs) across the United States. The analysis aimed to explicate the association between physical child abuse and both sociodemographic and behavioral health covariates to better inform and identify risk factors associated with ED admissions for abuse. The study also explicated differences between confirmed and suspected physical child abuse cases. The study utilized a nationally representative sample of hospital-owned EDs that included 319,676,625 ED admissions between 2006 and 2017 for children under 18-years-old. The analysis included a trend analysis, bivariate descriptive statistics, and multivariate logistic regression models were employed. Children with a physical child abuse diagnosis were less likely to be from higher income communities (aOR = 0.61, 95% CI [0.53, 0.71]), less likely to be female (aOR = 0.93, 95% CI [0.90, 0.96]), and more likely to be uninsured (aOR = 1.65, 95% CI [1.48, 1.84]). Children with attention-deficit hyperactivity disorder (aOR = 1.36, 95% CI [1.14, 1.62]) and a conduct disorder (aOR = 1.28, 95% CI [1.04, 1.58]) were more likely to have a physical abuse diagnosis. The sex-stratified analyses found that the higher rates of physical abuse among children with attention-deficit hyperactivity disorder were driven by the male subsample, while higher rates of abuse for those with conduct disorders were the result of the female subsample. A supplemental analysis of suspected versus confirmed physical child abuse for the fourth quarter of 2015 through 2017 also revealed sociodemographic and behavioral health differences. This study supports the need to consider sociodemographic and behavioral risk factors associated with physical child abuse to inform treatment and potential reoccurrence of abuse.

Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study

BACKGROUND AND OBJECTIVE

The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse.

METHODS

A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods.

RESULTS

Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not.

CONCLUSIONS

Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.

Comparison of crosswalk methods for translating ICD-9 to ICD-10 diagnosis codes for child maltreatment

BACKGROUND

A validated source of International Classification of Disease (1CD) 10th revision diagnostic codes to identify child maltreatment has not been developed. Such a reference would be essential for the practical purposes of administrative data-based research and public health surveillance.

OBJECTIVE

To evaluate the validity of diagnosis code classifications for child maltreatment following conversion from ICD 9th edition, clinical modification (ICD-9-CM) to 10th revision.

PARTICIPANTS AND SETTING

Children receiving inpatient or emergency medical care in the United States with ICD-9-CM/ICD-10-CM diagnosis codes for child maltreatment, identified using two large multicenter hospital-based datasets.

METHODS

We evaluated the performance of general equivalence mappings (GEMs) and network-based mappings for previously-validated ICD-9-CM diagnosis codes for child maltreatment in the 2013-2014 PHIS and 2012 KID and resulting ICD-10-CM codes in the 2018-2019 PHIS and 2016 KID datasets.

RESULTS

Of 56 previously-validated ICD-9-CM diagnoses, GEMs identified 15 with a similar proportion of diagnosed children in the KID ICD-9-CM and ICD-10 eras and 14 diagnoses in PHIS. Network-based mapping identified 18 diagnoses with similar proportions in the KID datasets, and 13 diagnoses in PHIS. For six diagnoses, the proportion of children identified in the ICD-10 era using network-based mapping was more than ten times the proportion identified in the ICD-9-CM era.

CONCLUSION

Neither crosswalk method provided consistently reliable conversions, due to both crosswalk methodology and changes introduced by the ICD 10th revision. These findings highlight the need for independent construction and validation of ICD-10-based definitions of child maltreatment as a precursor to administrative data-based research and public health surveillance.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.

National Trends in Emergency Department Visits for Child Maltreatment, 2007-2014

OBJECTIVE

To understand the prevalence of child maltreatment-related emergency department (ED) visits in the United States, we examined data from the 2007 to 2014 Nationwide Emergency Department Sample.

METHODS

Based on existing literature, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) ED discharge codes for children less than 10 years of age were characterized as specified child maltreatment, defined as visits with an explicit maltreatment ICD-9 CM or external causes of injury codes. The prevalence of child maltreatment visits per 100,000 children in the United States (based on Center for Disease Control Wide-ranging ONline Data for Epidemiologic Research estimates) overall and by sociodemographic factors was examined, and tests for trends over time were evaluated with Cochran-Armitage tests. Analyses were conducted in 2019.

RESULTS

The prevalence of child maltreatment based in ICD-9 CM discharge codes ED visits dropped from 69.2 visits per 100,000 in 2007 to 65.9 visits per 100,000 in 2014; this trend was statistically significant. The prevalence was lowest in 2010 (60.1 visits per 100,000 children). There were increases observed for some demographic groups in this period. Throughout the 8-year period examined, the prevalence of child maltreatment visits was highest for physical abuse compared with other forms of maltreatment, higher for boys compared with girls; highest for children younger than 1 year, and higher for children living in neighborhoods with the lowest median income compared with children in higher-income neighborhoods.

CONCLUSIONS

The Nationwide Emergency Department Sample data set is a valuable surveillance tool for examining trends in child maltreatment. Future studies should explore what factors may explain variations in child maltreatment over time to best develop prevention strategies.

Identification of physical abuse-related hospitalizations in young children: Impact of the transition to ICD-10-CM coding

BACKGROUND

Administrative healthcare databases are frequently used for child physical abuse (CPA)-related research and surveillance. In October 2015, the United States transitioned to the International Classification of Diseases, Clinical Modification-10th Revision (ICD-10-CM) coding regimen. ICD-10-CM expands coding related to CPA, including codes to differentiate suspected from confirmed CPA.

OBJECTIVE

This study examined the impact of the transition to ICD-10-CM coding on population-level trends in rates of hospitalizations coded for CPA.

PARTICIPANTS AND SETTINGS

Hospitalizations coded as related to CPA in children <5 years-of-age from 2010 to 2017 were identified across 19 Statewide Inpatient Databases.

METHODS

Interrupted time series analyses were used to assess the impact of the coding transition on hospitalizations coded for CPA, overall and by child race/ethnicity.

RESULTS

Of 9715 hospitalizations coded for CPA, 2797 (29%) occurred after the coding transition, including 51% coded for suspected CPA and 49% coded for confirmed CPA. There was a marginally-significant increase in the trend in CPA-related hospitalization after the coding transition among all children (0.09 per 100,000 children-per-quarter, p = 0.06), a significant increase in the trend among white children (0.15 per 100,000 children-per-quarter, p = 0.01), and no change among Black or Hispanic children. After the coding transition, hospitalizations coded for suspected CPA increased significantly overall (0.10 per 100,000 children-per-quarter, p < 0.001), and in particular among white children (0.12 per 100,000 children-per-quarter, p = 0.01) but not among Black or Hispanic children.

CONCLUSIONS

The transition to ICD-10-CM differentially impacted trends in hospitalizations coded for CPA by child race/ethnicity. Further research is necessary to discern the reasons for these discrepancies.

Assessing, Consulting, Reporting Heuristics in Professional Decision-Making Regarding Suspected Child Maltreatment in Community Healthcare Services

This study investigated child protection decision-making practices of healthcare-professionals in community-health-services. We examined the effect of heuristics in professional judgments regarding suspected maltreatment, as affected by the child's ethnicity, gender, and family socioeconomic-status, as well as the healthcare-worker's workload-stress, and personal and professional background. Furthermore, we examined how these variables influence judgments regarding suspected maltreatment and intentions to consult and report child-maltreatment. We used an experimental survey design including vignettes manipulating the child's characteristics. Data was collected from 412 professionals employed at various community-health-service-clinics of the largest health-management organization in northern Israel. Findings show that all subjective factors have a significant effect on suspected child-maltreatment assessment, which appears as a significant predictor of later decisions regarding consultation and reporting. This study lends support to prior research indicating that healthcare-professionals' decisions may incorporate biases, and suggests how the effects of these biases' are mediated through a sequence of decisions. Recommendations focus on providing regular consultation opportunities for practitioners.

Characteristics of child welfare investigations reported by healthcare professionals in Ontario: secondary analysis of a regional database

OBJECTIVES

This study examines the characteristics and outcomes of child welfare investigations reported by hospital-based and community-based healthcare professionals.

METHODS

A sample of 7590 child maltreatment-related investigations from the Ontario Incidence Study of Reported Child Abuse and Neglect-2018, a cross-sectional study, was analysed. Bivariate analyses compared characteristics of hospital and community healthcare-reported investigations. Chi-square automatic interaction detector analyses were used to predict the most influential factors in the decision to provide a family with services following a child welfare investigation from each referral source.

RESULTS

Community healthcare-reported investigations were more likely to have a primary concern of physical abuse while hospital-reported investigations were more likely to be focused on assessing risk of future maltreatment. Hospital-reported investigations were more likely to involve noted primary caregiver (eg, mental health issues, alcohol/drug abuse, victim of intimate partner violence (IPV)) and household risk factors. The most significant predictor of service provision following an investigation was having a caregiver who was identified as a victim of IPV in hospital-reported investigations (χ²=30.237, df=1, adj. p<0.001) and having a caregiver for whom few social supports was noted in community healthcare-reported investigations (χ²=18.892, df=1, adj. p<0.001).

CONCLUSION

Healthcare professionals likely interact with children who are at high risk for maltreatment. This study's findings highlight the important role that healthcare professionals play in child maltreatment identification, which may differ across hospital-based and community-based settings and has implications for future collaborations between the healthcare and child welfare systems.

Perception of Physical Child Abuse Among Parents and Professionals in a French Emergency Department

France has not prohibited all forms of corporal punishment, and the point at which an act is regarded as physical abuse is not clearly determined. The aim of our study was to compare perception of a caregiver's violent behavior toward his child by professionals and parents in an emergency department and determine characteristics associated with that perception. A cross-sectional study was conducted from November 2013 to October 2014 in the emergency department of the pediatric university hospital in Bordeaux, France. An anonymous self-administered questionnaire, including vignettes describing hypothetical situations of violent interaction between a parent and child, and items related to sociodemographic and family characteristics, was administered to professionals and parents. Vignettes included varying child's age and behavior, frequency of caregiver's behavior, hitting with/without an object, and targeted child's body part. Violent behavior was restricted to hitting for reasons of feasibility. Respondents were asked to rate the acceptability of situations on a 100-mm visual analog scale. Analyses were multivariate mixed Poisson regressions. A total of 1,001 participants assessed the vignettes. Participants were predominantly females (64%), married or living with a partner (87%), with a median age of 34 years. Professionals assessed vignettes as acceptable significantly more than parents (mean rating 2.8 times higher; p < .001). For both professionals and parents, all vignette characteristics were significantly associated with acceptability. Parents who had a child below 1 year old, those who had visited an emergency department many times in the past year, and those who had fewer children were less tolerant. Such findings indicate the need for additional research to better appreciate consequences and severity of violent behavior toward children, and the need to educate parents and professionals.

Child maltreatment surveillance following the ICD-10-CM transition, 2016-2018

BACKGROUND

Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type.

METHODS

We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected).

RESULTS

From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively).

CONCLUSIONS

The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.

Risk Factors for Child Maltreatment Fatalities in a National Pediatric Inpatient Database

BACKGROUND AND OBJECTIVES

Child maltreatment (CM) is recognized as a major public health concern, and an important number of children suffer injuries related to abuse and neglect that result in death. We sought to identify risk factors for CM fatalities among hospitalized children that can provide clinicians with information to recognize at-risk children and reduce further death.

METHODS

In this study, we included cases from the 2012 Kids' Inpatient Database with diagnosis codes related to CM who were <5 years of age and were not transferred to another facility. Potential demographic and clinical risk factors were identified and compared to child fatality in the hospital by using bivariate and multivariate analyses. To assess how cases coded specifically for maltreatment differed from similar cases that only suggested maltreatment, a reduced-model multivariable logistic regression for fatality was created.

RESULTS

We found 10 825 children <5 years who had inpatient diagnoses coded in their medical record for CM. Most demographic variables (age, race, and sex) were not significantly associated with fatality, whereas clinical variables (transferring in, drowning, ingestions, and burns) were significantly associated with fatality. There were regional differences on the basis of hospital location as well as significantly more chronic conditions, procedure charges, and longer lengths of stay among children who died. Controlling for significant risk factors, those with diagnoses specific for physical abuse had ∼3 times the odds of dying (odds ratio = 2.797; 95% confidence interval: 1.941-4.031).

CONCLUSIONS

In this study, although infancy and decreased income were associated with increased risk for fatality, more important factors were the types of injuries the child endured and whether the inpatient clinician had identified specific injuries indicating physical abuse.

Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006-2014

OBJECTIVE

To determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses.

METHODS

Nationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses.

RESULTS

The population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries.

CONCLUSIONS

Definitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.

Health-Care Utilization Patterns of Maltreated Youth

To examine in detail the health-care utilization patterns of maltreated children, we studied electronic health records (EHRs) of children assigned maltreatment-related codes in a large medical system. We compared youth with maltreatment-related diagnoses (N = 406) with those of well-matched youth (N = 406). Data were based on EHRs during a 4-year period from the University of Minnesota's Clinical Data Repository, which covers eight hospitals and over 40 clinics across Minnesota. A primary care provider (PCP) was assigned to over 80% of youth in both groups. As expected, however, the odds of not having a PCP were twice as high in the maltreated as in the comparison group. Also as expected, maltreated youth had higher rates of emergency department visits. We ruled out differences in age, gender, race, public insurance, duration in the medical system, type of specialty department, and clinic location as potential explanations for these differences. On the other hand, there were no significant differences between maltreated and comparison youth in hospitalizations, preventive visits, or office visits. Contrary to expectations, maltreated youth were not in the medical system for just a brief period of time and were not more likely to cancel or miss appointments. The current study adds to the research literature by providing more detailed information about the nature of health-care services used by children with maltreatment-related diagnoses.

Sentinel surveillance of child maltreatment cases presenting to Canadian emergency departments

Background

The Canadian Hospitals Injury Reporting Prevention Program (CHIRPP) is a sentinel surveillance program that collects and analyzes data on injuries and poisonings of people presenting to emergency departments (EDs) at 11 pediatric and eight general hospitals (currently) across Canada. To date, CHIRPP is an understudied source of child maltreatment (CM) surveillance data. This study: (1) describes CM cases identified in the CHIRPP database between1997/98 to 2010/11; (2) assesses the level of CM case capture over the 14-year period and; (3) uses content analysis to identify additional information captured in text fields.

Methods

We reviewed cases of children under 16 whose injuries were reported as resulting from CM from 1997/98 to 2010/11. A time trend analysis of cases to assess capture was conducted and content analysis was applied to develop a codebook to assess information from text fields in CHIRPP. The frequency of types of CM and other variables identified from text fields were calculated. Finally, the frequency of types of CM were presented by age and gender.

Results

A total of 2200 CM cases were identified. There was a significant decrease in the capture of CM cases between 1999 and 2005. Physical abuse was the most prevalent type (57%), followed by sexual assault (31%), unspecified maltreatment (7%), injury as the result of exposure to family violence (3%) and neglect (2%). Text fields provided additional information including perpetrator characteristics, the use of drugs and/or alcohol during the injury event, information regarding the involvement of non-health care professionals, whether maltreatment occurred during a visitation period with a parent and, whether the child was removed from their home.

Conclusions

The findings from this initial study indicate that CHIRPP could be a complimentary source of CM data. As an injury surveillance system, physical abuse and sexual assault were better captured than other types of CM. Text field data provided unique information on a number of additional details surrounding the injury event, including risk factors.

Maternal characteristics associated with injury-related infant death in West Virginia, 2010-2014

Although injury-related deaths have been documented among children and adult populations, insufficient attention has been directed towards injury-related infant deaths. The objective of this retrospective study was to investigate maternal and infant characteristics associated with injury-related infant deaths in West Virginia. Birth and infant mortality data for 2010-2014 were sourced from the West Virginia Bureau for Public Health, Charleston. Relative risk was calculated using log-binomial regression utilizing generalized estimating equations. Maternal characteristics associated with injury-related infant mortality in West Virginia were race/ethnicity ([Formula: see text] = 7.48, p = .03), and smoking during pregnancy ([Formula: see text], p < .00). Risk of a Black Non-Hispanic infant suffering an injury-related death was 4.0 (95% CL 1.7, 9.3) times that of infants of other races/ethnicities. Risk of an infant dying from an injury-related cause, if the mother smoked during pregnancy, was 2.9 (95% CL 1.6, 5.0) times the risk of such a death if maternal smoking status during pregnancy is unknown or no smoking, controlling for race/ethnicity. This study provides important information to public health stakeholders at both the state and local levels in designing interventions for partial reduction or prevention of injury-related infant mortality in West Virginia.

Identification of Child Maltreatment-Related Emergency Department Visits in Connecticut, 2011 to 2014

Child maltreatment identified by medical professionals is poorly represented in records of child protection. International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes may better represent the burden of maltreatment treated in clinical settings. Using emergency department (ED) discharge data from 2011 to 2014, we enumerated presentations of maltreatment treated in Connecticut EDs for children under 10 years. Of 790 080 discharges, child maltreatment was explicitly documented in 265 (0.03%) unique ED visits, consistent with prior studies. Sexual maltreatment was most prevalent. A total of 3634 visits included an ICD-9-CM code suggestive of maltreatment. Children with these codes were significantly younger, more likely to be of white race, and use private insurance. Use of ICD codes in child maltreatment surveillance may elucidate characteristics of maltreatment not captured by child welfare data. Combining ICD codes for explicit and suggestive maltreatment will aid in understanding the extent of this problem.

Child Sexual Abuse identified in Emergency Departments Using ICD-9-CM, 2011 to 2014

BACKGROUND

Child sexual abuse (CSA) is poorly identified due to its hidden nature and difficulty surrounding disclosure. Surveillance using emergency department (ED) data may identify victims and provide information on their demographic profile.

OBJECTIVES

Study aims were to calculate the prevalence of visits assigned an explicit or suggestive medical diagnosis code (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CSA and compare the demographic profile of ED visits by coding type.

METHODS

This study examined ED data for children < 10 years of age in Connecticut from 2011 to 2014. Cases involving CSA were identified using explicit and suggestive ICD-9-CM codes and age qualifiers previously established in the literature, and compared across visit characteristics (age, race/ethnicity, sex, and primary insurance payer, and town group).

RESULTS

ICD-9-CM codes for explicit CSA were identified in 110 ED visits, or 1.7 per 10,000 total ED visits. Inclusion of ICD-9-CM codes for suggestive CSA identified an additional 630 visits (9.7 per 10,000 visits). Suggestive codes identified proportionally more visits of younger (50% vs. 38%) and male (35% vs. 22%) children, compared with the explicit code (p < 0.05).

CONCLUSIONS

This study demonstrates one method for identifying CSA cases, which has the potential to increase surveillance of victims in the ED. Results imply that explicit codes alone may overlook most cases, whereas use of suggestive codes may identify additional cases, and proportionally more young and male victims. As the health consequences of CSA are severe, innovative forms of surveillance must be explored to detect a higher number of cases and improve the clinical care of patients.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments

OBJECTIVE

Emergency department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program, in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education; 2) provided consultation, case follow-up, and access to specialists; and 3) facilitated multidisciplinary case review. The aims of this study were to understand the Program's strengths andchallenges and to explore factors that influenced implementation.

METHODS

We used a qualitative research design with semistructured, one-on-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed 27 stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes.

RESULTS

Program strengths included 1) comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness, and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions, and 4) implementation flexibility. Program challenges/barriers to implementation included 1) variability of institutional support for the champions and 2) variability in awareness about the program.

CONCLUSIONS

A Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity, and support of the champions' time.

Association between emergency department utilization and the risk of child maltreatment in young children

BACKGROUND

This study aims to assess the association between emergency department (ED) utilization and the risk of child maltreatment.

METHODS

Using ED discharge data from the California's Office of Statewide Health Planning (OSHPD) and Development for 2008-2013, we performed a nested case-control study to examine the relationship between the frequency of ED visits and child maltreatment diagnosis under 4 years of age among children born in California between 2008 and 2009 who visited the ED.

RESULTS

The study sample consisted of 3772 children diagnosed with child maltreatment (cases) and 7544 children selected by incidence density sampling (controls). After adjustment for demographic characteristics, the estimated odds ratios of child maltreatment were 1.72 (95% CI:1.55-1.90) for those with two to three ED visits and 3.03 (95% CI: 2.69-3.41) for those with four or more ED visits, compared to children with one visit. Race/ethnicity, insurance status, and location of residence were also significantly associated with the risk of child maltreatment.

CONCLUSIONS

Young children with higher frequency of ED visits are at significantly increased risk of being victims of child maltreatment. ED utilization patterns and other established risk markers may assist healthcare professionals in identifying and treating victims of child maltreatment.

Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment

OBJECTIVE

To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms.

STUDY DESIGN

National Electronic Injury Surveillance System-All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends.

RESULTS

TBI-related ED visits (estimated n = 713 124) accounted for 28% of all injury-related ED visits by infants in the US, yielding an average annual rate of 1722 TBI-related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI-related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI-related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02-21.75) compared with those with unintentional TBI.

CONCLUSIONS

The rate of TBI-related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI-related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.

Risk factors for maltreatment-related infant hospitalizations in New York City, 1995-2004

BACKGROUND

Child maltreatment is a major public health problem, but population-based surveillance and research is hindered by limitations of official child welfare data. The present study used a promising complementary data source, hospital discharge data, to investigate risk factors for infant injuries suggestive of maltreatment.

METHODS

Discharge data from all hospital births to New York City residents from 1995 to 2004 were linked to birth certificates and to subsequent infant hospitalizations within 12 months after delivery. Probable maltreatment of infants was identified with 33 injury diagnosis codes highly correlated with maltreatment. Modified Poisson regression estimated the association of sociodemographic factors and pregnancy/birth characteristics with subsequent infant admission for probable maltreatment.

RESULTS

Risk factors for maltreatment included neonatal intensive care unit stays of more than 11 days (adjusted risk ratio [aRR] = 1.8; 95% confidence interval [CI]: 1.1-2.8), preterm birth (aRR = 1.6; 95% CI: 1.2-2.1), maternal age less than 20 years (aRR = 1.5; 95% CI: 1.2-1.9), and public insurance (aRR = 1.5; 95% CI: 1.2-1.9). Factors associated with reduced maltreatment risk included mother born outside the United States (aRR = 0.7; 95% CI: 0.6-0.8) and female infant (aRR = 0.7; 95% CI: 0.6-0.9).

CONCLUSIONS

Sociodemographic factors and challenges at birth (preterm, neonatal intensive care unit stays) are important risk factors for subsequent maltreatment-related hospitalization, with potential implications for prevention targeting.

Documentation of Child Maltreatment in Electronic Health Records

International Classification of Diseases codes for child maltreatment can aid surveillance and research, but the extent to which they are used is not well established. We documented prevalence of the use of maltreatment-related codes, examined demographic characteristics of youth assigned these codes, and compared results with previous studies. Data were extracted from electronic health records of 0- to 21-year-olds assigned 1 of 15 maltreatment-related International Classification of Diseases, Ninth Revision, codes who had encounters in a large medical system over a 4-year period. Only 0.02% of approximately 2.5 million youth had a maltreatment-related code, replicating other studies. Results provide a dramatic contrast to much higher rates based on self-report or informant-report and referrals to Child Protective Services. Lack of documentation of maltreatment in electronic health records can lead to missed chances at early intervention, inadequate coordination of health care, insufficient allocation of resources to addressing problems related to maltreatment, and flawed public health data.

Child maltreatment in U.S. emergency departments: Imaging and admissions

OBJECTIVE

We report imaging and admission ratios for children with definitive and suggestive maltreatment in a national sample of emergency departments (EDs).

METHODS

Using the 2012 Nationwide Emergency Department Sample (NEDS), we generated national estimates of ED visits for children <10 years with both definitive and suggestive maltreatment. Outcomes were admission/transfer ratios for children <10years and screening ratios by skeletal surveys and head computed tomography (CT) for children <2 years with suspected physical abuse. We compared hospitals with low, medium, and high pediatric ED volumes using multivariable logistic regression.

RESULTS

The 2012 national estimate of U.S. ED visits (children <10years) with definitive maltreatment is 14,457 (95% CI: 11,987-16,928). Suggestive child maltreatment was seen in an additional 103,392 (95% CI: 90,803-115,981) pediatric ED visits. After controlling for patient case mix, high volume hospitals had a significantly higher adjusted odds ratio (AOR) of admission/transfer among definitive cases (AOR=1.74, 95% CI: 1.08-2.81), and medium volume hospitals had a higher odds of admission/transfer among suggestive cases (AOR=1.24, 95% CI: 1.02-1.50) when compared with low volume hospitals. In hospitals with reliable reporting of imaging procedures, high volume hospitals reported skeletal surveys (age <2 years) significantly more often than low volume hospitals, AOR=3.32 (95% CI: 1.25-8.84); the AORs for head CT did not differ by hospital volume.

CONCLUSIONS

Low volume hospitals were less likely to screen by skeletal survey, but head CT ratios were not affected by ED volume. Low volume hospitals were also less likely to admit or transfer.

Under-ascertainment from healthcare settings of child abuse events among children of soldiers by the U.S. Army Family Advocacy Program

In cases of maltreatment involving children of U.S. Army service members, the U.S. Army Family Advocacy Program (FAP) is responsible for providing services to families and ensuring child safety. The percentage of cases of maltreatment that are known to FAP, however, is uncertain. Thus, the objective of this retrospective study was to estimate the percentage of U.S. Army dependent children with child maltreatment as diagnosed by a military or civilian medical provider who had a substantiated report with FAP from 2004 to 2007. Medical claims data were used to identify 0-17year old child dependents of soldiers who received a medical diagnosis of child maltreatment. Linkage rates of maltreatment medical diagnoses with corresponding substantiated FAP reports were calculated. Bivariate and multivariable analyses examined the association of child, maltreatment episode, and soldier characteristics with linkage to substantiated FAP reports. Across 5945 medically diagnosed maltreatment episodes, 20.3% had a substantiated FAP report. Adjusting for covariates, the predicted probability of linkage to a substantiated FAP report was higher for physical abuse than for sexual abuse, 25.8%, 95% CI (23.4, 28.3) versus 14.5%, 95% CI (11.2, 17.9). Episodes in which early care was provided at civilian treatment facilities were less likely to have a FAP report than those treated at military facilities, 9.8%, 95% CI (7.3, 12.2) versus 23.6%, 95% CI (20.8, 26.4). The observed low rates of linkage of medically diagnosed child maltreatment to substantiated FAP reports may signal the need for further regulation of FAP reporting requirements, particularly for children treated at civilian facilities.

Diagnosis of Elder Abuse in U.S. Emergency Departments

OBJECTIVES

To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets.

DESIGN

Retrospective cross-sectional analysis.

SETTING

U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS).

PARTICIPANTS

All ED visits of individuals aged 60 and older.

MEASUREMENTS

The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse.

RESULTS

In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012-0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68-2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36-3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84-2.65), and septicemia (OR = 1.92, 95% CI = 1.44-2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits.

CONCLUSION

The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted.

Relationship between Insurance Type and Discharge Disposition From the Emergency Department of Young Children Diagnosed with Physical Abuse

OBJECTIVES

To describe the disposition of young children diagnosed with physical abuse in the emergency department (ED) setting and identify factors associated with the decision to discharge young abused children.

STUDY DESIGN

We performed a retrospective cross-sectional study of children less than 2 years of age diagnosed with physical abuse in the 2006-2012 Nationwide Emergency Department Sample. National estimates were calculated accounting for the complex survey design. We developed a multivariable logistic regression model to evaluate the relationship between payer type and discharge from the ED compared with admission with adjustment for patient and hospital factors.

RESULTS

Of the 37 655 ED encounters with a diagnosis of physical abuse among children less than 2 years of age, 51.8% resulted in discharge, 41.2% in admission, 4.3% in transfer, 0.3% in death in the ED, and 2.5% in other. After adjustment for age, sex, injury type, and hospital characteristics (trauma designation, volume of young children, and hospital region), there were differences in discharge decisions by payer and injury severity. The adjusted percentage discharged of publicly insured children with minor/moderate injury severity was 56.2% (95% CI 51.6, 60.7). The adjusted percentages discharged were higher for both privately insured children at 69.9% (95% CI 64.4, 75.5) and self-pay children at 72.9% (95% CI 67.4, 78.4). The adjusted percentages discharged among severely injured children did not differ significantly by payer.

CONCLUSIONS

The majority of ED visits for young children diagnosed with abuse resulted in discharge. The notable differences in disposition by payer warrant further investigation.