1
|
Henry MK, Schilling S, Shults J, Feudtner C, Katcoff H, Egbe TI, Johnson MA, Andronikou S, Wood JN. Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals. JAMA Netw Open 2022; 5:e225005. [PMID: 35442455 PMCID: PMC9021910 DOI: 10.1001/jamanetworkopen.2022.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. OBJECTIVE To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. EXPOSURES Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. MAIN OUTCOMES AND MEASURES Use of neuroimaging by CT or MRI. RESULTS Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001). CONCLUSIONS AND RELEVANCE This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.
Collapse
Affiliation(s)
- M. Katherine Henry
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Schilling
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Justine Shults
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics, Children's Hospital of Philadelphia
| | - Hannah Katcoff
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Teniola I. Egbe
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell A. Johnson
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joanne N. Wood
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Factors associated with the decision of a French hospital to report child abuse to judicial rather than administrative authorities. Arch Pediatr 2021; 28:360-365. [PMID: 33994269 DOI: 10.1016/j.arcped.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/22/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Two independent sectors manage the child protection system in France: judicial and administrative protection. The choice between judicial or administrative reporting depends on the seriousness of the case. The goal of this study was to determine the characteristics associated with the decision in a French pediatric hospital to report child abuse to judicial instead of administrative authorities. METHODS A retrospective study was conducted. Participants were all the children (n=83) who were admitted from 2017 to 2018 to the emergency department (ED) and the general ward of a pediatric university hospital in France, and were reported for suspicion of child abuse by the professional teams. The children who were suspected victims of sexual abuse were excluded. Multivariate logistic regressions were used. RESULTS A total of 47 children were reported to judicial authorities, and 36 to administrative authorities. Their median age was 7 years. Suspicion of physical abuse (odds ratio [OR]: 21.2; 95% confidence interval [CI]: 4.5-99.1), cases reported by the pediatric ward team (OR: 9.1; 95% CI: 1.9-43.6), adult person different from parents who accompanied the child to the ED (OR: 5.8; 95% CI: 1.2-28.6), and perception of parental behavior as inappropriate and non-cooperative (OR: 6.6; 95% CI: 1.4-29.6) were associated with a higher risk of the case being reported to judicial authorities. Data were often unavailable for parental health issues, history of child abuse, and intimate partner violence. CONCLUSION Some factors associated with the choice of report type were most likely quite subjective. Better documentation and standardization are needed.
Collapse
|
3
|
Affiliation(s)
- Suzanne B Haney
- University of Nebraska Medical Center and Children's Hospital and Medical Center, Omaha, Nebraska
| |
Collapse
|
4
|
Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
Collapse
Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink? Arch Dis Child 2020; 106:archdischild-2020-320192. [PMID: 33122332 DOI: 10.1136/archdischild-2020-320192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND National guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma. OBJECTIVES To investigate whether this guidance is followed, and the associations between clinical presentation and CT findings, to determine whether guidance could be refined. MATERIALS AND METHODS A retrospective case note review of all children <2 years old who underwent medical assessment for suspected abuse (2009-2017). Outcome measures were frequency of CT-head, and diagnostic yield of intracranial injury, skull fracture or both. RESULTS CT-head was undertaken in 60.3% (152/252) of children <12 months old and 7.8% (13/167) of those aged 12-24 months. The diagnostic yield in children who had a CT-head was 27.1% in children <6 months old, 14.3% in those 6-12 months old (p=0.07) and 42.6% (6/13) in those 12-24 months old. For those with head swelling or neurological impairment, it was 84.2% (32/38). In children <12 months old without these clinical features, the estimated prevalence of occult head injury was 6.1% (7/115). The strongest predictors of an abnormal CT-head were swelling to the head (OR 46.7), neurological impairment (OR 20.6) and a low haemoglobin (OR 11.8). CONCLUSION All children <2 years of age with suspected physical abuse and neurological impairment or head swelling should undergo CT-head. Where the technical skills and the requisite expertise to interpret MRI exist, an MRI scan may be the optimal first-line neuroimaging investigation in infants who are neurologically stable with injuries unrelated to the head to minimise cranial radiation exposure.
Collapse
Affiliation(s)
- Kathryn Glenn
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Elizabeth Nickerson
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Verity Bennett
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | - Emily Morris
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Una Murtagh
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Katina Kontos
- Department of Community Child Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alison Mary Kemp
- Division of Population Medicine, Cardiff University College of Biomedical and Life Sciences, Cardiff, UK
| |
Collapse
|
6
|
Gregory KA, Fingarson AK. Bruising in Infants and Children: Minor Skin Injuries Can Have Major Implications. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
7
|
Henry MK, Lindberg DM, Wood JN. More data, more questions: No simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma. CHILD ABUSE & NEGLECT 2020; 107:104561. [PMID: 32544698 DOI: 10.1016/j.chiabu.2020.104561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 06/11/2023]
Abstract
Abusive head trauma (AHT) is the leading cause of fatal child physical abuse. Victims may initially present with clinically occult AHT without overt signs of head trauma or with only subtle, nonspecific symptoms, which can make timely recognition of AHT challenging. Research has shown missed opportunities for early detection of AHT in the medical setting are common and can lead to repeated injury. Neuroimaging is needed to diagnose clinically occult AHT but is not without risk. Researchers have worked to understand the yield of neuroimaging in detection of clinically occult AHT and to identify risk factors, yet findings have varied widely across studies. Identifying which children undergoing physical abuse evaluations are at highest risk of clinically occult AHT is key to development of evidence-based imaging decision support tools for clinicians. Here we discuss the recent literature, identify potential reasons for variation across studies, and offer opportunities for future research.
Collapse
Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine. 12401 E. 17th Ave., Aurora, CO 80238, United States; The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave., Aurora, CO 80238, United States
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; PolicyLab, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, United States
| |
Collapse
|
8
|
Henry MK, Feudtner C, Fortin K, Lindberg DM, Anderst JD, Berger RP, Wood JN. Occult head injuries in infants evaluated for physical abuse. CHILD ABUSE & NEGLECT 2020; 103:104431. [PMID: 32143091 PMCID: PMC7276264 DOI: 10.1016/j.chiabu.2020.104431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/05/2020] [Accepted: 02/19/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Abusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3-37.3 %. OBJECTIVES (1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries. PARTICIPANTS AND SETTING We conducted a retrospective, stratified, random systematic sample of 529 infants <12 months evaluated for physical abuse at 4 urban children's hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded. METHODS Sampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age <6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests. RESULTS Of 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants <6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6-12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury. CONCLUSIONS Occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.
Collapse
Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States.
| | - Chris Feudtner
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States
| | - Kristine Fortin
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States
| | - Daniel M Lindberg
- Department of Emergency Medicine and The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17(th) Ave. Aurora, CO, 80238, United States
| | - James D Anderst
- Department of Pediatrics, Division of Child Adversity and Resilience, University of Missouri Kansas City School of Medicine and Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States
| |
Collapse
|
9
|
Clinically occult abusive head trauma: which age group should we screen? Pediatr Radiol 2019; 49:1378-1379. [PMID: 31352513 DOI: 10.1007/s00247-019-04477-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
|