First name
Joanne
Middle name
N
Last name
Wood

Title

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

Year of Publication

2022

Number of Pages

105653

Date Published

06/2022

ISSN Number

1873-7757

Abstract

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.

DOI

10.1016/j.chiabu.2022.105653

Alternate Title

Child Abuse Negl

PMID

35779985

Title

Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children.

Year of Publication

2022

Date Published

06/2022

ISSN Number

1876-2867

Abstract

OBJECTIVE: Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse.

METHODS: We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed.

RESULTS: Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse."

CONCLUSIONS: ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.

DOI

10.1016/j.acap.2022.06.011

Alternate Title

Acad Pediatr

PMID

35777658

Title

Pediatric Emergency Medicine Physicians' Perceptions of Colleagues' Clinical Performance Over Career Span.

Year of Publication

2022

Date Published

06/2022

ISSN Number

1535-1815

Abstract

OBJECTIVE: The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric emergency medicine (PEM) is a high-acuity, multitasking, diagnostically complex and procedurally demanding specialty. Aging's impact on clinical performance in PEM has not been examined. We aimed to assess PEM physician's' perceptions of peers' clinical performance over career span.

METHODS: We surveyed 478 PEM physician members of the American Academy of Pediatrics' Section on Emergency Medicine survey study list-serve in 2020. The survey was designed by the investigators with iterative input from colleagues. Respondents rated, using a 5-point Likert scale, the average performance of 4 age categories of PEM physicians in 9 clinical competencies. Additional items included concerns about colleague's performance and preferences for age of physician managing a critically ill child family member.

RESULTS: We received 232 surveys with responses to core initial items (adjusted response rate, 49%). Most respondents were 36 to 49 (34.9%) or 50 to 64 (47.0%) years old. Fifty-three percent reported ever having concern about a colleague's performance. For critical care-related competencies, fewer respondents rated the ≥65-year age group as very good or excellent compared with midcareer physicians (36-49 or 50-64 years old). The ratings for difficult communications with families were better for those 65 years or older than those 35 years or younger. Among 129 of 224 respondents (58%) indicating a preferred age category for a colleague managing a critically ill child relative, most (69%) preferred a 36 to 49-year-old colleague.

CONCLUSIONS: Pediatric emergency medicine physicians' perceptions of peers' clinical performance demonstrated differences by peer age group. Physicians 65 years or older were perceived to perform less well than those 36 to 64 years old in procedural and multitasking skills. However, senior physicians were perceived as performing as well if not better than younger peers in communication skills. Further study of age-related PEM clinical performance with objective measures is warranted.

DOI

10.1097/PEC.0000000000002785

Alternate Title

Pediatr Emerg Care

PMID

35766881

Title

Characterizing Multiple Perpetrator Sexual Assaults in the Adolescent Female Population.

Year of Publication

2022

Date Published

06/2022

ISSN Number

1873-4332

Abstract

STUDY OBJECTIVE: To determine whether differences exist between the acute presentations and post-assault needs of youth presenting to an emergency department (ED) following multiple perpetrator sexual assault (MPSA) compared with those presenting after single perpetrator sexual assault.

METHODS: A retrospective cohort study of all female adolescents evaluated in an urban pediatric ED between 2014 and 2021 for acute sexual assault was conducted. Demographic characteristics and assault outcomes were assessed using bivariate analyses.

RESULTS: Survivors of MPSA were not more likely than survivors of single perpetrator assaults to be diagnosed with an anal-genital injury or sexually transmitted infection but were more likely to re-present in the subsequent year for an emergent mental health concern (31% vs 11%, P = .001), including suicide attempt (6% vs 1%, P = .022).

CONCLUSION: The high rate of subsequent ED visits for mental health concerns among female adolescent survivors of MPSA highlights the need for providing specialized support to this population.

DOI

10.1016/j.jpag.2022.06.003

Alternate Title

J Pediatr Adolesc Gynecol

PMID

35760285

Title

Child Abuse Pediatrics Research Network: The CAPNET Core Data Project.

Year of Publication

2022

Date Published

07/2022

ISSN Number

1876-2867

Abstract

OBJECTIVE: Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network.

METHODS: We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021.

RESULTS: Among 3667 patients with 3721 encounters, 69.4% were < 3 years old; 44.3% < 1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPS performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild / intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse.

CONCLUSION: Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.

DOI

10.1016/j.acap.2022.07.001

Alternate Title

Acad Pediatr

PMID

35840086

Title

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

Year of Publication

2022

Date Published

08/2022

ISSN Number

1098-4275

Abstract

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.

DOI

10.1542/peds.2022-056284

Alternate Title

Pediatrics

PMID

35707943

Title

Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse.

Year of Publication

2022

Date Published

2022 Apr 27

ISSN Number

2194-802X

Abstract

<p><strong>OBJECTIVES: </strong>Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis.</p>

<p><strong>METHODS: </strong>We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process.</p>

<p><strong>RESULTS: </strong>The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR).</p>

<p><strong>CONCLUSIONS: </strong>Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.</p>

DOI

10.1515/dx-2022-0008

Alternate Title

Diagnosis (Berl)

PMID

35475729

Title

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals.

Year of Publication

2022

Number of Pages

e225005

Date Published

2022 Apr 01

ISSN Number

2574-3805

Abstract

<p><strong>Importance: </strong>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.</p>

<p><strong>Objective: </strong>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.</p>

<p><strong>Design, Setting, and Participants: </strong>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.</p>

<p><strong>Exposures: </strong>Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital.</p>

<p><strong>Main Outcomes and Measures: </strong>Use of neuroimaging by CT or MRI.</p>

<p><strong>Results: </strong>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 &lt;3 months vs ages 9 to &lt;12 months, 13.2; 95% CI, 9.54-18.2; P &lt; .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P &lt; .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 &lt; .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).</p>

<p><strong>Conclusions and Relevance: </strong>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.</p>

DOI

10.1001/jamanetworkopen.2022.5005

Alternate Title

JAMA Netw Open

PMID

35442455

Title

Child Abuse Imaging and Findings in the Time of COVID-19.

Year of Publication

2022

Number of Pages

65-69

Date Published

2022 Feb 01

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVE: </strong>To assess the impact of the COVID-19 pandemic on physical abuse in young children, we compared the following before and during the pandemic: (1) skeletal survey volume, (2) percent of skeletal surveys revealing clinically unsuspected (occult) fractures, and (3) clinical severity of presentation. We hypothesized that during the pandemic, children with minor abusive injuries would be less likely to present for care, but severely injured children would present at a comparable rate to prepandemic times. We expected that during the pandemic, the volume of skeletal surveys would decrease but the percentage revealing occult fractures would increase and that injury severity would increase.</p>

<p><strong>METHODS: </strong>We conducted a retrospective study of children younger than 2 years undergoing skeletal surveys because of concern for physical abuse at a tertiary children's hospital. Subjects were identified by querying a radiology database during the March 15, 2019-October 15, 2019 (pre-COVID-19) period and the March 15, 2020-October 15, 2020 (COVID-19) period, followed by chart review to refine our population and abstract clinical and imaging data.</p>

<p><strong>RESULTS: </strong>Pre-COVID-19, 160 skeletal surveys were performed meeting the inclusion criteria, compared with 125 during COVID-19, representing a 22% decrease. No change was observed in identification of occult fractures (6.9% pre-COVID vs 6.4% COVID, P = 0.87). Clinical severity of presentation did not change, and child protective services involvement/referral decreased during COVID.</p>

<p><strong>CONCLUSIONS: </strong>Despite a &gt;20% decrease in skeletal survey performance early in the pandemic, the percent of skeletal surveys revealing occult fractures did not increase. Our results suggest that decreases in medical evaluations for abuse did not stem from decreased presentation of less severely injured children.</p>

DOI

10.1097/PEC.0000000000002630

Alternate Title

Pediatr Emerg Care

PMID

35100743

Title

Recent Trends in Marijuana-Related Hospital Encounters in Young Children.

Year of Publication

2021

Date Published

2021 Jul 26

ISSN Number

1876-2867

Abstract

<p><strong>OBJECTIVES: </strong>Multiple states have passed legislation permitting marijuana use. The impact of legalization on trends in hospital encounters for marijuana exposures in young children across states remains unknown. We aimed to describe trends in marijuana-related hospital encounters over time in children &lt;6 years and assess the association of state-level marijuana legislation with the rate of marijuana-related hospitalizations.</p>

<p><strong>METHODS: </strong>We identified inpatient, emergency department and observation encounters for children &lt;6 years with marijuana exposures (defined by International Classification of Diseases diagnosis codes) unique on the patient-year level at 52 children's hospitals in the Pediatric Health Information System database from 01/01/2004-12/31/2018. Trends in encounters across the study period were evaluated using negative binomial regression with outcome of marijuana-related hospital encounters and year as the predictor variable accounting for clustering by hospital. We then estimated a negative binomial regression difference-in-differences model to examine the association between the main outcome and state recreational and medical marijuana legalization.</p>

<p><strong>RESULTS: </strong>Of the 1296 included unique patient-year encounters, 50% were female with mean age 2.1 years (SD=1.4). Fifty percent were inpatient (n=645) and 15% required intensive care with 4% requiring mechanical ventilation. There was a 13.3-fold increase in exposures in 2018 compared to 2004 (p &lt;0.001). We did not find an effect of state legalization status for recreational (p=0.24) or medical (p=0.30) marijuana.</p>

<p><strong>CONCLUSIONS: </strong>The observed dramatic increase in marijuana-related hospital encounters highlights the need for prevention strategies aimed at reducing unintentional marijuana exposures in young children, even in states without legislation permitting marijuana use.</p>

DOI

10.1016/j.acap.2021.07.018

Alternate Title

Acad Pediatr

PMID

34325061

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