<p>Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes. </p>

<p><strong>OBJECTIVES: </strong>The aim of this study was to evaluate the effectiveness of clinical pathway implementation and quality improvement (QI) interventions to increase the percentage of infants with extremity fractures undergoing evaluation for suspected physical abuse, including skeletal survey (SS), and consultation with social work, and/or Child Protection Team.</p>

<p><strong>METHODS: </strong>Charts were retrospectively reviewed to establish percentage of infants less than 12 months old with extremity fractures undergoing an SS and consultation during the prepathway (January 1, 2012 to December 31, 2013) and postpathway (January 1, 2014 to June 30, 2015) periods. Using an Ishikawa framework, key process drivers were identified and additional QI interventions (clinical decision support and provider education) were developed and implemented. Impact of QI interventions on study metrics during active QI (July 1, 2015 to June 30, 2016) and post-QI periods (July 1, 2016 to December 31, 2016) was monitored using statistical process control charts. Logistic regression assessed predictors of obtaining an SS, consultation use, and occult fracture detection.</p>

<p><strong>RESULTS: </strong>Skeletal survey use pre- and postpathway averaged 40%, surpassing 60% on average during active QI and post-QI periods. Consultation performance averaged 46% pre- and postpathway, increasing to nearly 67% during active QI; consultation performance decreased during post-QI to 60%. A lack of trauma history and presence of femur or humerus fracture were associated with increased SS use and consultation (both P &lt; 0.001). Overall 20% of SS revealed occult fractures.</p>

<p>Sexual abuse of children is prevalent in today's society. In 2012, approximately 686,000 children (9.2 per 1000) in the United States were determined to be victims of substantiated child abuse and neglect, according to national data compiled by child protective service agencies; victimization rates were highest for children younger than 1 year. Nearly 9.3% of maltreated children were victims of sexual abuse, this finding was reported by US Department of Health and Human Services (http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-…). Previous research has shown that as many as 1 in 3 girls and 1 in 7 boys will be sexually abused during childhood (Child Abuse Negl. 2003;27:1205-1222). Although sexual abuse seems to be less common in boys than girls, this may be partly due to underdiagnosis and underreporting of sexual abuse in boys (Arch Dis Child. 2007;92:328-331). Clinicians should therefore consider the possibility of sexual abuse when boys present with genital injuries, because failing to recognize and diagnose sexual abuse can pose an ongoing safety risk to a child. However, an erroneous diagnosis of sexual abuse can have equally hazardous repercussions, including removal of a child from their caregivers or prosecution of an innocent individual. A number of medical conditions can mimic child sexual abuse injuries, including anal fissures, failure of midline fusion, perianal streptococcal dermatitis, and straddle injury (J Pediatr Health Care. 2009;23:283-288 and Acta Paediatr. 2011;100:590-593). The following case involves a 5-week-old male infant who presented to the pediatric emergency department with an avulsion injury to his penis concerning for sexual abuse. He was ultimately diagnosed with a relatively rare anatomic variant of the genitalia and determined to have sustained an accidental injury whose appearance mimicked abuse.</p>

<p><strong>OBJECTIVE: </strong>To assess the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), codes in identifying cases of child physical abuse in 4 children's hospitals.</p>

<p><strong>METHODS: </strong>We included all children evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at 4 children's hospitals from January 1, 2007, to December 31, 2010. Subjects included both patients judged to have injuries from abuse and those judged to have injuries from accidents or to have medical problems. The ICD-9-CM codes entered in the hospital discharge database for each child were compared to the decisions made by the CAPs on the likelihood of abuse. Sensitivity and specificity were calculated. Medical records for discordant cases were abstracted and reviewed to assess factors contributing to coding discrepancies.</p>

<p><strong>RESULTS: </strong>Of 936 cases of suspected physical abuse, 65.8% occurred in children &lt;1 year of age. CAPs rated 32.7% as abuse, 18.2% as unknown cause, and 49.1% as accident/medical cause. Sensitivity and specificity of ICD-9-CM codes for abuse were 73.5% (95% confidence interval 68.2, 78.4), and 92.4% (95% confidence interval 90.0, 94.0), respectively. Among hospitals, sensitivity ranged from 53.8% to 83.8% and specificity from 85.4% to 100%. Analysis of discordant cases revealed variations in coding practices and physicians' notations among hospitals that contributed to differences in sensitivity and specificity of ICD-9-CM codes in child physical abuse.</p>

<p><strong>CONCLUSIONS: </strong>Overall, the sensitivity and specificity of ICD-9-CM codes in identifying cases of child physical abuse were relatively low, suggesting both an under- and overcounting of abuse cases.</p>