OBJECTIVE. Diagnosis of child abuse is difficult and may reflect patient, practitioner, and system factors. Previous studies have demonstrated potential lethal consequences if cases of abuse are missed and suggested a role for continuing medical education in improving the accuracy of diagnosis of suspected abuse. Although the majority of injured American children are treated at general hospitals, most published studies of severe injury resulting from child abuse have been conducted at children’s hospitals. The objective of this study was to evaluate the role of hospital type in observed variations in the frequency of diagnosis of child physical abuse among children with high-risk injuries.
METHODS. Hospital discharge data were evaluated, and adjusted rates of abuse diagnosis were reported according to hospital type. A regression model estimated the number of cases of abuse that would have been diagnosed if all hospitals identified abuse as frequently as observed at pediatric specialty hospitals. This study consisted of children who were <1 year old and admitted to US hospitals in 1997 for treatment of traumatic brain injury or femur fracture, excluding penetrating trauma or motor-vehicle–related injury. A total of 2253 weighted cases were analyzed.
RESULTS. The proportion of patients with a medical diagnosis of child abuse varied widely between hospital types: 29% of the cases were diagnosed as abuse at children’s hospitals compared with 13% at general hospitals. An estimated 178 infants (39% of total) with these specific injuries would have been identified as abused had they been treated at children’s rather than general hospitals.
CONCLUSIONS. Hospital type was associated with large variations in the frequency of diagnosis of child abuse. This variation was not related to observed differences in the patients or their injuries and may result from systematic underdiagnosis in general hospitals. This result has implications for quality-improvement programs at general hospitals, where the majority of injured children in the United States receive emergent medical care.
Trokel et. al. have reinforced the need for child abuse education for all health professionals. The percentage of infants wiith subdurals/epidurals diagnosed with child abuse (Table 2) is quite low in general and children's hospitals. This may reflect problems with coding, as the authors note in the discussion; the E codes, even when used, may not reflect the medical staff's true suspicions. It would be ideal to know how many cases were referred to child protective services. Many clinicians and hospitals may recognize child abuse, treat and report appropriately, but not document the diagnosis adequately for the coding staff. Children's hospital coding staff are more likely to be accurate here.
The large number of "other" head injury also needs explanation. A chart study would be interesting here.
Conflict of Interest:
None declared