Variation in occult injury screening for children with suspected abuse in selected US children's hospitals

Abstract

Objective: To describe variation across selected US children's hospitals in screening for occult fractures in children <2 years old diagnosed with physical abuse and in infants <1 year old who have injuries associated with a high likelihood of physical abuse.

Methods: We performed a retrospective study of children <2 years old with a diagnosis of physical abuse and infants <1 year old with non-motor vehicle crash-associated traumatic brain injuries or femur fractures admitted to 40 hospitals within the Pediatric Hospital Information System database from January 1, 1999, to December 31, 2009. We examined variation among the hospitals in the performance of screening for occult fractures as defined by receipt of skeletal survey or radionuclide bone scan. Marginal standardization implemented with logistic regression analysis was used to examine hospital variation after adjusting for patient demographic characteristics, injury severity, and year of admission.

Results: Screening for occult fractures was performed in 83% of the 10,170 children <2 years old with a diagnosis of physical abuse, 68% of the 9942 infants who had a traumatic brain injury, and 77% of the 2975 infants who had femur fractures. After adjustment for patient characteristics, injury severity, and year of admission, hospitals varied significantly in use of screening for occult fractures in all 3 groups of children.

Conclusions: The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.

FIGURE 1

Variation in screening for occult fractures in young children diagnosed with physical abuse (A) across hospitals and (B) over time. The type of child abuse services is based on a survey conducted by NACHRI in 2008 that categorized services available for 22 of 40 hospitals: (1) no services; (2) child abuse services; (3) child abuse team; or (4) child abuse programs. All remaining hospitals were included in unknown/other category.

FIGURE 2

Variation in screening for occult fractures in infants who had TBI. Results were generated from logistic regression analysis using marginal standardization, adjusting for age, insurance, gender, year of admission, and severity of TBI based on the ICD-9-CM/AIS score for the head region.

FIGURE 3

Variation in screening for occult fractures in infants who had femur fractures. Results were generated from logistic regression analysis by using marginal standardization, adjusting for age, insurance, gender, year of admission, and severity of the femur fracture based on the ICD-9-CM/AIS score for the lower extremities.