Evaluation for Occult Fractures in Injured Children
Joanne N Wood1, Benjamin French2, Lihai Song3
1Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Departments of Pediatrics, and woodjo@email.chop.edu.
Insights
Hospital evaluation rates for occult fractures in young children with abuse-related injuries vary significantly. Teaching hospitals and those with higher patient volumes are more likely to perform these crucial evaluations.
Area of Science:
- Pediatric Trauma
- Child Abuse Forensics
- Healthcare Quality Improvement
Background:
- Occult fractures are common in physically abused children.
- Variations in diagnostic evaluation can impact patient outcomes.
- Identifying factors influencing evaluation practices is crucial for improving care.
Purpose of the Study:
- To analyze hospital variation in occult fracture evaluation for young children (<2 years) with physical abuse.
- To investigate evaluation practices for infants (<1 year) with injuries highly suggestive of abuse.
- To identify child and hospital factors associated with these evaluation disparities.
Main Methods:
- Retrospective study using the Premier database (2009-2013).
- Included children <2 years with physical abuse diagnosis and infants <1 year with non-motor vehicle crash traumatic brain injury or femur fractures.
- Examined across-hospital variation and child/hospital-level factors.
Main Results:
- Occult fracture evaluations were performed in 48-53% of the studied pediatric populations.
- Significant hospital variation in evaluation rates was observed across all groups.
- Teaching hospitals and those with higher annual volumes of young, injured children showed increased evaluation likelihood.
Conclusions:
- Substantial variation exists in occult fracture evaluations for young children with abuse or high-risk injuries.
- These findings highlight significant opportunities for quality improvement in managing this vulnerable population.
- Standardizing evaluation protocols may improve detection and care for abused children.
Objectives:
To examine variation across US hospitals in evaluation for occult fractures in (1) children <2 years old diagnosed with physical abuse and (2) infants <1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation.
Methods:
We performed a retrospective study in children <2 years old with a diagnosis of physical abuse and in infants <1 year old with non-motor vehicle crash-related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child- and hospital-level factors associated with evaluation for occult fractures.
Results:
Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P < .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P < .001).
Conclusions:
Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.
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