P O L IC Y LA B September 14, 2020 UNDERSTANDING ... - CT-AAP

P O L IC Y LA B

UNDERSTANDING &ADDRESSING DISPARITIES IN PHYSICAL ABUSE EVALUATIONS

Joanne N. Wood, MD, MSHP

policylab.chop.edu | @PolicyLabCHOP

September 14, 2020

Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the New Jersey of Academy of Family Physicians and Hezekiah Beardsley Connecticut Chapter of the American Academy of Pediatrics and the Yale University School of Medicine. The New Jersey Academy of Family Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The New Jersey Academy of Family Physicians designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DIS C L OS UR E SF unding• NIC HD K 23HD 071967• NIC HD R 24 HD 09841501A1• R ay E . Helfer S ociety• C enter for P ediatric C linical

Effectiveness at CHOP

OBJ E C TIVE S1. Describe the epidemiology and

child physical abuse in the U.S .2. Identify challenges to recognizing

and diagnosing abusive injuries in young children.

3. Describe the impact of biasesand variation in practice on care for suspected victims of abuse.

4. Identify opportunities for reducingdisparities and improving care forvictims of abuse.

OUTL INE

1 • E pidemiology of P hysical Abuse

2 • Diagnostic C hallenges

3 • Disparities in P ractice

4 • Strategies for Improvement

5

C HIL D PHY S IC AL AB USE IN THE U.S.

Each year in the U.S.:• 120,000 children identified as victims of physical

abuse

• Nearly 5,000 children hospitalized

• 600 children die

6

C HIL D AB US E DIS P R OP OR TIONATE LY IMPAC TS MOS T VUL NE R AB L E

6U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child Maltreatment 2018. Available from https://www.acf.hhs.gov/cb/research-data-technology /statistics-research/child-maltreatment.

47%7%

11%

13%

4%

1%2%2%2%

3%

1% 1%1% 1%

2% 1% 11%%

by Ag e

<1 1 2

3 4 5

6 7 8

9 10 11

12 13 14

15 16 17

Children under age 2 years account for• >60% of maltreatment related deaths

C hild Abus e Deaths

http://www.acf.hhs.gov/cb/research-data-technology

http://www.acf.hhs.gov/cb/research-data-technology

C HIL D AB US E DIS P R OP OR TIONATE LY IMPAC TS MOS T VUL NE R AB L E

7Leventhal JM, Martin KD, Gaither JR. Using U.S. data to estimate the incidence of serious physical abuse in children. Pediatrics. 2012.

Children under age 2 years account for• >70% of abuse related hospitalizations

C HIL D AB US E DIS P R OP OR TIONATE LY IMPAC TS MOS TVUL NE R AB L E

Photo by Philip Steury Photography/Shutterstock

Children living in poverty

• 3 times more likely to be physically abused

Children with disabilities

• 3 time more likely to be abused

Children in homes with domestic violence, substance abuse, social isolation, unmarried live-in partner

• Increased risk of abuse

9

OUTL INE

1 • E pidemiology and Impact ofAbuse




10

P HY S IC AL AB US E : DIAG NOS TIC C HAL L E NG E S

Leventhal JM, Martin KD, Gaither JR. Using U.S. data to estimate the incidence of serious physical abuse in children. Pediatrics. 2012.

R ecognizing & diagnosing abuse is challenging• Young preverbal patients – limits history & physical examination

11


U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. Washington, D.C.2016.


• Misleading histories

R elations hip ofP erpetrator to Victim

12




• Few injuries are pathognomonic for abuse

13


14



• Few injuries are pathognomonic for abuse

• Biases

OUTL INE





15

DIS PAR IT IE S AND VAR IATION

10 m.o. infant presents with boggy swelling and skull fracture after reported fall from car seat on counter.

Is the decision to perform and abuse evaluation (and make a report) fair and equitable regardless of care setting and family characteristics? Or does it depend on

• Pediatric hospital vs. community hospital• Pediatric hospital A vs. hospital B• Provider who happens to be working that night• Race and ethnicity• Socioeconomic status• Family composition

16

DIAG NOS E D C AS E S OF AHT: 1999

Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-626.

17

Nearly 1 in 3 children diagnosed with AHT had prior missed opportunity for diagnosis in a 1999 study.

173 children with abusive head trauma (AHT)

31% seen by physician and diagnosis missed• 28% reinjured

• 41% medical complications

4 of 5 deaths might have been prevented

MIS S E D VS . R E C OGNIZE D ANT (J E NNY 1999)

18

Factors associated with missed AHT in univariate analysis• Young age• Lack of severe symptoms at initial visit

• Seizures, respiratory compromise, abnormal status change, or abnormal respirations

• Absence of facial / scalp injuries• Absence of other (non-head) injuries• White race (vs minority)• Intact families

MIS S E D VS . R E C OG NIZE D ANT (JE NNY 1999)

19

Factors associated with recognized AHT in multivariate analysis• Abnormal respiratory status

• OR7.23; 95% CI, 2.4-21.3; P<.001• Seizures present

• OR, 6.67; 95% CI, 2.5-17.3; P<.001• Facial and/or scalp injury present

• OR, 4.81; 95% CI, 2.1-11.0; P<.001• Parents not living together

• OR, 2.49; 95% CI, 1.1-5.7; P = .03

MIS S E D VS . R E C OG NIZE D ANT (JE NNY 1999)

20

“Infants with recognized AHT were more likely to be minority children or children whose mothers and fathers were not living together. We speculate that this may represent a subtle bias in decision making based on the physician's assessment of risk. A physician examining a white child from an intact family may be less likely to think about the possibility of child abuse.”

R AC IAL DIF F ER E NC ES IN E VAL UATION OF F R AC TUR ES F ORABUS E

21

R AC IAL DIF F ER E NC ES IN E VAL UATION OF F R AC TUR ES F OR AB USE

Objectives : To determine whether there are racial differences in the evaluation and C P S reporting of young children hospitalized for fractures .Desig n:• R etros pective chart review• 388 children < 3 years hospitalized for acute primary skull or long-

bone fracture• Urban US academic children's hospital, 1994 and 2000.Main Outcome Meas ures :• Ordering of skeletal surveys• R eports of suspected abusePredictor Variables :• Age• S ex• R ace• Insurance• Appropriateness of S S• L ikelihood of abuse

22


23


Independent Association of Race, Likelihood of Abuse, Appropriateness of Skeletal Survey, and Insurance Status on the Likelihood of Ordering a Skeletal Survey

24


Adjusted percentages and RR of obtaining a skeletal survey stratified by likelihood of abuse, age, insurance and SS appropriateness.

Minority children young er than 1 year with abus ive injuries had a nearly equal likelihood of a s keletal s urvey being performed as their

white counterparts .

25


Adjusted percentages and RR of obtaining a skeletal survey stratified by likelihood of abuse, age, insurance and SS appropriateness.

Minority children >12 months with likely accidental injuries were more than 5 times more likely to have a s keletal s urvey inappropriately obtained than were their white counterpart

26

R AC IAL DIF F ER E NC ES IN R E P OR TING OF F RAC TURE S F OR AB USE

27

DIS PAR IT IE S IN C HIL D AB US E E VAL UAT ION & R E P OR T ING

Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288(13):1603-1609.

Minority children > 12 months with likely accidental injuries were:• 5 times more likely to have a skeletal

survey

• 3 times more likely to be reported to CPS

Rates of skeletal survey and reports were similar among white and minority infants with abusive injuries

28

DIS PAR IT IE S IN C HIL D ABUS E E VAL UATION & R E P OR T ING

29

E VAL UAT ION OF INFANT S WIT H HIGH-R IS K INJ UR IE S

• P revalence of S S performance in infants < 1 y.o. with non-MVCassociated TBI or femur fractures at 40 pediatric and 40 community hospitals .

• Association of race with likelihood of S S performance in infants < 1y.o. with non-MVC associated TBI or femur fractures at 40 pediatric and 40+ community hospitals .

30

VAR IATION IN E VAL UATION OF F EMUR

General hospitals (n=562 infants)

53% overall 26% to 77%

Pediatric hospitals (n=2975 infants)

77% overall 44% to 94%

F R AC TUR E S

S keletal survey use in infants with femur fractures:

1009080706050403020100

Skel

etal

Sur

vey

Pe

rform

ance

(%)

80 Hospitals

40 Children's Hospitals40 General Hospitals

• Wood JN, French B, Song L, Feudtner C. Evaluation for occult fractures in injured children. Pediatrics. 2015;136(2).• Wood JN, Feudtner C, Medina SP, Luan X, Localio R, Rubin DM. Variation in occult injury screening for children

with suspected abuse in selected US children's hospitals. Pediatrics. 2012;130(5):853-860.

General hospitals (n=562 infants)53% overall26% to 77%

P ediatric hospitals (n=2975 infants77% overall44% to 94%

VAR IATION IN E VAL UATION OF TBI

S keletal survey use in infants with TBI:

1009080

)ey% 70v(reu 60Sncalm 50aetrlo 40efkerS 30P

2010 40 Children's Hospitals

0 46 General Hospitals

86 Hospitals

1009080706050403020100

Ske

leta

l Sur

vey

P

erfo

rman

ce(%

)

86 Hospitals

40 Children's Hospitals46 General Hospitals

• Wood JN, French B, Song L, Feudtner C. Evaluation for occult fractures in injured children. Pediatrics. 2015;136(2).• Wood JN, Feudtner C, Medina SP, Luan X, Localio R, Rubin DM. Variation in occult injury screening for children

with suspected abuse in selected US children's hospitals. Pediatrics. 2012;130(5):853-860.

DIS PAR ITIE S IN EVAL UATIONS OF HIGH RIS K INJ UR IE SAssociation of race and insurance with skeletal survey performance

General Hospitals P ediatric Hospitals

TB I F emur TB I F emurOR P -value OR P -value OR P-value OR P -value

Insurance

P rivate R ef R ef R ef R ef

Medicaid 2.38 <0.001 1.44 0.02 1.56 <0.001 1.58 <0.001

R ace

White R ef R ef R ef R ef

Black 1.16 0.52 1.72 0.02 1.57 <0.001 1.30 0.07

AS S OC IATION OF R AC E AND INS UR ANC E WITH S K E L ETALS UR VE Y P E R F OR MANC E IN INFANTS WIT H TBI

Aim: To evaluate theassociation of race and socioeconomic status with skeletal surveyperformance in infants with traumatic brain injury (TBI)

Study P opulation:

Infants admitted to 39 pediatric hospitals from J anuary 2004-J une2008 with non-MVC TBI.

34

AS S OC IAT ION OF R AC E AND INS UR ANC E WIT H S K E L E TALS UR VE Y P E RF OR MANC E IN INFANT S WIT H TB IP redictors of skeletal survey performance in >3,000 infants diagnosed with TB I at 39 pediatric hospitals .

N (% ) PAge

<1 mo 204 (63.8)1–6 mo 1451 (72.7) .0027–12 mo 550 (73.5)

R aceWhite 956 (67.8)Black 526 (84.0)

<.001Hispanic 385 (70.8)

InsurancePrivate 352 (54.5)Public 1437 (80.6) <.001

TBI severityMild 22 (53.9)Moderate 1164 (66.1) <.001S evere 1010 (81.0)

Other injuriesPresent 232 (87.2)

<.001Absent 1973 (70.5)

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ADJ US T E D P R OP OR T ION OF INFANT S WIT H TB I WHO

Joanne N. Wood et al. Pediatrics 2010;126:408-414

©2010 by American Academy of Pediatrics

R E C E IVE D A S K E L E TAL S UR VE Y, AC C OR DING TO R AC E

Mild / Moderate TBI

35

Joanne N. Wood et al. Pediatrics 2010;126:408-414

©2010 by American Academy ofPediatrics

ADJ US T E D P R OP OR T ION OF INFANTS WIT H TBI WHO R E C E IVE D A S K E L E TAL S UR VE Y, AC C OR DING TO R AC E

S evere TBI

Lane WG, Dubowitz H. What factors affect the identification and reporting of child abuse-related fractures?. Clin Orthop Relat Res. 2007;461:219-225. doi:10.1097/BLO.0b013e31805c0849

VIG NE TTE S TUDY OF C HIL D AB US E R E P OR TING BYOR THOP E DIS TS

Assessed:1. How skilled are orthopedists in distinguishing abuse-related

from noninflicted fractures and making appropriate child protective services reports?

2. Are decisions influenced by orthopedist training or by the race or socioeconomic status of injured children?

Design:• 10 case vignettes mailed to orthopedists• 2 versions: race and SES of families differed

38

VIG NE TTE S TUDY OF C HIL D AB US E R E P OR TING B Y

Lane WG, Dubowitz H. What factors affect the identification and reporting of child abuse-related fractures?. Clin Orthop Relat Res. 2007;461:219-225. doi:10.1097/BLO.0b013e31805c0849

OR THOP E DIS TS

Findings:• Pediatric orthopedists better than orthopedists at accurately

identifying abuse-related injuries

• 82% versus 73%

• More likely to classify injury as abusive and make report if

• Parent a factory worker vs. teacher

• Parent a clerk vs. nurse

• NO differences by race

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DIS PAR IT IE S IN C HIL D AB US E E VAL UAT IONS

Literature demonstrates:• Racial and SES based disparities exist in child abuse

evaluation and reporting decisions

• Disparities are not limited to one center• It is complicated• Interactions between race and SES exist• Disparities differ among racial and ethnic groups• Disparities are more pronounced in:

• Older children• Likely accidental injuries• Less severe injuries

• There is still a lot we don’t know

40

S UMMAR Y : S TAT E OF C URR E NT P R AC T IC E

C urrent state of medical care for young victims of physical abuse is characterized by missed opportunities to diagnose abuse and protect children from further harm, variation and disparities in which children are evaluated for abuse and reported to child protective services.

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OUTL INE





42

S TR ATE G IE S F OR E L IMINATING DIS PAR IT IE S

43

Am J Public Health. 2019 January; 109(Suppl 1): S64–S69

Health Services Research Opportunities to Eliminate Health Care Disparities: National Institute on Minority Health and Health Disparities Science Visioning Initiative (2019)1. Evaluate how newly developed patient care models affect health care

disparities.2. Incorporate and evaluate QI initiatives to reduce health care disparities in

health systems and show how they can be disseminated and implementedmore broadly.

3. Evaluate the effect of legislative changes on access to and quality of care received by health disparity populations.

4. Examine the effect of payer-based changes on improving health outcomes and patient satisfaction among health disparity populations.

5. Identify patterns of underuse and overuse of health care and how inappropriate care can lead to health disparities.

6. Understand how current standards of care and guidelines may contribute to health disparities.

7. Develop a comprehensive understanding of how to deliver culturally competent care in health care settings.

8. 8. Examine patient preferences and how they contribute to health disparities.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356134/

One Component of an Improvement Strategy:

• Clinical decisions support tools

• Quality Improvement

44

C HIL D AB US E C L INIC AL DE C IS ION S UP P OR T TOOL S

Clinical Pathways & Order Sets

Electronic Health Record Alerts

Universal Screening Tools

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Structured care plans that outline steps in the care of patients with a specific clinical problem

C L INIC AL PATHWAY S

46

C URRE NT PATH WAY PRE S E NC E

2016 survey of 41 CHA hospitals• Pathways varied in types of injuries included, format,

recommendations

None 39%

One 44%

More than 1/3 of major tertiary care pediatric hospitals don’t have any child abuse pathways

Two 10%

3 or more 7%

47

PHY S IC ALS TANDAR DIZING E VAL UATION OF S US P E C TE D AB US E IN A PE DIATR IC E D

Riney LC, Frey TM, Fain ET, Duma EM, Bennett BL, Murtagh Kurowski E. Standardizing the Evaluation of Nonaccidental Trauma in a Large Pediatric Emergency Department. Pediatrics. 2018;141(1):e20171994. doi:10.1542/peds.2017-1994

Aim: Increase the percent of patients evaluated in the emergency department for physical abuse who receive guideline adherent evaluation

48

S TANDAR DIZING E VAL UATION OF S US P E CTE D PHY S IC ALAB US E IN A PE DIATR IC E D

Multidisciplinary QI Team

Plan-do study-act cycles

Interventions:

• Guideline development

• Integration of guideline into work flow

• Order set construction

• Family communication strategy

• Provider education


49

S TANDAR DIZING E VAL UATION OF S US P E CTE D PHY S IC ALAB US E IN A PE DIATR IC E D

Strengths:• Multidisciplinary

Approach• Improved adherence to

guidelines for children with recognizedconcern for NAT

L imitations:• Unknown impact on

recognition of NAT• Unknown impact on

disparities

P roportion of visits adherent to the NAT guideline, J anuary 2015 -March 2017


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E L IMINATING DIS PAR ITY IN E VAL UATION F OR AB US E IN INFANTS WITH HE AD INJURY

E L IMINATING DIS PAR ITY IN E VAL UATION F OR AB US E IN INFANTS WITH HE AD INJUR Y

• Black infants underwent SS more than white infants– 90.5% vs 69.3%, P=0.01

• => Guideline implemented: ALL infants with unwitnessed head injury get SS

• Black infants and white infants underwent SS equally– 92.3% vs. 84.6%, P=1.0

E L IMINATING DIS PAR ITY IN E VAL UATION F OR AB US E IN INFANTS WITH HE AD INJUR Y

• Pre-guideline:– 29% of SS positive– 20% with SS diagnosed as abused

• Post-guideline– More patients underwent SS– 29% of SS positive– 22% with SS diagnosed as abused

=> Detection of more cases of abuse

IMPR OVE ADHER E NC E TO S KEL E TAL S UR VEYR E C OMME NDATIONS IN INFANTS WITH F R AC TUR E S

Multidisciplinary QI Team

Plan-do study-act cycles

Interventions:

• Pathway development & implementation

• Order set

• Provider education

• Revision of pathway & order set

54

S KE L E TAL S UR VE Y QUAL ITY IMPR OVEME NT INITIATIVE

• Multidisciplinary QI Team Effort to Improve Adherence to Skeletal Survey Recommendations in Infants with Fractures

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S KE L E TAL S UR VE Y QUAL ITY IMPR OVEME NT INITIATIVE


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IMPR OVE ADHER E NC E TO S KEL E TAL S UR VEYR E C OMME NDATIONS IN INFANTS WITH F R AC TUR E S

The clinician can click on this embedded link to see the fracture

pathway section that lists inclinical indicators suspicious of

physical abuse.

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S KE L E TAL S UR VE Y QUAL ITY IMPR OVEME NT INITIATIVE ATC HOP


58

E MR BAS E D AL E R T S

2016 Survey of 41 tertiary care pediatric hospitals

• Fewer than 1 in 4 had any EMR based alerts for child abuse

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E MR BAS E D AL E R T S

UP MC study of 30 age-specific triggers embedded in E MR• Sensitivity 96.8%

• Specificity 98.5%

• Acceptable, feasible

• No increase in compliance with AAP guidelines

84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group

Srinivasan Suresh, Richard A Saladino, Janet Fromkin, Emily Heineman, Tom McGinn, Rudolph Richichi, Rachel P Berger, Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children’s Hospital, Journal of the American Medical Informatics Association, Volume 25, Issue 7, July 2018, Pages 833–840,Rachel P Berger, Richard A Saladino, Janet Fromkin, Emily Heineman, Srinivasan Suresh, Tom McGinn, Development of an electronicmedical record–based child physical abuse alert system, Journal of the American Medical Informatics Association, Volume 25, Issue 2,February 2018, Pages 142–149, https://proxy.library.upenn.edu:2101/10.1093/jamia/ocx063

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S TANDAR DIZING C AR E & R E DUC ING DIS PAR IT IE S

Clinical decision support tools can increase adherence to child abuse evaluation guidelines & decrease disparities:• Include QI approach and active

monitoring• Stratify outcomes by race and SES• Assess impact on disparities• Remember that presence of disparities

may be influenced by:• Severity of injury• Age of child• Likelihood of abuse

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B etter res earch for C hild Abus e Pediatrics

MIS S ION: C AP NE T conducts rigorous, multi-center research in order to make the care of potentially abused children and their families more effective, safe, and fair.

https://capnetresearch.org/

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@PolicyLabCHOP

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