Clinical Decision Rules to Discriminate Bruising Caused by Physical Child Abuse

区分儿童身体虐待造成的瘀伤的临床决策规则

• 批准号: 8644817
• 负责人: Mary Clyde Pierce
• 金额: $ 56.34万
• 依托单位: LURIE CHILDREN'S HOSPITAL OF CHICAGO
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-05-30 至 2016-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8644817
• 关键词: 4 year old; Accident and Emergency department; Acute; Address; Affect; Age-Months; Algorithms; Caring; Case-Control Studies; Cause of Death; Cessation of life; Characteristics; Child; Child Abuse; Child Abuse and Neglect; Childhood; Classification; Clinical; Consult; Contusions; Data; Data Set; Decision Making; Decision Modeling; Development; Diagnosis; Direct Costs; Ear; Early Diagnosis; Emergency Medicine; Emergency Situation; Evaluation; Facilities and Administrative Costs; Failure; Family; Fetal Death; Goals; Health; Healthy People 2010; Healthy People 2020; Infant; Injury; Medical; Methods; Modeling; National Institute of Child Health and Human Development; Neck; Observational Study; Outcome; Patients; Pediatrics; Pilot Projects; Population; Predictive Value; Prevention; Public Health; Research; Research Personnel; Sensitivity and Specificity; Skin; Societies; Specificity; Testing; Trauma; Trees; United States; Validation; Visit; Work; child physical abuse; disability; evidence based guidelines; high risk; improved; infant death; interest; maltreatment; meetings; mortality; physical abuse; point of care; prevent; prospective; screening; success; tool; usability

DESCRIPTION (provided by applicant): Child abuse affects over 1 million children each year in the United States at an estimated annual direct and indirect cost exceeding $103.8 billion. Many cases of physical child abuse are missed initially because early signs of abuse, such as bruising, go unrecognized. This lack of recognition leads to errors in decision making which in turn leads to poor patient outcomes. When abuse is missed, repeat injury occurs in up to 80% of victims with mortality rates as high as 30%; these cases are all preventable. Bruising is one of the most common signs of physical child abuse and is missed as an early warning sign in up to 44% of fatal and near-fatal cases. Currently, no evidence-based guidelines exist to aid clinicians in decision-making for discriminating bruises caused by abusive vs. accidental trauma. However, evidence from several studies indicates that discriminating characteristics do exist. The predictive accuracy of these findings has not yet been determined or incorporated into a practical decision-making model, such as a clinical decision rule, for the acute care setting. Clinical decision rules are "point-of-care" decision tools that help improve accuracy in decision making and may therefore improve health outcomes for children and families. This study will provide the first practical screening tool in the form of a bruising clinical decision rule (BCDR) for discriminating bruises caused by physical child abuse. The proposed study is a prospective observational study of bruising characteristics in children < 4 years of age. This proposal will build on previous work by the investigators in which a BCDR was derived for discriminating bruises caused by physical child abuse with excellent sensitivity (97%) and specificity (84%). Data on bruising characteristics will be collected by a pediatric emergency medicine research team and child abuse experts on 2,360 children with bruising. The proposed study will address the following specific aims: 1) Identify discriminating bruising characteristics utilizing a detailed prospective skin assessment approach to allow for model input and development 2) Determine the predictive accuracy of our existing BCDR to discriminate bruising caused by abusive vs. accidental trauma when applied prospectively in different clinical settings, and 3) Determine if the predictive accuracy of the existing BCDR can be improved upon with the additional dataset collected prospectively, or generate a new BCDR should the existing model prove inadequate. CDR modeling will be performed using a binary recursive partitioning algorithm. Success of this study will result in a BCDR which can be used as a screening tool to identify children and infants with bruising who are at high risk for physical abuse and require further evaluation. Our long term goal is to change practice through evidence-based guidelines in order to decrease the number of unrecognized cases of physical child abuse, thereby preventing further abuse, improving patient outcomes, and decreasing the large burden to society.

描述（由申请人提供）：在美国，虐待儿童每年影响超过 100 万儿童，估计每年的直接和间接损失超过 1,038 亿美元。许多儿童身体虐待案件最初都被忽视，因为虐待的早期迹象（例如瘀伤）未被识别。这种缺乏认识会导致决策错误，进而导致患者治疗效果不佳。如果忽视虐待，高达 80% 的受害者会重复受伤，死亡率高达 30%；这些情况都是可以预防的。瘀伤是虐待儿童最常见的迹象之一，在高达 44% 的致命和近乎致命案件中，瘀伤是一个早期预警信号而被忽视。目前，尚无基于证据的指南来帮助临床医生做出区分虐待性创伤和意外创伤引起的瘀伤的决策。然而，多项研究的证据表明，歧视性特征确实存在。这些发现的预测准确性尚未确定或纳入实际决策模型中，例如急性护理环境的临床决策规则。临床决策规则是“即时护理”决策工具，有助于提高决策的准确性，从而改善儿童和家庭的健康结果。这项研究将以瘀伤临床决策规则（BCDR）的形式提供第一个实用的筛查工具，用于区分儿童身体虐待造成的瘀伤。拟议的研究是一项针对 4 岁以下儿童瘀伤特征的前瞻性观察研究。该提案将建立在研究人员之前的工作基础上，其中 BCDR 是为了区分儿童身体虐待造成的瘀伤而得出的，具有出色的敏感性 (97%) 和特异性 (84%)。儿科急诊医学研究小组和儿童虐待专家将收集 2,360 名有瘀伤的儿童的瘀伤特征数据。拟议的研究将解决以下具体目标：1）利用详细的前瞻性皮肤评估方法来识别瘀伤特征，以允许模型输入和开发2）确定我们现有的 BCDR 的预测准确性，以区分虐待性创伤和意外创伤引起的瘀伤3) 确定是否可以通过前瞻性收集的额外数据集来提高现有 BCDR 的预测准确性，或者在现有模型证明不足时生成新的 BCDR。 CDR 建模将使用二进制递归分区算法来执行。这项研究的成功将产生 BCDR，它可以用作筛查工具，以识别有瘀伤的儿童和婴儿，这些儿童和婴儿面临身体虐待的高风险并需要进一步评估。我们的长期目标是通过基于证据的指南改变实践，以减少未被识别的儿童身体虐待案件的数量，从而防止进一步的虐待，改善患者的治疗结果，并减轻社会的巨大负担。