Clinical Decision Rules to Discriminate Bruising Caused by Physical Child Abuse

虐待儿童每年在美国影响超过100万儿童，估计每年的直接和间接成本超过1038亿美元。许多身体虐待儿童的案件最初被遗漏，因为虐待的早期迹象，如瘀伤，无法识别。这种认识的缺乏导致决策错误，这反过来又导致患者预后不良。当虐待被遗漏时，高达80%的受害者会发生重复伤害，死亡率高达30%;这些案件都是可以预防的。瘀伤是身体虐待儿童最常见的迹象之一，在高达44%的致命和近乎致命的病例中，瘀伤作为早期预警信号被遗漏。目前，还没有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造成的瘀伤的决策。然而，几项研究的证据表明，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的决策模型，如临床决策规则，为急性护理设置。临床决策规则是“即时”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状况。这项研究将提供第一个实用的筛选工具的形式的瘀伤临床决策规则（BCDR）的歧视瘀伤造成的身体虐待儿童。这项研究是一项关于4岁以下儿童瘀伤特征的前瞻性观察研究。这项建议将建立在以前的工作，由调查人员，其中一个BCDR是由身体虐待儿童所造成的歧视瘀伤具有良好的敏感性（97%）和特异性（84%）。一个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。拟议的研究将针对以下具体目标：1）利用详细的前瞻性皮肤评估方法识别区别性瘀伤特征，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，以区分当在不同的临床环境中前瞻性应用时由虐待与意外创伤引起的瘀伤，以及3）确定现有BCDR的预测准确性是否可以通过前瞻性收集的额外数据集来提高，或者如果现有模型被证明不充分，则生成新的BCDR。CDR建模将使用二进制递归分区算法进行。这项研究的成功将产生一个BCDR，可用作筛选工具，以确定儿童和婴儿的瘀伤谁是身体虐待的高风险，并需要进一步评估。我们的长期目标是通过循证指南改变实践，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，改善患者的预后，并减轻社会的巨大负担。

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.