Clinical Decision Rules to Discriminate Bruising Caused by Physical Child Abuse

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成本超过1038亿美元。许多儿童身体虐待的案例最初都没有被发现，因为虐待的早期迹象，如瘀伤，没有被发现。这种认识的缺乏导致决策错误，进而导致患者预后不良。如果错过虐待，高达80%的受害者会再次受伤，死亡率高达30%；这些病例都是可以预防的。瘀伤是儿童身体虐待最常见的迹象之一，但在高达44%的致命和接近致命的案件中，这一早期预警信号被忽视了。目前，尚无基于证据的指导方针来帮助临床医生区分由虐待性创伤和意外性创伤引起的瘀伤。然而，来自几项研究的证据表明，区别性特征确实存在。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，为急症护理设置。临床决策规则是“护理点”决策工具，有助于提高决策的准确性，从而可能改善儿童和家庭的健康结果。本研究将提供第一个实用的筛选工具，以瘀伤临床决策规则（BCDR）的形式，用于区分儿童身体虐待引起的瘀伤。该研究是一项针对4岁以下儿童瘀伤特征的前瞻性观察研究。该建议将建立在研究者先前工作的基础上，其中BCDR用于区分儿童身体虐待引起的瘀伤，具有出色的灵敏度（97%）和特异性（84%）。儿童急诊医学研究组和儿童虐待专家将对2360名有瘀伤的儿童收集瘀伤特征数据。建议的研究将涉及以下具体目标：1)利用详细的前瞻性皮肤评估方法识别可区分的瘀伤特征，以允许模型输入和开发2)确定现有BCDR在不同临床环境中用于区分虐待性和意外性创伤引起的瘀伤的预测准确性，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。或者在现有模式被证明不足的情况下，生成一个新的BCDR。CDR建模将使用二进制递归划分算法执行。这项研究的成功将产生BCDR，它可以作为一种筛选工具，用于识别有瘀伤的儿童和婴儿，这些儿童和婴儿有遭受身体虐待的高风险，需要进一步评估。我们的长期目标是通过以证据为基础的指导方针改变实践，以减少未被发现的儿童身体虐待病例的数量，从而防止进一步的虐待，改善患者的治疗效果，减少对社会的巨大负担。

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.