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100多万儿童，估计每年的直接和间接损失超过1038亿美元。许多身体虐待儿童的案件最初被遗漏，因为早期的虐待迹象，如瘀伤，没有被识别出来。这种缺乏认识会导致决策失误，进而导致患者预后不佳。当虐待被错过时，高达80%的受害者会发生重复伤害，死亡率高达30%；这些病例都是可以预防的。瘀伤是身体虐待儿童的最常见迹象之一，在高达44%的致命和接近致命的案例中，瘀伤被漏掉作为早期预警信号。目前，还没有循证指南可以帮助临床医生做出区分虐待和意外创伤造成的瘀伤的决策。然而，来自几项研究的证据表明，区别特征确实存在。这些发现的预测准确性尚未确定或纳入用于急性护理环境的实际决策模型，如临床决策规则。临床决策规则是有助于提高决策准确性的“关注点”决策工具，因此可能会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，用于区分身体虐待儿童造成的瘀伤。这项拟议的研究是对4岁儿童的擦伤特征进行的前瞻性观察研究。这项建议将建立在调查人员之前的工作基础上，在这些工作中，BCDR被用于区分身体虐待儿童造成的瘀伤，具有极好的灵敏度(97%)和特异度(84%)。儿科急救医学研究小组和虐待儿童专家将收集2360名擦伤儿童的擦伤特征数据。拟议的研究将致力于以下具体目标：1)利用详细的前瞻性皮肤评估方法来识别区分擦伤的特征，以便进行模型输入和开发；2)确定我们现有的BCDR的预测准确性，以区分在不同临床环境中预期应用时由虐待和意外创伤造成的瘀伤；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进行改进，或者在现有模型被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。这项研究的成功将导致BCDR的产生，该BCDR可用作筛查工具，以确定哪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循证指导改变做法，以减少未被确认的身体虐待儿童案件的数量，从而防止进一步的虐待，改善患者结局，并减轻社会的巨大负担。 公共卫生相关性：这项研究建议建立以证据为基础的指南，以改进对身体虐待儿童的早期发现。这项提议直接符合《消除一切形式种族歧视国际公约》的优先利益，包括：改善健康结果，减少可预防的死亡和残疾人数，并使受虐待儿童有机会充分发挥其健康和富有成效的生活潜力。此外，研究结果将有助于帮助我国实现以下2010年健康人目标和公共卫生问题：15-33：减少儿童的虐待和虐待死亡16-1：减少胎儿和婴儿死亡16-2：降低儿童死亡率此外，研究目标与拟议的《健康人2020》中提出的减少非致命性儿童虐待和儿童虐待死亡的主要联邦目标直接一致。

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. PUBLIC HEALTH RELEVANCE: This research proposes to establish evidence-based guidelines to improve early detection of physical child abuse. This proposal is directly in line with NICHD priority interests, including: improvements in health outcomes, decreasing the number of preventable deaths and disabilities, and allowing abused children to have the chance to achieve their full potential for healthy and productive lives. Additionally, study results will be instrumental in helping our nation meet the following Healthy People 2010 goals and public health issues: 15-33: Reduce maltreatment and maltreatment fatalities of children 16-1: Reduce fetal and infant deaths 16-2: Reduce the rate of child deaths Additionally, study objectives are in direct alignment with key federal objectives as stated in the proposed Healthy People 2020 of reducing non-fatal child maltreatment and child maltreatment deaths.