Keenan Heather T, Cook Lawrence J, Olson Lenora M, Bardsley Tyler, Campbell Kristine A
Department of Pediatrics, University of Utah, Salt Lake City, Utah
Department of Pediatrics, University of Utah, Salt Lake City, Utah.
Pediatrics. 2017 Nov;140(5). doi: 10.1542/peds.2017-1188.
Poor and minority children with injuries concerning for abuse are evaluated and diagnosed for abuse differentially. We hypothesized that 2 steps in the decision-making process would influence evaluation and diagnosis: social intuition from meeting the family and objective social information associated with child abuse risk.
Between 2009 and 2013, 32 child abuse pediatricians (CAPs) submitted 730 child abuse consultations including original medical evaluations and diagnoses. CAPs evaluated and diagnosed each other's cases. Comparisons of evaluations and diagnoses were made by levels of social understanding available to the CAP: meeting the family (social intuition and information), reading the case (social information), and reading the case without social information. Evaluations were compared with a consensus gold standard by using logistic regression modeling adjusting for child and CAP characteristics. Diagnostic categories were compared by level of social understanding and diagnostic certainty by using contingency tables.
CAPs without access to social intuition were approximately twice as likely to perform gold standard evaluations for neurotrauma and long bone fracture compared with CAPs who met families. Diagnostic agreement fell from 73.3% (95% confidence interval [CI]: 70.1%-76.5%) when social information was present to 66.5% (95% CI: 63.1%-70.0%) when social information was restricted. In cases with less certainty, agreement dropped to 51.3% (95% CI: 46.0%-56.7%).
Social intuition and information play a role in the physical child abuse decision-making process, which may contribute to differential diagnosis. Simple interventions including decision tools, check lists, and peer review may structure evaluations to ensure children's equal treatment.
受虐待风险相关受伤的贫困儿童和少数族裔儿童在虐待评估和诊断方面存在差异。我们假设决策过程中的两个步骤会影响评估和诊断：与家庭接触时的社会直觉以及与儿童虐待风险相关的客观社会信息。
2009年至2013年期间，32名儿童虐待儿科医生（CAP）提交了730例儿童虐待咨询案例，包括原始医学评估和诊断。CAP相互评估和诊断对方的案例。根据CAP可获得的社会理解水平对评估和诊断进行比较：与家庭接触（社会直觉和信息）、阅读案例（社会信息）以及阅读无社会信息的案例。通过对儿童和CAP特征进行调整的逻辑回归模型，将评估结果与共识金标准进行比较。使用列联表按社会理解水平和诊断确定性对诊断类别进行比较。
与接触家庭的CAP相比，无法获得社会直觉的CAP对神经创伤和长骨骨折进行金标准评估的可能性约为两倍。当有社会信息时，诊断一致性从73.3%（95%置信区间[CI]：70.1%-76.5%）降至社会信息受限情况下的66.5%（95%CI：63.1%-70.0%）。在确定性较低的案例中，一致性降至51.3%（95%CI：46.0%-56.7%）。
社会直觉和信息在儿童身体虐待决策过程中发挥作用，这可能导致诊断差异。包括决策工具、检查表和同行评审在内的简单干预措施可以构建评估，以确保儿童得到平等对待。
