识别提示儿童身体虐待的损伤：创伤质量改进计划的创新应用。
Identifying injuries suggestive of child physical abuse: An innovative application of the Trauma Quality Improvement Program.
机构信息
From the Department of Pediatrics (L.R.), Division of Pediatric Emergency Medicine (L.O., D.M.), Division of Pediatric Surgery (C.W.S.), Johns Hopkins All Children's Hospital, St. Petersburg, Florida.
出版信息
J Trauma Acute Care Surg. 2024 Aug 1;97(2):272-277. doi: 10.1097/TA.0000000000004274. Epub 2024 Feb 12.
BACKGROUND
Child physical abuse (CPA) carries high risk of morbidity and mortality. Screening for CPA may be limited by subjective risk criteria and racial and socioeconomic biases. This study derived, validated, and compared age-stratified International Classification of Diseases, 10th revision (ICD-10) diagnosis codes indicating high risk of CPA.
METHODS
Injured children younger than 6 years from the Trauma Quality Improvement Program (TQIP) database were included; years 2017 to 2018 were used for derivation and 2019 for validation. Confirmed CPA was defined as a report of abuse plus discharge with alternate caregiver. Patients were classified as high vs. low CPA risk by three methods: (1) abuse-specific ICD-10 codes, (2) previously validated high-risk ICD-9 codes crosswalked to equivalent ICD-10 codes, and (3) empirically-derived ICD-10 codes from TQIP. These methods were compared with respect to sensitivity, specificity, area under the receiver-operator curve (AUROC), and uniformity across race and insurance strata.
RESULTS
A total of 122,867 children were included (81,347 derivation cohort, 41,520 validation cohort). Age-stratified high-risk diagnoses derived from TQIP consisted of 40 unique codes for ages 0 year to 2 years, 30 codes for ages 3 years to 4 years, and 20 codes for ages 5 years to 6 years. In the validation cohort, 890 children (2.1%) had confirmed CPA. On comparison with abuse-specific and crosswalked ICD-9 codes, TQIP-derived codes had the highest sensitivity (70% vs. 19% vs. 54%) and the highest AUROC (0.74 vs. 0.59 vs. 0.68, p < 0.0001) for confirmed abuse across all age groups. Age-based risk stratification using TQIP-derived codes demonstrated low variability by race (25% White vs. 25% Hispanic vs. 28% Black patients considered high-risk) and insurance status (23% privately insured vs. 26% uninsured).
CONCLUSION
High-risk CPA injury codes empirically derived from TQIP produced the best diagnostic characteristics and minimized some disparities. This approach, while requiring further validation, has the potential to improve CPA injury surveillance and decrease bias in screening protocols.
LEVEL OF EVIDENCE
Diagnostic Test/Criteria; Level III.
背景
儿童身体虐待（CPA）具有较高的发病率和死亡率风险。CPA 的筛查可能受到主观风险标准以及种族和社会经济偏见的限制。本研究旨在推导、验证并比较了国际疾病分类第 10 版（ICD-10）诊断代码，这些代码表明存在较高的 CPA 风险。
方法
从创伤质量改进计划（TQIP）数据库中纳入年龄小于 6 岁的受伤儿童；2017 年至 2018 年用于推导，2019 年用于验证。经证实的 CPA 定义为虐待报告加上有替代照顾者的出院。通过三种方法将患者分为高风险和低风险 CPA：（1）特定于虐待的 ICD-10 代码，（2）先前经过验证的高风险 ICD-9 代码转换为等效的 ICD-10 代码，以及（3）从 TQIP 中得出的经验性 ICD-10 代码。比较这些方法在敏感性、特异性、接收者操作特征曲线下面积（AUROC）以及种族和保险分层方面的均匀性。
结果
共纳入 122867 名儿童（推导队列 81347 名，验证队列 41520 名）。从 TQIP 中得出的年龄分层高风险诊断包括 0 岁至 2 岁的 40 个独特代码，3 岁至 4 岁的 30 个代码以及 5 岁至 6 岁的 20 个代码。在验证队列中，有 890 名儿童（2.1%）患有经证实的 CPA。与特定于虐待和转换的 ICD-9 代码相比，TQIP 衍生的代码在所有年龄组中具有最高的敏感性（70%比 19%比 54%）和最高的 AUROC（0.74 比 0.59 比 0.68，p <0.0001）。基于 TQIP 衍生代码的年龄风险分层，根据种族（白人患者的高风险比例为 25%，西班牙裔为 25%，黑人患者为 28%）和保险状况（私人保险为 23%，无保险为 26%）差异不大。
结论
从 TQIP 中得出的高风险 CPA 损伤代码具有最佳的诊断特征，并最大程度地减少了一些差异。这种方法虽然需要进一步验证，但具有改善 CPA 损伤监测和减少筛查方案偏倚的潜力。
证据水平
诊断测试/标准；III 级。
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