Elsevier

Child Abuse & Neglect

Volume 134, December 2022, 105938
Child Abuse & Neglect

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

https://doi.org/10.1016/j.chiabu.2022.105938Get rights and content

Abstract

Background

Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic.

Objective

To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three.

Participants and setting

Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231).

Methods

We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed.

Results

Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3).

Conclusion

This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

Introduction

Child maltreatment is a major public health problem leading to significant pediatric morbidity and mortality (Vaithianathan et al., 2018). In 2020 alone, roughly 7.1 million children in the United States were subject of maltreatment reports and over one-third of maltreatment victims were younger than four years (U.S. Department of Health & Human Services, 2022). Child maltreatment is associated with an elevated risk of common and high-cost pediatric illnesses, which result in a substantial health care burden in terms of both short- and long-term health care use (Peterson et al., 2018). Therefore, an understanding of health care use patterns of potential maltreated children may help prevent escalating or recurrent subsequent maltreatment and reduce inappropriate use of health care.

Children who have been previously maltreated are at high risk of developing diseases, illnesses, or conditions because of new maltreatment (Hindley et al., 2006) or complications from prior maltreatment (Huffhines & Jackson, 2019). These children are likely to experience recurrence of maltreatment (Hindley et al., 2006) and to receive acute health care service for injuries such as fractures and burns (Hunter & Bernstein, 2019; King et al., 2015) that may have resulted from an act related to maltreatment. They may also use acute health care due to increased chance of developing chronic health conditions that may be complicated by previous maltreatment, such as asthma, obesity, diabetes, and eczema (Huffhines & Jackson, 2019; Jackson et al., 2016; Jee et al., 2006; Lanier et al., 2010). This raises important concerns for health care providers in assessing pediatric health outcomes and risk of maltreatment recurrence for children who have a previous concern of maltreatment.

Consistent evidence has shown that compared to children in the general population, children who have experienced maltreatment are high utilizers of emergency department (ED) and inpatient hospitalization (Guenther et al., 2009; Kuang et al., 2018; O'Donnell et al., 2010). Several prevalence studies have estimated incidences of maltreatment-related ED visits or hospitalization among the general pediatric population (Hunter & Bernstein, 2019; King et al., 2015). However, prior studies focused primarily on patterns of health service use before children were diagnosed with maltreatment or involved in child protective service (CPS) systems (Kuang et al., 2018; O'Donnell et al., 2010). Few studies have examined children's health care use or maltreatment-related medical encounters after they were identified as being at risk for maltreatment.

With such a high risk of acute health care use and development of undiagnosed or untreated chronic health conditions (e.g., Lanier et al., 2010), children at risk for maltreatment are likely to have preventable ED or hospital admissions (Szilagyi et al., 2015). Some of these chronic conditions (e.g., asthma) are considered to be ambulatory care sensitive conditions (ACSCs) for which an ED visit or hospital admission could be prevented by proper treatment in primary care (Burgdorf & Sundmacher, 2014). Hospitalization and ED visit for ACSCs could serve as an important indicator to quantify health care use disparities among children with previous concerns for maltreatment and children of the general population (Lichtl et al., 2017). Despite this, no research has focused on the prevalence of ACSCs in pediatric patients who have been evaluated for concerns of maltreatment.

Healthcare encounters are one of the only settings in which nearly all young children in the United States are regularly evaluated by a non-caregiver for health, growth, and development, which can provide potential opportunity to identify and prevent adverse pediatric health outcomes among children at risk of maltreatment. Given the high risk of maltreatment recurrence (Hindley et al., 2006), potential for ongoing health complications related to past maltreatment (Jonson-Reid et al., 2012), and improper use of acute health care for chronic conditions (Szilagyi et al., 2015), it is imperative to assess patterns of high-cost, intensive care use (e.g., ED and inpatient visits) among children with previous concerns of maltreatment. This could help facilitate our understanding of how healthcare systems could provide sentinel information about these children's wellbeing over time and ameliorate negative health outcomes.

Evidence as to whether or not potential maltreatment is related to higher rates of subsequent health care use is limited. Moreover, pediatric studies that evaluated health care use of maltreated children have not comprehensively considered these health care use patterns together. Our study addresses this research gap to improve recommendations for care of this high-risk population and prevent escalating or recurrent maltreatment.

This study used information from the electronic health records (EHR) data for children from birth to three years old who were medically evaluated at a child abuse and neglect subspecialty clinic in a teaching and research hospital in the U.S. The aim of this study was to quantify the association of being evaluated for a concern of maltreatment with subsequent acute health care utilization. We assessed three health care utilization outcomes over 18 months after a child received an evaluation for maltreatment, including (1) ED use and inpatient hospitalization, (2) child maltreatment-related ED use and inpatient hospitalization, and (3) ED use and inpatient hospitalization for ACSCs.

Section snippets

Data source

Data came from electronic health records (EHR) spanning 3/1/2013 to 6/30/2019 from a large academic health system in the southeastern United States. This health system serves about 85 % of children in its primary catchment area. There are one tertiary care and two community-based hospitals, each with an ED. Healthcare is coordinated by utilizing a single EHR system that captures patients' information from a network of primary care and specialty clinics. The university Institutional Review Board

Descriptive analysis

Our total sample included 21,598 children. Below we describe the sample evaluated for a concern of maltreatment and the general pediatric population, respectively.

Discussion

Our study aimed to assess whether a child maltreatment evaluation was associated with a higher risk of subsequent health care use over an 18-month period. Our findings revealed that, compared to the general pediatric population who were not evaluated for maltreatment, receiving a medical evaluation for a concern of maltreatment was significantly associated with higher hazards of subsequent ED visits or inpatient hospitalizations and maltreatment-related visits. The observed associations could

Conclusion

This study examined the association between receiving a maltreatment evaluation and risk of subsequent health care use among children from birth to age three. Specifically, we found that a receipt of maltreatment evaluation was associated with higher risk for a subsequent ED visit or inpatient hospitalization, and a maltreatment-related visit. Hospitals and EDs should pay attention to complications of maltreatment, maltreatment history, and health needs of high-risk children. Child abuse and

Funding

This work was supported by the Duke Endowment, ABC Thrive Bass Connections, and the Translating Duke Health Children's Health and Discovery Initiative.

Role of funder/sponsor

None of the funders had any role in the design or conduct of this study. The state Division of Social Services and/or the Human Services Business Information & Analytics Office does not take responsibility for the scientific validity or accuracy of methodology, results, statistical analyses, or conclusions presented.

Declaration of competing interest

None.

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