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Racial, Ethnic, and Socioeconomic Disparities in the Nationwide Management of Childhood Non-Accidental Trauma
Bellal A. Joseph1, Joseph Sakran2, Omar Obaid1, Lynn Gries1, Raul Reina1, Michael Ditillo1, Tanya Anand1, Tanya Zakrison3
1Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, Arizona, United States, 2Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States, 3Critical Trauma Research, The University of Chicago Medicine, Chicago, Illinois, United States

Objective:Non-accidental trauma (NAT) from child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with initiation of abuse investigations and change of caregiver at discharge following reported childhood NAT on a national scale.
Methods: This was a 2-year retrospective cohort analysis of the 2017-2018 ACS TQIP. All children (<18yrs) presenting with suspected or confirmed NAT and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcome measures were rates of abuse investigations initiated among all patients with an abuse report filed, and change of caregiver at discharge among all survivors with an abuse investigation initiated. Multivariable regression analysis was performed to identify independent predictors of outcome measures, adjusting for patient age, gender, race, ethnicity, comorbidities, insurance status, injury severity, emergency department (ED) vitals, form of abuse, perpetrator of abuse, and ACS pediatric trauma center verification level.
Results: A total of 7,774 pediatric patients with non-accidental trauma and an abuse report filed were identified. The mean age was 55 years, 4,221 (54%) patients were White, 2,297 (30%) were Black, 1,543 (20%) were Hispanic, and 5,298 (68%) had government insurance. The most common mechanism of injury was blunt (63%), followed by burns (10%) and penetrating (10%), and the median ISS was 5[1-12]. The most common form of abuse was physical (81.3%), followed by neglect (10.3%), sexual (8.3%), and psychological (0.1%). The most common perpetrator of abuse was a care provider or teacher (49.5%), followed by a member of the immediate family (30.5%), or a member of the extended, step, or foster family (20.0%). Overall, 6,377 (82%) abuse investigations were initiated for patients with a filed abuse report. Of these investigations, 1,967 (33%) resulted in a change of caregiver at discharge among the survivors of hospitalization. Table describes the factors independently associated with outcome measures. Black children were more likely to have an abuse investigation initiated despite being a minority of patients with abuse reports filed, and both Black and Hispanic children were more likely to experience a change of caregiver based on an investigation. Privately insured children were less likely to experience both an abuse investigation and a change in caregiver.
Conclusion: Our findings indicate that significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of childhood abuse and NAT, regardless of form and perpetrator of abuse, injury severity, and pediatric trauma center verification level. Further studies are strongly warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.


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