Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children.

OBJECTIVE: Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse. METHODS: We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed. RESULTS: Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse." CONCLUSIONS: ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.

Applying a diagnostic excellence framework to assess opportunities to improve recognition of child physical abuse.

OBJECTIVES: Diagnostic excellence is an important domain of healthcare quality. Delays in diagnosis have been described in 20-30% of children with abusive injuries. Despite the well characterized epidemiology, improvement strategies remain elusive. We sought to assess the applicability of diagnostic improvement instruments to cases of non-accidental trauma and to identify potential opportunities for system improvement in child physical abuse diagnosis. METHODS: We purposefully sampled 10 cases identified as having potential for system level interventions and in which the child had prior outpatient encounters to review. Experts in pediatrics, child abuse, and diagnostic improvement independently reviewed each case and completed SaferDx, a validated instrument used to evaluate the diagnostic process. Cases were subsequently discussed to map potential opportunities for improving the diagnostic process to the DEER Taxonomy, which classifies opportunities by type and phase of the diagnostic process. RESULTS: The most frequent improvement opportunities identified by the SaferDx were in recognition of potential alarm symptoms and in expanding differential diagnosis (5 of 10 cases). The most frequent DEER taxonomy process opportunities were in history taking (8 of 10) and hypothesis generation (7 of 10). Discussion elicited additional opportunities in reconsideration of provisional diagnoses, understanding biopsychosocial risk, and addressing information scatter within the electronic health record (EHR). CONCLUSIONS: Applying a diagnostic excellence framework facilitated identification of systems opportunities to improve recognition of child abuse including integration of EHR information to support recognition of alarm symptoms, collaboration to support vulnerable families, and communication about diagnostic reasoning.

Assessing the utility of screening electrocardiograms in paediatric patients following COVID-19.

OBJECTIVE: To determine the utility of screening electrocardiograms after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children in detecting myocarditis related to coronavirus disease 2019 (COVID-19). STUDY DESIGN: A retrospective chart review was performed at a large paediatric academic institution to identify patients with prior SARS-CoV-2 infection who received a screening electrocardiogram by their primary care providers and were subsequently referred for outpatient cardiology consultation due to an abnormal electrocardiogram. The outcomes were the results from their cardiology evaluations, including testing and final diagnoses. RESULTS: Among 46 patients, during their preceding COVID-19 illness, the majority had mild symptoms, 4 were asymptomatic, and 1 had moderate symptoms. The median length of time from positive SARS-CoV-2 test to screening electrocardiogram was 22 days, and many electrocardiogram findings that prompted cardiology consultation were normal variants in asymptomatic adolescent athletes. Patients underwent frequent additional testing at their cardiology appointments: repeat electrocardiogram (72%), echocardiogram (59%), Holter monitor (11%), exercise stress test (7%), and cardiac MRI (2%). Five patients were incidentally diagnosed with CHD or structural cardiac abnormalities, and three patients had conduction abnormalities (pre-mature atrial contractions, pre-mature ventricular contractions, borderline prolonged QTc), although potentially incidental to COVID-19. No patients were diagnosed with myocarditis or ventricular dysfunction. CONCLUSION: In a small cohort of children with prior COVID-19, who were primarily either asymptomatic or mildly symptomatic, subsequent screening electrocardiograms identified various potential abnormalities prompting cardiology consultation, but no patient was diagnosed with myocarditis. Larger multi-centre studies are necessary to confirm these results and to evaluate those with more severe disease.

Rice land protection in a transitional economy: The case of Vietnam.

Agricultural land protection (ALP) is a standard policy response to a desire for food security. However, ALP may result in a misallocation of resources. Examining rice land policy in Vietnam, we determine the optimal level of rice land protected against other crops using a stochastic optimization model built on top of a general equilibrium framework, combined with sequential micro-simulations on household data. We find that converting part of protected rice land enhances economic efficiency. Nonetheless, the policy is relatively pro-rich, implying a trade-off between poverty reduction and economic efficiency, making some households in already poor areas worse off. Our approach can be applied to land-use planning generally, highlighting the relevant tradeoffs and the search for needed optimal land-use policies.

Strategies in infectious disease prevention and management among US-bound refugee children.

For multiple reasons, including exposure to violence or trauma, nutritional deficiencies, and an inconsistent medical infrastructure, refugee children are at an increased risk for many infectious diseases. Among these are tuberculosis, malaria, helminthic infections, and neglected tropical diseases. Our purposes are to review the US Centers for Disease Control and Prevention's pre-departure program of testing and presumptive therapy for these infections and to review the possible presentations, symptomatology, diagnostic tools, and recommended therapies, if necessary, upon arrival to the US. An understanding of these non-endemic infections, their diagnosis, and their management will improve the domestic medical exam and help to ease the transition for newly arrived immigrant children, their families, and their receiving communities.