Missed and missing cases of abusive injuries: the magnitude and the measurement of the problem.

ABSTRACT

OBJECTIVE: The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children. METHOD: Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases. RESULTS: The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases. CONCLUSIONS: A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases. PRACTICE IMPLICATIONS Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-health-oriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.