Kent P Hymel1, Wouter Karst2, Mark Marinello3, Bruce E Herman4, Terra N Frazier5, Christopher L Carroll6, Veronica Armijo-Garcia7, Matthew Musick8, Kerri Weeks9, Suzanne B Haney10, Afshin Pashai11, Ming Wang12. 1. Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA. Electronic address: kphymel@gmail.com. 2. Department of Forensic Medicine, Netherlands Forensic Institute, PO Box 24044, 2490, AA, The Hague, the Netherlands. 3. Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA. Electronic address: mmarinell2@mcvh-vcu.edu. 4. Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA. Electronic address: Bruce.Herman@hsc.utah.edu. 5. Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA. Electronic address: tnfrazier@cmh.edu. 6. Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA. Electronic address: Ccarrol@connecticutchildrens.org. 7. University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA. Electronic address: Mirelesv@uthscsa.edu. 8. Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA. Electronic address: mamusick@texaschildrens.org. 9. Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA. 10. Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA. Electronic address: shaney@childrensomaha.org. 11. Department of Health Administration and Policy, George Mason University, 4400 University Drive, Fairfax, VA 22030, USA. 12. Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA. Electronic address: mwang@phs.psu.edu.
Abstract
BACKGROUND: The PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy. OBJECTIVE: To compare the AHT screening performances of the "PediBIRN-4" CDR vs. the simplified 3-variable CDR in PICU settings. PARTICIPANTS AND SETTINGS: 973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. METHODS: Retrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations. RESULTS: Applied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑'d ≥19%), positive predictive value (↑'d ≥8%), and ROC AUC (↑'d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13). CONCLUSION: The PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.
BACKGROUND: The PediBIRN 4-variable clinical decision rule (CDR) detects abusive head trauma (AHT) with 96% sensitivity in pediatric intensive care (PICU) settings. Preliminary analysis of its performance in Pediatric Emergency Department settings found that elimination of its fourth predictor variable enhanced screening accuracy. OBJECTIVE: To compare the AHT screening performances of the "PediBIRN-4" CDR vs. the simplified 3-variable CDR in PICU settings. PARTICIPANTS AND SETTINGS: 973 acutely head-injured children <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. METHODS: Retrospective, secondary analysis of the combined, prospective PediBIRN data sets. AHT definitional criteria and physicians' diagnoses were applied iteratively to sort patients into abusive vs. other head trauma cohorts. Outcome measures of CDR performance included sensitivity, specificity, predictive values, likelihood ratios, ROC AUC, and the correlation between each CDR's patient-specific estimates of AHT probability and the overall positive yield of patients' completed abuse evaluations. RESULTS: Applied accurately and consistently, both CDR's would have performed with sensitivity ≥93% and negative predictive value ≥91%. Eliminating the PediBIRN-4's fourth predictor variable resulted in significantly higher specificity (↑'d ≥19%), positive predictive value (↑'d ≥8%), and ROC AUC (↑'d ≥5%), but a 3% reduction in sensitivity. Both CDRs provided patient-specific estimates of abuse probability very strongly correlated with the positive yield of patients' completed abuse evaluations (Pearson's r = 0.95 and 0.91, p = .13). CONCLUSION: The PediBIRN 3-variable CDR performed with greater AHT screening accuracy than the 4-variable CDR. Both are good predictors of the results of patients' subsequent completed abuse evaluations.
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Authors: Mary Clyde Pierce; Kim Kaczor; Douglas J Lorenz; Gina Bertocci; Amanda K Fingarson; Kathi Makoroff; Rachel P Berger; Berkeley Bennett; Julia Magana; Shannon Staley; Veena Ramaiah; Kristine Fortin; Melissa Currie; Bruce E Herman; Sandra Herr; Kent P Hymel; Carole Jenny; Karen Sheehan; Noel Zuckerbraun; Sheila Hickey; Gabriel Meyers; John M Leventhal Journal: JAMA Netw Open Date: 2021-04-01