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Identification of Physical Abuse Cases in Hospitalized Children

1. Summarise the study designs for both studies provided for the appraisal and explain how both of these studies fulfil the criteria for the study designs you have identified 

The research conducted by Goldsbury et al., (2011) used the secondary data in the form of electronic medical records of patients with prostate cancer and the results produced were accurate. There were 0 false positive tests and it was helpful in fulfilling the criteria of Quantitative analysis design via chi square test. The second research, conducted by Hooft et al., (2013) utilized primary source for collecting data by including children who were victims of physical abuse as participants and were evaluated by CAPs (Child Abuse Peadiatrician). The criteria for study design was fulfilled as the CAP’s documentation was considered gold standard.

2. Broadly identify the ICD codes used in both studies. Compare and contrast how the codes have been used in both studies and discuss quality related issues surrounding the use of coded data in the context of the studies. 

The codes used in the study conducted by Hooft et al., 2013 included ICD 9 codes 995.50, 995.54 which were diagnosis code for child physical abuse; 955.55 was used for child shaken abuse, 995.95 was used for child neglect and other abuse; E96.0, E966, E698.0-E968.9 included codes for fright, brawl and assault of a child; E967.0-967.9 were used for perpetrator of child and adult abuse. The research categorized the abuse codes into three parts one was accidental and other was physical abuse and the third was injury or abuse to an unknown cause. The third one was considered to be in “non-abuse” category for the purpose of simplification of data and improvement of accuracy. However, the results were less accurate due to the discrepancies in documentation as well as ICD coding of the children’s condition.

The ICD 9 codes are less accurate information of the condition and therefore ICD 10 codes should have been used for improving specificity and sensitivity for research (Mainor et al., 2019). Furthermore, as per the research, “ICD-9-CM Official Guidelinesfor Coding and Reporting,” documentation of questionable,probable, or suspected diagnosis is sufficient information to code for a given diagnosis. When discussing cause of injury coding with E-codes for abuse, however, the guidelines state that they are questionable, probable, or suspected”. Along with the documentation discrepancy in the physician’s record were made due to lack of sufficient coding knowledge by the physicians (Patel, Walker & Lo, 2018), errors were also made by the coders which further reduced the sensitivity of the test to 75 per cent (Hashemipour et al., 2019).

In the research conducted by Goldsbury et al, (2011) used ICD-10 coding. The results were accurately as compared to the previous study which used ICD 9 coding system. This was because the ICD 10 coding system is more specific in providing the details or the accurate information of the disease/diagnosis (Khokhar et al., 2016). The documentation from cancer registry data as well as the inpatient records of the prostate cancer patients recorded nearly 31 procedural and 40 diagnostic codes from each of the patient’s reports. The results revealed 99 per cent of the data obtained for the medical records of the patient’s matched with the CCR (Central Cancer Registry) of NSW. As per the research, “Sensitivity was defined as the probability of an event beingrecorded in the administrative data if it was recorded by PCOS (Prostate cancer outcomes Study), while specificity was the probability of an event not being recorded in the administrative data if not recorded by PCOS.” Furthermore, the research also compared the data obtained from the inpatient treatment and hospitalization records with the Medicare claim records and they were found to be consistent for diagnosis as well as the treatment. The treatment dates and dated for surgical procedures were also matched for validating the data. Thorough verification of the collected data from various prominent sources, contributed to the authenticity of the research and the sensitivity of the data analysis (Manamley et al., 2016; Gao, 2019).

3. Evaluate the methodology of oneof these studies.

Things you should consider include:sample size; external validity; selection of data sources; methods of data collection; data to be collected; use of codes; method of data analysis; how potential bias was/was not minimised (eg. Selection bias, measurement bias, recall bias); cost; ethics and any other relevant issues.

Evaluation of Methodology of research conducted by Hooft et al., (2013): Participants: The sample size included children who were victims of physical abuse at the Yale- New Haven Children’s Hospital within the time period between 1st January 2007 and 31st Dec 2010. The age group selected was of children less than 18 years. The identification of the participants was done in via the child abuse registry. The evaluation and coding of the diagnosis were done by the child abuse physician. For verification of the abuse the child abuse physicians were made to use a 7-point scale which helped in decision making and coding of the abuse. The rating used is as follows: 1: Definite abuse 2: Likely abuse 3: Questionable abuse 4: Unknown Cause 5: Questionable accident/questionable medical cause 6: Likely accident/questionable medical cause 7: Definite accident/questionable medical cause The form was filled by the CAP after the discharge of the patient from the hospital. The CAP was requested to reflect on his decision making related to child abuse and the clinical impression which was determined during the hospitalization.

ICD-9 Coding system was used for establishing the diagnosis of the child abuse victims post their discharge and were matched with the electronic registry for child abuse. The discrepancies in the E codes of the victims were noted and aappropriate information obtained from the CAP’s consultation notes and the notes of the other physicians’, the discharge summary was abstracted by a primary reviewer. These were then used to identify as well as categorization of the reasons for incongruency between the CAP’s decision and the codes retrieved from the discharge database. The research categorized the abuse codes into three parts one was accidental and other was physical abuse and the third was injury or abuse to an unknown cause. The third one was considered to be in “non-abuse” category for the purpose of simplification of data and improvement of accuracy. However, the researcher underpins that the sensitivity of ICD 9 codes is only 77 per cent.

Therefore, they were less accurate. Ethical consideration: It is imperative for any research to consider the ethical aspect related to the participants and the various stakeholders involved in the research. Therefore, for this study consideration of ethical aspects has been focused on. Emphasis was laid on data security and anonymity for the protection of the demographic data of the children and their parents were safeguarded, by the researchers. There were no ethical biases or biases of any other kind. The study was approved by “Yale School of Medicine Institutional Review Board.” Positive and negative aspects of the research include identification of errors in documentation of diagnosis by CAPs and exposed the area where the reformation Is required. The research highlighted the necessity for replacing ICD 9 coding system with ICD 10 coding system. The negative aspects revealed the inefficacy of the research to make in reliable in the field of testing child abuse due to poor documentation due to lack of knowledge of the physicians.

4. Discuss the results of one study selected for the appraisal in (4) above

This should include identification of statistically significant effects and, for each of these effects, identification of the relevant statistics. Decide if the effect found in the study is clinically or practically important and provide a rationale for this decision.

RESULTS research conducted by Hooft et al., (2013): The results revealed discrepancy in data of CAPs documentation and the Central Child Registry (CCR). As per the CCR there are 133 cases were reported for physical child abuse, whereas, CAPs reported 43 cases of children as categorized for definite child abuse and 25 cases as questionable child abuse and 65 cases were categorized into accidental/medical causes. The discrepancy primarily was due to the lack of description in ICD 9 guidelines for the diagnosis provided by the physician; hence no codes were assigned to a minimum of 10 cases for abuse and 11 for accidents, almost in 04 cases the diagnosis was found to be miscoded. There were also 05 cases which were accurate in documentation by the physician and 05 cases which produced errors from coders, probably due to the difficulty in communicating the impression or diagnostic details to the coders or lack of clarity in coding guidelines. For instance, when a child presented to the hospital, with a bruise, the CAP considered the bruise as a physical abuse and waivered the subjective as well as objective assessment, which probably included hypertension or feeding issues or any other disease diagnosis. While coding the coder only coded hypertension without documenting the abusive injury. Due to these errors the research failed to produce accurate results (Lorenzetti et al., 2018). The importance of the research is clinically imperative to make changes in the healthcare system pertaining to documentation in order to avoid errors and make research more reliable.

5. Determine whether or not you would make any changes to the design of the study you appraised in (4) above. Justify your decision. (~150 words)

Recommendations for the study conducted by Hooft et al., (2013): for improving the research quality the changes should include, review of coding information. The documentation should be reviewed by a registered nurse to identify the errors before the coding information is sent to the research facilities/health insurance companies or Medicare. The coders should be certified by in ICD – 10 coding system and ICD-10 should be used as it is more specific and more accurate information of the disease/diagnosis. It also includes broader range of disease which can be covered in coding which were previously not available in ICD-9 (Stewart et al., 2017). Another change required is in the processing is to enhance the knowledge of coding in the healthcare professionals. This will lead to lesser complications while assigning the codes due to clarity in diagnosis description (Patel, Walker & Lo, 2018)

6. References Used for Identification of Physical Abuse Cases in Hospitalized Children

Gao, Y. (2019). Research on the Role and Status of the Library in the All-out, Thorough, and All-round Education Mechanism Taking Zhuhai College of Jilin University as an Example. In 5th International Conference on Arts, Design and Contemporary Education (ICADCE 2019). Atlantis Press.

Goldsbury, D., Smith, D., Armstrong, B. and O'Connell, D., (2011). Using linked routinely collected health data to describe prostate cancer treatment in New South Wales, Australia: a validation study. BMC Health Services Research, 11(1).

Hashemipour, M., Khorrami, F., Ansari, M., Baniasadi, T., Davari, N., & Shahi, M. (2019). The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences. Journal of Health and Biomedical Informatics, 6(3), 231-242.

Hooft, A., Ronda, J., Schaeffer, P., Asnes, A. and Leventhal, J., (2013). Identification of Physical Abuse Cases in Hospitalized Children: Accuracy of International Classification of Diseases Codes. The Journal of Pediatrics, 162(1), pp.80-85

Joshi-Patel, A. A., Walker, L., & Lo, H. Y. (2018). Improving Critical Care Documentation and Billing Amongst Pediatric Hospital Medicine Providers. 488-488

Khokhar, B., Jette, N., Metcalfe, A., Cunningham, C. T., Quan, H., Kaplan, G. G., ... & Rabi, D. (2016). Systematic review of validated case definitions for diabetes in ICD-9-coded and ICD-10-coded data in adult populations. BMJ open, 6(8), e009952.

Lorenzetti, D. L., Quan, H., Lucyk, K., Cunningham, C., Hennessy, D., Jiang, J., & Beck, C. A. (2018). Strategies for improving physician documentation in the emergency department: a systematic review. BMC emergency medicine, 18(1), 36.

Mainor, A. J., Morden, N. E., Smith, J., Tomlin, S., & Skinner, J. (2019). ICD-10 Coding Will Challenge Researchers. Medical care, 57(7), e42-e46. Manamley, N.,

Mallett, S., Sydes, M. R., Hollis, S., Scrimgeour, A., Burger, H. U., & Urban, H. J. (2016). Data sharing and the evolving role of statisticians. BMC medical research methodology, 16(1), 37-43.

Stewart, C., Crawford, P. M., & Simon, G. E. (2017). Changes in coding of suicide attempts or self-harm with transition from ICD-9 to ICD-10. Psychiatric services, 68(3), 215-215.

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