Assessment of suspicion of abuse in the primary care setting.
OBJECTIVES: To describe the primary care practitioner's assessment of the likelihood that an injury was caused by physical abuse. The hypotheses were 1) practitioners face great uncertainty as to the possibility that an injury may have been caused by abuse; a measure that assigns variable degrees of suspicion to childhood injuries can be developed that will reveal this uncertainty; and 2) practitioner factors and patient factors influence this suspicion. METHODS: Primary care practitioners in a regional practice-based research network prospectively collected information about each consecutive office encounter during a 4-week study period. For injury-related visits, the practitioner described injury type, reported cause and severity, and the practitioner's assessment of the cause of injury. Practitioners also used a 5-point Suspicion Scale to identify their level of suspicion that the injury was caused by abuse, with 1 equating to impossible and 5 equating to virtually certain. A subset of practitioners gave information about child and family risk factors. The practitioner's reporting activity was not studied. RESULTS: Participating practitioners (n = 85) in 17 practices collected information about 12 510 office encounters, including 659 injuries. Although the practitioners assessed no injuries as "caused by abuse," they rated 21% of the injuries as having "some suspicion" of abuse. Practitioners were more likely to have "some suspicion" of abuse for those children who were Hispanic or African-American (vs. White) (P =.001, chi(2)) and for those children whose mothers had no college education (P =.018, chi(2)). In multivariate logistic regression modeling, "some suspicion" of abuse was associated with higher injury severity (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7, 7.0), age <6 years (OR 2.9, 95% CI 1.5, 5.6), Medicaid or self-pay health care (OR 1.4, 95% CI 1.4, 5.3), practitioner identification of family risk factors (OR 4.8, 95% CI 1.6, 14.6), and more recent practitioner education about child abuse (OR 2.9, 95% CI 1.4, 5.8). CONCLUSION: Primary care practitioners reported some degree of suspicion that 21% of injuries they evaluated were caused by abuse. Patient factors and practitioner factors influenced their suspicion.