title: Patterns of health care use that may identify young children who are at risk for maltreatment.
abstract: OBJECTIVE
  Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children.
  
  
  METHODS
  We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non-emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child's primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities.
  
  
  RESULTS
  We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40-4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96-24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints.
  
  
  CONCLUSIONS
  Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.
authors.affiliation: Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. friedlaender@email.chop.edu
authors.forename: Eron Y
authors.initials: EY
authors.lastname: Friedlaender
authors.forename: David M
authors.initials: DM
authors.lastname: Rubin
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Alpern
authors.forename: David S
authors.initials: DS
authors.lastname: Mandell
authors.forename: Cindy W
authors.initials: CW
authors.lastname: Christian
authors.forename: Evaline A
authors.initials: EA
authors.lastname: Alessandrini
mesh_terms: D016022:Case-Control Studies; D002649:Child Abuse / Q000175:diagnosis* / Q000517:prevention & control; D002662:Child Health Services / Q000706:statistics & numerical data*; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008484:Medicaid; D009819:Office Visits / Q000706:statistics & numerical data; D012306:Risk; D014481:United States