Elsevier

Child Abuse & Neglect

Volume 38, Issue 9, September 2014, Pages 1533-1539
Child Abuse & Neglect

Impact of telemedicine on the quality of forensic sexual abuse examinations in rural communities

https://doi.org/10.1016/j.chiabu.2014.04.015Get rights and content

Abstract

To assess the quality and diagnostic accuracy of pediatric sexual abuse forensic examinations conducted at rural hospitals with access to telemedicine compared with examinations conducted at similar hospitals without telemedicine support. Medical records of children less than 18 years of age referred for sexual abuse forensic examinations were reviewed at five rural hospitals with access to telemedicine consultations and three comparison hospitals with existing sexual abuse programs without telemedicine. Forensic examination quality and accuracy were independently evaluated by expert review of state mandated forensic reporting forms, photo/video documentation, and medical records using two structured implicit review instruments. Among the 183 patients included in the study, 101 (55.2%) children were evaluated at telemedicine hospitals and 82 (44.8%) were evaluated at comparison hospitals. Evaluation of state mandatory sexual abuse examination reporting forms demonstrated that hospitals with telemedicine had significantly higher quality scores in several domains including the general exam, the genital exam, documentation of examination findings, the overall assessment, and the summed total quality score (p < 0.05 for each). Evaluation of the photos/videos and medical records documenting the completeness and accuracy of the examinations demonstrated that hospitals with telemedicine also had significantly higher scores in several domains including photo/video quality, completeness of the examination, and the summed total completeness and accuracy score (p < 0.05 for each). Rural hospitals using telemedicine for pediatric sexual abuse forensic examination consultations provided significantly higher quality evaluations, more complete examinations, and more accurate diagnoses than similar hospitals conducting examinations without telemedicine support.

Introduction

Child sexual abuse is a serious, underreported problem in the United States. In 2010, of 720,000 substantiated cases of child maltreatment, more than 66,000 children were victims of sexual abuse (U.S. Department of Health & Human Services, 2010). Interviews of adults suggest the incidence of sexual abuse in childhood is significantly higher, closer to 20% of girls and between 5% and 10% of boys (Finkelhor, 1994). When an allegation of child sexual abuse occurs, specialized training in interviewing, forensic evaluation, evidence collection, and diagnosis is necessary for the provision of quality care. Without this expertise, pediatric victims of sexual abuse may receive incomplete evaluations, inappropriate procedures, and inaccurate assessments. Anything short of a comprehensive evaluation and accurate diagnosis can result in serious ramifications for the investigation and the safety and protection of the child.

Rural communities providing services for child victims of sexual abuse face unique challenges due to disproportionately high rates of abuse (Menard & Ruback, 2003) likely stemming from issues of poverty, substance abuse, mental health issues, lower educational attainment as well as fewer resources to support families, all of which are linked to child maltreatment (Child Welfare Information Gateway, 2012, Sudol, 2009). Additionally, there are relatively few health care providers trained and experienced in this field and they often work within urban child advocacy centers or academic health centers (Paradise, Winter, Finkel, Berenson, & Beiser, 1999). Examiners working in rural communities typically do not treat a sufficient volume of patients to attain and retain proficiency and often work in relative isolation, leading to high rates of burnout (Townsend & Campbell, 2009). As a result, child victims in rural communities are less likely to receive comprehensive forensic examinations (Walsh, Cross, Jones, Simone, & Kolko, 2007) and are more likely to require transport to centers with child abuse expertise. The latter scenario can cause additional stress to the child and family and travel time may contribute to degradation of biologic evidence. Further, transporting children long distances to obtain specialty services contributes to increased costs incurred by counties and the overall healthcare system.

Telemedicine is increasingly used to overcome barriers and inequities in access to specialty services. Studies in a variety of clinical settings have demonstrated that telemedicine can increase the quality of care (Callahan et al., 2005, Dharmar et al., 2013, Marcin et al., 2005, Rosenfeld et al., 2000), improve patient and provider satisfaction (Burton et al., 2002, Dharmar et al., 2013, Marcin et al., 2004, Whitten and Love, 2005), and improve community members’ perception of locally available care (Nesbitt, Marcin, Daschbach, & Cole, 2005). While it is not possible to have child sexual abuse specialists in every community, telemedicine allows specialists at regional centers to support less experienced examiners at a distance. We previously demonstrated positive changes in the completeness of sexual abuse examinations when rural examiners were supported by specialists through telemedicine consultations (MacLeod et al., 2009). Building on the findings from this work, we sought to evaluate the impact of a telemedicine-based consultation program on the quality and accuracy of child sexual abuse examinations in rural communities. The first aim of the study was to determine the quality of care provided by evaluating the State of California's Office of Emergency Services (OES) mandatory sexual abuse examination forms completed by providers at the time of the forensic examination. The second aim was to evaluate and compare the completeness of the forensic examinations and the accuracy of the final diagnosis. We hypothesized that examinations conducted at hospitals with telemedicine would result in higher quality OES evaluations and more complete and accurate diagnostic findings compared to examinations conducted at similar rural hospitals, without telemedicine support.

Section snippets

Study Design

A retrospective review of child sexual abuse forensic examinations was conducted at eight rural hospitals in Northern California. Five of the hospitals had access to telemedicine to obtain expert consultations during forensic examinations and three hospitals did not. Of the five telemedicine hospitals, four did not have an existing child abuse program prior to the installation of telemedicine and one had an established program, yet relatively inexperienced examiners, most having conducted fewer

Results

A total of 226 children were eligible for inclusion. Among these, 135 received sexual abuse examinations at the five telemedicine hospitals and 91 cases were randomly sampled from children who received sexual abuse examinations at the three comparison hospitals. Of this population, 27 (11.9%) could not be evaluated because the OES forms could not be located and 16 (7.1%) because photo/video evidence could not be located. Thirty-four of these excluded cases were from telemedicine hospitals and

Discussion

Pediatric sexual abuse forensic examinations conducted by novice practitioners at rural hospitals using telemedicine for expert sexual abuse consultations resulted in significantly higher quality evaluations, more complete examinations, and more accurate diagnoses than examinations conducted by established practitioners without telemedicine consultations at comparison hospitals with existing pediatric sexual abuse programs. These findings were determined based on objective evaluations by two

Conclusion

We found that telemedicine consultations provided to practitioners conducting child sexual abuse examinations at rural hospitals resulted in high quality and highly accurate examinations compared to those conducted at existing child sexual abuse programs at similar hospitals. Improved examination quality and accurate diagnostic assessments are critical to informing child welfare agencies and law enforcement. These findings support models of care utilizing telemedicine to provide specialty

Contributor's statement

Sheridan Miyamoto: Conceptualized and designed study, conducted the intervention, data collection, interpreted the results, drafted the manuscript, and approved the final manuscript. Madan Dharmar: Conceptualized and designed study, conducted the study, conducted the data analysis, interpreted the results, drafted the manuscript, and approved the final manuscript. Cathy Boyle: Conceptualized and designed study, conducted the intervention, critically reviewed the manuscript, and approved the

Conflict of interest

None of the above authors have a financial disclosure or conflict of interest.

Acknowledgements

We acknowledge the administrative work conducted by Candace Sadorra as well as the technical work conducted by Juan Trujano that made this project possible. We also acknowledge and thank our rural community providers and hospitals for being our partners in this work.

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    This work was supported, in part, by grants from Maternal and Child Health Bureau of Health Resources and Services Administration (HRSA R40MC08723) and the William Randolph Hearst Foundation. The funding sponsors had no involvement in study design, collection, analysis, interpretation of the data, or writing the report, or the decision to submit the results of this work for publication.

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