Teens Receive Inconsistent Emergency Care After Sexual Assault

About 10 percent of high school girls and half as many high school boys report that they have been sexually assaulted in Centers for Disease Control and Prevention (CDC) surveys. But when these young victims come to pediatric emergency rooms, they are not consistently getting recommended tests and treatment, according to new research from The Children’s Hospital of Philadelphia.

“Our study was remarkable in that there was so much variation in the care adolescents received after sexual assault,” said Samantha Schilling, MD, MSHP, an assistant clinical professor at the University of North Carolina School of Medicine who is first author of the study, conducted when she was a fellow at CHOP and at the Leonard Davis Institute of Health Economics at the University of Pennsylvania (LDI). “While overall performance wasn’t ideal, there were also wide ranges in testing and treatment for infections and pregnancy.”

Dr. Schilling worked with CHOP and Penn colleagues including senior author Joanne N. Wood, MD, MSHP, a CHOP PolicyLab faculty member, assistant professor at Penn’s Perelman School of Medicine, and Penn LDI senior fellow, to conduct a retrospective analysis of health data from adolescents seen in 38 pediatric emergency rooms over a 10-year period, 2004 to 2013. The demographic data of patients, combined with data on the tests and treatments they received, provided a picture of care adolescents received in this treatment setting when seen for sexual assault. The study results appeared online Oct. 28 in the journal Pediatrics.

Guidelines from the CDC and American Academy of Pediatrics (AAP) recommend testing youth for sexually transmitted infections chlamydia and gonorrhea when they report sexual assault, as well as testing for pregnancy in female victims past the age of puberty. These guidelines also call for physicians to provide prophylactic treatment for these infections and emergency contraception, even before the testing outcome is known.

Yet the rates at which teens received these tests and treatments were low overall and highly varied between hospitals, Dr. Schilling and colleagues found. On average, 44 percent of victims received the recommended testing, with rates between 6 and 89 percent. On average, 35 percent of victims received recommended prophylaxis, ranging from zero to 57 percent among different hospitals.

One key finding offers a potential means of improving the consistency and quality of care for these teens:

“The presence of a specialized pathway did show a modest improvement in care,” Dr. Schilling said.

A specialized pathway is a standard set of steps for evaluation and care for patients seen with a given chief complaint. For example, pathways of care exist for children with asthma, and for infants under 56 days of age who come to the hospital with a fever. Some hospitals have adopted specialized pathways for sexual assault.

In a survey of specialized physicians from each of the participating hospitals about their routine practices for sexual assault evaluations, researchers asked about whether and when the hospital had established specialized sexual assault pathways and teams in the emergency department. Overall, 30 percent of the sexual assault cases in the study were seen at hospitals that had a specialized care pathway. These cases had higher rates of receiving recommended prophylaxis treatments even when adjusted for other hospital characteristics.

The presence of a specialized team of clinicians to address sexual assault was not associated with any difference in the quality of care. Dr. Schilling said that may be because the nature of teams was too variable.

“Future research that would be helpful in understanding solutions and the nature of the problem would include more detailed studies looking at the specific structure, training, and peer-review process for specialized teams, as well as studies to understand more about the content and the methods of delivery of specialized pathways,” Dr. Schilling said. “Understanding the structure of teams and pathways that work well, and disseminating and implementing more models like them, will ultimately help improve the care that adolescents who have been sexually assaulted receive in emergency settings.”