Performance of screening tests for child physical abuse in accident and emergency departments

Article history

The research reported in this issue of the journal was funded by the HTA programme as project number 03/37/06. The contractual start date was in January 2005. The draft report began editorial review in February 2007 and was accepted for publication in March 2008. As the funder, by devising a commissioning brief, the HTA Programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

None

Copyright statement

© Queen’s Printer and Controller of HMSO 2008. This work was produced by Woodman et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2008 Queen’s Printer and Controller of HMSO

Definition and burden of physical abuse

Physical abuse was defined in 2006 in the UK government’s Green Paper Working together to safeguard children as follows: ‘Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child’ (Section 1.30). 2 In addition, local authorities have a duty under the 1989 Children Act to take any action to safeguard or promote a child’s welfare when they ‘have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’. 5 This requirement recognises that physical abuse may occur as a result of physical violence, whether or not the child is injured.

The recent United Nationsworld report on violence against children published in 2006 left no room for doubt about the scale and impact of the global burden of violence against children. 5,6 Across the world, an estimated 80–98% of children suffered physical punishment in their homes, with one-third or more experiencing severe physical punishment resulting from the use of implements. The report emphasised that only a small proportion of the widespread violence is detected and reported to children’s services because of the hidden nature of abuse, fears of the child and family members, and stigma or mistrust of social services and others in authority. 6 These factors make the true incidence and characteristics of physical abuse difficult to measure.

Even when physical abuse is suspected and reported it can be difficult to quantify because of problems with thresholds for confirmation and lack of routinely collected data. Currently in the UK, the child protection register (CPR) offers the only routine data on the incidence of physical abuse. As Figure 1 shows, registration is the final stage of child protection proceedings in the UK and represents a very high threshold for defining physical abuse. In 2003, only 0.1% of the child population under 16 years was newly registered on the CPR under the category of physical or multiple abuse (Figure 1). This figure substantially underestimates the incidence of physical abuse in the UK.

FIGURE 1.

Social services investigations in England during 1 year (2003–4). 9

The impact of violence against children is often long term, resulting in increased susceptibility to adverse social, emotional, cognitive and health outcomes, and huge economic costs to society. 7 Social services costs alone are considerable. The annual survey of local authorities’ social services child and family teams estimated that in 2005 44% of their budget, or £30.5 million per week, was spent on child abuse and neglect, equivalent to £1.6 billion per year. 8

Policy in the UK

The tragic death of Victoria Climbié in 2000 highlighted the ineffective and muddled detection of abuse by agencies in the UK. In his inquiry into Victoria’s death, Lord Laming identified an ‘institutional malaise’ in children’s services and specified that the major failings were inefficient detection of abuse, failure to act appropriately when there were concerns, poor record keeping and poor communication within and between agencies. 10

In response to Lord Laming’s recommendations10 the government published a Green Paper, Every child matters. This committed the government to strengthening coordination of services and interagency communication by establishing local safeguarding boards, mandating a duty of cooperation between agencies, and integrating children’s services at a local level through the establishment of children’s trusts and Contact Point (previously known as the Information Sharing Index), an index of all children that documents their needs and contacts with agencies. 11 The Children Act 2004 (Sections 11 and 12)12 provided the legislative basis for these changes. Contact Point and the Common Assessment Framework (CAF) will be fully implemented in all areas of England by mid 2009; they have cost £224 million to implement with an anticipated £41 million running costs each year. 13

The Children Act 2004 mandated training in the recognition of and response to child abuse and neglect for all staff in contact with children. Professional bodies responded by publishing guidelines and competences for their members, which are designed to protect both children and the professional. 3,14–17 All accident and emergency (A&E) staff are expected to receive training in child protection, which ranges from hourly training sessions to a compulsory 3 days a year, depending on their level of contact with children and child protection responsibilities. 3,12,18 The process of screening, assessment and referral of children with suspected physical abuse in A&E is summarised in Table 1.

The recognition of the need for better training has focused attention on the signs and symptoms that staff should be trained to look for. The Royal College of Paediatricians and Child Health (RCPCH) recently produced guidelines on the detection and management of child abuse and neglect and highlighted the poor quality of the evidence underpinning many of the recommendations and the need for more research. 14 Signs and symptoms suggestive of physical abuse cited by the report included injury in infants, vague, unwitnessed, inconsistent or discrepant history, unexplained injuries, delayed presentation, injuries not consistent with a child’s development, repeated attendance for injury, and multiple bruises in certain areas such as the face, head and neck. In some cases the evidence underpinning these markers of abuse is based on case series of abused children or on comparisons between definitely abused children and healthy children seen in routine child health clinics. 19,20

Despite the uncertain evidence on the performance of these features for predicting physical abuse, they are being increasingly used in checklists, aide-memoires and protocols in A&E departments to improve detection by front-line A&E staff. 14,20–23 To date, no systematic evaluation has determined which factors are most predictive of physical abuse and which might overwhelm the paediatric team with false-positive referrals of non-abused children. The aim of this study was to address this gap in the evidence by evaluating the performance of screening tests for physical abuse in A&E.

Overview of systematic review methods

We carried out a series of systematic reviews to address objectives (1), (2) and (3). Because of the paucity of valid and relevant evidence we adopted an ‘exploratory’ approach to each review question. We used broad inclusion criteria to select studies for review because we could not anticipate all of the important elements of the study methods that could affect validity and applicability. This approach allowed us to examine the relationship between study quality and results and helped to define limits within which the true estimate might lie. We selected studies to inform the parameters for the clinical effectiveness model using epidemiological principles. By making explicit the rationale for the estimates used in the clinical effectiveness model, readers can use the data to test alternative interpretations.

Clinical effectiveness model

We developed a simple clinical effectiveness model based on a scoping review of the literature and discussions with health and social services providers (Figure 2). The model was based on a hypothetical population of children (< 16 years) in the UK and provides a simplified representation of the occurrence of physical abuse, the risk of resulting injury requiring medical attention, attendance at A&E of physically abused and non-abused injured children, detection by screening in A&E, and referral or not to social services. Injury was defined as head injury, fractures, burns, bruises or ‘other’ and excluded poisoning, foreign bodies and fabricated illness. More details on the classification of injuries are given in Table 10. Physical abuse was defined as at least one act of severe violence (kick, bite, scald/burn, ‘beat up’, hit with object, shake a young child, or threaten to use a weapon) from a parent or carer towards a child. 5

FIGURE 2.

Flow diagram showing the steps included in the model. CLN, community liaison nurse; CPR, child protection register; SWA, social work active.

Parameters defining the probability of outcomes at each step of this pathway were obtained from the systematic reviews (Chapter 4) and entered into the model using Microsoft Excel^®. The model then multiplied the parameters to generate the probabilities of the outcomes used to measure the clinical effectiveness of screening: the proportion of abused children detected in A&E and referred to social services, and the proportion of non-abused children unnecessarily referred to social services for suspected abuse. We assumed that all referrals from doctors in A&E to social services would result in an ‘initial assessment’ as required under Section 47 of the 1989 Children Act. 5

Screening tests

We defined screening tests as any criterion or ‘test’ that would be universally applied to all injured children to detect those with suspected physical abuse. We accepted any characteristic or form of assessment provided that it was universally applied. We selected screening strategies based on existing A&E protocols or tests used in UK A&E departments, as revealed in a review of the published literature and interviews with staff in five A&E departments. 14,20–23 We added one further protocol, whether the child is social work active (systematic review 8, Table 12). Although not yet in use, this information will be recorded on Contact Point in all local authorities in England by 2009. 13,24

The types of screening strategies examined are listed in Table 2. The base-case strategy, standard care, comprised the history and examination of an injured child conducted by A&E staff. We sought evidence on two other clinical screening tests: the use of a checklist to enhance the initial clinical screening assessment and the use of a community liaison nurse to scrutinise all child attendance records for children with possible abuse missed by A&E staff. We then evaluated the effectiveness of adding screening protocols, based on characteristics of the child, to the clinical assessment screen.

The study had three main limitations. First, it was restricted to physical abuse, the remit given by the funders, even though this is frequently linked to other forms of abuse. Second, we included only injured children, who account for about one-third of all A&E attendees. 25,26 Third, we did not consider the important policy question of whether screening reduces the adverse consequences of physical abuse over the child’s lifetime and improves their quality of life. This would require information on the benefits and harms of detection, failure to detect abuse and false-positive referrals, and the benefits and harms of interventions offered by social services and other agencies. These questions were beyond the scope of our study.

Methods

We developed a database of abstracts based on the six methods shown in Figure 3. Searches were limited to studies published after 1974 when major changes in the way that child abuse was managed were instituted in the UK (see Inclusion criteria). Start dates for each method are given below. Further details of the search methods are reported in Appendix 1.

1. Method 1: The initial scoping search was carried out in August 2004 and was based on Medical Subject Headings (MeSH) and text word terms for child, abuse, maltreatment, violence and punishment. The search yielded 186 references.

2. Method 2: We developed a more detailed search strategy that was used on MEDLINE in October 2005. This search yielded 6880 references.

3. Methods 3: The third source was the publications catalogue of the National Society for the Prevention of Cruelty to Children (NSPCC), which was searched in September 2005. We included any references that appeared to be relevant to physical abuse. This search yielded 492 references.

4. Method 4: As the type of evidence sought was complex and heterogeneous and could relate to clinical, management or policy issues in health or social care, we complemented the protocol-driven search (method 2) by carrying out four types of ‘targeted search’ in January 2006 (Appendix 1, Table 25). 28

   1. First, we listed the most valuable studies found from the scoping search (‘gold standard’ papers, n = 16). Using the Web of Science we found all subsequently published papers that cited each source paper.

   2. Second, using the ‘related articles’ search on the Web of Science we found papers (previously or subsequently published) that shared references with each source paper.

   3. Third, we identified papers with the same subject terms, headings or MeSH terms as each of our source papers by using the ‘related articles’ algorithm on PubMed. We imported the 20 most relevant papers and those other papers identified by our search terms.

   4. In the fourth step we applied search terms across databases [including Department of Health database (DH-Data), British Nursing Index and Cumulative Index to Nursing and Allied Health (CINAHL)] that were not covered by our main protocol-driven search. These four search techniques yielded 1216 references (deduplicated, n = 1056).

5. Method 5: The third search method was snowballing. This involved judgement and was based on scanning reference lists, hand searching journals, searching the internet and chasing up professional contacts for unpublished data. This method is especially useful for identifying high-quality studies in obscure locations. 28 This search yielded 577 references.

6. Method 6: Finally, we carried out a search of three key journals (Pediatrics, Child Abuse and Neglect and Child Abuse Review) in October 2006 to identify any relevant studies published since the original protocol search was carried out in October 2005. Inclusion of studies in the database relied on the researcher’s judgement. This search yielded an additional seven studies.

FIGURE 3.

Flow diagram summarising methods used for identification of studies to include in the nine reviews.

Inclusion criteria

The inclusion criteria are reported separately for each review question in Chapter 4. Two inclusion criteria applied to all review questions. First, studies had to be published after 1974, as this was the year of the inquiry into the death of Maria Colwell, who died from injuries inflicted by her stepfather in 1973. The report made recommendations for child protection procedures that have formed the basis for child protection in the UK over the last 30 years. These recommendations included the establishment of area child protection committees (now replaced by local safeguarding boards),10 the establishment of a child protection register and the system of multidisciplinary case conferences. The Maria Colwell report identified inadequacies in the handling of the case by services and emphasised the need for professional accountability and multidisciplinary communication. 29 Second, we excluded studies relating to developing countries because recognition of child abuse and services for dealing with abuse are likely to differ from the UK setting.

All abstracts were scanned by a single reviewer (JW) who determined whether they were potentially relevant to one or more of the review questions. The full article was retrieved for all potentially eligible studies and separately appraised for each review question by one reviewer (JW). A second reviewer then appraised all included studies and any borderline decisions (RG).

Results

The numbers of abstracts identified by each search source are shown in Figure 3. The final pooled database comprised 7383 unique articles. Figure 3 shows the number of studies retrieved for appraisal and included for each review topic. Included unpublished data are shown in brackets.

Methods, results and model parameters

In this chapter we report the methods and findings of a series of systematic reviews that informed parameter estimates at each step of the assessment pathway (see Figure 2). For each review question we report the inclusion criteria, the quality of the included studies and the results of the review. The derivation of the relevant parameters for the clinical effectiveness model is reported in Chapter 5. All forest plots are based on fixed-effects meta-analyses and show proportions and 95% confidence intervals.

The systematic reviews can be considered in three parts, representing the burden of abuse, the incidence and characteristics of attendees at A&E, and the performance of clinical screening tests.

Burden of abuse

Two reviews were conducted to determine the incidence of severe parental violence and the consequent risks of injury requiring medical attention. We classified severe violence from a parent or carer (defined as punching, kicking, biting, hitting with a hard object, inflicting a scald or burn, shaking a young child, or threatening with a weapon) as physical abuse. Over 80% of physical abuse is perpetrated by a parent, parental figure or non-professional carer and this figure remains constant across all age groups under 16 years. 30 Consequently, our definition captures the large majority of physical abuse cases. The definition also includes children at risk of injury as well as those actually injured and is therefore consistent with the minimum threshold for mandatory investigation as laid out in Section 47 of the 1989 UK Children Act5 and definitions of physical abuse used in recent reports by the World Health Organization and the United Nations. 6,31 In this study we assume that severe parental violence is equivalent to physical abuse.

Systematic review 1: Incidence of physical abuse

Review methods

The review aimed to determine the age-specific incidence of physical abuse. We included studies that reported any measure of physical abuse or severe physical punishment or discipline perpetrated by parents or carers which could be used to derive the annual incidence of physical abuse.

To aid comparison between studies we classified the results into two categories:

1. severe violence (assumed to be equivalent to physical abuse): kick, bite, scald/burn, ‘beat up’, hit with object, shake a young child, (threaten to) use a weapon

2. physical abuse (severity of abuse unknown) reported by agencies involved in child protection.

We grouped all included studies according to the reporting source: parents, self-report and agency. To assist analysis of the variation between the included studies we report additional results for minor violence [slap, spank, slap, push, grab, shove (no injury/lasting marks)] and for violence over the child’s lifetime. Table 27 in Appendix 2 shows excluded studies that reported physical abuse over the child’s lifetime but not in the past year.

Review results

A total of 19 studies were identified (Table 3). Five were based on parental reports, three on self-reports and 11 on agency reports (including two unpublished studies). Methods and results for the two unpublished studies30,32 are reported in Appendix 4. All studies underestimated the incidence of physical abuse as they reported the prevalence of children with one or more episodes of severe violence in the previous 12 months. Further reasons for underestimation of abuse from these studies are poor response to surveys, under-reporting by parents and misclassification of abuse as accidents in agency figures. One further UK study was excluded as it was based on violence perpetrated by mothers of 8-month-old babies. 33

TABLE 3 - Incidence of parent or carer violence in the past year: results of systematic review 1

First author, country, year of publication	Methods	Risk of violence (% of total child population)
Parent reports
Ghate, UK, 200234	A total of 1249 parents with a child < 13 years, randomly selected from the 1991 UK census, had face-to-face interviews about discipline in the past 12 months (59.3% responded). Violence was measured by the Misbehaviour Response Scale. We classified punching, kicking and hitting with a hard object as consistent with physical abuse, and smacking, slapping on the arms or legs, grabbing and pushing as minor violence Minor violence in the past year [overall 868/1222 (71.0%)]: 0–1 years: 8%; 1–2 years: 61%; 2–4 years: 82.7%; 5–7 years: 64.7%; 8–10 years: 54.7%; 11–13 years: 37%; total < 13 years: 705/1222 (57.7%) The age-specific incidence as entered into our model gives a weighted average of 8.8%	Physical abuse in the past year: 0–1 years: 7/203 (3.45%); 2–4 years: 34/292 (11.6%); 5–7 years: 25/261 (9.6%); 8–10 years: 30/261 (11.5%); 11–13 years: 15/205 (7.3%); total < 13 years: 111/1222 (9.1%) Physical abuse during childhood < 13 years: 134/1222 (11.0%)
Bardi, Italy, 200135	A total of 2388 families with school-age children < 13 years in Tuscany completed an anonymous questionnaire sent out through schools in 1998 (50% responded). Violence was measured using the Conflict Tactics scale (CT scale). 48,49 We classified punching, kicking and hitting with a hard object as physical abuse, and smacking, slapping on the arms or legs, grabbing or pushing as minor abuse Minor abuse over 12 months: 1877/2388 (78.6%)	Physical abuse in the past year: 198/2388 (8.3%)
Theodore, USA, 200536	A total of 1435 mothers (≥ 18 years) with an index child under 18 years in Carolina, USA, identified by random sampling, were interviewed anonymously by telephone in 2002 about discipline (52% responded). We classified punching, kicking, hitting with a hard object or shaking a child under 2 years as physical abuse. Only violence inflicted by the mother was recorded	Physical abuse in the past year: < 5 years: 10/365 (2.8%); 5–8 years: 17/321 (5.3%); 9–12 years: 18/298 (5.9%); 13–17 years: 17/448 (3.9%); total < 18 years: 62/1435 (4.3%)
Wolfner, USA, 199337	A total of 3232 parents (18–85 years) with a child < 18 years were identified by random sampling and interviewed by telephone in 1985 (84% responded). Measurement of violence was based on the CT scale. We classified violence intended to cause injury as physical abuse, including kicking, biting, hitting with an object and threatening with or using a knife or gun Minor physical abuse in past year: overall < 18 years: 2001/3232 (61.9%); < 2 years: 323/567 (57%); 3–6 years: 659/740 (88.8%); 7–12 years: 553/771 (71.7%); 13–17 years: 406/1149 (35.3%)	Physical abuse in past year: < 2 years: 45/567 (7.9%); 3–6 years: 106/740 (14.3%); 7–12 years: 96/771 (12.5%); 13–17 years: 102/1149 (8.9%); total < 18 years: 356/3232 (11.0%)
Gelles, USA and Sweden, 198638	USA: 1146 two-parent families with children between 3 and 17 years; Sweden: nationally representative sample of 1105 single and two-parent families with children between 3 and 17 years in 1980 Parents were interviewed face to face at home about family violence (CT scale). Physical abuse: kicking, biting, hitting with an object, threatening with or using a knife or gun	Physical abuse in the last year: USA: 162/1146 (14.2%); Sweden: 51/1105 (4.6%)
Self-reports
Sebre, Baltic/Eastern Europe, 200441	A total of 1145 children (10–14 years) in Latvia, Lithuania, Macedonia and Moldova were randomly selected to complete a questionnaire about ‘thought, feelings and relationships’ in 1998–2000. Violence was measured using the CT scale. Frequent minor violence such as slapping or being hit with an object, kicked, punched or burned/scalded was considered equivalent to physical abuse	Physical abuse in past year: 244/1145 (21.3%)
Sariola, Finland, 199242	Classes including 7435 students aged 14–15 years were randomly sampled and given questionnaires distributed by the school nurse (96% responded). Violence was measured using the CT scale. Hitting with a fist/object, kicking, biting and threatening/using a knife/weapon were classified as physical abuse; slapping, hitting and grabbing were classified as minor physical abuse Minor physical abuse: in the last year: 1344/7264 (18.5%); during childhood: 5223/7264 (71.9%)	Physical abuse in past year: 334/7264 (4.6%); physical abuse during childhood < 15 years: 559/7264 (7.7%)
Nelson, USA, 199543	A total of 1957 school students aged 14–18 years in 25 schools, randomly selected across Atlanta state, completed an adolescent survey questionnaire in 1993 including three questions about ‘physical abuse’ by parents (82% responded of whom 75% answered questions on physical abuse). We classified hitting with an object and punching and kicking as physical abuse	Physical abuse in past year: 319/1957 (16.3%); physical abuse during childhood < 18 years: 550/1957 (28.1%)
Agency reports
Social services data for Hammersmith and Fulham, 2005 (unpublished audit; see Appendix 4)32	Audit of initial assessments by social services for suspected physical abuse in children (< 18 years) in one referral centre during 3 months in 2005 (153 initial assessments, missing data for a further 28). Reports ranged from slapping to obvious injury The incidence of initial assessment for physical abuse was estimated as 13.6% times the incidence of initial assessments for any reason in England (290,800/9,804,000 = 0.29%)9	Initial assessment for physical abuse over 12 months: 17/153 (11.1%)
Metropolitan Police, UK (London), 2005 (unpublished)30	All children < 16 years reported to London Metropolitan Police child protection unit in 12 months (2005) for ‘violence against the person’ by any perpetrator. We classified ‘acts of violence’ as physical abuse. We assumed that children comprised 19.5% of the total population of 7.2 million (based on census projections for London 2002). Some children may have been reported more than once	Physical abuse (reported to police) in the last year: 0–2 years: 317/184320 (0.20%); 2–4 years: 547/276480 (0.20%); 5–9 years: 1300/471600 (0.28%); 10–15 years: 2271/4716000 (0.48%); total < 16 years: 4435/1404000 (0.32%)
Child protection register (CPR), England, 20049	Registrations on the CPR for physical abuse or ‘multiple abuse’ from 2003 to 2004. Denominator population taken from England Office for National Statistics 2003 figures.50 We derived the age distribution of new registrations by assuming it was equitable with the age distribution of children on the register on 31 March 2004	CPR (new cases): < 1 year:1283/575000 (0.22%); 1–4 years: 2981/2273000 (0.013%); 5–9 years: 2794/3150000 (0.09%); 10–15 years: 2941/3780000 (0.08%); total < 16 years: 10000/9778000 (0.10%)
Creighton, UK, 200445	Systematic review of sexual and physical abuse from substantiated reports to official agencies in 2003–4. Denominator estimates taken from national websites51	CPR (12 months): USA: 145550/60646000 (0.24%); Australia: 7560/3978800 (0.19%)
Sibert, UK, 200252	Consultant paediatricians and senior clinical medical officers in Wales returned cards about children < 14 years diagnosed with an injury (grievous bodily harm) following physical abuse in Wales 1996–8. Reports for babies < 1 year were supplemented by cases on the CPR. We have adjusted the data (reduced by 50%) to report cases over 12 months	Severe injury reported by senior medical staff over 12 months: < 1 year: 26/35200 (0.074%); 1–4 years: 13/141200 (0.0092%); 5–13 years: 2/424500 (0.00047%); total < 14 years: 41/600900 (0.007%)
Creighton, UK, 198553	Children placed on CPR for physical abuse in 1981 in parts of England and Wales. Denominator population calculated from rates. All children were registered for physical abuse	CPR (over 12 months): < 16 years: 6532/10,910,300 (0.06%)
Lindell, Sweden, 200154	Physical abuse in children (< 15 years) by a parent or carer reported to the police in one district in 1986 and 1996 and substantiated by/registered with official agencies. Denominator based on police district	Substantiated physical abuse in the past year (to police): 145/27724 (0.05%)
Christensen, Denmark, 199939	Health visitors returned questionnaires reporting visible signs of parental violence in children. The study covered 80% of infants in Denmark in 1991 (83% response rate). Health visitors visit children 5–6 times in their first year	Visible injury reported by health visitor over 12 months: < 1 year: 502/50151 (1%); 1–2 years: 361/18042 (1%); 2–3 years: 136/6798 (2%); 3–4 years: 73/3634 (2%); total < 4 years: 1072/78625 (1.4%)
US Department of Health and Human Services, USA, 2006 (NIS-3)44	New cases of suspected physical abuse identified by 5800 professionals involved in child protection in 42 counties in 1993 (Table 3–1 in NIS-3 report). Children were classified as physically abused according to the harm standard (requires demonstrable harm) or the endangerment standard (includes children at risk of injury). Overall there are an estimated additional 1,261,800 children defined as abused under the endangerment standard. Denominators calculated from the rate (difference caused by rounding)	New cases of physical abuse (harm) reported in all US children within 12 months: 381,700/66,964,912 (0.57%); physical abuse (endangerment): 614,100/67,483,516 (0.91%)
Trocmé, Canada, 200346	Children (< 16 years) on the Canadian CPR for physical abuse in 1998	On CPR for physical abuse (point prevalence): 15,300/5,583,942 (0.25%)
Gessner, Alaska, 200455	Deaths or hospital admissions due to physical abuse in infants (< 1 year) born between 1994 and 2000 (n = 70,842) in four states, using linked databases. A total of 72 of the 325 reports of physical abuse led to hospitalisation (n = 58), death (n = 4) or both (n = 10)	Physical abuse (reported to social services) over 12 months: < 1 year: 325/70,842 (0.46%)

Parent-reported physical abuse

Figure 4 shows the proportion of parents who reported one or more episodes of physical abuse in the previous 12 months. Data were collected by telephone or face-to-face interviews except for one study35 based on anonymous questionnaires (see Table 3).

FIGURE 4.

Prevalence of parent-reported physical abuse in the past year.

The prevalence of 9.1% reported by Ghate et al. 34 in the UK study (age-adjusted figure for UK is 8.8%) was consistent with studies in the US (11%36) and Italy (8.3%34) but higher than a US study (4.3%36) in which only maternal violence was recorded. The relatively low rate of severe physical abuse in Sweden (4.6%38) may reflect long-standing legislation prohibiting physical punishment in the home. All but two studies37,39 had relatively low response rates (50–60%).

The annual prevalence of physical abuse reported in the UK study was similar to the rate reported for the child’s lifetime by May-Chahal and Cawson40 (7%), although different methods were used (see Appendix 2, Table 27). In studies using the same methods, the lifetime prevalence of abuse was close to but higher than the annual prevalence (Appendix 2, Table 27).

Self-reported physical abuse in the past year

Figure 5 shows results for three studies of self-reported physical abuse. All were based on questionnaires completed by adolescents. The annual incidence ranged from 4.6% to 21.3% and was highest in Eastern Europe41 and lowest in Finland. 42 One US study43 reported slightly higher rates of severe physical abuse (16.3%) than the parent-reported incidence for adolescents in the US national study37 (11%). This may reflect differences in the study populations, methods and definitions, as well as variation according to reporting source (see Table 3).

FIGURE 5.

Prevalence of self-reported physical abuse in the last year.

Agency-reported physical abuse in the past year

Figure 6 shows the prevalence of parent or carer physical abuse reported by agencies. Results varied enormously depending on the agency, their criteria for notification and the event reported (child affected by one or more episodes, as with the CPR figures,9 or individual episodes, as in the Metropolitan Police audit30).

FIGURE 6.

Incidence of agency-reported physical abuse in the past year.

In the UK, agencies reported substantially fewer children than the 8.8% subjected to physical abuse each year based on parent reports. The Metropolitan Police found 0.38 reports per 100 child-years in 2005. 30 This is roughly equivalent to 1 in 23 physically abused children, assuming both studies were drawn from the same population and that no children were reported to the police twice in 1 year [i.e. 1/(0.38/8.8)]. A similar rate was found for social services in an unpublished audit of one London borough. During 3 months in 2005, 11.1% (17/153) of ‘initial assessments’ for children under 18 years were for physical abuse. Extrapolating to the national rate of initial assessments (2.9%9), approximately 0.39% of children would undergo an initial assessment each year for physical abuse (see Table 3). The proportion of reports that were common to social services and police records is not known and we found no UK figures on the incidence of physical abuse suspected by professionals, referred to social services or investigated.

The fact that agencies detect far less abuse than is reported by parents or victims has been well established by North American studies. The large US National Incidence Study of Child Abuse and Neglect (NIS-3),44 which surveyed 5600 professionals involved in detecting child abuse in 42 counties, found that professionals reported one or more episodes of physical abuse in 0.58% of children each year, but estimated that only 28% of all types of abuse identified by professionals were investigated by child protection services. A similar discrepancy between identification and reporting is suggested by the high rate (1.4%) of visible evidence of physical abuse reported by health visitors in Denmark. 39 One explanation for these disparities is that some abused children may be followed up by social services for other reasons. An audit of consecutive initial assessments by social services in one London borough found 16 children undergoing initial assessment for suspected physical abuse, but a further 11 with currently documented parental violence were referred for other reasons and only 3 out of the 11 were investigated for other types of abuse (unpublished audit;32 Table 3 and Appendix 4).

Further decrement occurs in the frequency of investigation of physical abuse if agency reports are based on substantiated rather than suspected abuse. In the UK, the proportion of children placed on the CPR for physical abuse is less than 1 in 100 of those abused and less than one in three of the children who undergo initial assessment (per year: 0.08% of all children are on the CPR, 0.33% have initial assessment, 8.8% are physically abused). Similarly, Figure 6 shows that studies reporting suspected physical abuse found approximately twice as many cases as those reporting substantiated abuse in the US45 (0.24% versus 0.4%) and Canada46 (0.27% versus 0.5%). The US NIS-3 study found that 60% of all types of abuse investigated were unsubstantiated. 44,47 This is partly due to insufficient evidence or concern about further serious harm to warrant substantiation in abused children. In addition, children with accidental injuries may be falsely labelled as abused. There are few data on the proportion of false positives but expert opinion elicited for this study suggests that they account for only 10–20% of children undergoing initial assessment for physical abuse. An audit of social service referrals in the London Borough of Camden suggested that, among consecutive children referred for initial assessment for physical abuse to social services, only 3/26 index children (excluding siblings) were false positives (RE Gilbert, unpublished audit, Camden Social Services; Table 3 and Appendix 4).

The average figures reported in Table 3 hide substantial variation in overall rates of social services investigations according to locality8 and differences in age distributions according to agency. According to parent and self-report studies, the incidence of severe physical abuse is as high, or higher, in school-age children as in preschool children. Notification to the police follows a similar pattern. 30 However, the rate of child protection registration for physical abuse decreases markedly in school-age children. 9

In summary, these results provide strong evidence that parental physical abuse is poorly reported by agencies. As self-reported abuse is limited by the age of children who can be surveyed, parent reports provide the most reliable evidence of parent-inflicted physical abuse. The rates from such studies for severe parental violence in the past year are moderately consistent. 34–36 In the UK, approximately 1 in 11 children (8.8%) were subjected to violence each year of a severity consistent with physical abuse (Table 3).

Systematic review 2: Risk of injury requiring medical attention due to physical abuse

Review methods

The aim of the review was to determine the risk of injury requiring medical attention in children subjected to physical abuse. We included studies of physically abused children that reported the risk of injury after an episode of abuse. Although less representative of all abused children in the community, we restricted studies to agency reports of children presenting to services as the assessment of injury was likely to be objective. We excluded studies based on parent reports or self-reports as assessments of injury and the need for medical attention are less likely to be objective and parents may be reluctant to admit to injury. We defined injuries requiring medical attention as severe cuts or lacerations, fractures, severe burns, head injuries and internal injuries, or according to the author’s classification of injuries needing medical attention. As the data were limited we included high- or low-risk groups of children reported to services.

Review results

Seven studies met the inclusion criteria (Table 4 and Figure 7). All involved physically abused children referred to child protection services.

TABLE 4 - Risk of injury requiring medical attention due to physical abuse: results of systematic review 2

First author, country, year of publication	Methods	Risk of injury
Suspected physical abuse
Metropolitan Police, UK (London), 2005 (unpublished data, Wareing 2006)30	Duty officer classified severity of injury in 5188 children (< 16 years) reported to the Metropolitan Police child protection unit in 2005 for physical abuse by parents. Injuries coded by police as moderate or serious were classified as requiring medical attention Any injury (minor or worse): < 2 years: 46.0%; 2–4 years: 39.3%; 5–9 years: 48.7%; 10–15 years: 64.7%; overall < 16 years: 55.5%	Injury requiring medical attention: < 2 years: 88/317 (27.8%); 2–4 years: 79/574 (14.4%); 5–9 years: 172/1300 (13.2%); 10–15 years: 341/2271 (15.01%); total < 16 years: 680/4435(15.3%)
English, USA, 200060	Children (< 18 years) with suspected physical abuse reported to social services and considered not to require further investigation. All (n = 862) were referred to a voluntary community-based support organisation. Injury ascertained by staff using a standard severity rating	Injury (> minor): 4/862 (0.46%)
Substantiated physical abuse
Gibbons, UK, 199556	A total of 170 children (< 6 years) placed on NSPCC register for physical abuse in 1981. Injuries requiring medical attention (fractures, head injury, internal injury, severe burns or toxic ingestion) were documented from case conference reports	Injury requiring medical attention: 27/170 (16%)
Creighton, UK, 198553	A total of 4329 children (< 18 years) placed on NSPCC register for physical abuse between 1977 and 1982. Injuries requiring medical attention (fractures, head injury, internal injury, severe burns or toxic ingestion) were documented from case conference reports	Injury requiring medical attention: 519/4329 (12%)
Lindell, Sweden, 200154	A total of 145 children (< 15 years) with substantiated physical abuse reported to police (1986 and 1996). Fractures, burns and head or mouth injury were classified as requiring medical attention. Any injury reported in 75/145 (51.7%)	Injury requiring medical attention: 7/145 (4.8%)
Trocmé, Canada, 200357	Nationally representative sample of 7672 children (< 16 years) reported to Canadian social services for suspected child abuse or neglect in 1998. A total of 3780 had substantiated abuse, of whom 1010 had physical abuse. Injury was reported by age group for 3780 children, classified as minor or requiring medical attention. Any injury reported in 379/1010 (37.5%) with physical abuse	Injury requiring medical attention: physical abuse: 70/1010 (6.9%); any abuse: < 1 year: 34/230 (14.8%); 1–3 years: 33/604 (5.5%); 4–7 years: 29/991 (2.9%); 8–11 years: 23/916 (2.5%); 12–15 years: 32/1012 (3.2%); < 16 years: 151/3753 (4%)
Zuravin, USA, 199461	A total of 789 out of 2944 children reported to Child Protection Services in Baltimore City in 1984 for physical abuse were analysed. Injury classified as requiring medical attention included same or worse than sprain, mild concussion, broken teeth, cuts requiring sutures, second-degree burns, fractures or more than two ‘mild’ injuries on any body part. Any injury, including mild, reported in 497/789(63.0%)	Injury requiring medical attention: 146/789 (18.5%)

FIGURE 7.

Risk of injury requiring medical attention given a single physical abuse event.

Of the included studies, all three UK studies reported high rates of injury compared with recent studies elsewhere. The high rate in the Metropolitan Police study (15.3%) (2006, unpublished data30) may reflect increased police involvement when there is a visible injury, better recording of marks by police than by other agencies or, in the absence of guidelines, overestimation of the need for medical attention. The other two UK studies were based on children registered in the early 1980s (injury prevalence 12%53 and 16%56) and may reflect more severe abuse 25 years ago than currently or a higher threshold of severity before cases were registered.

The risk of injury was moderately consistent in the two most recent studies in Canada57 (6.9%) and Sweden54 (4.8%). Excluded studies based on self-reported injury occurring over a period ranging from 12 months to the whole of childhood reported high rates of injury requiring medical attention (from 14%58 to 26%59). In contrast, the study by Ghate et al. 34 found a very low rate of reported visible injury suggesting parental reluctance to disclose inflicted injury. Only four parents (out of 1249) responded to the question ‘Have you ever inflicted any injury on your child that required medical attention?’ All four parents said ‘No’.

Attendance at A&E

In this section we report a series of systematic reviews to determine the incidence of attendance at A&E and how the characteristics of the child vary according to whether or not the injury was due to physical abuse.

Systematic review 3: Risk of attending A&E after injury due to physical abuse

Direct measurement of the risk of a physically abused child attending A&E is difficult as some abused children may never be detected. Instead, we estimated this parameter indirectly (see Chapter 5) by addressing the following four questions, which can be mapped onto the tree in Figure 8:

1. What is the prevalence of A&E attendance in physically abused children who are injured [(a + c)/all abused and injured in Figure 8]?

2. What is the prevalence of confirmed physical abuse in all injured children attending A&E [a/(a + b + c + d) in Figure 8]?

3. What is the prevalence of confirmed and suspected physical abuse in injured children attending A&E [(a + b)/(a + b + c + d) in Figure 8]?

4. What is the prevalence of confirmed abuse in injured children with suspected physical abuse attending A&E [a/(a + b) in Figure 8]?

FIGURE 8.

Diagram showing how review questions (b)–(d) indirectly inform the probability of A&E attendance in injured, physically abused children [question (a)].

Review 3(a): Risk of A&E attendance in physically abused and injured children

Review methods

We included any study that reported presentation for medical services in children with confirmed physical abuse.

Review results

We found one study in which 4695 undergraduate students were interviewed and asked to recall any episodes of physical abuse by their parents (defined as injury due to parental violence) and whether they received medical attention (Table 5). A total of 592/4695 (12.6%) respondents reported one or more episodes of physical abuse, of which 146 involved fractures or head injury and were likely to have required medical attention. A total of 94 (0.16%) students reported having received medical attention for an abusive injury. If all A&E attendances were related to severe injuries (this is unclear in the report), 64% (94/146) of those with severe injury attended.

TABLE 5 - Risk of attending A&E after injury due to physical abuse: results of systematic reviews 3(a)–3(c)

First author, country, year of publication	Methods	Results
(a) Risk of A&E attendance in physically abused and injured children, (a + c)/all abused and injured
Berger, USA, 198889	A representative sample of psychology undergraduates (n = 4695) completed a questionnaire including questions on parental violence during childhood, specific injuries resulting from violence and whether they ever received medical attention. A total of 592/4695 (12.6%) reported any injury due to parental violence in childhood, of which 55% were bruises, 18.1% cuts, 4.7% dental injuries, 7.6% burns, 6.7% broken bones and 10.5% head injury. We classified burns, broken bones and head injuries as likely to require medical attention (n = 146). A total of 94 attended A&E but it is not known for which type of injury	Risk of injury receiving medical attention: all injuries: 94/592 (15.9%); severe injuries: 94/146 (64.4%)
(b) Prevalence of confirmed physical abuse in all injured children attending A&E, a/(a + b + c + d)
Macgregor, UK (Scotland), 200362	Records of 434 children < 1 year who presented to A&E with injury in 2000 were reviewed. Abuse was measured by referral to social services for suspected abuse	Confirmed abuse: 6/434 (1.3%)
Moore, UK (Liverpool), 199266	A total of 110 children < 16 years presenting to children’s A&E in 1988 and claiming assault were interviewed by researchers. Abuse was based on disclosure by the child or caretaker (n = 15). We assumed that 27% (3767) of the 13,951 A&E attendances were for injury25,26,65	Disclosed abuse: 15/3767 (0.40%)
Chang, USA, 200564	Discharge records of 58,558 children (< 15 years) attending or admitted to hospital for injury in 1997 or 1998 were analysed for child abuse E-codes. We assumed that children with abuse recorded on the discharge database would have been referred to social services. ‘All centres’ includes non-trauma centre hospitals (n = 31,681) and data collected from a level 1 paediatric trauma centre during the development phase of the study (n = 11,919)	Abuse recorded on discharge: paediatric trauma centres: 65/551 (1.24%); trauma centres also serving adults: 158/21,326 (0.7%); total (all centres): 447/58,558 (0.76%)
Pless, Canada, 198765	A total of 2211 children (< 6 years) attending children’s A&E with injury or poisoning in 1976. Specially trained nurses screened children using a checklist, full undressed examination, and discussion with physician (n = 1563). Abuse confirmed by hospital child protection team (resulting in referral to social services)	Confirmed abuse: 14/2211 (0.6%)
(c) Prevalence of suspected physical abuse in injured children attending A&E, (a + b)/(a + b + c + d)
Suspected abuse defined by referral to the paediatric team
Benger, UK (Bristol), 200221	A total of 1000 injured children < 5 years consecutively attending a children’s A&E department. Referral to senior medical staff for suspected abuse recorded retrospectively from records	Referral to paediatrician: 6/1000 (0.6%)
Pless, Canada, 198765	Children < 6 years attending A&E for injury/poisoning during 18 weeks in 1976 [see review 3(b)]. Referrals for suspected abuse to hospital child protection team	Suspect and confirmed: 36/2211 (1.6%)
Suspected abuse defined by a risk score
Palazzi, Italy, 200578	A total of 10,175 children (< 15 years) presenting to 19 children’s A&E departments on random census days in 2000. Staff used a six-point suspicion index for all children. A score of equal to or more than 4 positive points indicated suspected abuse (n = 204). Of 204, 18% (36/204) were for suspected physical/sexual abuse	High score for physical/sexual abuse: 36/10175 (0.4%)
Johnson, USA, 198679	A total of 333 children < 5 years presenting with injury to A&E (1981–2). Abuse (any) based on retrospective classification of inadequately explained/unexplained injury (45 children with incomplete records excluded)	Suspected abuse: 3/288 (1.0%)

Review 3(b): Prevalence of confirmed physical abuse in all injured children attending A&E

Review methods

We included studies that reported confirmation of physical abuse in children attending A&E with any type of injury. We excluded studies that confined abuse detection to specific type of injuries (e.g. burns or fractures) as these are not representative of all attendances at A&E. We judged referral to social services to be an adequate marker of confirmation of physical abuse.

Review results

Four studies62–66 were included (Table 5; Figure 9, confirmed studies). The prevalence of confirmed physical abuse among injured children ranged from 0.37% to 1.38% (Figure 10). There were two UK studies. One,62 limited to injured infants attending A&E (1.3% had confirmed physical abuse), overestimates the risk for all children as infants are at higher risk of abuse. The other UK study by Moore and Robson66 likely underestimates the risk of abuse as detection of abuse required disclosure of parental assault. In a large US study by Chang et al. ,64 based on attendances for injury and discharge diagnoses at 1196 hospitals, the overall prevalence of confirmed abuse was 0.76%; however, the prevalence was higher in paediatric trauma centres, presumably because staff were more alert to the possibility of abuse. A similar prevalence of abuse (0.64%) was reported in a study by Pless et al. 65 from Canada in 1976, which was restricted to children under 6 years of age.

FIGURE 9.

Prevalence of confirmed and confirmed plus suspected physical abuse in all injured children attending A&E: systematic reviews 3(b) and 3(c). Note: confirmed abuse = a/(a + b + c + d), review 3(b); confirmed and suspected abuse = (a + b)/(a + b +c + d), review 3(c).

FIGURE 10.

Prevalence of confirmed abuse in injured children referred for suspected physical abuse [a/(a + b) in Figure 8]: systematic review 3(d).

These figures contrast with results from studies of high-risk patients or studies with low thresholds for measuring abuse that were excluded from this review. For example, in studies looking at fractures in children between birth and 3 years of age, the prevalence of abuse in injured children ranged from 23% to as high as 83% for children under 2 years with rib fractures. 67–70 The prevalence of abuse in young children with head injury was also high, ranging from 14% to 70% depending on the age of the child, the type and severity of head injury and the measurement of physical abuse. 71–76

Systematic review 3(c): Prevalence of confirmed and suspected physical abuse in injured children attending A&E

Review methods

We included studies that reported any measure of suspected abuse in children attending A&E for injury. Studies restricted to specific injuries were excluded. We included studies that did not differentiate between injury due to physical abuse or neglect, provided that they included physical abuse.

Review results

We found four studies, of which one (Pless et al. 65) was included in review 3(b) of confirmed physical abuse (see Table 5, Figure 9). These are analysed below according to the criteria for defining suspected abuse. 21,65,77–79

Suspected abuse defined by referral to the paediatric team

Two studies measured suspected abuse by referral to a paediatrician or the child abuse team within the hospital. 21,65 Benger and Pearce21 found that 0.6% of injured children under 5 years attending a UK children’s A&E department were referred to a paediatrician. Similar results were found in a Canadian children’s A&E department: between 0.6% and 1.4% of injured children under 6 years were referred to the hospital child protection team for any abuse, and about half of these were for physical abuse (i.e. 0.3–0.8% from 1976 to 1984; the figure for 1976 of 0.64% is used in Figure 9). 65

Suspected abuse defined by a risk score

Two studies78,79 used a risk score to identify children with suspected abuse, although a suspicious score did not necessarily result in referral. Palazzi et al. 78 conducted a multicentre study in 19 A&E departments in Italy and found that 0.35% of 10,175 injured children had a high score (≥ 4 points) for physical abuse.

Systematic review 3(d): Prevalence of confirmed abuse in injured children referred for suspected physical abuse from A&E

Information on the probability of confirmed abuse in injured children referred from A&E can be used to validate estimates used in the clinical effectiveness model for the prevalence of confirmed abuse in injured children attending A&E [a/(a + b + c + d)]. This information, known as the positive predictive value or post-test probability, may be drawn from studies that follow up referrals for suspected abuse or from the paediatrician’s experience. Consequently, we addressed this question using published studies and estimates from experts.

Review methods

We included any study that reported any measure of confirmation of physical abuse (separately from other types of abuse) in children with any type of injury who were referred for suspected physical abuse. We assumed that ‘inflicted’ injury or ‘non-accidental’ injury referred to physical abuse, and ‘abuse’ (with no further definition) referred to all types of abuse and neglect. As few studies reported referrals from A&E we accepted any hospital setting. We sought expert opinion from three paediatricians who assess referrals from A&E.

Review results

We found nine studies (Table 6). 72,74,80–86 Post-test probability varied between 20% and 95% depending on the type and severity of injury, the threshold for referral, the criteria for confirmation of abuse and the accuracy of clinicians who decided which children to refer. All of the included studies were based on specific injury groups that would be classified post hoc, after investigation, and which are therefore likely to be based on highly selected populations, at higher risk of abuse than the average injured child attending A&E. 65,70,87 The included studies suggest some consistency in the risk of abuse for burns80,81 but not for other types of injury.

TABLE 6 - Prevalence of confirmed abuse in injured children referred for suspected physical abuse from A&E [a/(a + b)]: systematic review 3(d)

CAP, child abuse and protection; CPR, child protection register; SS, social services.

First author, country, year of publication	Age	Admitted (Y/N)	Injury, setting, time	Test for abuse	Confirmation of abuse	Confirmed physical abuse (%)
Burns
Kumar, UK, 198481	< 9 years	Y	Burns unit, 1977–81	Referral to SS	SS confirm	30/78 (38.5%)
Clark, USA, 199780	< 16 years	N	Burns, A&E, 1990–1	Referral to SS (standard care)	SS confirm	1/3 (33.3%)
	< 18 years	N	Burns, A&E, 1992–3	Referral to SS (checklist)	SS confirm	7/26 (26.9%)
Fractures
Hoskote, UK, 200384	< 1 year	N	Fracture, A&E, 1993–4	Referral to SS	Children registered on CPR	7/9 (77.8%)
Carty, UK, 200285	< 16 years	N	Fracture, radiology department, 1984–96	Referral to SS	Admitted/court confirm	435/467 (83.2%)
Oral, USA, 200382	< 3 years	N	Fracture, children’s emergency department, 1995–8	Referral to SS	Researchers confirm	85/89 (95.5%)
Scherl, USA, 200083	< 6 years	Y	Diaphyseal femur fracture, children’s hospital, 1986–96	Referral to SS	SS confirm	13/76 (17.1%)
Ziegler, Australia, 200586	< 3 years	N	Fracture, emergency department (tertiary), 2001–2	Referral to SS	SS confirm	4/16 (25%)
Head injury
Brown, USA, 200372	< 4 years	Y	Head injury, 1993–9	Referral to SS/police	Hospital, SS, police confirm	8/38 (21.0%)
Jenny, USA,199974	< 3 years	Y	Head injury, children’s hospital, 1993–6	Referral to hospital CAP team	CAP team confirm	119/173 (68.8%)

Three consultant paediatricians gave their opinion on the risk of confirmed physical abuse in injured children referred by A&E staff to the paediatric team, usually a paediatric registrar, for assessment. The estimates were 5–10%, higher than 2–10%, and 50–60%. Such variation reflects recall bias, variation in feedback about the outcome of referrals and knowledge about referrals to the paediatric team as a whole, as well as real differences in the skills of A&E staff, the threshold for referral and the populations studied. 35,57,64,88,89

Systematic review 4: Incidence of attendance of all injured children at A&E

Review methods

To determine the annual incidence of attendance of injured children at A&E according to age group we included any UK study that reported the number of attendances for all injuries at A&E in any age group and the denominator population. We excluded studies from outside the UK as patterns of primary care and emergency care provision differ across countries. We accepted attendances for accidents as equivalent to attendances for injury but excluded reports of all attendances as the proportion due to injury varies by age group and may be affected by relative ease of access to primary care and A&E. 25,26

Review results

We found seven studies (Table 7 and Figure 11). 62,88,90–94 Two studies from Norwich91,92 were combined as they used the same geographic population and methods but studied different age groups. All six studies were based on children attending A&E after 1989 and all but one were based on routine hospital coding of the principal reason for attendance. The largest and most nationally representative study was based on unpublished data provided by the Royal Society for the Prevention of Accidents (RoSPA) for A&E departments across the UK in 2000–2. 88 The RoSPA used interviews with patients in A&E departments to categorise reasons for attendance. The Norwich study estimated the denominator population based on person-years of residence using child health records. 91,92 All other studies estimated the denominator population from point prevalence census data. 62,88,90,93,94

TABLE 7 - Incidence of attendance of all injured children at A&E: results of systematic review 4

First author, place, year of publication	Methods	Number of injury attendances/denominator (rate per 100 child-years)
Brownscome, Bath, 200490	Resident children (< 5 years) attending A&E for accidents, including those found to have no injury (n = 165), identified by A&E audit (1997–2000)	< 5 years: 2300/4245 (13.1 per 100 child-years)
MacGregor, Aberdeen, 200362	Infants (< 1 year) attending A&E for injury were identified by case note review (2000). Population estimated. These data are not represented in Figure 11 as they are only for children under 1 year	< 1 year: 434/6000 (7.2 per 100 child-years)
Royal Society for the Prevention of Accidents (RoSPA), UK, 2002 (unpublished)88	Patients interviewed at 16 representative A&E departments (2000–2). Numerator assumed to be approximately 5% of all UK attendances. We calculated denominator based on mid-population estimates for 2002. Accident attendances with foreign bodies or ‘no injury’ were excluded (5% of total accidents). The age-specific incidence entered into our model gives a weighted average of 19.0 per 100 child-years	< 1 year: 3322/32,244 (10.3 per 100 child-years); 1–4 years: 26,791/134,293 (20.0 per 100 child-years); 5–9 years: 26,637/185,390 (16.9 per 100 child-years); 10–15 years 46,423/216,673 (21.4 per 100 child-years); total < 16 years: 103,173/568,600 (18.1 per 100 child-years)
Reading, Norwich, 199992 and Haynes, Norwich, 200391	Resident children identified from A&E records and injury classified by researchers (0–4 years in 1994; 5–14 years in 1999). Poisoning or foreign bodies were excluded. Denominator recorded as person-time of residence from child health records	0–4 years: 2012.02/18,693 (10.76 per 100 child-years); 5–10 years: 1829/12,868.2 (14.2 per 100 child-years); 11–14 years: 1636/8575.8 (19.1 per 100 child-years); total < 15 years: 5477/40,140 (13.6 per 100 child-years)
Walsh, Newcastle, 199694	Random sample of resident children attending two A&E departments for accidental injury (< 16 years), identified from A&E records and classified by researchers (1990). Denominator based on census	< 5 years: (22.5 per 100 child-years); 5–9 years: (19.0 per 100 child-years); 10–15 years: (27.5 per 100 child-years); total < 16 years: 11,682/54,400 (21.5 per 100 child-years)
Lyons, South Wales, 199593	Resident children (< 15 years) attending three A&E departments for injury (1993). Denominator based on census	< 15 years: 10117/55,588 (18.2 per 100 child-years)

FIGURE 11.

Incidence of attendance of all injured children at A&E (per 100 child-years).

In the four studies that reported results for all ages, the incidence of attendance ranged from 13.6 per 100 child-years in Norwich to 21.5 per 100 child-years in Newcastle. 91,92,94 The RoSPA reported an incidence for the UK of 18.1 per 100 child-years. 88 The low rate of injury attendances in Norwich,79,80 Bath90 and Aberdeen62 may reflect better access to or a preference for primary care services in these areas. 88

Characteristics of children attending A&E for injury

In this section we review the evidence on the performance of a range of child characteristics or markers that have been used in screening protocols to determine which children should be referred directly to the paediatricians for assessment of suspected child abuse. Characteristics that have been used to date include young age (e.g. infants or children under 2 years), fractures or head injury in young children,22 children currently on the CPR,22,95 and repeated attendance for injury (Ian Maconochie, St Mary’s Hospital, London, February 2006, and Ben Lloyd and Jane Mattison, Royal Free Hospital, London, January 2006, personal communication). 1,20,96,97

Several potentially important characteristics were not evaluated because of a lack of UK data. These include presentation during night-time hours,98,99 parental mental illness and drug abuse, and domestic violence, all of which are factors evaluated by the community liaison nurse (Ben Lloyd, January 2006, personal communication).

As the prevalence of physical abuse in injured children attending A&E is very low (about 1%), only characteristics that are very strongly associated with abuse will have any appreciable impact on the probability of abuse. Consequently, although the quality of the research literature relating to this question was generally poor, strong associations should nevertheless be apparent.

Performance of clinical screening assessments for detecting physical abuse in A&E

We defined a screening test as any test that could be applied in routine practice to all injured children. We assumed that a positive screen test would result in referral to the paediatric team for investigation of suspected abuse, whereas a negative result would lead to no referral. The paediatric team would undertake one or more assessments to confirm or exclude physical abuse. Confirmation of physical abuse by paediatricians would result in referral to social services for suspected abuse. We report test performance in terms of sensitivity and specificity as some studies reported one or other but not both. A further reason for not reporting LRs in this section is that the clinical threshold for determining suspicion or not was not explicit or reproducible in any of studies. 4

In the previous sections we reviewed the performance of characteristics in the child that could be used as markers in screening protocols to determine which children are at sufficiently high risk of abuse to warrant direct referral to the paediatrician. In this section we report the findings of systematic reviews to determine the performance of clinical screening assessments based on the initial history and examination in A&E. These were defined as:

1. Standard Care. Initial history and examination by a triage nurse and/or A&E doctor.

2. Checklist. Use of a checklist to enhance recall of the key elements of the history and examination that should be considered as part of standard care.

3. Community liaison nurse (CLN). The CLN would scrutinise all child attendance records to detect suspected abuse missed by A&E staff.

The review sought studies that simultaneously measured sensitivity and the false-positive rate. Two subsequent reviews analysed studies that separately reported sensitivity or specificity. These were used to provide corroborative evidence for levels of sensitivity and the false-positive rate seen in practice.

Methods

We used a clinical effectiveness model to illustrate the impact of different markers or clinical screening assessments on the effectiveness of screening in A&E. The findings do not provide a reliable quantification of the relative performance of screening strategies for physical abuse because of the poor quality of the studies and their limited applicability to the UK. Given these problems we did not model the uncertainty in the parameters using a probabilistic approach. Instead, we used point estimates for all parameters. The findings do provide information about the rank order of strategies.

We used a simple decision-analytic model to determine the clinical effectiveness of screening tests for physical abuse in children attending A&E. The structure of the model, shown in Figure 12, was based on a review of the literature and discussion with experts. The model had three main elements: a hypothetical population of physically abused and non-abused children and their attributes (e.g. age), the annual incidence of attendance at A&E for injury with characteristics of attendees based on the population subgroups, and the performance of screening and confirmatory testing in A&E.

FIGURE 12.

Flow diagram for detection in the accident and emergency department. The population section divides the overall population into subgroups based on demographic data [e.g. age, social work active (SWA) and child protection registration (CPR) status]. The attendance section generates representative annual A&E attendances for each population subgroup (age, injury type, repeat attendance, SWA, CPR) based on attendance data. The testing section calculates the percentage of attendances referred at each level of screening and confirmatory testing for each attendance category based on test data.

We assumed that the main outcomes of concern to service providers would be to maximise detection of physical abuse while minimising false-positive referrals. We also recorded intermediary outcomes that could be audited in practice. These were the proportion of all injured children referred to the paediatric team and the proportion of children assessed by paediatricians and social services who were truly abused. From a societal perspective, the proportion of injured abused children who receive appropriate medical attention would be a further concern. This outcome raises questions about other agencies, apart from A&E, that detect physical abuse in the community, and is discussed briefly in systematic review 10.

Derivation of parameters used in the model

The parameters used in the model are listed in Table 15. We derived the parameters using the following methods.

TABLE 15 - Model parameters

NA, not applicable; ONS, Office for National Statistics.

Parameter		Input value	Numbers	Source
Population characteristics
Child population in the UK
1	All children < 16 years	100%	11,597,500	UK population mid 200550
2	Infants < 1year	6.2%	715,914
3	1–4 years	23.4%	271,161
4	5–9 years	30.7%	3,560,432
5	10–15 years	39.7%	4,609,542
Annual prevalence of physical abuse in children in the UK
6	Infants < 1 year	4.3%	8.75/203	UK study of parent-reported severe violence35 (systematic review 1). Weighted average = 8.8%
7	1–4 years	11.6%	34/292
8	5–9 years	9.6%	25/261
9	10–15 years	7.3%	15/205
Risk of injury requiring medical attention after a single physical abuse event
10	Infants < 1 year	25.5%	NA	Canadian study of children with substantiated physical abuse57 (systematic review 2). Weighted average = 6.9%
11	1–4 years	9.4%	NA
12	5–9 years	5.0%	NA
13	10–15 years	4.9%	NA
Characteristics of children attending A&E
Prevalence of physical abuse in A&E attendances for injury
14	All children < 16 years	1%		Researcher opinion based on systematic reviews 3b, 3c64
Annual incidence of A&E attendance for injury per 100 child-years
15	Infants < 1 year	10.3	3322/32,244	RoSPA study in the UK88 and population estimates for 2002 (systematic review 4)9. Weighted average = 19.0 per 100 child-years
16	1–4 years	20.0	26,791/134,293
17	5–9 years	16.9	26,637/185,390
18	10–15 years	21.4	46,423/216,673
Likelihood ratio for age group
19	Infants < 1 year	9.45	NA	Indirect estimate from two UK studies (systematic review 5b)88,102
20	1–4 years	1.71	NA
21	5–9 years	0.66	NA
22	10–15 years	0.3	NA
Prevalence of type of injury in all injured children attending A&E
	Infants < 1 year		235	Unpublished dataset from one London A&E 2003–5 (systematic review 6)26,102
23	Head injury	26.8%	63
24	Fracture	5.1%	12
25	Burns	57.9%	136
26	Bruises	10.1%	24
27	Other	0.0%	0
	1–4 years		1599
28	Head injury	6.6%	105
29	Fracture	120.1%	193
30	Burns	77.1%	1232
31	Bruises	4.3%	68
32	Other	0.0%
	5–9 years		1660
33	Head injury	4.8%	80
34	Fracture	22.4%	371
35	Burns	70.9%	1177
36	Bruises	1.9%	32
37	Other	0.0%
	10–15 years		1671
38	Head injury	2.9%	42
39	Fracture	23.7%	400
40	Burns	72.0%	1209
41	Bruises	1.3%	20
42	Other	0.3%	0
Likelihood ratio for type of injury
43	Head injury < 16 years	1	NA	Researcher opinion based on direct and indirect comparisons88 (systematic reviews 6a, 6b)26,75,102
44	Fracture < 16 years	1	NA
45	Burns < 16 years	1	NA
46	Bruises < 16 years	1	NA
47	Other < 16 years	1	NA
Prevelance of repeat attendance for injury at A&E
	Infants < 1 year		2928	Unpublished data from five London A&E departments from 2000 to 200626,106
48	Single attendance	51.2%	1499
49	Second/third attendances	37.6%	1103
50	Fourth+ attendances	11.1%	326
	1–4 years		11,560
51	Single attendance	49.0%	5668
52	Second/third attendances	35.9%	4148
53	Fourth+ attendances	15.1%	1744
	5–9 years		4387
54	Single attendance	72.2%	3166
55	Second/third attendances	24.5%	1077
56	Fourth+ attendances	3.3%	144
	10–15 years		4387
57	Single attendance	72.2%	3166
58	Second/third attendances	24.5%	1077
59	Fourth+ attendances	3.3%	144
Likelihood ratio for repeat attendance for injury
60	All children < 16 years	1	NA	US study with adjustment for social factors and researcher opinion [systematic review 7(a)]106
Prevalence of being social work active (SWA)
61	Infants < 1 year	2.7%	15,249/2,273,000	Uses rate of SWA for all children (2.1%, 2004) and ONS population data (2002).50 Weighted average = 2.16%
62	1–4 years	2.1%	46,913/3,150,000
63	5–9 years	1.8%	55,173/3,780,000
64	10–15 years	2.3%	88,002/3,780,000
Likelihood ratio for being SWA
65	Infants < 1 year	7.19		Indirectly derived (systematic review 8)
66	1–4 years	2.46
67	5–9 years	3.04
68	10–15 years	4.10
Prevalence of being on child protection register (CPR)
69	Infants < 1 year	0.62%	3539/8909	All registrations at March 2004 (n = 31,000)9 and ONS population data for the same year50 Average = 0.33%
70	1–4 years	0.39%	8909/3,150,000
71	5–9 years	0.29%	9276/3,150,000
72	10–15 years	0.18%	9276/5,041,200
Likelihood ratio for being on CPR
73	Infants < 1 year	12.68		Indirectly derived (systematic review 8)
74	1–4 years	4.10
75	5–9 years	4.72
76	10–15 years	6.58
Test performance of clinical assessments in A&E
Standard care
77	Sensitivity	43.5%		Derived as midpoint between two studies.72,82 Estimate extremely uncertain
78	False-positive rate	5.0%
Community liaison nurse
79	% Abused cases	15.5%	(43.5%/25.3) × 9	Increase in sensitivity and false-positive rate assuming parameters 78 and 79. Unpublished audit in one London A&E18
80	False-positive rate	3.9%	421/10885.7
Paediatric assessment of screen-positive cases
81	Sensitivity	90.0%		Researcher opinion – highly optimistic and uncertain
82	False-positive rate	2.5%

Population characteristics

Child population in the UK (parameters 1–5)

We used the estimated mid-year population for the UK for 2005 published by the Office of National Statistics grouped by the age categories shown in Table 15 (URL: www.statistics.gov.uk/downloads/theme_population/KPVS32_2005/KPVS2005.pdf).

Annual prevalence of physical abuse in children in the UK (parameters 6–9; based on systematic review 1)

We used the rate of parent-reported physical abuse by Ghate et al. 35 because the findings were most relevant to the UK, most recent and most consistent with other parent-reported studies. 36,37 As we lacked data on the frequency of multiple episodes of abuse we assumed that the prevalence rate was equivalent to the incidence rate (i.e. each child suffered only one episode of abuse per year). 35

We derived incidence rates of abuse for each age group using unpublished data provided by Ghate et al. (see Table 3). The data were manipulated to match the age groups used in the model as follows. We applied the rate for the 0–1 year olds to infants less than 1 year, the rate for 2–4 year olds to children aged 1–4 years, the rate for 5–10 year olds to children aged 5–9 years, and the rate for 11–13 year olds to children aged 10–15 years. We increased the rate for infants by 25% to take into account the fact that approximately 25% of children in this age group would have been less than 12 months at interview. On average, standardising for the age distribution in the UK we estimated that 8.8% of children are physically abused each year.

Risk of injury requiring medical attention following a single physical abuse event (parameters 10–13; based on systematic review 2)

We used the results reported by Trocmé et al. 57 (6.9%) as the best available estimate for the risk of injury in all physically abused children. This study was recent, the results were consistent with a similar study in Sweden,54 and social services routinely recorded whether children required medical attention, regardless of whether or not they saw a doctor. As data were not presented in the form that we needed, we used the average prevalence rate of injury requiring medical attention due to physical abuse and the age distribution for any maltreatment, including neglect (Table 4). We used the data of Trocmé et al. for 1–3 year-olds for our 1- to 4-year-old group, the data for 4–7 year-olds for our 5- to 9-year-old group and an average of the results for 8–11 and 12–15 year-olds for our group aged from 10 to 15 years.

As expected, the younger the child, and hence the more vulnerable, the higher the risk of injury requiring medical attention (see Table 4). Trocmé and colleagues commented on the surprisingly low rate of injury in children with substantiated physical abuse, 57% of whom had no injury at all but were nevertheless considered to be at significant risk of harm. Absence of injury may be even more common for physically abused children in the community than among children with substantiated abuse. Consequently, the estimate used in the model is very uncertain.

Characteristics of children attending A&E

Prevalence of physical abuse in A&E attendances for injury [parameter 14; based on systematic reviews 3(b) and 3(c) using notation (a + c)/(a + b + c + d) from Figure 8]

We used results from the two most representative studies reporting the prevalence of confirmed abuse in injured children attending A&E or admitted to hospital [a/(a + b + c + d) from Figure 8]. Chang et al. 64 reported an overall prevalence of 0.76% and Pless et al. 65 a prevalence of 0.6%. These figures exclude an unknown number of abused children who were not detected (false negatives). Surprisingly, the study based in 19 Italian A&E departments78 of suspected abuse in injured children reported a much lower prevalence (0.4%), despite including false-positive referrals and using a low threshold for detection based on a clinical score. On balance, we judged that the prevalence of physical abuse in injured children attending A&E is 1% or less. This estimate is uncertain and takes no account of variation by age.

Annual incidence of A&E attendance for injury per 100 child-years (parameters 15–18; based on systematic review 4)

We used the age-specific incidence rates reported by RoSPA. 88 This was most likely to be nationally representative and was within the range of estimates reported by other studies. 9

Likelihood ratio for age group [parameters 19–22; based on systematic reviews 5(a) and 5(b)]

We defined four age groups based on broad developmental criteria (under 1 year olds are mostly unable to walk) and schooling: infants (under 1 year), preschool (1–4 years), primary school (5–9 years) and secondary school (10–15 years). Only two studies reported age groups in abused and non-abused children attending A&E78,101 and only one study,101 from Hawaii, reported separate results for infants and preschool children. As we doubted the applicability of the findings in Hawaii to the UK setting, we indirectly compared the age distribution reported for abused and injured children by Shrivastava102 with the nationally representative RoSPA dataset88 (Table 8), making the arguable assumption that they were drawn from the same population. We then estimated the LRs for each age group, assuming that the overall prevalence of physical abuse was 1% (Table 16). The results are similar to the LRs reported for severely injured children admitted to hospital (Table 8). Although the best available estimates, they are flawed for at least three reasons. First, children were not from the same population or assessed in the same way in both studies. Second, the RoSPA data includes some abused children. Third, expectation that infancy is a predictor of abuse would have affected detection in the study by Shrivastava. Consequently, the results of the clinical effectiveness analysis are likely to overestimate the performance of infancy as a marker for abuse.

TABLE 16 - Estimated age distribution in physically abused and non-abused children and derived likelihood ratios and post-test probabilities: using results from systematic review 5b

Figures are estimates for UK A&E attendances based on the proportion of all abusive injuries reported by Shrivastava102 (see Table 8) and an estimated prevalence of abuse of 1% in A&E attendances for injury.

Age group	Abuseda	Non-abuseda	All (RoSPA)	Likelihood ratio	Post-test probability
Under 1 year	6399.249	67,031.75	73431	9.45	8.7%
1–4 years	10,371.2	600,138.8	610,510	1.71	1.7%
5–9 years	4192.612	628,375.4	632,568	0.66	0.7%
10–15 years	3309.957	1,107,483	1,110,792.5	0.30	0.3%
< 16 years	24,273.02	2,403,028	2,427,302	1.0	1.0%

Prevalence of type of injury in all injured children attending A&E [parameters 23–42; based on systematic review 6(b)]

We used unpublished data25 on 5165 injured children attending an inner London A&E department (University College Hospital London; Table 10) as this reported results for all age groups and had few attendances classified as ‘other’. The distribution of the type of injury by age group was similar to two other studies reporting results for all age groups. 88,105

Likelihood ratio for type of injury [parameters 43–47; based on systematic reviews 6(a) and 6(b)]

We found no clear evidence that the type of injury was associated with the risk of physical abuse. There was weak evidence from the direct comparison of abused and non-abused children in the TARNlet study to suggest that age confounded any association between type of injury and abuse. This was confirmed by indirect comparisons showing similar distributions of type of injury in abused children and in all injured children (see Table 8). 75 We therefore assumed that the LR was 1.0 for all types of injury in the clinical effectiveness model.

Prevalence of repeat attendance for injury at A&E [parameters 48–59; based on systematic review 7(b)]

We used unpublished data from five inner London A&E departments to determine the prevalence of repeated attendance for injury (see Table 11). 26

Likelihood ratio for repeat attendance for injury [parameter 60; based on systematic review 7(a)]

We judged that there was no association between repeat attendance and physical abuse, based on a US study that took into account socioeconomic status. 106 Weak, but statistically significant, associations were found for two other studies (see Table 11). 78,107

Prevalence of being social work active or on the CPR (parameters 61–64 and 69–72)

We used national figures for the number of children who were SWA or on the CPR in England during 2003–4. 9,50 For CPR we used published figures for children newly registered or re-registered for any reason during 12 months in 2003–4. The figure, 31,000, was higher than the point prevalence of children on the CPR during 1 week in 2003, but we reasoned that health professionals might be able to obtain information about current and recent CPR status. Being SWA is a marker indicating that a child is currently or has been in the last 12 months allocated to a social worker or to the duty team. We assumed that this status would apply to children undergoing an initial assessment, at least temporarily, and we therefore used national data on the incidence of initial assessments. As statistical returns for initial assessments do not include information on age or reason for referral, we extrapolated the age distribution from the CPR data. We assumed that 11% of all initial assessments are for physical abused based on an audit in two London local authorities, supported by expert opinion (see Appendix 4).

Likelihood ratio for being social work active or on the CPR (parameters 65–68 and 73–76; based on systematic review 8)

In the absence of more robust data we assumed that the estimates provided by Gorin123 reflected the prevalence of physical abuse in the subsequent year for children on the CPR for physical abuse (67%). We assumed the same risk applied to children who are SWA.

We calculated the LRs as shown in Table 17 using the notation in Figure 13. The prevalence of physical abuse in all children [(a₁ + c₁)/(a₁ + b₁ + c₁ + d₁)] was assumed to be 8.8% (weighted average from Ghate et al. ,34 systematic review 1). The overall prevalence of children on the CPR, 0.32% [(a₁ + b₁)/(a₁ + b₁ + c₁ + d₁)], was based on national figures (see previous section). 9,50 The proportion of children on the CPR experiencing subsequent physical abuse over the next year was estimated to be 34.4% [a/(a + b)], based on a risk of 66% in children registered for physical or mixed abuse (29% of 0.32% on the CPR) and a risk of 19% in those registered for other reasons. 9,123 The estimates vary for each age group because of the varying prevalence of CPR- or SWA-positive status (Table 17). The LR for being SWA for all children was 3.5, consistent with the LR of 4.1 observed by Palazzi et al. (see Table 12). 78,89

TABLE 17 - Derivation of likelihood ratios for being social work active (SWA+) or on the child protection register (CPR+)

	Notation	All	Under 1 year	1–4 years	5–9 years	10–15 years	Data source
Number of children in England (2005)	a1 + b1 + c1 + d1	9,720,800	606,400	2,286,900	2,981,500	3,846,000	Office for National Statistics, 2005, Series VS, No. 32, PP1, No. 28
Prevalence of physical abuse in all children (%)	(a1 + c1)/(a1 + b1 + c1 + d1)	8.8	4.3	11.6	9.6	7.3	Based on parent-reported severe violence in 12 months (Ghate, 200235)
Child protection registration (CPR+)
Number on CPR at any one time (any abuse)	a1 + b1	31,000	3539	8909	9276	9276	Tables 5a and 5b, National Statistics, 2004, DfES; new or re-registrations during the 12 months 2003–4
Prevalence of CPR+ among all children (%)	(a1 + b1)/(a1 + b1 + c1 + d1)	0.32	0.58	0.39	0.31	0.24	Parameters 69–72, Table 15
Data to estimate prevalance of physical abuse in CPR+ in 12 months
Proportion CPR+ for physical or mixed abuse (%)		32.3	36.3	33.5	30.1	31.7	Table 4c, National Statistics, 2004, DfES
Prevalence of physical abuse in 12 months in children CPR+ (%)	a1/(a1 + b1)	34.4	36.3	35.0	33.4	34.1	Assumed risk of severe violence in next 12 months is 66% for children registered for physical abuse and 19% for others (see text)
Derived variables
Probability of CPR+ in children exposed to physical abuse (%)	a1/(a1 + c1)	1.25	4.93	1.17	1.08	1.13
Likelihood ratio for CPR+	(a1/(a1 + c1))/(b1/(b1 + d1)	5.43	12.68	4.10	4.72	6.58	Parameters 73–76, Table 15
Social work active (SWA+)
Prevalence of SWA+ among all children (%)	(a2 + c2)/(a2 + b2 + c2 + d2)	2.10	2.65	2.06	1.75	2.33	Table 7b, National Statistics, 2004, DfES: proportion of children undergoing initial assessment during 12 months (age breakdown extrapolated from CPR) Parameters 61–64, Table 15
Data to estimate prevalence of physical abuse in SWA+ in 12 months
Proportion of SWA+ children referred for physical abuse (%)		11.1	11.1	11.1	11.1	11.1	Based on audit of initial assessments
Prevalence of physical abuse in 12 months in children on CPR (%)	a2/(a2 + b2)	24.3	24.3	24.3	24.3	24.3	Assumed risk of severe violence in next 12 months is 66% for children registered for physical abuse and 19% for others (see text)
Derived variables
Probability of SWA+ in children exposed to physical abuse (%)	a2/(a2 + c2 )	6.03	15.06	4.35	4.46	7.79
Likelihood ratio for SWA+	(a2/(a2 + c2 ))/(b2/(b2 + d2 ))	3.467	7.19	2.46	3.04	4.10	Parameters 59–65, Table 15

FIGURE 13.

Child protection registration (CPR) status in abused and non-abused children.

Test performance of clinical assessments in A&E

Standard care: sensitivity and false-positive rate (parameters 77 and 78; Table 15)

The estimated sensitivity and false-positive rate for standard care are very uncertain, being based on poor-quality data interpreted as follows. First, we fixed the false-positive rate at 5%, although, in practice, this will vary according to the threshold for referral to paediatricians, which in turn is determined by the availability of paediatricians and the experience of the clinical screening assessors. A rate of 5% is lower than that reported in many studies based on routine practice [systematic review 9(c)],65,72,82 but higher than the 2% considered feasible for all injured children in a UK children’s A&E department (Jonathan Benger, United Bristol NHS Healthcare Trust and University of the West of England, August 2006, personal communication). 21

Second, we estimated sensitivity for a 5% false-positive rate for the only two studies that reported sensitivity and a false-positive rate for standard care [systematic review 9(a); see Table 13]. 72,82 Receiver operator curves (ROCs) were derived using the diagnostic odds ratio and assuming that the curve was symmetrical (Figure 14; diagnostic odds ratio = odds sensitivity/odds false-positive rate). 4 Third, we derived a curve for the midpoint for sensitivity, at a 5% false-positive rate, between these two studies (Figure 14). Weaknesses of this method include the assumption that the results of the two studies are comparable, that the ROC curve is symmetrical, and that there is a continuous scale of detection that could correspond to a 5% false-positive rate. The sensitivity was estimated as 43.5% for a 5% false-positive rate.

FIGURE 14.

Sensitivity and false-positive rate of clinical screening assessments. In the receiver operating curves, squares show actual study results.

We attempted to address the weaknesses of the method above by indirectly comparing the result with other studies. Although higher rates for sensitivity were reported by seven out of eight studies (60–89%), it is likely that many operated at much higher false-positive rates. All were biased in favour of overestimation of sensitivity [systematic review 9(b); see Table 13]. Findings from before and after studies showed that detection rates more than doubled in three of five studies, although what proportion was due to false-positive cases is not known (see Table 14). Taking all these data into account, the research team accepted the estimates for standard care as reasonable but uncertain.

Community liaison nurse: sensitivity and false-positive rate (parameters 79 and 80)

To estimate the sensitivity for the CLN in addition to standard care, we assumed that the sensitivity of standard care in the study by Lloyd was equivalent to the base-case scenario of 43.5% (25.3 cases detected). We estimated that sensitivity increased to 59.0% with the addition of CLN screening [43.5% × (1 + (9/25.3)); see systematic review 9(a)]. 18 The false-positive rate increased from 5% to 8.9% (Figure 14 and see Table 13).

Paediatric assessment of screen-positive cases: sensitivity and false-positive rate (parameters 81 and 82)

The performance of the paediatric assessment was held constant at a sensitivity of 90% and a false-positive rate of 2.5%. In practice, the performance of confirmatory testing (the paediatric assessment) would be expected to change with the probability of abuse in children referred from A&E, but we found no data to quantify such variation.

Results

Table 19 depicts the results of the clinical effectiveness analyses for the base-case strategy and the increase in sensitivity and false-positive rates from adding screening by a CLN or a protocol stipulating markers that should result in direct assessment by the paediatrician. The proportion of all injured children assessed by the paediatrician ranges from 5.4% (standard care) to 38% if all children with two or more repeated attendances at A&E for injury within the last 12 months are referred (strategy 7). The proportion of injured children assessed by the paediatrician can be readily audited and provides critical information on the need for paediatric services to respond to A&E referrals.

The other critical outcome is the prevalence of abuse among children referred to social services. Most estimates range between 64% and 76% (Table 19, column 11). These figures concur with opinions from paediatricians and social workers. This marker could be audited, given feedback from social services on the outcome of the initial assessment, and would provide an important measure of the performance of A&E screening and paediatric assessments. The high ratio of abused to non-abused false-positive referrals is achieved because the paediatrician is assumed to have a very low false-positive rate (2.5%). In practice, this will depend on their experience and workload. Overall, the proportion of all abused children attending A&E with injury who are referred to social services is less than 60%, or around 1% of all injury episodes (Table 19, column 13) due to abuse each year in the community.

Table 20 lists strategies in rank order of increasing detection of abused children relative to standard care. The CLN and the strategy involving referral of all children with two or more previous A&E attendances detect the most cases. The latter strategy would overwhelm paediatric services, with assessments needed of an estimated 38% of all injured children seen in A&E. Consequently, the CLN appears to be the best option.

Key findings

We found consistent evidence that physical abuse affects 1 in 11 children in the UK each year. The proportion of abused children who require medical attention is small but poorly quantified. We estimated that approximately 1% of all child attendances at A&E for injury are for physical abuse, amounting to just under 1 in 50 of all physical abuse episodes in the community.

We found clear evidence that physically abused children who do attend A&E are missed but that the performance of the clinical screening assessment was poorly quantified. We found no evidence that any test was highly predictive of physical abuse. There was weak evidence that use of a checklist or a CLN improved the performance of the screening assessment in A&E. We estimated that the best strategy involved the standard clinical assessment screen combined with a CLN. This option would result in referral to social services of about half of the abused children attending A&E. Given the poor quality of the data, this result is highly uncertain.

The addition of protocols stipulating immediate paediatric assessment of children with specific markers plus clinical screening assessment of those without these markers offered only marginal benefits and the number of additional false-positive referrals exceeded the number of additional abused children detected (see Table 20). The most effective protocol involved referral of all injured infants and all injured children who were social work active. The benefits of protocols declined as the clinical screening assessment improved. We found no clear evidence that repeated A&E attendance, type of injury or age group, apart from infancy, were predictive of physical abuse.

Our findings show that few incidents of physical abuse are investigated by social services or police and, of these, a small minority are detected in A&E.

Strengths and limitations of the study

A major strength of the study was the use of a simple model to explain the rationale for the review questions and the way that the results were integrated. We used broad inclusion criteria for each review, thereby allowing examination of the range of results and factors contributing to variation between studies. We also took into account the fact that abused children attend A&E for accidents. We left no review questions unanswered, although the answer was sometimes very uncertain and based on indirect evidence.

The main limitation was the poor quality of the source data. As a result, the estimates generated by the model were very uncertain. We did not attempt to model the uncertainty using a probabilistic model as this would not have addressed the far greater problems of bias and questionable applicability to the UK of many of the studies. We selected parameter inputs for the model using epidemiological principles to judge threats to validity and applicability. The potential for bias was compounded by the use of indirect evidence to derive some parameter estimates (e.g. in the estimation of the prevalence of injured, abused children attending A&E). As far as possible we examined the face validity of model outputs by comparison with expert opinion and external data not used in the model.

A second limitation is that the burden of physical abuse inevitably depends on how it is defined, which in turn hinges on the level of violence towards children that society regards as acceptable. We used a widely accepted definition for severe parental violence to define the annual prevalence of physical abuse in children in the community. The figure of 9% was consistent with other studies. Even if the lowest reported estimate were used (4%), our findings of a huge gap between the occurrence and detection of abuse would be unchanged.

Third, we limited the study by focusing on screening tests for physical abuse in injured children despite the fact that physical abuse often occurs in association with other forms of abuse and neglect and that the pathway of referral to social services is similar. Benefits of detection of one type of abuse impinge on other types, as well as on other social problems, but this was outside the scope of our study. We further limited the study to detection of physical abuse in injured children, despite the fact that physical abuse may be found during examination of children for medical problems such as asthma.

Fourth, we did not investigate several potential screening tests because of lack of data. The timing of attendance at A&E (night-time) and the severity of the injury are both associated with physical abuse and warrant further investigation. 75,98,99 Bruising to the head or face may also offer a feasible screening test without requiring a fully undressed examination, but its performance needs to be assessed in the A&E population. 19 We could not evaluate direct questioning of school-age children as we found no relevant studies, despite the recommendation by Lord Laming that children with suspected abuse be questioned about the injury. 10 Finally, we evaluated checklists as a composite test as there were insufficient data to determine the performance of individual questions. Others have suggested that the most predictive question relates to inconsistency between the explanation and injury;140 however, this question is likely to be highly operator dependent as experience is required to know which events constitute a consistent explanation.

A fifth limitation was the use of fixed performance characteristics for the paediatric confirmatory assessment. In practice, paediatric scrutiny will vary depending on the threshold for referral by the A&E screeners. In addition, ward staff may make an important contribution to the overall detection of abuse by the hospital by identifying abused children, particularly those with severe injuries, who were not referred by A&E staff. We ignored this contribution as our focus was on A&E.

Finally, the Victoria Climbié inquiry identified poor coordination between services as one of the main problems that could have averted her death, rather than failure to identify physical abuse. We limited our analyses by not considering failures in the chain of referrals, as we aimed to reflect the optimal decision options facing service providers rather than implementation issues.

Implications for practice

A small minority of physically abused children present to A&E, and some abused and injured children may not receive the medical care that they need. Any efforts to improve detection of physical abuse in A&E should not discourage presentation of injured children for medical attention. The priority should be for abused children to be able to access medical attention if they need it.

Our findings suggest that improving the clinical screening assessment, based on a clinical synthesis of findings in the history and examination, is likely to be more useful than protocols, except where the paediatric expertise of assessors is minimal. All of the strategies examined involved referral of at least 5% of injured children to paediatricians, which may exceed existing capacity. Lower rates of referral to paediatricians would substantially diminish the proportion of abused children detected.

Improvements in the performance of the clinical assessment depend on training, feedback and experience, and might be enhanced by paediatric or other child protection expertise on site. Whether policy should focus on input by paediatricians or CLNs, or both, is unclear.

Further improvements in the overall detection of physical abuse by A&E might be achievable by taking action for the large number of abused children referred to paediatricians for suspected abuse who fail to reach the high level of certainty of abuse required to justify referral to social services. Such children fail to have the suspicion of abuse put on record for access by other professionals and, most importantly, fail to access supportive interventions. Lowering the threshold for action for such children could result in referral to social services to address the child’s social needs (i.e. as a ‘child in need’ referral) rather than referral solely on the grounds of abuse. Alternatively, the paediatrician could refer the child and family directly to supportive services in the community (e.g. Sure Start, parenting training). Completion of the CAF form will be used as a vehicle to record concerns about additional needs for information sharing but the practicalities of clinicians in A&E filling in an eight-page form need to be addressed. 141 Finally, standardised recording and coding of the clinical diagnosis or suspicion of abuse or neglect, whether or not children are referred to social services, would greatly enhance the potential for identifying children at risk by allowing clinicians to establish a cumulative record of abuse or neglect.

We found a lack of feedback about the outcome of suspected physical abuse within the hospital and from social services to A&E staff. All CLNs that we spoke to relied on their handwritten records of cases that they identified. Routinely compiled electronic records could provide invaluable feedback to staff at all levels and allow audits of the rate of referral for suspected abuse. Feedback implemented via regular multidisciplinary meetings to review child protection cases in A&E, outpatients and inpatients could be used as a model to offer opportunities for training, ensure that data are up to date and improve multidisciplinary working (Ben Lloyd, January 2006, personal communication). 18

Every paediatrician that we interviewed complained of a lack of feedback from some social services departments about whether children underwent an initial assessment at all and what further action was taken. In the clinical effectiveness model we assumed that all referrals from paediatric to social services for physical abuse would be investigated, as stipulated in Working together,2 but this may not be the case. 142 We received anecdotal reports that, during preliminary discussions with social services, doctors had to ‘choose their words carefully’ to avoid being deterred from making a formal referral. There was a perception that services were so stretched that new referrals were discouraged or that investigations might be limited. Many professionals who we interviewed expressed the need for telephone access to experienced social services advice to assist with judgements about referral and management of potential abuse. Several commented that they felt the existing services did not meet this need. Consideration could be given to making such advice centrally available.

Feedback to medical staff is mandatory for children proceeding to a Section 47 inquiry. However, we found anecdotal evidence that Section 47 inquiries occur in a minority of children considered to have been physically abused. Similar concerns were echoed in a recent Department of Health report142 that highlighted the continuing problem of varying thresholds for investigation. This view is supported by a recent report143 on costs and outcomes of children’s social care that highlighted the drastic rationing that takes place when children are referred, with cases closed after initial assessment despite high levels of need.

Various interventions or classification as a ‘child in need’ may pre-empt the need for a Section 47 inquiry and may offer the most beneficial approach for the child and family. However, lack of investigation for physical abuse can be construed as evidence that social services considered abuse had not occurred. The extent of this problem is hard to fathom as, although routine statistics record referrals to social services, initial assessments and subsequent investigations, they record the principal reason for investigation only at the end point, CPR. Hence, the burden of abuse measured by referrals and subsequent management cannot be determined. There also appears to be an undue emphasis on CPR as this is the only point at which abuse is coded, whereas the vast majority of abused children investigated by social services never reach this stage.

Consideration needs to be given to the feasibility of accessing information on whether a child is social work active from Contact Point (previously known as the Information Sharing Index), which member of staff will do this, and how the time taken for access (currently 2–3 minutes) can be reduced. We found strong evidence that the CPR was suboptimally used routinely and for individual children in A&E because of difficulties in access and unclear policy. 119,120 Contact Point could offer benefits for multidisciplinary working that extend beyond physical abuse, but ease of access to a reliable, up-to-date record will be key.

Research recommendations

It was striking how little high-quality research had been generated in the UK compared with North America. Part of the reason may be the lack of electronic databases that allow linkage between social services and health databases. With the current enormous investment in data systems in both arenas in the UK there is scope for large-scale studies.

1. Well-designed, large-scale studies are required to evaluate the effectiveness of assessments that are currently used in A&E for identifying abused children and initiating appropriate interventions. In particular, the role and effectiveness of the CLN warrants further research. Investigation is also required into which information obtained from other sources in the community is most effective for informing decisions about management of possible abuse or neglect.

2. Studies are needed to evaluate the feasibility, acceptability and effectiveness of new tests such as direct questioning of school-age children about injuries, assessment of bruising on the head and face, timing of attendance at A&E, information from the cumulative record of health-care use, and information from agencies outside health.

3. Monitoring is needed of the incidence of abuse identified by professionals working with children and how this is changing over time. National data on reasons for CPR should be extended to referrals to social services and analysed alongside studies of abuse identified by professionals to determine how much is referred.

4. Research is required to investigate the reasons for referral to social services and for completion of the CAF form, subsequent actions and re-referrals. Such a study would be important to gain a more accurate picture of the extent of abuse dealt with by social services, much of which may be labelled under non-abuse categories, or dealt with by information sharing via CAFs without involvement of social services.

5. Periodic local hospital A&E audits of patients with suspected abuse or neglect, actions taken within hospital, and contacts made with other agencies should be encouraged.

6. A working party should be established to determine the research priorities across health services, social services, education and police. With the introduction of electronic records in health and social services there will be considerable scope for high-quality large-scale studies, based on a combination of routine records and primary data collection. The working group should include expertise in population research and epidemiology, the different service areas and policy priorities, and should build on and complement the existing research agenda developed by the Department for Children, Schools and Families. For too long, interventions in child abuse have followed investigations of high-profile cases. A population-based approach is needed to generate high-quality research to underpin the effectiveness of the extremely costly services that exist to address this serious and common condition.

Information about service provision

We are grateful to the following individuals who contributed to the study. They facilitated site visits, discussed the child protection procedures in their departments, gave their expert opinions about the model structure or specific parameters and/or provided feedback on preliminary results.

Data contributed

We are very grateful to the following individuals who contributed datasets or specific analyses based on unpublished data. They did so free of charge and responded in full to queries. As far as we are aware they gain no academic recognition for this.

Analyses from study on family violence and discipline: Dr Deborah Ghate provided unpublished analyses from a study of parent-reported violence to children.

Child Protection Report (Royal Free Hospital, London), 2005: Dr Ben Lloyd (Royal Free Hampstead NHS Trust) provided two unpublished audits conducted at the Trust: one of abused children referred to social services during 9 months in 2005; the other on the outcome of children detected by the community liaison nurse for A&E.

Dataset for study using a reminder flowchart: Dr Jonathan Benger provided the datasets for an audit of the use of a reminder flowchart in the A&E department of Frenchay Hospital, Bristol. These data were not analysed in our project as they did not contain information on the outcome of children referred.

Evidence that doctors often fail to diagnose child abuse and neglect: Dr Russell Dominic Croft (East and North Hertfordshire NHS Trust) provided us with his unpublished paper of a personal case series of missed diagnoses of child abuse and neglect between 1994 and 2006.

Electronic Child Health Register database: Brent Taylor (University College Hospital) and Graeme Hall (Royal Free Hospital) provided a database of over 55,000 children under 8 years who attended five London Hospitals between 2000 and 2006 (average period of data contribution 4.4 years).

Home and Leisure Accident Surveillance System (HASS) database: the Royal Society for the Prevention of Accidents provided specific analyses of the HASS survey of patients attending 18 UK A&E departments in 2002.

London Borough of Camden: Bodil Mlynarska and Paul Bain collaborated with an audit of children referred to social services for physical abuse.

Identifying children at risk of abuse by using a risk assessment form at University College London Hospital A&E department: Ella Rachamin (SHO, UCH), Deborah Hodes (Consultant Community Paediatrician, Camden PCT), Leona Bull (Psychologist, Institute of Child Health), Ann Lloyd (Liaison Health Visitor, UCH), Sonia Jenkins (Child Protection Advisor, UCH), Ann Kilby (Consultant Paediatrician and the paediatric team, UCH), Claire Walford (A&E Consultant, UCH), Dr Rao (Paediatric Registrar, UCH) and Gayle Davies (Ward Clerk on Paediatric Ward, UCH) collaborated with an audit of referrals to the paediatric team using a checklist for all children attending UCLH A&E department over 8 weeks in 2005. These data were not included in the analyses.

London Borough of Hammersmith and Fulham Children’s Services: Tim Deacon, Etiene Steyn, Ann Harvey, Marcelino Radcliffe, Debbie Grusin, Ross Tuckley and Ivy Sseruma collaborated with an audit of the primary reason for initial assessment of children by social services.

London Metropolitan Police: Caroline Wareing, Martin Arnold, Carly Mellin and Ken Shuttlewood at the London Metropolitan Police Child Abuse Investigation Command provided aggregate data on the number of children referred for physical abuse in 2004 and 2005 (n = 5395).

Norwich Accident Project database: Richard Reading and Robin Haynes (University of East Anglia) supplied the original databases used for two papers on A&E department attendances at one hospital by children resident in Norwich city in 1994 and 1999.

TARNlet: Fiona Lecky, Omar Bouamra and Martin Smith on behalf of the Trauma and Audit Research Network provided analyses of data on 17,640 children attending 20 core hospitals in England and Wales and admitted with severe trauma between 1996 and 2004. The data were analysed according to age group, diagnosis of abuse and type of injury. Data were also provided on time trends in A&E attendances.

University College Hospital London NHS Trust: Information services provided data on the number of A&E attendances by age and injury type.

Co-investigators

Dr Jill Ellis (Institute of Child Health) and Professor Ken Stein (Peninsula Medical School, University of Exeter) were co-applicants and helped to develop the original application and gave feedback on the model in the early stages.

We are grateful to the following collaborators: Melissa Harden (Centre for Paediatric Evidence Based Medicine, Institute of Child Health) who carried out scoping searches and provided support and advice on further searches and referencing; Sam Hellmuth (Centre for Paediatric Evidence Based Medicine, Institute of Child Health) who carried out the main searches for all of the systematic reviews; Leona Bull (Centre for Paediatric Evidence Based Medicine, Institute of Child Health) who contributed as a research fellow in the early stages of the study.

Contribution of authors

Jenny Woodman carried out the systematic reviews of the literature and analyses of primary data and the decision-analytic model and, together with Ruth Gilbert, wrote the report. Martin Pitt designed and developed the decision model and contributed to the analyses. Deborah Hodes contributed to the design of the study and commented on results and drafts of the report. Brent Taylor contributed to the design of the study and commented on results and drafts of the report. Reinhard Wentz carried out the ‘targeted’ searches and gave feedback on the searches chapter of the report. Ruth Gilbert was the principal investigator for the project and had overall responsibility for all aspects of the study.

Disclaimers

The views expressed in this publication are those of the authors and not necessarily those of the HTA Programme or the Department of Health.

Health Technology Assessment reports published to date

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7. Neonatal screening for inborn errors of metabolism: cost, yield and outcome.

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8. Preschool vision screening.

   A review by Snowdon SK, Stewart-Brown SL.

9. Implications of socio-cultural contexts for the ethics of clinical trials.

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10. A critical review of the role of neonatal hearing screening in the detection of congenital hearing impairment.

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12. Routine preoperative testing: a systematic review of the evidence.

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14. When and how to assess fast-changing technologies: a comparative study of medical applications of four generic technologies.

    A review by Mowatt G, Bower DJ, Brebner JA, Cairns JA, Grant AM, McKee L.

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2. Screening for ovarian cancer: a systematic review.

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6. Effectiveness of hip prostheses in primary total hip replacement: a critical review of evidence and an economic model.

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7. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials.

   By Song F, Glenny AM.

8. Bone marrow and peripheral blood stem cell transplantation for malignancy.

   A review by Johnson PWM, Simnett SJ, Sweetenham JW, Morgan GJ, Stewart LA.

9. Screening for speech and language delay: a systematic review of the literature.

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10. Resource allocation for chronic stable angina: a systematic review of effectiveness, costs and cost-effectiveness of alternative interventions.

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11. Detection, adherence and control of hypertension for the prevention of stroke: a systematic review.

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12. Postoperative analgesia and vomiting, with special reference to day-case surgery: a systematic review.

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13. Choosing between randomised and nonrandomised studies: a systematic review.

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14. Evaluating patient-based outcome measures for use in clinical trials.

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15. Ethical issues in the design and conduct of randomised controlled trials.

    A review by Edwards SJL, Lilford RJ, Braunholtz DA, Jackson JC, Hewison J, Thornton J.

16. Qualitative research methods in health technology assessment: a review of the literature.

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    By Nicholl J, Hughes S, Dixon S, Turner J, Yates D.

18. Systematic review of endoscopic ultrasound in gastro-oesophageal cancer.

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19. Systematic reviews of trials and other studies.

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20. Primary total hip replacement surgery: a systematic review of outcomes and modelling of cost-effectiveness associated with different prostheses.

    A review by Fitzpatrick R, Shortall E, Sculpher M, Murray D, Morris R, Lodge M, et al.

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10. Methods for the analysis of quality-of-life and survival data in health technology assessment.

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12. Assessing the quality of reports of randomised trials: implications for the conduct of meta-analyses.

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    A review by Robert G, Milne R.

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    By Bradley M, Cullum N, Sheldon T.

18. Systematic reviews of wound care management: (2) Dressings and topical agents used in the healing of chronic wounds.

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    By Meads C, Cummins C, Jolly K, Stevens A, Burls A, Hyde C.

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8. Issues in methodological research: perspectives from researchers and commissioners.

   By Lilford RJ, Richardson A, Stevens A, Fitzpatrick R, Edwards S, Rock F, et al.

9. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy.

   By Cullum N, Nelson EA, Flemming K, Sheldon T.

10. Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review.

    By Hampson SE, Skinner TC, Hart J, Storey L, Gage H, Foxcroft D, et al.

11. Effectiveness of autologous chondrocyte transplantation for hyaline cartilage defects in knees: a rapid and systematic review.

    By Jobanputra P, Parry D, Fry-Smith A, Burls A.

12. Statistical assessment of the learning curves of health technologies.

    By Ramsay CR, Grant AM, Wallace SA, Garthwaite PH, Monk AF, Russell IT.

13. The effectiveness and cost-effectiveness of temozolomide for the treatment of recurrent malignant glioma: a rapid and systematic review.

    By Dinnes J, Cave C, Huang S, Major K, Milne R.

14. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary intention.

    By Lewis R, Whiting P, ter Riet G, O’Meara S, Glanville J.

15. Home treatment for mental health problems: a systematic review.

    By Burns T, Knapp M, Catty J, Healey A, Henderson J, Watt H, et al.

16. How to develop cost-conscious guidelines.

    By Eccles M, Mason J.

17. The role of specialist nurses in multiple sclerosis: a rapid and systematic review.

    By De Broe S, Christopher F, Waugh N.

18. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of orlistat in the management of obesity.

    By O’Meara S, Riemsma R, Shirran L, Mather L, ter Riet G.

19. The clinical effectiveness and cost-effectiveness of pioglitazone for type 2 diabetes mellitus: a rapid and systematic review.

    By Chilcott J, Wight J, Lloyd Jones M, Tappenden P.

20. Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and preregistration house officers in preoperative assessment in elective general surgery.

    By Kinley H, Czoski-Murray C, George S, McCabe C, Primrose J, Reilly C, et al.

21. Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) Acute day hospital versus admission; (2) Vocational rehabilitation; (3) Day hospital versus outpatient care.

    By Marshall M, Crowther R, Almaraz- Serrano A, Creed F, Sledge W, Kluiter H, et al.

22. The measurement and monitoring of surgical adverse events.

    By Bruce J, Russell EM, Mollison J, Krukowski ZH.

23. Action research: a systematic review and guidance for assessment.

    By Waterman H, Tillen D, Dickson R, de Koning K.

24. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of gemcitabine for the treatment of pancreatic cancer.

    By Ward S, Morris E, Bansback N, Calvert N, Crellin A, Forman D, et al.

25. A rapid and systematic review of the evidence for the clinical effectiveness and cost-effectiveness of irinotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer.

    By Lloyd Jones M, Hummel S, Bansback N, Orr B, Seymour M.

26. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature.

    By Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, et al.

27. The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint.

    By Bryan S, Weatherburn G, Bungay H, Hatrick C, Salas C, Parry D, et al.

28. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of topotecan for ovarian cancer.

    By Forbes C, Shirran L, Bagnall A-M, Duffy S, ter Riet G.

29. Superseded by a report published in a later volume.

30. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial.

    By Kendrick D, Fielding K, Bentley E, Miller P, Kerslake R, Pringle M.

31. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients.

    By McColl E, Jacoby A, Thomas L, Soutter J, Bamford C, Steen N, et al.

32. A rapid and systematic review of the clinical effectiveness and cost-effectiveness of paclitaxel, docetaxel, gemcitabine and vinorelbine in non-small-cell lung cancer.

    By Clegg A, Scott DA, Sidhu M, Hewitson P, Waugh N.

33. Subgroup analyses in randomised controlled trials: quantifying the risks of false-positives and false-negatives.

    By Brookes ST, Whitley E, Peters TJ, Mulheran PA, Egger M, Davey Smith G.

34. Depot antipsychotic medication in the treatment of patients with schizophrenia: (1) Meta-review; (2) Patient and nurse attitudes.

    By David AS, Adams C.

35. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression.

    By Churchill R, Hunot V, Corney R, Knapp M, McGuire H, Tylee A, et al.

36. Cost analysis of child health surveillance.

    By Sanderson D, Wright D, Acton C, Duree D.

1. A study of the methods used to select review criteria for clinical audit.

   By Hearnshaw H, Harker R, Cheater F, Baker R, Grimshaw G.

2. Fludarabine as second-line therapy for B cell chronic lymphocytic leukaemia: a technology assessment.

   By Hyde C, Wake B, Bryan S, Barton P, Fry-Smith A, Davenport C, et al.

3. Rituximab as third-line treatment for refractory or recurrent Stage III or IV follicular non-Hodgkin’s lymphoma: a systematic review and economic evaluation.

   By Wake B, Hyde C, Bryan S, Barton P, Song F, Fry-Smith A, et al.

4. A systematic review of discharge arrangements for older people.

   By Parker SG, Peet SM, McPherson A, Cannaby AM, Baker R, Wilson A, et al.

5. The clinical effectiveness and cost-effectiveness of inhaler devices used in the routine management of chronic asthma in older children: a systematic review and economic evaluation.

   By Peters J, Stevenson M, Beverley C, Lim J, Smith S.

6. The clinical effectiveness and cost-effectiveness of sibutramine in the management of obesity: a technology assessment.

   By O’Meara S, Riemsma R, Shirran L, Mather L, ter Riet G.

7. The cost-effectiveness of magnetic resonance angiography for carotid artery stenosis and peripheral vascular disease: a systematic review.

   By Berry E, Kelly S, Westwood ME, Davies LM, Gough MJ, Bamford JM, et al.

8. Promoting physical activity in South Asian Muslim women through ‘exercise on prescription’.

   By Carroll B, Ali N, Azam N.

9. Zanamivir for the treatment of influenza in adults: a systematic review and economic evaluation.

   By Burls A, Clark W, Stewart T, Preston C, Bryan S, Jefferson T, et al.

10. A review of the natural history and epidemiology of multiple sclerosis: implications for resource allocation and health economic models.

    By Richards RG, Sampson FC, Beard SM, Tappenden P.

11. Screening for gestational diabetes: a systematic review and economic evaluation.

    By Scott DA, Loveman E, McIntyre L, Waugh N.

12. The clinical effectiveness and cost-effectiveness of surgery for people with morbid obesity: a systematic review and economic evaluation.

    By Clegg AJ, Colquitt J, Sidhu MK, Royle P, Loveman E, Walker A.

13. The clinical effectiveness of trastuzumab for breast cancer: a systematic review.

    By Lewis R, Bagnall A-M, Forbes C, Shirran E, Duffy S, Kleijnen J, et al.

14. The clinical effectiveness and cost-effectiveness of vinorelbine for breast cancer: a systematic review and economic evaluation.

    By Lewis R, Bagnall A-M, King S, Woolacott N, Forbes C, Shirran L, et al.

15. A systematic review of the effectiveness and cost-effectiveness of metal-on-metal hip resurfacing arthroplasty for treatment of hip disease.

    By Vale L, Wyness L, McCormack K, McKenzie L, Brazzelli M, Stearns SC.

16. The clinical effectiveness and cost-effectiveness of bupropion and nicotine replacement therapy for smoking cessation: a systematic review and economic evaluation.

    By Woolacott NF, Jones L, Forbes CA, Mather LC, Sowden AJ, Song FJ, et al.

17. A systematic review of effectiveness and economic evaluation of new drug treatments for juvenile idiopathic arthritis: etanercept.

    By Cummins C, Connock M, Fry-Smith A, Burls A.

18. Clinical effectiveness and cost-effectiveness of growth hormone in children: a systematic review and economic evaluation.

    By Bryant J, Cave C, Mihaylova B, Chase D, McIntyre L, Gerard K, et al.

19. Clinical effectiveness and cost-effectiveness of growth hormone in adults in relation to impact on quality of life: a systematic review and economic evaluation.

    By Bryant J, Loveman E, Chase D, Mihaylova B, Cave C, Gerard K, et al.

20. Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice: a randomised controlled trial.

    By Zermansky AG, Petty DR, Raynor DK, Lowe CJ, Freementle N, Vail A.

21. The effectiveness of infliximab and etanercept for the treatment of rheumatoid arthritis: a systematic review and economic evaluation.

    By Jobanputra P, Barton P, Bryan S, Burls A.

22. A systematic review and economic evaluation of computerised cognitive behaviour therapy for depression and anxiety.

    By Kaltenthaler E, Shackley P, Stevens K, Beverley C, Parry G, Chilcott J.

23. A systematic review and economic evaluation of pegylated liposomal doxorubicin hydrochloride for ovarian cancer.

    By Forbes C, Wilby J, Richardson G, Sculpher M, Mather L, Reimsma R.

24. A systematic review of the effectiveness of interventions based on a stages-of-change approach to promote individual behaviour change.

    By Riemsma RP, Pattenden J, Bridle C, Sowden AJ, Mather L, Watt IS, et al.

25. A systematic review update of the clinical effectiveness and cost-effectiveness of glycoprotein IIb/IIIa antagonists.

    By Robinson M, Ginnelly L, Sculpher M, Jones L, Riemsma R, Palmer S, et al.

26. A systematic review of the effectiveness, cost-effectiveness and barriers to implementation of thrombolytic and neuroprotective therapy for acute ischaemic stroke in the NHS.

    By Sandercock P, Berge E, Dennis M, Forbes J, Hand P, Kwan J, et al.

27. A randomised controlled crossover trial of nurse practitioner versus doctor-led outpatient care in a bronchiectasis clinic.

    By Caine N, Sharples LD, Hollingworth W, French J, Keogan M, Exley A, et al.

28. Clinical effectiveness and cost – consequences of selective serotonin reuptake inhibitors in the treatment of sex offenders.

    By Adi Y, Ashcroft D, Browne K, Beech A, Fry-Smith A, Hyde C.

29. Treatment of established osteoporosis: a systematic review and cost–utility analysis.

    By Kanis JA, Brazier JE, Stevenson M, Calvert NW, Lloyd Jones M.

30. Which anaesthetic agents are cost-effective in day surgery? Literature review, national survey of practice and randomised controlled trial.

    By Elliott RA Payne K, Moore JK, Davies LM, Harper NJN, St Leger AS, et al.

31. Screening for hepatitis C among injecting drug users and in genitourinary medicine clinics: systematic reviews of effectiveness, modelling study and national survey of current practice.

    By Stein K, Dalziel K, Walker A, McIntyre L, Jenkins B, Horne J, et al.

32. The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature.

    By Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, et al.

33. The effectiveness and cost-effectiveness of imatinib in chronic myeloid leukaemia: a systematic review.

    By Garside R, Round A, Dalziel K, Stein K, Royle R.

34. A comparative study of hypertonic saline, daily and alternate-day rhDNase in children with cystic fibrosis.

    By Suri R, Wallis C, Bush A, Thompson S, Normand C, Flather M, et al.

35. A systematic review of the costs and effectiveness of different models of paediatric home care.

    By Parker G, Bhakta P, Lovett CA, Paisley S, Olsen R, Turner D, et al.

1. How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study.

   By Egger M, Jüni P, Bartlett C, Holenstein F, Sterne J.

2. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of home versus hospital or satellite unit haemodialysis for people with end-stage renal failure.

   By Mowatt G, Vale L, Perez J, Wyness L, Fraser C, MacLeod A, et al.

3. Systematic review and economic evaluation of the effectiveness of infliximab for the treatment of Crohn’s disease.

   By Clark W, Raftery J, Barton P, Song F, Fry-Smith A, Burls A.

4. A review of the clinical effectiveness and cost-effectiveness of routine anti-D prophylaxis for pregnant women who are rhesus negative.

   By Chilcott J, Lloyd Jones M, Wight J, Forman K, Wray J, Beverley C, et al.

5. Systematic review and evaluation of the use of tumour markers in paediatric oncology: Ewing’s sarcoma and neuroblastoma.

   By Riley RD, Burchill SA, Abrams KR, Heney D, Lambert PC, Jones DR, et al.

6. The cost-effectiveness of screening for Helicobacter pylori to reduce mortality and morbidity from gastric cancer and peptic ulcer disease: a discrete-event simulation model.

   By Roderick P, Davies R, Raftery J, Crabbe D, Pearce R, Bhandari P, et al.

7. The clinical effectiveness and cost-effectiveness of routine dental checks: a systematic review and economic evaluation.

   By Davenport C, Elley K, Salas C, Taylor-Weetman CL, Fry-Smith A, Bryan S, et al.

8. A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women’s preferences in the management of menorrhagia.

   By Kennedy ADM, Sculpher MJ, Coulter A, Dwyer N, Rees M, Horsley S, et al.

9. Clinical effectiveness and cost–utility of photodynamic therapy for wet age-related macular degeneration: a systematic review and economic evaluation.

   By Meads C, Salas C, Roberts T, Moore D, Fry-Smith A, Hyde C.

10. Evaluation of molecular tests for prenatal diagnosis of chromosome abnormalities.

    By Grimshaw GM, Szczepura A, Hultén M, MacDonald F, Nevin NC, Sutton F, et al.

11. First and second trimester antenatal screening for Down’s syndrome: the results of the Serum, Urine and Ultrasound Screening Study (SURUSS).

    By Wald NJ, Rodeck C, Hackshaw AK, Walters J, Chitty L, Mackinson AM.

12. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation.

    By Calvert N, Hind D, McWilliams RG, Thomas SM, Beverley C, Davidson A.

13. A systematic review of atypical antipsychotics in schizophrenia.

    By Bagnall A-M, Jones L, Lewis R, Ginnelly L, Glanville J, Torgerson D, et al.

14. Prostate Testing for Cancer and Treatment (ProtecT) feasibility study.

    By Donovan J, Hamdy F, Neal D, Peters T, Oliver S, Brindle L, et al.

15. Early thrombolysis for the treatment of acute myocardial infarction: a systematic review and economic evaluation.

    By Boland A, Dundar Y, Bagust A, Haycox A, Hill R, Mujica Mota R, et al.

16. Screening for fragile X syndrome: a literature review and modelling.

    By Song FJ, Barton P, Sleightholme V, Yao GL, Fry-Smith A.

17. Systematic review of endoscopic sinus surgery for nasal polyps.

    By Dalziel K, Stein K, Round A, Garside R, Royle P.

18. Towards efficient guidelines: how to monitor guideline use in primary care.

    By Hutchinson A, McIntosh A, Cox S, Gilbert C.

19. Effectiveness and cost-effectiveness of acute hospital-based spinal cord injuries services: systematic review.

    By Bagnall A-M, Jones L, Richardson G, Duffy S, Riemsma R.

20. Prioritisation of health technology assessment. The PATHS model: methods and case studies.

    By Townsend J, Buxton M, Harper G.

21. Systematic review of the clinical effectiveness and cost-effectiveness of tension-free vaginal tape for treatment of urinary stress incontinence.

    By Cody J, Wyness L, Wallace S, Glazener C, Kilonzo M, Stearns S, et al.

22. The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation.

    By Loveman E, Cave C, Green C, Royle P, Dunn N, Waugh N.

23. The role of modelling in prioritising and planning clinical trials.

    By Chilcott J, Brennan A, Booth A, Karnon J, Tappenden P.

24. Cost–benefit evaluation of routine influenza immunisation in people 65–74 years of age.

    By Allsup S, Gosney M, Haycox A, Regan M.

25. The clinical and cost-effectiveness of pulsatile machine perfusion versus cold storage of kidneys for transplantation retrieved from heart-beating and non-heart-beating donors.

    By Wight J, Chilcott J, Holmes M, Brewer N.

26. Can randomised trials rely on existing electronic data? A feasibility study to explore the value of routine data in health technology assessment.

    By Williams JG, Cheung WY, Cohen DR, Hutchings HA, Longo MF, Russell IT.

27. Evaluating non-randomised intervention studies.

    By Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, et al.

28. A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self- help guidebook and patient-centred consultations on disease management and satisfaction in inflammatory bowel disease.

    By Kennedy A, Nelson E, Reeves D, Richardson G, Roberts C, Robinson A, et al.

29. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review.

    By Dinnes J, Loveman E, McIntyre L, Waugh N.

30. The value of digital imaging in diabetic retinopathy.

    By Sharp PF, Olson J, Strachan F, Hipwell J, Ludbrook A, O’Donnell M, et al.

31. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy.

    By Law M, Wald N, Morris J.

32. Clinical and cost-effectiveness of capecitabine and tegafur with uracil for the treatment of metastatic colorectal cancer: systematic review and economic evaluation.

    By Ward S, Kaltenthaler E, Cowan J, Brewer N.

33. Clinical and cost-effectiveness of new and emerging technologies for early localised prostate cancer: a systematic review.

    By Hummel S, Paisley S, Morgan A, Currie E, Brewer N.

34. Literature searching for clinical and cost-effectiveness studies used in health technology assessment reports carried out for the National Institute for Clinical Excellence appraisal system.

    By Royle P, Waugh N.

35. Systematic review and economic decision modelling for the prevention and treatment of influenza A and B.

    By Turner D, Wailoo A, Nicholson K, Cooper N, Sutton A, Abrams K.

36. A randomised controlled trial to evaluate the clinical and cost-effectiveness of Hickman line insertions in adult cancer patients by nurses.

    By Boland A, Haycox A, Bagust A, Fitzsimmons L.

37. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women’s physical and psychological health needs.

    By MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al.

38. Estimating implied rates of discount in healthcare decision-making.

    By West RR, McNabb R, Thompson AGH, Sheldon TA, Grimley Evans J.

39. Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling.

    By Cooper BS, Stone SP, Kibbler CC, Cookson BD, Roberts JA, Medley GF, et al.

40. Treatments for spasticity and pain in multiple sclerosis: a systematic review.

    By Beard S, Hunn A, Wight J.

41. The inclusion of reports of randomised trials published in languages other than English in systematic reviews.

    By Moher D, Pham B, Lawson ML, Klassen TP.

42. The impact of screening on future health-promoting behaviours and health beliefs: a systematic review.

    By Bankhead CR, Brett J, Bukach C, Webster P, Stewart-Brown S, Munafo M, et al.

1. What is the best imaging strategy for acute stroke?

   By Wardlaw JM, Keir SL, Seymour J, Lewis S, Sandercock PAG, Dennis MS, et al.

2. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.

   By Mant J, McManus RJ, Oakes RAL, Delaney BC, Barton PM, Deeks JJ, et al.

3. The effectiveness and cost-effectiveness of microwave and thermal balloon endometrial ablation for heavy menstrual bleeding: a systematic review and economic modelling.

   By Garside R, Stein K, Wyatt K, Round A, Price A.

4. A systematic review of the role of bisphosphonates in metastatic disease.

   By Ross JR, Saunders Y, Edmonds PM, Patel S, Wonderling D, Normand C, et al.

5. Systematic review of the clinical effectiveness and cost-effectiveness of capecitabine (Xeloda®) for locally advanced and/or metastatic breast cancer.

   By Jones L, Hawkins N, Westwood M, Wright K, Richardson G, Riemsma R.

6. Effectiveness and efficiency of guideline dissemination and implementation strategies.

   By Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al.

7. Clinical effectiveness and costs of the Sugarbaker procedure for the treatment of pseudomyxoma peritonei.

   By Bryant J, Clegg AJ, Sidhu MK, Brodin H, Royle P, Davidson P.

8. Psychological treatment for insomnia in the regulation of long-term hypnotic drug use.

   By Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M.

9. Improving the evaluation of therapeutic interventions in multiple sclerosis: development of a patient-based measure of outcome.

   By Hobart JC, Riazi A, Lamping DL, Fitzpatrick R, Thompson AJ.

10. A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography.

    By Kaltenthaler E, Bravo Vergel Y, Chilcott J, Thomas S, Blakeborough T, Walters SJ, et al.

11. The use of modelling to evaluate new drugs for patients with a chronic condition: the case of antibodies against tumour necrosis factor in rheumatoid arthritis.

    By Barton P, Jobanputra P, Wilson J, Bryan S, Burls A.

12. Clinical effectiveness and cost-effectiveness of neonatal screening for inborn errors of metabolism using tandem mass spectrometry: a systematic review.

    By Pandor A, Eastham J, Beverley C, Chilcott J, Paisley S.

13. Clinical effectiveness and cost-effectiveness of pioglitazone and rosiglitazone in the treatment of type 2 diabetes: a systematic review and economic evaluation.

    By Czoski-Murray C, Warren E, Chilcott J, Beverley C, Psyllaki MA, Cowan J.

14. Routine examination of the newborn: the EMREN study. Evaluation of an extension of the midwife role including a randomised controlled trial of appropriately trained midwives and paediatric senior house officers.

    By Townsend J, Wolke D, Hayes J, Davé S, Rogers C, Bloomfield L, et al.

15. Involving consumers in research and development agenda setting for the NHS: developing an evidence-based approach.

    By Oliver S, Clarke-Jones L, Rees R, Milne R, Buchanan P, Gabbay J, et al.

16. A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery.

    By Reeves BC, Angelini GD, Bryan AJ, Taylor FC, Cripps T, Spyt TJ, et al.

17. Does early magnetic resonance imaging influence management or improve outcome in patients referred to secondary care with low back pain? A pragmatic randomised controlled trial.

    By Gilbert FJ, Grant AM, Gillan MGC, Vale L, Scott NW, Campbell MK, et al.

18. The clinical and cost-effectiveness of anakinra for the treatment of rheumatoid arthritis in adults: a systematic review and economic analysis.

    By Clark W, Jobanputra P, Barton P, Burls A.

19. A rapid and systematic review and economic evaluation of the clinical and cost-effectiveness of newer drugs for treatment of mania associated with bipolar affective disorder.

    By Bridle C, Palmer S, Bagnall A-M, Darba J, Duffy S, Sculpher M, et al.

20. Liquid-based cytology in cervical screening: an updated rapid and systematic review and economic analysis.

    By Karnon J, Peters J, Platt J, Chilcott J, McGoogan E, Brewer N.

21. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement.

    By Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns SC, et al.

22. Autoantibody testing in children with newly diagnosed type 1 diabetes mellitus.

    By Dretzke J, Cummins C, Sandercock J, Fry-Smith A, Barrett T, Burls A.

23. Clinical effectiveness and cost-effectiveness of prehospital intravenous fluids in trauma patients.

    By Dretzke J, Sandercock J, Bayliss S, Burls A.

24. Newer hypnotic drugs for the short-term management of insomnia: a systematic review and economic evaluation.

    By Dündar Y, Boland A, Strobl J, Dodd S, Haycox A, Bagust A, et al.

25. Development and validation of methods for assessing the quality of diagnostic accuracy studies.

    By Whiting P, Rutjes AWS, Dinnes J, Reitsma JB, Bossuyt PMM, Kleijnen J.

26. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy.

    By Garry R, Fountain J, Brown J, Manca A, Mason S, Sculpher M, et al.

27. Methods for expected value of information analysis in complex health economic models: developments on the health economics of interferon-β and glatiramer acetate for multiple sclerosis.

    By Tappenden P, Chilcott JB, Eggington S, Oakley J, McCabe C.

28. Effectiveness and cost-effectiveness of imatinib for first-line treatment of chronic myeloid leukaemia in chronic phase: a systematic review and economic analysis.

    By Dalziel K, Round A, Stein K, Garside R, Price A.

29. VenUS I: a randomised controlled trial of two types of bandage for treating venous leg ulcers.

    By Iglesias C, Nelson EA, Cullum NA, Torgerson DJ, on behalf of the VenUS Team.

30. Systematic review of the effectiveness and cost-effectiveness, and economic evaluation, of myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction.

    By Mowatt G, Vale L, Brazzelli M, Hernandez R, Murray A, Scott N, et al.

31. A pilot study on the use of decision theory and value of information analysis as part of the NHS Health Technology Assessment programme.

    By Claxton K, Ginnelly L, Sculpher M, Philips Z, Palmer S.

32. The Social Support and Family Health Study: a randomised controlled trial and economic evaluation of two alternative forms of postnatal support for mothers living in disadvantaged inner-city areas.

    By Wiggins M, Oakley A, Roberts I, Turner H, Rajan L, Austerberry H, et al.

33. Psychosocial aspects of genetic screening of pregnant women and newborns: a systematic review.

    By Green JM, Hewison J, Bekker HL, Bryant, Cuckle HS.

34. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status.

    By Critchley HOD, Warner P, Lee AJ, Brechin S, Guise J, Graham B.

35. Coronary artery stents: a rapid systematic review and economic evaluation.

    By Hill R, Bagust A, Bakhai A, Dickson R, Dündar Y, Haycox A, et al.

36. Review of guidelines for good practice in decision-analytic modelling in health technology assessment.

    By Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al.

37. Rituximab (MabThera®) for aggressive non-Hodgkin’s lymphoma: systematic review and economic evaluation.

    By Knight C, Hind D, Brewer N, Abbott V.

38. Clinical effectiveness and cost-effectiveness of clopidogrel and modified-release dipyridamole in the secondary prevention of occlusive vascular events: a systematic review and economic evaluation.

    By Jones L, Griffin S, Palmer S, Main C, Orton V, Sculpher M, et al.

39. Pegylated interferon α-2a and -2b in combination with ribavirin in the treatment of chronic hepatitis C: a systematic review and economic evaluation.

    By Shepherd J, Brodin H, Cave C, Waugh N, Price A, Gabbay J.

40. Clopidogrel used in combination with aspirin compared with aspirin alone in the treatment of non-ST-segment- elevation acute coronary syndromes: a systematic review and economic evaluation.

    By Main C, Palmer S, Griffin S, Jones L, Orton V, Sculpher M, et al.

41. Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups.

    By Beswick AD, Rees K, Griebsch I, Taylor FC, Burke M, West RR, et al.

42. Involving South Asian patients in clinical trials.

    By Hussain-Gambles M, Leese B, Atkin K, Brown J, Mason S, Tovey P.

43. Clinical and cost-effectiveness of continuous subcutaneous insulin infusion for diabetes.

    By Colquitt JL, Green C, Sidhu MK, Hartwell D, Waugh N.

44. Identification and assessment of ongoing trials in health technology assessment reviews.

    By Song FJ, Fry-Smith A, Davenport C, Bayliss S, Adi Y, Wilson JS, et al.

45. Systematic review and economic evaluation of a long-acting insulin analogue, insulin glargine

    By Warren E, Weatherley-Jones E, Chilcott J, Beverley C.

46. Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: a randomised controlled trial and health economic analysis.

    By McCarthy CJ, Mills PM, Pullen R, Richardson G, Hawkins N, Roberts CR, et al.

47. Clinical and cost-effectiveness of once-daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a systematic review and economic evaluation.

    By Green C, Colquitt JL, Kirby J, Davidson P, Payne E.

48. Acupuncture of chronic headache disorders in primary care: randomised controlled trial and economic analysis.

    By Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM, Ellis N, et al.

49. Generalisability in economic evaluation studies in healthcare: a review and case studies.

    By Sculpher MJ, Pang FS, Manca A, Drummond MF, Golder S, Urdahl H, et al.

50. Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations.

    By Wallace P, Barber J, Clayton W, Currell R, Fleming K, Garner P, et al.

1. Randomised controlled multiple treatment comparison to provide a cost-effectiveness rationale for the selection of antimicrobial therapy in acne.

   By Ozolins M, Eady EA, Avery A, Cunliffe WJ, O’Neill C, Simpson NB, et al.

2. Do the findings of case series studies vary significantly according to methodological characteristics?

   By Dalziel K, Round A, Stein K, Garside R, Castelnuovo E, Payne L.

3. Improving the referral process for familial breast cancer genetic counselling: findings of three randomised controlled trials of two interventions.

   By Wilson BJ, Torrance N, Mollison J, Wordsworth S, Gray JR, Haites NE, et al.

4. Randomised evaluation of alternative electrosurgical modalities to treat bladder outflow obstruction in men with benign prostatic hyperplasia.

   By Fowler C, McAllister W, Plail R, Karim O, Yang Q.

5. A pragmatic randomised controlled trial of the cost-effectiveness of palliative therapies for patients with inoperable oesophageal cancer.

   By Shenfine J, McNamee P, Steen N, Bond J, Griffin SM.

6. Impact of computer-aided detection prompts on the sensitivity and specificity of screening mammography.

   By Taylor P, Champness J, Given- Wilson R, Johnston K, Potts H.

7. Issues in data monitoring and interim analysis of trials.

   By Grant AM, Altman DG, Babiker AB, Campbell MK, Clemens FJ, Darbyshire JH, et al.

8. Lay public’s understanding of equipoise and randomisation in randomised controlled trials.

   By Robinson EJ, Kerr CEP, Stevens AJ, Lilford RJ, Braunholtz DA, Edwards SJ, et al.

9. Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies.

   By Greenhalgh J, Knight C, Hind D, Beverley C, Walters S.

10. Measurement of health-related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology.

    By Smith SC, Lamping DL, Banerjee S, Harwood R, Foley B, Smith P, et al.

11. Clinical effectiveness and cost-effectiveness of drotrecogin alfa (activated) (Xigris®) for the treatment of severe sepsis in adults: a systematic review and economic evaluation.

    By Green C, Dinnes J, Takeda A, Shepherd J, Hartwell D, Cave C, et al.

12. A methodological review of how heterogeneity has been examined in systematic reviews of diagnostic test accuracy.

    By Dinnes J, Deeks J, Kirby J, Roderick P.

13. Cervical screening programmes: can automation help? Evidence from systematic reviews, an economic analysis and a simulation modelling exercise applied to the UK.

    By Willis BH, Barton P, Pearmain P, Bryan S, Hyde C.

14. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation.

    By McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E, et al.

15. Clinical effectiveness, tolerability and cost-effectiveness of newer drugs for epilepsy in adults: a systematic review and economic evaluation.

    By Wilby J, Kainth A, Hawkins N, Epstein D, McIntosh H, McDaid C, et al.

16. A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine.

    By Peveler R, Kendrick T, Buxton M, Longworth L, Baldwin D, Moore M, et al.

17. Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation.

    By Hartwell D, Colquitt J, Loveman E, Clegg AJ, Brodin H, Waugh N, et al.

18. A randomised controlled comparison of alternative strategies in stroke care.

    By Kalra L, Evans A, Perez I, Knapp M, Swift C, Donaldson N.

19. The investigation and analysis of critical incidents and adverse events in healthcare.

    By Woloshynowych M, Rogers S, Taylor-Adams S, Vincent C.

20. Potential use of routine databases in health technology assessment.

    By Raftery J, Roderick P, Stevens A.

21. Clinical and cost-effectiveness of newer immunosuppressive regimens in renal transplantation: a systematic review and modelling study.

    By Woodroffe R, Yao GL, Meads C, Bayliss S, Ready A, Raftery J, et al.

22. A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis.

    By Stevenson M, Lloyd Jones M, De Nigris E, Brewer N, Davis S, Oakley J.

23. A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma.

    By Smith JR, Mugford M, Holland R, Candy B, Noble MJ, Harrison BDW, et al.

24. An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales.

    By Roderick P, Nicholson T, Armitage A, Mehta R, Mullee M, Gerard K, et al.

25. Imatinib for the treatment of patients with unresectable and/or metastatic gastrointestinal stromal tumours: systematic review and economic evaluation.

    By Wilson J, Connock M, Song F, Yao G, Fry-Smith A, Raftery J, et al.

26. Indirect comparisons of competing interventions.

    By Glenny AM, Altman DG, Song F, Sakarovitch C, Deeks JJ, D’Amico R, et al.

27. Cost-effectiveness of alternative strategies for the initial medical management of non-ST elevation acute coronary syndrome: systematic review and decision-analytical modelling.

    By Robinson M, Palmer S, Sculpher M, Philips Z, Ginnelly L, Bowens A, et al.

28. Outcomes of electrically stimulated gracilis neosphincter surgery.

    By Tillin T, Chambers M, Feldman R.

29. The effectiveness and cost-effectiveness of pimecrolimus and tacrolimus for atopic eczema: a systematic review and economic evaluation.

    By Garside R, Stein K, Castelnuovo E, Pitt M, Ashcroft D, Dimmock P, et al.

30. Systematic review on urine albumin testing for early detection of diabetic complications.

    By Newman DJ, Mattock MB, Dawnay ABS, Kerry S, McGuire A, Yaqoob M, et al.

31. Randomised controlled trial of the cost-effectiveness of water-based therapy for lower limb osteoarthritis.

    By Cochrane T, Davey RC, Matthes Edwards SM.

32. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain.

    By Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, et al.

33. Cost-effectiveness and safety of epidural steroids in the management of sciatica.

    By Price C, Arden N, Coglan L, Rogers P.

34. The British Rheumatoid Outcome Study Group (BROSG) randomised controlled trial to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis.

    By Symmons D, Tricker K, Roberts C, Davies L, Dawes P, Scott DL.

35. Conceptual framework and systematic review of the effects of participants’ and professionals’ preferences in randomised controlled trials.

    By King M, Nazareth I, Lampe F, Bower P, Chandler M, Morou M, et al.

36. The clinical and cost-effectiveness of implantable cardioverter defibrillators: a systematic review.

    By Bryant J, Brodin H, Loveman E, Payne E, Clegg A.

37. A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study.

    By Kendrick T, Simons L, Mynors-Wallis L, Gray A, Lathlean J, Pickering R, et al.

38. The causes and effects of socio-demographic exclusions from clinical trials.

    By Bartlett C, Doyal L, Ebrahim S, Davey P, Bachmann M, Egger M, et al.

39. Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis.

    By Epps H, Ginnelly L, Utley M, Southwood T, Gallivan S, Sculpher M, et al.

40. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study.

    By Hobbs FDR, Fitzmaurice DA, Mant J, Murray E, Jowett S, Bryan S, et al.

41. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty.

    By Keating JF, Grant A, Masson M, Scott NW, Forbes JF.

42. Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland.

    By Durham RC, Chambers JA, Power KG, Sharp DM, Macdonald RR, Major KA, et al.

43. The effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber pacemakers for bradycardia due to atrioventricular block or sick sinus syndrome: systematic review and economic evaluation.

    By Castelnuovo E, Stein K, Pitt M, Garside R, Payne E.

44. Newborn screening for congenital heart defects: a systematic review and cost-effectiveness analysis.

    By Knowles R, Griebsch I, Dezateux C, Brown J, Bull C, Wren C.

45. The clinical and cost-effectiveness of left ventricular assist devices for end-stage heart failure: a systematic review and economic evaluation.

    By Clegg AJ, Scott DA, Loveman E, Colquitt J, Hutchinson J, Royle P, et al.

46. The effectiveness of the Heidelberg Retina Tomograph and laser diagnostic glaucoma scanning system (GDx) in detecting and monitoring glaucoma.

    By Kwartz AJ, Henson DB, Harper RA, Spencer AF, McLeod D.

47. Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints: systematic review and economic evaluation.

    By Clar C, Cummins E, McIntyre L, Thomas S, Lamb J, Bain L, et al.

48. Systematic review of effectiveness of different treatments for childhood retinoblastoma.

    By McDaid C, Hartley S, Bagnall A-M, Ritchie G, Light K, Riemsma R.

49. Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis.

    By Roderick P, Ferris G, Wilson K, Halls H, Jackson D, Collins R, et al.

50. The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children.

    By Dretzke J, Frew E, Davenport C, Barlow J, Stewart-Brown S, Sandercock J, et al.

1. The clinical and cost-effectiveness of donepezil, rivastigmine, galantamine and memantine for Alzheimer’s disease.

   By Loveman E, Green C, Kirby J, Takeda A, Picot J, Payne E, et al.

2. FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke.

   By Dennis M, Lewis S, Cranswick G, Forbes J.

3. The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews.

   By Black C, Bagust A, Boland A, Walker S, McLeod C, De Verteuil R, et al.

4. A systematic review of the effectiveness and cost-effectiveness of neuroimaging assessments used to visualise the seizure focus in people with refractory epilepsy being considered for surgery.

   By Whiting P, Gupta R, Burch J, Mujica Mota RE, Wright K, Marson A, et al.

5. Comparison of conference abstracts and presentations with full-text articles in the health technology assessments of rapidly evolving technologies.

   By Dundar Y, Dodd S, Dickson R, Walley T, Haycox A, Williamson PR.

6. Systematic review and evaluation of methods of assessing urinary incontinence.

   By Martin JL, Williams KS, Abrams KR, Turner DA, Sutton AJ, Chapple C, et al.

7. The clinical effectiveness and cost-effectiveness of newer drugs for children with epilepsy. A systematic review.

   By Connock M, Frew E, Evans B-W, Bryan S, Cummins C, Fry-Smith A, et al.

8. Surveillance of Barrett’s oesophagus: exploring the uncertainty through systematic review, expert workshop and economic modelling.

   By Garside R, Pitt M, Somerville M, Stein K, Price A, Gilbert N.

9. Topotecan, pegylated liposomal doxorubicin hydrochloride and paclitaxel for second-line or subsequent treatment of advanced ovarian cancer: a systematic review and economic evaluation.

   By Main C, Bojke L, Griffin S, Norman G, Barbieri M, Mather L, et al.

10. Evaluation of molecular techniques in prediction and diagnosis of cytomegalovirus disease in immunocompromised patients.

    By Szczepura A, Westmoreland D, Vinogradova Y, Fox J, Clark M.

11. Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study.

    By Wu O, Robertson L, Twaddle S, Lowe GDO, Clark P, Greaves M, et al.

12. A series of systematic reviews to inform a decision analysis for sampling and treating infected diabetic foot ulcers.

    By Nelson EA, O’Meara S, Craig D, Iglesias C, Golder S, Dalton J, et al.

13. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial).

    By Michaels JA, Campbell WB, Brazier JE, MacIntyre JB, Palfreyman SJ, Ratcliffe J, et al.

14. The cost-effectiveness of screening for oral cancer in primary care.

    By Speight PM, Palmer S, Moles DR, Downer MC, Smith DH, Henriksson M, et al.

15. Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis.

    By Goodacre S, Sampson F, Stevenson M, Wailoo A, Sutton A, Thomas S, et al.

16. Systematic review of the effectiveness and cost-effectiveness of HealOzone® for the treatment of occlusal pit/fissure caries and root caries.

    By Brazzelli M, McKenzie L, Fielding S, Fraser C, Clarkson J, Kilonzo M, et al.

17. Randomised controlled trials of conventional antipsychotic versus new atypical drugs, and new atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or intolerant of, current drug treatment.

    By Lewis SW, Davies L, Jones PB, Barnes TRE, Murray RM, Kerwin R, et al.

18. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation.

    By Rodgers M, Nixon J, Hempel S, Aho T, Kelly J, Neal D, et al.

19. Cognitive behavioural therapy in addition to antispasmodic therapy for irritable bowel syndrome in primary care: randomised controlled trial.

    By Kennedy TM, Chalder T, McCrone P, Darnley S, Knapp M, Jones RH, et al.

20. A systematic review of the clinical effectiveness and cost-effectiveness of enzyme replacement therapies for Fabry’s disease and mucopolysaccharidosis type 1.

    By Connock M, Juarez-Garcia A, Frew E, Mans A, Dretzke J, Fry-Smith A, et al.

21. Health benefits of antiviral therapy for mild chronic hepatitis C: randomised controlled trial and economic evaluation.

    By Wright M, Grieve R, Roberts J, Main J, Thomas HC, on behalf of the UK Mild Hepatitis C Trial Investigators.

22. Pressure relieving support surfaces: a randomised evaluation.

    By Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, et al.

23. A systematic review and economic model of the effectiveness and cost-effectiveness of methylphenidate, dexamfetamine and atomoxetine for the treatment of attention deficit hyperactivity disorder in children and adolescents.

    By King S, Griffin S, Hodges Z, Weatherly H, Asseburg C, Richardson G, et al.

24. The clinical effectiveness and cost-effectiveness of enzyme replacement therapy for Gaucher’s disease: a systematic review.

    By Connock M, Burls A, Frew E, Fry-Smith A, Juarez-Garcia A, McCabe C, et al.

25. Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model.

    By Thomas KS, Keogh-Brown MR, Chalmers JR, Fordham RJ, Holland RC, Armstrong SJ, et al.

26. A systematic literature review of the effectiveness of non-pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use.

    By Robinson L, Hutchings D, Corner L, Beyer F, Dickinson H, Vanoli A, et al.

27. A review of the evidence on the effects and costs of implantable cardioverter defibrillator therapy in different patient groups, and modelling of cost-effectiveness and cost–utility for these groups in a UK context.

    By Buxton M, Caine N, Chase D, Connelly D, Grace A, Jackson C, et al.

28. Adefovir dipivoxil and pegylated interferon alfa-2a for the treatment of chronic hepatitis B: a systematic review and economic evaluation.

    By Shepherd J, Jones J, Takeda A, Davidson P, Price A.

29. An evaluation of the clinical and cost-effectiveness of pulmonary artery catheters in patient management in intensive care: a systematic review and a randomised controlled trial.

    By Harvey S, Stevens K, Harrison D, Young D, Brampton W, McCabe C, et al.

30. Accurate, practical and cost-effective assessment of carotid stenosis in the UK.

    By Wardlaw JM, Chappell FM, Stevenson M, De Nigris E, Thomas S, Gillard J, et al.

31. Etanercept and infliximab for the treatment of psoriatic arthritis: a systematic review and economic evaluation.

    By Woolacott N, Bravo Vergel Y, Hawkins N, Kainth A, Khadjesari Z, Misso K, et al.

32. The cost-effectiveness of testing for hepatitis C in former injecting drug users.

    By Castelnuovo E, Thompson-Coon J, Pitt M, Cramp M, Siebert U, Price A, et al.

33. Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation.

    By Kaltenthaler E, Brazier J, De Nigris E, Tumur I, Ferriter M, Beverley C, et al.

34. Cost-effectiveness of using prognostic information to select women with breast cancer for adjuvant systemic therapy.

    By Williams C, Brunskill S, Altman D, Briggs A, Campbell H, Clarke M, et al.

35. Psychological therapies including dialectical behaviour therapy for borderline personality disorder: a systematic review and preliminary economic evaluation.

    By Brazier J, Tumur I, Holmes M, Ferriter M, Parry G, Dent-Brown K, et al.

36. Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model.

    By Whiting P, Westwood M, Bojke L, Palmer S, Richardson G, Cooper J, et al.

37. Cognitive behavioural therapy in chronic fatigue syndrome: a randomised controlled trial of an outpatient group programme.

    By O’Dowd H, Gladwell P, Rogers CA, Hollinghurst S, Gregory A.

38. A comparison of the cost-effectiveness of five strategies for the prevention of nonsteroidal anti-inflammatory drug-induced gastrointestinal toxicity: a systematic review with economic modelling.

    By Brown TJ, Hooper L, Elliott RA, Payne K, Webb R, Roberts C, et al.

39. The effectiveness and cost-effectiveness of computed tomography screening for coronary artery disease: systematic review.

    By Waugh N, Black C, Walker S, McIntyre L, Cummins E, Hillis G.

40. What are the clinical outcome and cost-effectiveness of endoscopy undertaken by nurses when compared with doctors? A Multi-Institution Nurse Endoscopy Trial (MINuET).

    By Williams J, Russell I, Durai D, Cheung W-Y, Farrin A, Bloor K, et al.

41. The clinical and cost-effectiveness of oxaliplatin and capecitabine for the adjuvant treatment of colon cancer: systematic review and economic evaluation.

    By Pandor A, Eggington S, Paisley S, Tappenden P, Sutcliffe P.

42. A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness.

    By Chen Y-F, Jobanputra P, Barton P, Jowett S, Bryan S, Clark W, et al.

43. Telemedicine in dermatology: a randomised controlled trial.

    By Bowns IR, Collins K, Walters SJ, McDonagh AJG.

44. Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model.

    By Davies L, Brown TJ, Haynes S, Payne K, Elliott RA, McCollum C.

45. Clinical effectiveness and cost-effectiveness of laparoscopic surgery for colorectal cancer: systematic reviews and economic evaluation.

    By Murray A, Lourenco T, de Verteuil R, Hernandez R, Fraser C, McKinley A, et al.

46. Etanercept and efalizumab for the treatment of psoriasis: a systematic review.

    By Woolacott N, Hawkins N, Mason A, Kainth A, Khadjesari Z, Bravo Vergel Y, et al.

47. Systematic reviews of clinical decision tools for acute abdominal pain.

    By Liu JLY, Wyatt JC, Deeks JJ, Clamp S, Keen J, Verde P, et al.

48. Evaluation of the ventricular assist device programme in the UK.

    By Sharples L, Buxton M, Caine N, Cafferty F, Demiris N, Dyer M, et al.

49. A systematic review and economic model of the clinical and cost-effectiveness of immunosuppressive therapy for renal transplantation in children.

    By Yao G, Albon E, Adi Y, Milford D, Bayliss S, Ready A, et al.

50. Amniocentesis results: investigation of anxiety. The ARIA trial.

    By Hewison J, Nixon J, Fountain J, Cocks K, Jones C, Mason G, et al.

1. Pemetrexed disodium for the treatment of malignant pleural mesothelioma: a systematic review and economic evaluation.

   By Dundar Y, Bagust A, Dickson R, Dodd S, Green J, Haycox A, et al.

2. A systematic review and economic model of the clinical effectiveness and cost-effectiveness of docetaxel in combination with prednisone or prednisolone for the treatment of hormone-refractory metastatic prostate cancer.

   By Collins R, Fenwick E, Trowman R, Perard R, Norman G, Light K, et al.

3. A systematic review of rapid diagnostic tests for the detection of tuberculosis infection.

   By Dinnes J, Deeks J, Kunst H, Gibson A, Cummins E, Waugh N, et al.

4. The clinical effectiveness and cost-effectiveness of strontium ranelate for the prevention of osteoporotic fragility fractures in postmenopausal women.

   By Stevenson M, Davis S, Lloyd-Jones M, Beverley C.

5. A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines.

   By Raynor DK, Blenkinsopp A, Knapp P, Grime J, Nicolson DJ, Pollock K, et al.

6. Oral naltrexone as a treatment for relapse prevention in formerly opioid-dependent drug users: a systematic review and economic evaluation.

   By Adi Y, Juarez-Garcia A, Wang D, Jowett S, Frew E, Day E, et al.

7. Glucocorticoid-induced osteoporosis: a systematic review and cost–utility analysis.

   By Kanis JA, Stevenson M, McCloskey EV, Davis S, Lloyd-Jones M.

8. Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection.

   By Low N, McCarthy A, Macleod J, Salisbury C, Campbell R, Roberts TE, et al.

9. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation.

   By Connock M, Juarez-Garcia A, Jowett S, Frew E, Liu Z, Taylor RJ, et al.

10. Exercise Evaluation Randomised Trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only.

    By Isaacs AJ, Critchley JA, See Tai S, Buckingham K, Westley D, Harridge SDR, et al.

11. Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of mild chronic hepatitis C: a systematic review and economic evaluation.

    By Shepherd J, Jones J, Hartwell D, Davidson P, Price A, Waugh N.

12. Systematic review and economic evaluation of bevacizumab and cetuximab for the treatment of metastatic colorectal cancer.

    By Tappenden P, Jones R, Paisley S, Carroll C.

13. A systematic review and economic evaluation of epoetin alfa, epoetin beta and darbepoetin alfa in anaemia associated with cancer, especially that attributable to cancer treatment.

    By Wilson J, Yao GL, Raftery J, Bohlius J, Brunskill S, Sandercock J, et al.

14. A systematic review and economic evaluation of statins for the prevention of coronary events.

    By Ward S, Lloyd Jones M, Pandor A, Holmes M, Ara R, Ryan A, et al.

15. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers.

    By Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al.

16. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial.

    By Weindling AM, Cunningham CC, Glenn SM, Edwards RT, Reeves DJ.

17. Screening for type 2 diabetes: literature review and economic modelling.

    By Waugh N, Scotland G, McNamee P, Gillett M, Brennan A, Goyder E, et al.

18. The effectiveness and cost-effectiveness of cinacalcet for secondary hyperparathyroidism in end-stage renal disease patients on dialysis: a systematic review and economic evaluation.

    By Garside R, Pitt M, Anderson R, Mealing S, Roome C, Snaith A, et al.

19. The clinical effectiveness and cost-effectiveness of gemcitabine for metastatic breast cancer: a systematic review and economic evaluation.

    By Takeda AL, Jones J, Loveman E, Tan SC, Clegg AJ.

20. A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease.

    By Collins R, Cranny G, Burch J, Aguiar-Ibáñez R, Craig D, Wright K, et al.

21. The clinical effectiveness and cost-effectiveness of treatments for children with idiopathic steroid-resistant nephrotic syndrome: a systematic review.

    By Colquitt JL, Kirby J, Green C, Cooper K, Trompeter RS.

22. A systematic review of the routine monitoring of growth in children of primary school age to identify growth-related conditions.

    By Fayter D, Nixon J, Hartley S, Rithalia A, Butler G, Rudolf M, et al.

23. Systematic review of the effectiveness of preventing and treating Staphylococcus aureus carriage in reducing peritoneal catheter-related infections.

    By McCormack K, Rabindranath K, Kilonzo M, Vale L, Fraser C, McIntyre L, et al.

24. The clinical effectiveness and cost of repetitive transcranial magnetic stimulation versus electroconvulsive therapy in severe depression: a multicentre pragmatic randomised controlled trial and economic analysis.

    By McLoughlin DM, Mogg A, Eranti S, Pluck G, Purvis R, Edwards D, et al.

25. A randomised controlled trial and economic evaluation of direct versus indirect and individual versus group modes of speech and language therapy for children with primary language impairment.

    By Boyle J, McCartney E, Forbes J, O’Hare A.

26. Hormonal therapies for early breast cancer: systematic review and economic evaluation.

    By Hind D, Ward S, De Nigris E, Simpson E, Carroll C, Wyld L.

27. Cardioprotection against the toxic effects of anthracyclines given to children with cancer: a systematic review.

    By Bryant J, Picot J, Levitt G, Sullivan I, Baxter L, Clegg A.

28. Adalimumab, etanercept and infliximab for the treatment of ankylosing spondylitis: a systematic review and economic evaluation.

    By McLeod C, Bagust A, Boland A, Dagenais P, Dickson R, Dundar Y, et al.

29. Prenatal screening and treatment strategies to prevent group B streptococcal and other bacterial infections in early infancy: cost-effectiveness and expected value of information analyses.

    By Colbourn T, Asseburg C, Bojke L, Philips Z, Claxton K, Ades AE, et al.

30. Clinical effectiveness and cost-effectiveness of bone morphogenetic proteins in the non-healing of fractures and spinal fusion: a systematic review.

    By Garrison KR, Donell S, Ryder J, Shemilt I, Mugford M, Harvey I, et al.

31. A randomised controlled trial of postoperative radiotherapy following breast-conserving surgery in a minimum-risk older population. The PRIME trial.

    By Prescott RJ, Kunkler IH, Williams LJ, King CC, Jack W, van der Pol M, et al.

32. Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen.

    By Bamford J, Fortnum H, Bristow K, Smith J, Vamvakas G, Davies L, et al.

33. The clinical effectiveness and cost-effectiveness of inhaled insulin in diabetes mellitus: a systematic review and economic evaluation.

    By Black C, Cummins E, Royle P, Philip S, Waugh N.

34. Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis.

    By Thompson Coon J, Rogers G, Hewson P, Wright D, Anderson R, Cramp M, et al.

35. The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Homebased compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence.

    By Jolly K, Taylor R, Lip GYH, Greenfield S, Raftery J, Mant J, et al.

36. A systematic review of the clinical, public health and cost-effectiveness of rapid diagnostic tests for the detection and identification of bacterial intestinal pathogens in faeces and food.

    By Abubakar I, Irvine L, Aldus CF, Wyatt GM, Fordham R, Schelenz S, et al.

37. A randomised controlled trial examining the longer-term outcomes of standard versus new antiepileptic drugs. The SANAD trial.

    By Marson AG, Appleton R, Baker GA, Chadwick DW, Doughty J, Eaton B, et al.

38. Clinical effectiveness and cost-effectiveness of different models of managing long-term oral anti-coagulation therapy: a systematic review and economic modelling.

    By Connock M, Stevens C, Fry-Smith A, Jowett S, Fitzmaurice D, Moore D, et al.

39. A systematic review and economic model of the clinical effectiveness and cost-effectiveness of interventions for preventing relapse in people with bipolar disorder.

    By Soares-Weiser K, Bravo Vergel Y, Beynon S, Dunn G, Barbieri M, Duffy S, et al.

40. Taxanes for the adjuvant treatment of early breast cancer: systematic review and economic evaluation.

    By Ward S, Simpson E, Davis S, Hind D, Rees A, Wilkinson A.

41. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation.

    By Burr JM, Mowatt G, Hernández R, Siddiqui MAR, Cook J, Lourenco T, et al.

42. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models.

    By Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I.

43. Contamination in trials of educational interventions.

    By Keogh-Brown MR, Bachmann MO, Shepstone L, Hewitt C, Howe A, Ramsay CR, et al.

44. Overview of the clinical effectiveness of positron emission tomography imaging in selected cancers.

    By Facey K, Bradbury I, Laking G, Payne E.

45. The effectiveness and cost-effectiveness of carmustine implants and temozolomide for the treatment of newly diagnosed high-grade glioma: a systematic review and economic evaluation.

    By Garside R, Pitt M, Anderson R, Rogers G, Dyer M, Mealing S, et al.

46. Drug-eluting stents: a systematic review and economic evaluation.

    By Hill RA, Boland A, Dickson R, Dündar Y, Haycox A, McLeod C, et al.

47. The clinical effectiveness and cost-effectiveness of cardiac resynchronisation (biventricular pacing) for heart failure: systematic review and economic model.

    By Fox M, Mealing S, Anderson R, Dean J, Stein K, Price A, et al.

48. Recruitment to randomised trials: strategies for trial enrolment and participation study. The STEPS study.

    By Campbell MK, Snowdon C, Francis D, Elbourne D, McDonald AM, Knight R, et al.

49. Cost-effectiveness of functional cardiac testing in the diagnosis and management of coronary artery disease: a randomised controlled trial. The CECaT trial.

    By Sharples L, Hughes V, Crean A, Dyer M, Buxton M, Goldsmith K, et al.

50. Evaluation of diagnostic tests when there is no gold standard. A review of methods.

    By Rutjes AWS, Reitsma JB, Coomarasamy A, Khan KS, Bossuyt PMM.

51. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding.

    By Leontiadis GI, Sreedharan A, Dorward S, Barton P, Delaney B, Howden CW, et al.

52. A review and critique of modelling in prioritising and designing screening programmes.

    By Karnon J, Goyder E, Tappenden P, McPhie S, Towers I, Brazier J, et al.

53. An assessment of the impact of the NHS Health Technology Assessment Programme.

    By Hanney S, Buxton M, Green C, Coulson D, Raftery J.

1. A systematic review and economic model of switching from nonglycopeptide to glycopeptide antibiotic prophylaxis for surgery.

   By Cranny G, Elliott R, Weatherly H, Chambers D, Hawkins N, Myers L, et al.

2. ‘Cut down to quit’ with nicotine replacement therapies in smoking cessation: a systematic review of effectiveness and economic analysis.

   By Wang D, Connock M, Barton P, Fry-Smith A, Aveyard P, Moore D.

3. A systematic review of the effectiveness of strategies for reducing fracture risk in children with juvenile idiopathic arthritis with additional data on long-term risk of fracture and cost of disease management.

   By Thornton J, Ashcroft D, O’Neill T, Elliott R, Adams J, Roberts C, et al.

4. Does befriending by trained lay workers improve psychological well-being and quality of life for carers of people with dementia, and at what cost? A randomised controlled trial.

   By Charlesworth G, Shepstone L, Wilson E, Thalanany M, Mugford M, Poland F.

5. A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study.

   By Hirst A, Dutton S, Wu O, Briggs A, Edwards C, Waldenmaier L, et al.

6. Methods of prediction and prevention of pre-eclampsia: systematic reviews of accuracy and effectiveness literature with economic modelling.

   By Meads CA, Cnossen JS, Meher S, Juarez-Garcia A, ter Riet G, Duley L, et al.

7. The use of economic evaluations in NHS decision-making: a review and empirical investigation.

   By Williams I, McIver S, Moore D, Bryan S.

8. Stapled haemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation.

   By Burch J, Epstein D, Baba-Akbari A, Weatherly H, Fox D, Golder S, et al.

9. The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review.

   By Loveman E, Frampton GK, Clegg AJ.

10. Payment to healthcare professionals for patient recruitment to trials: systematic review and qualitative study.

    By Raftery J, Bryant J, Powell J, Kerr C, Hawker S.

11. Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation.

    By Chen Y-F, Jobanputra P, Barton P, Bryan S, Fry-Smith A, Harris G, et al.

12. The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation.

    By Hockenhull JC, Dwan K, Boland A, Smith G, Bagust A, Dundar Y, et al.

13. Stepped treatment of older adults on laxatives. The STOOL trial.

    By Mihaylov S, Stark C, McColl E, Steen N, Vanoli A, Rubin G, et al.

14. A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial.

    By Goodyer IM, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, et al.

15. The use of irinotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer: systematic review and economic evaluation.

    By Hind D, Tappenden P, Tumur I, Eggington E, Sutcliffe P, Ryan A.

16. Ranibizumab and pegaptanib for the treatment of age-related macular degeneration: a systematic review and economic evaluation.

    By Colquitt JL, Jones J, Tan SC, Takeda A, Clegg AJ, Price A.

17. Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease.

    By Mowatt G, Cummins E, Waugh N, Walker S, Cook J, Jia X, et al.

18. Structural neuroimaging in psychosis: a systematic review and economic evaluation.

    By Albon E, Tsourapas A, Frew E, Davenport C, Oyebode F, Bayliss S, et al.

19. Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta₂ agonists for the treatment of chronic asthma in adults and children aged 12 years and over.

    By Shepherd J, Rogers G, Anderson R, Main C, Thompson-Coon J, Hartwell D, et al.

20. Systematic review and economic analysis of the comparative effectiveness of different inhaled corticosteroids and their usage with long-acting beta₂ agonists for the treatment of chronic asthma in children under the age of 12 years.

    By Main C, Shepherd J, Anderson R, Rogers G, Thompson-Coon J, Liu Z, et al.

21. Ezetimibe for the treatment of hypercholesterolaemia: a systematic review and economic evaluation.

    By Ara R, Tumur I, Pandor A, Duenas A, Williams R, Wilkinson A, et al.

22. Topical or oral ibuprofen for chronic knee pain in older people. The TOIB study.

    By Underwood M, Ashby D, Carnes D, Castelnuovo E, Cross P, Harding G, et al.

23. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial.

    By George S, Pockney P, Primrose J, Smith H, Little P, Kinley H, et al.

24. A review and critical appraisal of measures of therapist–patient interactions in mental health settings.

    By Cahill J, Barkham M, Hardy G, Gilbody S, Richards D, Bower P, et al.

25. The clinical effectiveness and cost-effectiveness of screening programmes for amblyopia and strabismus in children up to the age of 4–5 years: a systematic review and economic evaluation.

    By Carlton J, Karnon J, Czoski-Murray C, Smith KJ, Marr J.

26. A systematic review of the clinical effectiveness and cost-effectiveness and economic modelling of minimal incision total hip replacement approaches in the management of arthritic disease of the hip.

    By de Verteuil R, Imamura M, Zhu S, Glazener C, Fraser C, Munro N, et al.

27. A preliminary model-based assessment of the cost–utility of a screening programme for early age-related macular degeneration.

    By Karnon J, Czoski-Murray C, Smith K, Brand C, Chakravarthy U, Davis S, et al.

28. Intravenous magnesium sulphate and sotalol for prevention of atrial fibrillation after coronary artery bypass surgery: a systematic review and economic evaluation.

    By Shepherd J, Jones J, Frampton GK, Tanajewski L, Turner D, Price A.

29. Absorbent products for urinary/faecal incontinence: a comparative evaluation of key product categories.

    By Fader M, Cottenden A, Getliffe K, Gage H, Clarke-O’Neill S, Jamieson K, et al.

30. A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness.

    By French B, Leathley M, Sutton C, McAdam J, Thomas L, Forster A, et al.

31. The effectiveness and cost-effectivness of minimal access surgery amongst people with gastro-oesophageal reflux disease – a UK collaborative study. The reflux trial.

    By Grant A, Wileman S, Ramsay C, Bojke L, Epstein D, Sculpher M, et al.

32. Time to full publication of studies of anti-cancer medicines for breast cancer and the potential for publication bias: a short systematic review.

    By Takeda A, Loveman E, Harris P, Hartwell D, Welch K.

Health Technology Assessment Programme

1. Director, NIHR HTA Programme, Professor of Clinical Pharmacology, University of Liverpool

2. Director, Medical Care Research Unit, University of Sheffield