Inpatient hospitalization and intimate partner violence: who are we treating?

Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery

ABSTRACT

This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV)

PURPOSE

To recognize the imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV).

MATERIALS AND METHODS

A retrospective radiological review of 688 patients self-reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 30 patients with 89 thoracic injuries. Imaging and demographic data were collected.

RESULTS

Thirty survivors with 89 injuries to the thorax were identified with a median age of 43.5 years (21-65 years). IPV was reported or disclosed as the direct cause of injury in 50% (15/30) of survivors, including all nine patients who sustained penetrating injuries. The most common injury type was fracture (72%, 64/89) with 52 rib, 3 sternal, 2 clavicular, and 7 vertebral fractures. There were 3 acromioclavicular dislocations. Among rib fractures, right lower anterior rib fractures (9-12 ribs) were the most common(30%, 16/52). There were 10 superficial soft tissue injuries. There were 12 deep tissue injuries which included 2 lung contusions, 2 pneumomediastinum, 7 pneumothoraces, 1 hemothorax. One third of patients had concomitant injuries of other organ systems, most commonly to the head and face, followed by extremities and one third of patients had metachronous injuries.

CONCLUSION

Acute rib fractures with concomitant injuries to the head, neck, face, and extremities with an unclear mechanism of injury should prompt the radiologist to discuss the possibility of IPV with the ordering physician.

ADVANCES IN KNOWLEDGE

Recognizing common injuries to the thorax will prompt the radiologists to suspect IPV and discuss it with the clinicians.

Victims of Severe Intimate Partner Violence Are Left Without Advocacy Intervention in Primary Care Emergency Rooms: A Prospective Observational Study

Intimate partner violence (IPV) is a common cause of musculoskeletal injury. Although serious injuries are relatively rare, IPV is one of the leading causes of homicide. IPV victims seeking help in health care are known to be at specific risk of re-abuse. Previous studies of IPV victims in emergency room (ER) settings have focused on injury patterns, but little is known about the violence behind bruises and fractures. The aim of this study was to examine how violence severity and known risk factors for lethal re-abuse in IPV victims attending ERs are associated with injury severity, different patient groups, and referral to advocacy services. This was a prospective, observational, multicenter study of 146 self-reporting IPV victims in two Level IV trauma centers in Helsinki from October 2012 to November 2013. In our sample, serious injuries were rare, but patients had typically suffered severe violence, and half had at least one risk factor for lethal re-abuse. Both sexes and all age groups were represented among the patient profiles, and 88% attended ERs outside common working hours. Only 19% were referred to advocacy, and severe violence or risk factors for lethal re-abuse did not affect prevalence of referrals. Our results show that IPV victims in primary care ERs have typically either experienced severe violence or are at serious risk of re-abuse and even death. The resulting injuries do not usually require medical aftercare, and victims typically present outside common working hours. In the absence of a clear follow-up protocol, most IPV victims are left without any advocacy intervention.

Intimate partner violence in Greece: a study of 664 consecutive forensic clinical examinations

BACKGROUND

Intimate partner violence (IPV) is a well-known phenomenon, which affects mostly women. While IPV victims may attend emergency departments (EDs) seeking medical care, not all of them will make an allegation against their abusers.

OBJECTIVE

The aim of this study was to examine the prevalence and the characteristics of the victims, who had made an allegation about the violent incident and had been examined by a forensic pathologist for judicial purposes, and had attended EDs seeking medical care, before the forensic examination.

METHODS

We reviewed the archives of clinical examinations that were conducted at the Department of Forensic Medicine and Toxicology of National and Kapodistrian University of Athens during a 5-year period (2012-16).

RESULTS

Six hundred sixty-four clinical examinations were conducted at our Department for IPV allegations. According to our findings, women were more likely to seek medical care than men. Victims who have attended EDs were more likely to have sustained injuries located at least on the head or on the lower limbs.

CONCLUSION

The majority of IPV victims in the broader region of Attica (Greece) were women, usually married, and aged between 30 and 49 years old. Despite the fact that the majority of IPV incidents are not reported to police, every person who is engaged in the process of dealing with IPV victims has to be educated and adequately informed about this phenomenon, its implications and the possible ways to deal with it. Furthermore, victims need to be educated and informed adequately in waiting rooms of EDs.

Difficult conversations: Navigating intimate partner violence with standardized patients

BACKGROUND

One in three women in the US experience intimate partner violence (IPV) in their lifetime. There are minimal opportunities for medical students to learn about responding to IPV.

METHODS

Students participated in a learning intervention about recognizing and addressing IPV, followed by a standardized patient session. Students filled out a seven-question survey before and after the session, which assessed comfort addressing IPV, discussing resources, and practicing trauma-informed care. Responses were compared using the Mann-Whitney U test.

RESULTS

Sixteen medical students participated, response rate of 100%. The median score for comfort recognizing signs of IPV increased from 2 to 3 (p < 0.01); for asking patients about IPV, from 1 to 3.5 (p < 0.01); in knowledge of IPV resources, from 1 to 3 (p < 0.01); in preparedness to practice trauma informed care, from 2 to 3.5 (ns). Comfort addressing IPV improved from 1 to 3 (p < 0.01).

CONCLUSION

After the session, student preparedness and comfort addressing IPV increased. The learning intervention addressed information not in standard medical curricula. This module can be easily adapted to any medical school curricula.

Intimate partner violence-related hospitalizations in Appalachia and the non-Appalachian United States

The highly rural region of Appalachia faces considerable socioeconomic disadvantage and health disparities that are recognized risk factors for intimate partner violence (IPV). The objective of this study was to estimate the rate of IPV-related hospitalizations in Appalachia and the non-Appalachian United States for 2007–2011 and compare hospitalizations in each region by clinical and sociodemographic factors. Data on IPV-related hospitalizations were extracted from the State Inpatient Databases, which are part of the Healthcare Cost and Utilization Project. Hospitalization day, year, in-hospital mortality, length of stay, average and total hospital charges, sex, age, payer, urban-rural location, income, diagnoses and procedures were compared between Appalachian and non-Appalachian counties. Poisson regression models were constructed to test differences in the rate of IPV-related hospitalizations between both regions. From 2007–2011, there were 7,385 hospitalizations related to IPV, with one-third (2,645) occurring in Appalachia. After adjusting for age and rurality, Appalachian counties had a 22% higher hospitalization rate than non-Appalachian counties (ARR = 1.22, 95% CI: 1.14–1.31). Appalachian residents may be at increased risk for IPV and associated conditions. Exploring disparities in healthcare utilization and costs associated with IPV in Appalachia is critical for the development of programs to effectively target the needs of this population.