Making the 'invisible' visible: transforming the detection of intimate partner violence

Methodologic Approaches for Using Electronic Medical Records to Identify Experiences of Violence in Transgender and Cisgender People: Closing the Gap Between Diagnostic Coding and Lived Experiences

BACKGROUND

Transgender people experience extreme rates of violence and the electronic medical record (EMR) remains a mostly untapped resource to study the medical sequelae of such experiences.

OBJECTIVES

To develop and test a method for identifying experiences of violence using EMR data.

RESEARCH DESIGN

Cross-sectional study utilizing EMR data.

PEOPLE

Transgender and cisgender people seen at a regional referral center in Upstate New York.

MEASURES

We tested the utility of keyword searches and structured data queries to identify specific types of violence at various ages and in various contexts among cohorts of transgender and cisgender people. We compared the effectiveness of keyword searches to diagnosis codes and a screening question, "Are you safe at home?" using McNemar's test. We compared the prevalence of various types of violence between transgender and cisgender cohorts using the χ 2 test of independence.

RESULTS

Of the transgender cohort, 47% had experienced some type of violence versus 14% of the cisgender cohort (χ 2P value <0.001). Keywords were significantly more effective than structured data at identifying violence among both cohorts (McNemar P values all <0.05).

CONCLUSIONS

Transgender people experience extreme amounts of violence throughout their lives, which is better identified and studied using keyword searches than structured EMR data. Policies are urgently needed to stop violence against transgender people. Interventions are also needed to ensure safe documentation of violence in EMRs to improve care across settings and aid research to develop and implement effective interventions.

Imaging of Intimate Partner Violence, From the AJR Special Series on Emergency Radiology

Intimate partner violence (IPV) is a highly prevalent public health issue with multiple adverse health effects. Radiologists are well suited to assessing a patient's likelihood of IPV. Recognition of common IPV injury mechanisms and resulting target and defensive injury patterns on imaging and understanding of differences between patients who have experienced IPV and those who have not with respect to use of imaging will aid radiologists in accurate IPV diagnosis. Target injuries often involve the face and neck as a result of blunt trauma or strangulation; defensive injuries often involve an extremity. Awareness of differences in injury patterns resulting from IPV-related and accidental trauma can aid radiologists in detecting a mismatch between the provided clinical history and imaging findings to support suspicion of IPV. Radiologists should consider all available current and prior imaging in assessing the likelihood of IPV; this process may be aided by machine learning methods. Even if correctly suspecting IPV on the basis of imaging, radiologists face challenges in acting on that suspicion, including appropriately documenting the findings, without compromising the patient's confidentiality and safety. However, through a multidisciplinary approach with appropriate support mechanisms, radiologists may serve as effective frontline physicians for raising suspicion of IPV.

A Novel Technique to Identify Intimate Partner Violence in a Hospital Setting

Introduction

Intimate partner violence (IPV) is defined as sexual, physical, psychological, or economic violence that occurs between current or former intimate partners. Victims of IPV may seek care for violence-related injuries in healthcare settings, which makes recognition and intervention in these facilities critical. In this study our goal was to develop an algorithm using natural language processing (NLP) to identify cases of IPV within emergency department (ED) settings.

Methods

In this observational cohort study, we extracted unstructured physician and advanced practice provider, nursing, and social worker notes from hospital electronic health records (EHR). The recorded clinical notes and patient narratives were screened for a set of 23 situational terms, derived from the literature on IPV (ie, assault by spouse), along with an additional set of 49 extended situational terms, extracted from known IPV cases (ie, attack by spouse). We compared the effectiveness of the proposed model with detection of IPV-related International Classification of Diseases, 10th Revision, codes.

Results

We included in the analysis a total of 1,064,735 patient encounters (405,303 patients who visited the ED of a Level I trauma center) from January 2012–August 2020. The outcome was identification of an IPV-related encounter. In this study we used information embedded in unstructured EHR data to develop a NLP algorithm that employs clinical notes to identify IPV visits to the ED. Using a set of 23 situational terms along with 49 extended situational terms, the algorithm successfully identified 7,399 IPV-related encounters representing 5,975 patients; the algorithm achieved 99.5% precision in detecting positive cases in our sample of 1,064,735 ED encounters.

Conclusion

Using a set of pre-defined IPV-related terms, we successfully developed a novel natural language processing algorithm capable of identifying intimate partner violence.

Family Health Development: A Theoretical Framework

In recognition of the family as central to health, the concept of family, rather than individual, health has been an important area of research and, increasingly, clinical practice. There is a need to leverage existing theories of family health to align with our evolving understanding of Life Course Health Development, including the opportunities and constraints of the family context for promoting lifelong individual and population health. The purpose of this article is to propose an integrative model of family health development within a Life Course Health Development lens to facilitate conceptualization, research, and clinical practice. This model provides an organizing heuristic model for understanding the dynamic interactions between family structures, processes, cognitions, and behaviors across development. Potential applications of this model are discussed.

Longitudinal imaging history in early identification of intimate partner violence

OBJECTIVES

To describe the imaging findings of intimate partner violence (IPV)-related injury and to evaluate the role of longitudinal imaging review in detecting IPV.

METHODS

Radiology studies were reviewed in chronological order and IPV-related injuries were recorded among 400 victims of any type of abuse (group 1) and 288 of physical abuse (group 2) from January 2013 to June 2018. The likelihood of IPV was assessed as low/moderate/high based on the review of (1) current and prior anatomically related studies only and (2) longitudinal imaging history consisting of all prior studies. The first radiological study date with moderate/high suspicion was compared to the self-reported date by the victim.

RESULTS

A total of 135 victims (33.8%) in group 1 and 144 victims (50%) in group 2 demonstrated IPV-related injuries. Musculoskeletal injury was most common (58.2% and 44.5% in groups 1 and 2, respectively; most commonly lower/upper extremity fractures), followed by neurologic injury (20.9% and 32.9% in groups 1 and 2, respectively; most commonly facial injury). With longitudinal imaging history, radiologists were able to identify IPV in 31% of group 1 and 46.5% of group 2 patients. Amongst these patients, earlier identification by radiologists was provided compared to the self-reported date in 62.3% of group 1 (median, 64 months) and in 52.6% of group 2 (median, 69.3 months).

CONCLUSIONS

Musculoskeletal and neurological injuries were the most common IPV-related injuries. Knowledge of common injuries and longitudinal imaging history may help IPV identification when victims are not forthcoming.

KEY POINTS

• Musculoskeletal injuries were the most common type of IPV-related injury, followed by neurological injuries. • With longitudinal imaging history, radiologists were able to better raise the suspicion of IPV compared to the selective review of anatomically related studies only. • With longitudinal imaging history, radiologists were able to identify IPV earlier than the self-reported date by a median of 64 months in any type of abuse, and a median of 69.3 months in physical abuse.

Upper extremity fractures due to intimate partner violence versus accidental causes

Purpose

The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency departments (ED) and compare their anatomic location to those due to accidental falls or strikes.

Methods

An Institutional Review Board exempt, retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System’s All Injury Program data from 2005 through 2015 for all UEF sustained in women 15 to 54 years old. Injuries based on reported IPV versus accidental falls or strikes were analyzed accounting for the weighted, stratified nature of the data.

Results

IPV-related UEF represented 1.7% of all UEF and 27.2% of all IPV fractures. The finger was the most common fracture site in IPV (34.3%) and accidental striking (53.3%) but accounted for only 10% of fall-related UEF. There was a higher proportion of shoulder fractures in IPV (9.2%) compared to accidental falls (7.4%) or strikes (2.9%). The odds of a finger fracture were 4.32 times greater in IPV than falling and of a shoulder fracture were 3.65 greater in IPV than accidental striking (p < 0.0001).

Conclusions

While the finger is the most common site for IPV UEF, it is also the most common location for accidental striking. A lower proportion of finger fractures in fall and of shoulder/forearm fractures in accidental striking should prompt the radiologist to discuss the possibility of IPV with the ED physician in any woman presenting with a finger fracture due to fall and a shoulder/forearm fracture with a vague history of accidental striking.

Neck and Back Sprain and Hand Flexor Tendon Repair Are More Common in Victims of Domestic Violence Compared With Patients Who Were Not Victims of Domestic Violence: A Comparative Study of 1,204,596 Patients Using the National Trauma Data Bank

The purpose of this study was to determine the most common orthopedic diagnoses and procedures among patients who experience domestic violence (DV) and to determine whether these were more common in patients who experienced DV compared with those who did not.

Upper extremity injuries in the victims of intimate partner violence

OBJECTIVES

To recognize most common patterns of upper extremity (UE) injuries in victims of Intimate Partner Violence (IPV).

METHODS

Radiological review of 308 patients who reported physical IPV at our institution from January 2013 to June 2018, identified 55 patients with 88 unique UE injuries. Demographic data and injury patterns and associations were collected from the electronic medical records.

RESULTS

The cohort included 49 females and 6 males (age 19-63, mean 38). At the time of injury, IPV was reported in 15/88 (17%) and IPV screening was documented for 22/88 (25%) injuries. There were 46 fractures, 8 dislocations or subluxations, and 34 isolated soft tissue injuries, most commonly involving the hand (56/88). Fractures most commonly involved the fingers (21/46, 46%) and the 5th digit (8/27, 30%). Medial UE fractures (5th digit, 4th digit) constituted 44% of hand and finger fractures (12/27) and 26% of all fractures (12/46). Comminuted and displaced fractures were rare (8/46, 17%). Head and face injuries were the most common concomitant injuries (9/22, 41%) and subsequent injuries (21/61, 35%). Of 12 patients with recurrent UE injuries, 6 had recurrent injuries of the same hand. Five of 6 non-acute fractures (83%) were of the hand.

CONCLUSIONS

Hand and finger injuries are the most common UE injuries in patients with IPV, with finger being the most common site and medial hand the most common region of fracture. Repeated injuries involving the same site and a combination of medial hand and head or face injuries could indicate IPV.

KEY POINTS

• Upper extremity injuries in victims of intimate partner violence are most commonly seen in the hand and fingers. • Fingers are the most common site of fracture and the medial hand is the most common region of fracture in the upper extremity in victims of intimate partner violence. • In intimate partner violence victims with upper extremity injuries, concomitant injuries and subsequent injuries are most commonly seen in the head and neck region.

Recognizing Isolated Ulnar Fractures as Potential Markers for Intimate Partner Violence

PURPOSE

This study aimed to assess the incidence of intimate partner violence (IPV) in women with isolated ulnar fractures and compare the injury characteristics in victims of IPV with those who sustained the same fractures due to other causes.

METHODS

Electronic health records from three level I trauma centers were queried to identify a cohort of women, aged 18 to 50, sustaining isolated ulnar fractures from 2005 to 2019. Radiographs were reviewed for fracture location, comminution, and displacement. Demographic data, number of visits to the emergency department, and documentation of IPV were also collected. Patients were stratified into four groups based on clinical chart review: confirmed IPV, possible IPV, not suspected for IPV, and not IPV. Historical imaging analysis for IPV prediction was also performed.

RESULTS

There were 62 patients, with a mean age of 31 years (IPV: 12 confirmed, 8 possible, 8 suspected not IPV, 34 confirmed not IPV). Comparative analysis with and without suspected cases demonstrated IPV to be associated with nondisplaced fractures (95% versus 43%; P < .001 and 91% versus 44%; P = .012). Confirmed cases were also associated with homelessness (46% versus 0%; P < .001), and the number of documented emergency department visits (median 7.0; interquartile range 2.0-12.8 versus 1.0; interquartile range 1.0-2.0; P < .001). Formal documentation of IPV evaluation was completed in only 14 of 62 (22.5%) patients. Historical imaging analysis predicted IPV in 8 of 12 (75%) confirmed IPV cases.

CONCLUSION

Up to one-third of adult women sustaining isolated ulnar fractures may be the victims of IPV. Lack of displacement on radiographs, frequent emergency department visits, and homelessness would favor IPV etiology.

Imaging patterns of lower extremity injuries in victims of intimate partner violence (IPV)

PURPOSE

To describe the pattern and distribution of lower extremity injuries in victims of intimate partner violence (IPV).

MATERIALS AND METHODS

A retrospective radiological review of 688 patients reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 88 patients with 154 lower extremity injuries. All lower extremity injuries visible on radiological studies were analyzed. Concomitant, recurrent, and associated injuries were also collected, in addition to the demographic data.

RESULTS

The injuries consisted of 103 fractures, 46 soft tissue injuries, and 5 dislocations. The foot was the most common site of injury representing 39% (60/154) of total injuries, 48% (49/103) of fractures, 17% (8/46) of soft tissue injuries, and 3 dislocations. The ankle was the second most common site of injury representing 30% (47/154) of total injuries, 20% (21/103) of fractures, and 57% (26/46) of soft tissue injuries. Recurrent injuries of the lower extremity were seen in 30% (26/88) of victims who had 74 recurrent injuries. The most common sites of recurrent injury were the foot and ankle, representing 72% (53/74) of recurrent injuries.

CONCLUSION

Recurrent injuries of the foot and ankle, synchronous craniofacial injuries, and upper extremity injuries in young women (<35 years) should prompt radiologists to consider IPV.

Addressing intimate partner violence during the COVID-19 pandemic and beyond: how radiologists can make a difference

Faced with the COVID-19 pandemic, many countries both in Europe and across the world implemented strict stay-at-home orders. These measures helped to slow the spread of the coronavirus but also led to increased mental and physical health issues for the domestically confined population, including an increase in the occurrence of intimate partner violence (IPV) in many countries. IPV is defined as behavior that inflicts physical, psychological, or sexual harm within an intimate relationship. We believe that as radiologists, we can make a difference by being cognizant of this condition, raising an alert when appropriate and treating suspected victims with care and empathy. The aim of this Special Report is to raise awareness of IPV among radiologists and to suggest strategies by which to identify and support IPV victims. KEY POINTS: • The COVID-19 pandemic led to a marked increase in the number of intimate partner violence (IPV) cases, potentially leading to increased emergency department visits and radiological examinations. • Most IPV-related fractures affect the face, fingers, and upper trunk, and may easily be misinterpreted as routine trauma. • Radiologists should carefully review the medical history of suspicious cases, discuss the suspicion with the referring physician, and proactively engage in a private conversation with the patient, pointing to actionable resources for IPV victims.

Intimate Partner Violence: A Primer for Radiologists to Make the "Invisible" Visible

Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient's currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging-based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims' lives. ^©RSNA, 2020.

Incidence and characteristics of spinal injuries in the victims of intimate partner violence (IPV)

PURPOSE

To describe the incidence and patterns of the spinal injuries in the victims of physical IPV.

MATERIALS AND METHODS

With institutional review board (IRB) approval, we retrospectively reviewed patients referred to our institution's domestic violence intervention and prevention program with a diagnosis directly related to physical abuse between January 2013 and June 2018. Electronic health records and radiology reports were reviewed for all patients.

RESULTS

A total of 21/688 (3%) IPV patients with 41 vertebral injuries were identified. The study population comprised of 19/21 (90%) females. Median age of the included patients was 43 years with a range of 21-72 years. All vertebral injuries were AO type A spinal injuries. Upper lumbar spine (L1 and L2) was the most common level of injury followed by upper to mid-thoracic spine. The reported mechanism of the injury was IPV in 8/21 (38.0%), fall in 8/21(38.0%), and incidental in 5/21 (24.0%). Ten out of 21 (48%) patients had concomitant injuries, most commonly to the craniofacial region 5/21 (23%). Psychiatry history was positive in 17/21 (81%), and substance abuse was positive in 15/21 (71%) of the patients.

CONCLUSION

Incidence of spinal injuries is relatively low in IPV with morphologic AO type A injury being the most common type of injury and the upper lumbar spine being the most common level of injury.

Exacerbation of Physical Intimate Partner Violence during COVID-19 Pandemic

Background Intimate partner violence (IPV) is a global social and public health problem, but published literature regarding the exacerbation of physical IPV during the coronavirus disease 2019 (COVID-19) pandemic is lacking. Purpose To assess the incidence, patterns, and severity of injuries in IPV victims during the COVID-19 pandemic in 2020 compared with the prior 3 years. Materials and Methods The demographics, clinical presentation, injuries, and radiologic findings of patients reporting physical abuse arising from IPV during the statewide COVID-19 pandemic between March 11 and May 3, 2020, were compared with data from the same period for the past 3 years. Pearson χ² and Fisher exact tests were used for analysis. Results A total of 26 victims of physical IPV from 2020 (mean age, 37 years ± 13 [standard deviation]; 25 women) were evaluated and compared with 42 victims of physical IPV (mean age, 41 years ± 15; 40 women) from 2017 to 2019. Although the overall number of patients who reported IPV decreased during the pandemic, the incidence of physical IPV was 1.8 times greater (95% CI: 1.1, 3.0; P = .01). The total number of deep injuries was 28 during 2020 versus 16 from 2017 to 2019; the number of deep injuries per victim was 1.1 during 2020 compared with 0.4 from 2017 to 2019 (P < .001). The incidence of high-risk abuse defined by mechanism was two times greater in 2020 (95% CI: 1.2, 4.7; P = .01). Patients who experienced IPV during the COVID-19 pandemic were more likely to be White; 17 (65%) victims in 2020 were White compared with 11 (26%) in the prior years (P = .007). Conclusion There was a higher incidence and severity of physical intimate partner violence (IPV) during the coronavirus disease 2019 (COVID-19) pandemic compared with the prior 3 years. These results suggest that victims of IPV delayed reaching out to health care services until the late stages of the abuse cycle during the COVID-19 pandemic. © RSNA, 2020.

Intimate partner violence crisis in the COVID-19 pandemic: how can radiologists make a difference?

• The COVID-19 crisis resulted in a variety of physical and mental health issues beyond the viral infection itself, as indicated by an increase in domestic violence.

• Radiologists should be aware of typical intimate partner violence (IPV) injury patterns, actively ask potential IPV victims about the cause of injury, and be familiar with support systems for IPV victims of their institutions.

• Emergency and radiology departments should review their protocols for identifying and supporting IPV victims, and train their staff to work together to implement these measures during and beyond the COVID-19 crisis.