Identifying domestic violence within inpatient hospital admissions using medical records

Factors associated with suicide/self-inflicted injuries among women aged 18-65 years in the United States: A 13-year retrospective analysis of the National Inpatient Sample database

BACKGROUND

Suicide is a significant cause of mortality in the United States, accounting for 14.5 deaths/100,000. Although there are data on gender disparity in suicide/self-inflicted injury rates in the United States, few studies have examined the factors associated with suicide/self-inflicted injury in females.

OBJECTIVE

To determine factors associated with suicide/self-inflicted injuries among women aged 18-65 years in the United States.

METHODS

Hospitalizations for suicide or self-inflicted injuries were identified using the National Inpatient Sample database from 2003-2015 using sample weights to generate national estimates. Independent predictors of suicide/self-inflicted injuries were identified using multivariable regression models. Interaction term analysis to identify the interaction between race/ethnicity and income were conducted.

RESULTS

There were 1,031,693 adult women hospitalizations in the U.S. with a primary diagnosis of suicide/self-inflicted injury in the study period. The highest suicide/self-inflicted injury risk was among women aged 31-45years (OR = 1.23, CI = 1.19-1.27, p < 0.05). Blacks in the highest income strata had a 20% increase in the odds of suicide/self-inflicted injury compared to Whites in the lowest socioeconomic strata (OR = 1.20, CI = 1.05-1.37, p <0.05). Intimate partner violence increased suicide/self-inflicted injury risk 6-fold (OR = 5.77, CI = 5.01-6.65, p < 0.05).

CONCLUSION

Suicide risk is among women aged 31-45 years, higher earning Black women, intimate partner violence victims, uninsured, and current smokers. Interventions and policies that reduce smoking, prevents intimate partner violence, addresses racial discrimination and bias, and provides universal health coverage are needed to prevent excess mortality from suicide deaths.

A dual-method approach to identifying intimate partner violence within a Level 1 trauma center

BACKGROUND

Intimate partner violence (IPV) is a serious public health problem leading many health care organizations to recommend universal screening as part of standard health care practice. Prior work shows that most IPV victims and perpetrators are unidentified by health care staff. We sought to enhance the capacity of an urban trauma center to identify IPV using a dual-method screening tool, and to establish prevalence of IPV victimization and perpetration among this population.

METHODS

Patients aged 18 and older were recruited from a Level 1 trauma center from May 2015 to July 2017. Participants were assessed for IPV using a touch-screen tablet and then via face-to-face assessment. The data were used to determine feasibility of this dual method and to establish prevalence of IPV in this sample.

RESULTS

Of 586 eligible patients, 250 were successfully recruited for the study (43% response rate). Using the subscales of physical abuse, severe psychological abuse, and sexual coercion from the tablet-based Conflict Tactics Scale 2, 40% of women and 34% of men met criteria for IPV exposure in the past year and 35.6% of men and 50.6% of women met criteria using the face-to-face screen. In total, 102 patients (40.8%) screened positive using the dual method.

CONCLUSION

This study reports on a dual method to improve screening and identification of IPV in a Level 1 trauma center. Ultimately, the dual screening method identified more victims than either method on its own. Our findings provide evidence to standardize universal screening in our trauma center. Moving forward, we will link screening results to medical record data to identify predictors of patients' current experiences of psychological and physical IPV. Our ultimate goal is to use these predictors to build a model for identifying patients who are at high risk for IPV victimization or perpetration.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

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.

United States emergency department visits coded for intimate partner violence

BACKGROUND

Limited information exists about medical treatment for victims of intimate partner violence (IPV).

OBJECTIVE

Our aim was to estimate the number of emergency department (ED) visits and subsequent hospitalizations that were assigned a code specific to IPV and to describe the clinical and sociodemographic features of this population.

METHODS

Data from the Nationwide Emergency Department Sample from 2006-2009 were analyzed. Cases with an external cause of injury code of E967.3 (battering by spouse or partner) were abstracted.

RESULTS

From 2006-2009, there were 112,664 visits made to United States EDs with an e-code for battering by a partner or spouse. Most patients were female (93%) with a mean age of 35 years. Patients were significantly more likely to reside in communities with the lowest median income quartile and in the Southern United States. Approximately 5% of visits resulted in hospital admission. The mean charge for treat-and-release visits was $1904.69 and $27,068.00 for hospitalizations. Common diagnoses included superficial injuries and contusions, skull/face fractures, and complications of pregnancy. Females were more likely to experience superficial injuries and contusions, and males were more likely to have open wounds of the head, neck, trunk, and extremities.

CONCLUSIONS

From 2006 to 2009, there were approximately 28,000 ED visits per year with an e-code specific to IPV. Although a minority, 7% of these visits were made by males, which has not been reported previously. Future prospective research should confirm the unique demographic and geographic features of these visits to guide development of targeted screening and intervention strategies to mitigate IPV and further characterize male IPV visits.

Attributing selected costs to intimate partner violence in a sample of women who have left abusive partners: a social determinants of health approach

Selected costs associated with intimate partner violence were estimated for a community sample of 309 Canadian women who left abusive male partners on average 20 months previously. Total annual estimated costs of selected public- and private-sector expenditures attributable to violence were $13,162.39 per woman. This translates to a national annual cost of $6.9 billion for women aged 19–65 who have left abusive partners; $3.1 billion for those experiencing violence within the past three years. Results indicate that costs continue long after leaving, and call for recognition in policy that leaving does not coincide with ending violence.

Care provided in visits coded for intimate partner violence in a national survey of emergency departments

PURPOSE

This article describes the health status of and care provided to patients in visits coded to intimate partner violence (IPV) victims in a national survey of emergency departments (EDs). Visits coded for IPV were defined by International Classification of Diseases, 8th edition-Clinical Modification (ICD-9-CM) codes.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey for 1997-2001 were analyzed. The sample consisted of 111 ED visits with ICD codes for IPV (or 12 IPV visits per 10,000 ED visits, and 21 female IPV visits per 10,000 female ED visits).

FINDINGS

The majority of visits coded to IPV were for patients who presented with mild to moderate pain (86%), physical or sexual violence (50%), and injuries to the body (38%). The majority of patients in visits coded to IPV received radiologic testing, wound care, and pain medications (odds ratios [ORs], 1.6, 3.3, and 2.3 respectively). Disposition was mostly referral to another physician or clinic (42%) or return to the ED when needed (20%), but much less to nonphysician services such as social services, support services, and shelters (14%). Uninsured IPV patients were more likely to receive radiologic testing and pain medications (ORs 5.1 and 3, respectively). Patients seen by nurses were 9 times more likely to receive wound care.

CONCLUSION

Caution should be exercised when interpreting the study results because they reflect only coded IPV visits in the ED and these might be the most obvious IPV cases. The results signal the need for further studies to evaluate access to and the quality of care for IPV patients and to improve screening, documentation, coding, and management practices.

Using diagnostic codes to screen for intimate partner violence in Oregon emergency departments and hospitals

OBJECTIVES

Many of the 2.5 million Americans assaulted annually by intimate partners seek medical care. This project evaluated diagnostic codes indicative of intimate partner violence (IPV) in Oregon hospital and emergency department (ED) records to determine predictive value positive (PVP), sensitivity, and usefulness in routine surveillance. Statewide incidence of care for IPV was calculated and victims and episodes characterized.

METHODS

The study was a review of medical records assigned > or = 1 diagnostic codes thought predictive of IPV. Sensitivity was estimated by comparing the number of confirmed victims identified with the number predicted by statewide telephone survey. Patients were aged > or = 12 years, treated in any of 58 EDs or hospitals in Oregon during 2000, and discharged with one of three primary or 12 provisional codes suggestive of IPV. Outcome measures were number of victims detected, PPV and sensitivity of codes for detection of IPV, and description of victims.

RESULTS

Of 58 hospitals, 52 (90%) provided records. Case finding using primary codes identified 639 victims, 23% of all estimated female victims seen in EDs or hospitalized statewide. PVP was 94% (639/677). Provisional codes increased sensitivity (51%) but reduced PVP (50%). Highest incidence occurred in women aged 20-39 years, and those who were black. Hospitalizations were highest among women aged > or = 50 years, black people, or those with comorbid illness.

CONCLUSIONS

Three diagnostic codes used for case finding detect approximately one-quarter of ED- and hospital-treated victims, complement surveys, and facilitate description of injured victims.

Intimate partner violence: implications for critical care nursing

IPV presents a serious health risk to many women. Emergency and critical care nurses are in a prime position for identification of and intervention with these women. Careful assessment and recognition of symptoms and conditions associated with IPV helps nurses to identify victims and potential victims. Building a trusting and supportive environment, where women feel comfortable disclosing abuse, precedes effective intervention. Nursing practice can incorporate the myriad resources and successful programs to provide victims with quality care. Before discharge from the critical care unit or ED, nurses can help women to identify their risk and plan for safety. Effective nursing care in IPV combines the traditional critical care nursing skills synergistically with provision for the biopsychosocial needs of patients.

Fixing broken bones and broken homes: domestic violence as a patient safety issue

BACKGROUND

Domestic violence (DV) is a significant problem in terms of both patient harm and cost. To better address this problem, the diagnosis and treatment of DV are considered within the emerging model of patient safety and medical error reduction. The case of a female patient who presents in the clinical setting following an incident of DV shows how medical errors can be analyzed as they are in medical cases not involving DV, such as when a person with abdominal pain is sent away from the emergency department with instructions to take an acid reducer and later suffers a burst appendix.

ROOT CAUSE ANALYSIS

A number of factors inhibit the correct diagnosis and treatment of DV victims seeking additional treatment. Physicians often fail to screen for DV, misidentify symptoms, or deny the possibility of underlying DV, and patients often hide the symptoms and refuse to admit the problem. However, human factor errors related to knowledge, cultural norms, and individual biases; organizational factors, including lack of training and reimbursement; and technology factors related to information accessibility appear to play significant roles.

CONCLUSION

Failure to diagnose or adequately address DV can be interpreted as medical errors. Addressing DV requires a systemic response, which might begin with integrating education and training about DV into the clinical setting, ensuring the use of existing screening tools, and providing adequate and appropriate reimbursement levels.

A neural network model analysis to identify victims of intimate partner violence

The objective of this study was to determine if a neural network model can identify victims of intimate partner violence (IPV). A custom neural network model was constructed and trained using the 1995 ED databases at Truman Medical Center of all female visits. The input vector developed was an array of 100 binary elements containing, in coded form, the patient's age, day of week, primary diagnosis (excluding 995.81), disposition, race, time, and E-code. The trained network was then presented with a series of 19,830 female patients from the 1996 ED database to determine if it could discriminate cases from control subjects. The neural network identified 231 of 297 known IPV victims (sensitivity 78%) in the 1996 database. It also categorized 2234 false-positive patients out of 19,533 IPV-negative patients (specificity 89%). A computer-based neural network model, when supplied with information commonly available in the ED medical record, can identify victims of IPV.

The economic burden of hospitalizations associated with child abuse and neglect

OBJECTIVES

This study assessed the economic burden of child abuse-related hospitalizations.

METHODS

We compared inpatient stays coded with a diagnosis of child abuse or neglect with stays of other hospitalized children using the 1999 National Inpatient Sample of the Healthcare Costs and Utilization Project.

RESULTS

Children whose hospital stays were coded with a diagnosis of abuse or neglect were significantly more likely to have died during hospitalization (4.0% vs 0.5%), have longer stays (8.2 vs 4.0 days), twice the number of diagnoses (6.3 vs 2.8), and double the total charges (19,266 vs 9513 US dollars) than were other hospitalized children. Furthermore, the primary payer was typically Medicaid (66.5% vs 37.0%).

CONCLUSION

Earlier identification of children at risk for child abuse and neglect might reduce the individual, medical, and societal costs.

More harm than good? Diagnostic codes for child and adult abuse

This study sought to understand the reasons for the lack of use of ICD diagnostic codes for child and adult abuse. New Jersey professionals were recruited to participate in three focus groups on child abuse, adult or primarily woman abuse, and elder abuse. Participants included health care providers, advocates from the community, and representatives of state agencies and the insurance industry. Concerns about coding abuse included further jeopardizing victims/patients, diagnostic uncertainty, and lack of resources. Members of the child abuse group were somewhat more receptive to coding abuse. Reasons to code, such as for documentation and reimbursement were discussed and rebutted. Most participants concluded that use of the abuse codes should be judicious because they have the potential to do more harm than good. More research is needed on the implications of coding for victims/patients along with medical education in the identification of abuse in general and coding abuse in particular.