General characteristics of hospital stays related to violence

Table 1 describes the hospital utilization and costs associated with violence-related stays, as compared to stays unrelated to violence. In 2005, the hospital costs associated with violence-related stays totaled $2.3 billion. Hospitalizations associated with violence were, on average, less costly than stays unrelated to violence ($7,600 versus $8,800). While the average cost of stays related to self-inflicted violence was $5,500, the hospital costs associated with assault and maltreatment were significantly higher, averaging $11,800 and $11,200, respectively.

Table 1

Violence-related hospitalizations compared to all other hospitalizations, 2005.

Although stays associated with any violence were, on average, nearly half a day shorter than stays unrelated to violence (4.3 days versus 4.8 days), stays related to maltreatment resulted in hospitalizations that were almost two days longer (6.6 days). Stays resulting from self-inflicted violence averaged 3.9 days—one day shorter than stays for injuries sustained from assault by another person (4.9 days).

Compared to hospitalizations unrelated to violence, the rate of in-hospital deaths was 37 percent lower for stays associated with violence (1.5 percent versus 2.3 percent). In fact, the in-hospital death rate for self-inflicted violence (1.2 percent) was almost half that for stays unrelated to violence.⁴ Hospitalizations associated with assaults had an in-hospital death rate of 1.9 percent. Conversely, the rate of in-hospital deaths among patients admitted for trauma sustained as a result of maltreatment was 23 percent higher than the in-hospital death rate for stays unrelated to violence (2.9 percent versus 2.3 percent).

Hospital stays related to violence, by gender and age

Compared to hospitalizations unrelated to violence, violence-related stays occurred disproportionately among males (39.8 percent versus 54.2 percent) (figure 1). While males accounted for 82.4 percent of stays resulting from assaults, females accounted for the majority of hospitalizations related to maltreatment (63.9 percent) and self-inflicted violence (58.5 percent).⁵

Figure 1

Distribution of violence-related hospitalizations, by gender, 2005*. * Based on all-listed diagnoses. Excludes hospital stays for newborns. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide (more...)

Figure 2 illustrates that young adults and children were disproportionately hospitalized for violent traumas. Nearly three out of every four (74.1 percent) violence-related hospitalizations occurred among patients younger than 45 years old, as compared to 36.6 percent of hospitalizations not associated with violence. Young adults 18 to 44 years old made up the vast majority of stays associated with self-inflicted violence (62.0 percent) and assaults (68.3 percent). More than half (52.2 percent) of all hospitalizations related to maltreatment occurred among children younger than 18 years old. Elderly patients over 65 years old accounted for an additional 14.2 percent of stays associated with maltreatment.

Figure 2

Distribution of violence-related hospitalizations, by age group, 2005*. * Based on all-listed diagnoses. Excludes hospital stays for newborns. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide (more...)

Hospital stays related to violence, by primary payer

Reflecting the findings that a higher proportion of children and young adults are hospitalized as a result of violence, figure 3 shows that violence-related hospitalizations occurred disproportionately among patients covered by Medicaid and those who are uninsured. Compared to only 16.7 percent of stays unrelated to violence, 27.0 percent of violence-related stays were billed to Medicaid. Moreover, more than half (51.0 percent) of stays associated with maltreatment were billed to Medicaid. Similarly, the proportion of uninsured violence-related hospitalizations was more than four times the proportion of uninsured stays among hospitalizations unrelated to violence (22.6 percent versus 5.3 percent). In fact, uninsured patients accounted for 31.6 percent of stays associated with assaults—nearly six times the proportion of uninsured stays unrelated to violence.

Figure 3

Distribution of violence-related hospitalizations, by primary payer, 2005*. * Based on all-listed diagnoses. Excludes hospital stays for newborns. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide (more...)

Violence-related hospital stays were billed to Medicare and private insurance less frequently than hospitalizations not associated with violence. Medicare was billed for only 13.2 percent of violence-related stays—about one-third the rate of stays not associated with violence (41.9 percent). Medicare was billed for even fewer assault-related hospitalizations (7.4 percent). Conversely, the percentage of privately insured violence-related hospitalizations was only slightly lower than the percentage of privately insured stays unrelated to violence (30.0 percent versus 33.1 percent). However, privately insured patients comprised a significantly smaller percentage of stays associated with assault (21.1 percent) and maltreatment (18.9 percent).

Common principal diagnoses noted on hospital stays related to violence

With the exception of codes indicating maltreatment, codes indicating violence are reported as secondary diagnoses; thus, other conditions are primarily responsible for the patient’s admission to the hospital. Table 2 lists the most frequent principal diagnoses among stays related to self-inflicted violence, assault, and maltreatment. Among stays related to self-inflicted violence, over half were principally diagnosed with poisonings by medications and drugs (32.4 percent) or by psychotropic agents (23.8 percent). One in five stays related to self-inflicted violence had mood disorders (22.1 percent) as the principal reason for admission. Schizophrenia and substance-related disorders were also noted as principal causes of admission in these stays (3.2 percent and 2.6 percent, respectively).

Table 2

Top five principal diagnoses associated with violence-related hospitalizations, 2005.

For assault-related stays, nearly half of all hospitalizations were principally for serious physical injuries such as crushing or internal injuries (19.2 percent), skull and facial fractures (15.8 percent), and intracranial injuries (13.0 percent). Other injuries sustained during assaults and commonly noted as the principal diagnosis were open wounds of the head, neck, and trunk (9.8 percent) and open wounds of the extremities (5.4 percent).

Among stays associated with maltreatment, 33.3 percent noted other injuries and conditions due to external causes as the principal reason for admission. Among these other injuries and conditions were child physical abuse (49.8 percent), shaken infant syndrome (14.5 percent), and adult maltreatment syndrome (10.8 percent) (data not shown). Mood disorder was listed as the principal diagnosis for 5.4 percent of maltreatment-related hospitalizations. Intracranial injuries (5.0 percent), other complications of pregnancy (3.4 percent), and skull and face fractures (2.5 percent) were also among the top five principal diagnoses recorded for these stays.

Diagnoses, ICD-9-CM, E-codes, and Clinical Classifications Software (CCS)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient’s admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 12,000 ICD-9-CM diagnosis codes.

The External Cause of Injury Codes (commonly referred to as E-codes) supplement the ICD-9-CM diagnosis codes. These codes designate the cause of injury. Multiple E-codes may be present on a single hospital record.

CCS categorizes ICD-9-CM diagnoses into 260 clinically meaningful categories.⁶ This “clinical grouper” makes it easier to quickly understand patterns of diagnoses and procedures.

Case Definition

The ICD-9-CM codes defining violence include diagnoses and E-codes in the following range: 995.80–995.85, 995.50–995.59, V71.81, E967-E967.9, E960-E966, E968-E969, V71.5, V71.6, E950-E959, V62.84, E970-E978, E979.0-E979.9, E990-E999. It is important to note that these codes may be underutilized if there is stigma or fear associated with reporting violent behavior on the hospital record.

For this report, specific types of violence were defined as diagnoses and E-codes:

Self-inflicted

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E950.0-E959: Suicide and attempted suicide; self-inflicted injuries specified as intentional

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V62.84: Suicidal ideation

Assault

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E960.0-E966: Fight, brawl, rape; homicides and assaults using dangerous substances, firearms, explosives, cutting and piercing instruments

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E968.0-E968.3, E968.5-E969: Assault by fire and other unspecified means; late effects of injury purposely inflicted by others

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V71.5: Observation following alleged rape or seduction

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V71.6: Observation following other inflicted injury

Maltreatment

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995.5–995.59: Child maltreatment syndrome

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995.80–995.85: Adult maltreatment, unspecified; adult physical abuse; adult emotional/psychological abuse; adult sexual abuse; adult neglect (nutritional); other adult abuse and neglect

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V71.81: Observation and evaluation for abuse and neglect

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E967.0-E967.9: Child and battering/maltreatment; perpetrator codes

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E968.4: Criminal neglect

Types of hospitals included in HCUP

HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. They exclude long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals, but these types of discharges are included if they are from community hospitals.

Unit of analysis

The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate “discharge” from the hospital.

Costs and charges

Total hospital charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).⁷ Costs will tend to reflect the actual costs of production, while charges represent what the hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used because detailed charges are not available across all HCUP States. Hospital charges reflect the amount the hospital charged for the entire hospital stay and does not include professional (physician) fees. For the purposes of this Statistical Brief, costs are reported to the nearest hundred.

Payer

Payer is the expected primary payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:

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Medicare includes fee-for-service and managed care Medicare patients.

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Medicaid includes fee-for-service and managed care Medicaid patients. Patients covered by the State Children’s Health Insurance Program (SCHIP) may be included here. Because most state data do not identify SCHIP patients specifically, it is not possible to present this information separately.

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Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.

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Other includes Worker’s Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.

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Uninsured includes an insurance status of “self-pay” and “no charge.”

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

Admission source

Admission source indicates where the patient was located prior to admission to the hospital. Emergency admission indicates the patient was admitted to the hospital through the emergency department.

Discharge status

Discharge status indicates the disposition of the patient at discharge from the hospital, and includes the following six categories: routine (to home), transfer to another short-term hospital, other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home), home health care, against medical advice (AMA), or died in the hospital.