United States Emergency Department Visits Coded for Intimate Partner Violence

Abstract

Introduction

Each year in the United States (US), nearly 7 million women and 5.6 million men experience rape, physical violence, or stalking by an intimate partner (1). Intimate partner violence (IPV) results in injury for approximately 15% of women and 4% of men—half of which require medical care as a result of IPV (1). The emergency department (ED) is often the first point of care for victims of IPV experiencing acute injuries (2). Up to 14% of female patients treated in the ED are there for IPV-related conditions. In addition, between 5% and 38% of all women seen in the ED report experiencing IPV in the previous year (3).

Although a significant body of literature has emerged examining the prevalence of IPV in health care set-tings, as well as the effectiveness of IPV screening and intervention efforts, limited information exists about the medical treatment that victims of IPV receive (3—9). In addition, aggregate data about specific injuries and costs associated with IPV that can be gleaned from patient medical and billing records are garnered mostly from statewide surveillance systems, which precludes generalizability to the entire US population (10—13). Nationally representative estimates on this topic are dated or focus solely on treat-and-release ED visits (14—17).

Victims of IPV report having more unmet health care needs than nonvictims, despite utilizing the health care system more frequently and having higher medical expenses (3,18—20). In addition, in both ED and inpatient settings, patients seeking care for complaints unrelated to violence will often return for treatment for injuries as a result of IPV at a later date (3,21—24). One study found that women murdered by an intimate partner had an ED visit in the 2 years before their death, and the vast majority had at least one injury-related visit (25). These statistics underline the imperative for identifying patients who may be experiencing violence, yet a debate is still ongoing about the risks and benefits of universal screening for IPV in health care settings. The development of a targeted screening protocol for patients who may be experiencing IPV, but may not disclose to their provider, will not only give a more complete picture of the health care they receive, but can also establish a risk profile that can ultimately aid in appropriate diagnosis and management of these patients.

The objective of this study was to estimate the number of ED visits and subsequent hospitalizations that were as-signed a code specific to IPV in the US from 2006–2009 and to describe the clinical and socio demographic features of this population.

Methods

Results

Based on HCUP NEDS estimates, there were a total of 496,195,793 visits made to US EDs from 2006 to 2009, 112,664 of which had an e-code for battering by an intimate partner or spouse in the billing record. The mean annual estimate for the 4-year period was 28,166 visits. The demographic characteristics of the sample, stratified by discharged vs. admitted, are presented in Table 1. Visits were made mostly by female patients (93%). Mean age of the entire sample was 35 years and male patients were significantly older (40.42 years; 95% confidence interval [CI] 39.57—41.27) than female patients (34.74 years [95% CI 34.50-34.97]) presenting with IPV-related injuries. Approximately 5% of visits resulted in admission to the hospital. Patients that were treated and released from the ED were significantly younger than those admitted (34.52 years [95% CI 34.29-34.75] vs. 45.67 years [95% CI 44.63-46.71]). Most patients were self-pay, had private insurance, or used Medicaid as their primary payer, with a small number of patients covered by Medicare or other sources. In addition, patients were significantly more likely to reside in communities with the lowest median income quartile (≤$38,999) (34.21% [95% CI 31.84—36.65]) compared to all other income categories (2^nd quartile, 28% [95% CI 26.14-29.94], 3^rd quartile, 20.51% [95% CI 19.19-21.90], and 4^th quartile, 14.30% [95% CI 12.91-15.81]). Visits were also more likely to occur at EDs in the Southern region of the United States (34.80% [95% CI 31.76-37.96]) compared with the Northeast (19.47% [95% CI 16.75-22.52]), Midwest (25.79% [95% CI 23.09-28.69]), and West (19.94% [95% CI 17.77-22.30]).

Table 2 shows the mean and total charges for visits resulting in discharge from the ED and those that required admission to the hospital. Mean charge for those treated and released was $1904.69 and $27,068.00 for admitted patients. There were no significant differences in mean charges based on sex. During the 4-year period, visits and subsequent admissions for IPV resulted in > $300,000,000 in charges. The most common primary diagnosis for the visits was superficial injury and contusion. Other common primary diagnoses included the following: injuries and conditions due to external causes, sprains and strains, open wounds of head, neck, and trunk, skull and face fractures, and complications of pregnancy (Table 3). Females were significantly more likely to have superficial injuries and contusions (34.15% [95% CI 32.85-35.47] vs. males, 27.51% [95% CI 25.11-30.04] males), as well as sprains and strains (8.07% [95% CI 7.57-8.60] vs. males, 2.90% [95% CI 2.16-3.90]), and males were more likely to have open wounds of the head, neck, or trunk (19.76% [95% CI 17.82-21.85] vs. females, 6.15% [95% CI 5.79-6.53]) and open wounds of extremities (9.92% [95% CI 8.46-11.61] vs. females, 1.68% [95% CI 1.66-2.02]). As can be seen in Table 4, suture of skin and subcutaneous tissue was the most common principal procedure performed on patients. Males were significantly more likely to undergo suture of skin and subcutaneous tissue (43.06% [95% CI 36.99-49.35] vs. females, 17.78% [95% CI 15.23-20.64]), and females were more likely to receive traction, split, and wound care (10.73% [95% CI 8.70-13.8] vs. males, 4.92% [95% CI 2.98-8.02]), as well as diagnostic radiology techniques (14.22% [95% CI 10.49-18.98] vs. males, 4.30% [95% CI 2.04-8.85]) and computed tomography scans (10.95% [95% CI 8.73-13.64] vs. males, 3.05% [95% CI 1.64-5.60]).

Discussion

These findings are consistent with previous research using national probability samples to estimate IPV visits to the ED. Btoush et al. examined ED visits coded for IPV using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 to 2001 (14). The authors found 94% of visits were made my females and the mean age of patients was 35.5 years. The majority of patients lived in metropolitan areas, 38% were uninsured, and 31% had private insurance. Our study replicates these findings with more recent data. However, Btoush et al. reported an estimated 80,000-120,000 IPV-related ED visits annually, while our data estimates are closer to 28,000 visits per year (14). This discrepancy is almost certainly due to the use of different definitions for what is considered an IPV-related visit. The authors of earlier studies have intentionally chosen broader maltreatment codes to identify IPV (eg, adult maltreatment, unspecified; adult physical abuse; adult emotional/psychological abuse; adult sexual abuse), which may characterize abuse perpetrated by individuals other than intimate partners (eg, elder abuse, as-sault by a stranger, abuse between adult siblings, parental abuse toward adult children). We purposely selected only cases with an e-code (E967.3) that specified injuries were the result of violence by an intimate partner. In addition, the previously mentioned underutilization of e-codes may account for the differences between our estimates and those found in previous studies.

Our data corroborate previous studies of IPV-related injuries and treatment. IPV victims present to the ED with multiple complaints and injuries, often with contusions, lacerations, abrasions, and fractures to multiple body sites, especially the head, face, and neck (10,28—32). In their analysis of IPV and non—IPV-related assaults, Yau et al. found that IPV victims were significantly more likely to have head injuries than victims of non-IPV assaults (10). Earlier nationally representative data show the most common diagnoses for IPV-related ED visits to be injury to upper or lower extremities and injuries to the head, neck, and trunk, and that diagnostic/radiologic testing and wound care is often performed during IPV visits (17). A substantial proportion of such diagnoses and procedures were observed in IPV-related visits in the current study as well.

Although most of these findings further validate what is already known about ED visits coded for IPV on a national level, the current study adds several important elements to the literature on this topic, where earlier research was limited. First, the most current nationally representative data on this topic are now more than a decade old and, given the recent focus on IPV screening in health care settings, up-to-date estimates are needed (14,15,17). In addition, earlier studies concentrated solely on ED visits coded for IPV and did not offer specific information (such as principal diagnoses, procedures, and charges) about visits to the ED that resulted in admission. We were able to stratify our results by disposition status and report data on cases that were severe enough to warrant admission to the hospital. Small sample sizes in other studies precluded the ability to provide information about male victims of IPV, but our study provides information about the treatment of IPV perpetrated against male victims. Finally, earlier studies have intentionally cast a wide net with the inclusion of multiple codes that may characterize IPV, making it impossible to discern the perpetrator of the violence. The use of an e-code assigned specifically for IPV (that has a 96% sensitivity rate) increases the probability that the cases included in this study represent IPV and not violence committed by other groups of perpetrators, although likely under-estimates the true magnitude of the problem.

Conclusions

During the 4-year study period, there were 112,664 visits to US EDs for IPV with an e-code for battering by an intimate partner or spouse. The vast majority were female patients from lower-income communities in metropolitan regions. Visits from self-pay, privately insured, and Medicaid patients were equally represented in the data. Discharge diagnoses included mostly non-life threatening injuries. The cost of these visits totaled > $300 million from 2006–2009–close to $80 million annually. 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.

References