Intimate partner violence and clinical coding: issues with the use of the International Classification of Disease (ICD-10) in England

Walby S., Towers J., Balderston S., Corradi C., Francis B., Heiskanen M., Helweg-Larsen K., Mergaert L., Olive P., Palmer E., Stöckl H., Strid S.

Olive P.

Aims and Objectives The aim of this research was to explore the naming, or classification, of physical assaults by a partner as ‘intimate partner violence’ during emergency department consultations. Background Research continues to evidence instances when intimate partner physical violence is ‘missed’ or unacknowledged during emergency department consultations. Methods Theoretically this research was approached through complexity theory and the sociology of diagnosis. Research design was an applied, descriptive and explanatory, multiple-method approach that combined: qualitative semi-structured interviews with service users (n=8) and emergency department practitioners (n=9), and qualitative and quantitative document analysis of emergency department health records (n=28). Results This study found that multiple classifications of intimate partner violence were mobilised during emergency department consultations and that these different versions of intimate partner violence held different diagnostic categories, processes, and consequences. Conclusion The construction of different versions of intimate partner violence in emergency department consultations could explain variance in people's experiences and outcomes of consultations. The research found that the classificatory threshold for ‘intimate partner violence’ was too high. Strengthening systems of diagnosis (identification and intervention) so that all incidents of partner violence are named as ‘intimate partner violence’ will reduce the incidence of missed cases and afford earlier specialist intervention to reduce violence and limit its harms. Relevance to Clinical Practice This research found that identification of and response to intimate partner violence, even in contexts of severe physical violence, was contingent. By lowering the classificatory threshold so that all incidents of partner violence are named as ‘intimate partner violence’, practitioners could make a significant contribution to reducing missed intimate partner violence during consultations and improving health outcomes for this population. This research has relevance for practitioners in any setting where service-user report of intimate partner violence is possible. This article is protected by copyright. All rights reserved.

Olive P.

AIMS AND OBJECTIVES: The aim of this research was to explore women's emotional and affective responses following an incident of intimate partner violence experienced during emergency department attendances. BACKGROUND: A growing body of research has explored women's experiences of emergency departments following intimate partner violence still little remains known about the experience and impact of emotional and affective responses during these attendances. DESIGN: A descriptive qualitative design was used, underpinned theoretically by critical realism and postmodern complexity theory to attend to multiple, intersecting mechanisms that lie behind events and experiences. METHODS: Semistructured interviews with six women who had attended an emergency department directly following an incident of intimate partner violence. Interview data were transcribed and thematically analysed in nvivo9 using a coding framework. RESULTS: There were three interconnected key findings. First, was the commonality of acute stress experiences among women attending an emergency department following partner violence, second was that these acute stress reactions negatively impacted women's consultations, and third was the need for specialist domestic violence services at the point of first contact to assist service users navigate an effective consultation. CONCLUSIONS: Acute stress reactions were an important feature of women's experiences of emergency department consultations following intimate partner violence. Attending to psychological first aid; providing a safe and quiet space; and affording access to specialist violence advocacy services at the point of first contact will limit harm and improve health consultation outcomes for this population. RELEVANCE TO CLINICAL PRACTICE: This research provides an account of emotional and affective responses experienced by women attending emergency departments following intimate partner violence and explicates how these acute stress reactions impacted their consultation. This research has relevance for practitioners in many first contact health services, such as urgent and emergency care, general practice, community public health and mental health.© 2016 John Wiley & Sons Ltd. Language: en

Heyman R.E., Slep A.M., Foran H.M.

Nuanced, multifaceted, and content valid diagnostic criteria for intimate partner violence (IPV) have been created and can be used reliably in the field even by those with little-to-no clinical training/background. The use of such criteria such as these would likely lead to more reliable decision making in the field and more consistency across studies. Further, interrater agreement was higher than that usually reported for individual mental disorders. This paper will provide an overview of (a) IPV's scope and impact; (b) the reliable and valid diagnostic criteria that have been used and the adaptation of these criteria inserted in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM) and another adaptation proposed for the forthcoming International Statistical Classification of Diseases and Related Health Problems (ICD); (c) suggestions for screening of IPV in primary care settings; (d) interventions for IPV; and (e) suggested steps toward globally accepted programs.

McGovern A.P., Woodman J., Allister J., Van Vlymen J., Liyanage H., Jones S., Rafi I., De Lusignan S., Gilbert R.

Background Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE) but there is evidence of substantial under-recording.Aim To determine whether a simple coding strategy improved recording of maltreatment-related concerns in electronic primary care records.Design and Setting Clinical audit of rates of maltreatment-related coding before January 2010–December 2011 and after January–December 2012 implementation of a simple coding strategy in 11 English family practices. The strategy included encouraging general practitioners to use, always and as a minimum, the Read code ‘Child is cause for concern’. A total of 25,106 children aged 0–18 years were registered with these practices. We also undertook a qualitative service evaluation to investigate barriers to recording.Method Outcomes were recording of 1) any maltreatment-related codes, 2) child protection proceedings and 3) child was a cause for concern.Results We found increased recording of any maltreatment-related code (rate ratio 1.4; 95% CI 1.1–1.6), child protection procedures (RR 1.4; 95% CI 1.1–1.6) and cause for concern (RR 2.5; 95% CI 1.8–3.4) after implementation of the coding strategy. Clinicians cited the simplicity of the coding strategy as the most important factor assisting implementation.Conclusion This simple coding strategy improved clinician’s recording of maltreatment-related concerns in a small sample of practices with some ‘buy-in’. Further research should investigate how recording can best support the doctor–patient relationship.How this fits in Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE), but there is evidence of substantial underrecording. We describe a simple clinical coding strategy that helped general practitioners to improve recording of maltreatment-related concerns. These improvements could improve case finding of children at risk and information sharing.

Murray C.J., Ezzati M., Flaxman A.D., Lim S., Lozano R., Michaud C., Naghavi M., Salomon J.A., Shibuya K., Vos T., Wikler D., Lopez A.D.

Rhodes K.V., Kothari C.L., Dichter M., Cerulli C., Wiley J., Marcus S.

While victims of intimate partner violence (IPV) present to health care settings for a variety of complaints; rates and predictors of case identification and intervention are unknown. Examine emergency department (ED) case finding and response within a known population of abused women. Retrospective longitudinal cohort study. Police-involved female victims of IPV in a semi-rural Midwestern county. We linked police, prosecutor, and medical record data to examine characteristics of ED identification and response from 1999–2002; bivariate analyses and logistic regression analyses accounted for the nesting of subjects’ with multiple visits. IPV victims (N = 993) generated 3,426 IPV-related police incidents (mean 3.61, median 3, range 1–17) over the 4-year study period; 785 (79%) generated 4,306 ED visits (mean 7.17, median 5, range 1–87), which occurred after the date of a documented IPV assault. Only 384 (9%) ED visits occurred within a week of a police-reported IPV incident. IPV identification in the ED was associated with higher violence severity, being childless and underinsured, more police incidents (mean: 4.2 vs 3.3), and more ED visits (mean: 10.6 vs 5.5) over the 4 years. The majority of ED visits occurring after a documented IPV incident were for medical complaints (3,378, 78.4%), and 72% of this cohort were never identified as victims of abuse. IPV identification was associated with the day of a police incident, transportation by police, self-disclosure of “domestic assault,” and chart documentation of mental health and substance abuse issues. When IPV was identified, ED staff provided legally useful documentation (86%), police contact (50%), and social worker involvement (45%), but only assessed safety in 33% of the women and referred them to victim services 25% of the time. The majority of police-identified IPV victims frequently use the ED for health care, but are unlikely to be identified or receive any intervention in that setting.

Thavarajah D., Francis T., Rees L., Davies A.P.

Introduction: Clinical coding is important for financial payment, financial planning, provision of healthcare services, monitoring of health trends, audit, research and clinical governance. Coding among NHS trusts is performed by non-clinicans. The authors carried out an audit at Morriston Hospital, Swansea, to compare the difference between the way in which the coders and a surgeon coded for orthopaedic procedures. Morriston Hospital also receives tertiary referrals for more complex procedures that standard district general hospitals are unable to perform. Therefore, it also functions as a specialist trust. Methods: The authors undertook a retrospective analysisof 45 patient case notes of orthopaedic patients who had both trauma and elective orthopaedic surgery. These were first coded by the coder and then independently coded by the surgeon. Results: Clinical coders vs surgeons: Different code and different healthcare resource group (HRG) = 18%. Same code and same HRG = 33%. Different code and same HRG = 49%. Lost renumeration as a result = £4663 (over 1 month). Conclusions: Coding is often subject to inaccuracies due, in part, to the clinical coders (non-medical staff) and this could be improved. The coding system is flawed and generates inaccurate HRGs. Financial loss or gain can be a result of these flaws and inaccuracies. This is unacceptable for such a large organisation like the NHS, and is detrimental to individual trusts - both financially and for the provisionof health care.

Btoush R., Campbell J.C., Gebbie K.M.

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.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).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.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.

Bajaj Y., Crabtree J., Tucker A.G.

PurposeClinical coding is a process of accurate translation of written medical terms into codes. The Payment by Results initiative has focused attention on the quality of clinical coded data as all income for in patient services is derived from coded clinical data. The aim of this study was to evaluate the quality of clinical coded data by making comparisons between the information held on the dialect encoder system and the information recorded in the clinical case notes.Design/methodology/approachThe 50 episodes for this study were randomly selected from a list of all episodes ending August 2005 within the ENT specialty in a teaching hospital.FindingsThere were only 17 (34 per cent) episodes with a structured summary within the case notes. Of the 50 recorded primary diagnoses 42 (84 per cent) were correctly coded. Of the 43 recorded primary procedures, 37 (86 per cent) were correctly coded.Originality/valueThis study promotes a better awareness of the impact of poor coding and gives recommendations that will be helpful to those involved in coding processes.

Thiru K., Hague N.J., Wells S.E., de Lusignan S.

Summary Objective: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. Method: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. Results: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. Conclusions: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients’ views may help clarify the magnitude of this barrier.

Dusing G.J., Essue B.M., O'Campo P., Metheny N.

Sarkar R., Bassed R., Ozanne-Smith J.

Abstract Mortality data systems are upstream determinants of health, providing critical information on causes of death and population health trends and influencing health outcomes by shaping policies, research, and resource allocation. Moreover, the gender-related deaths of women and girls are significantly underrepresented or underrecognized in mortality data across many countries. This paper seeks to identify potential barriers and facilitators to improving the representation of femicide data. The primary barriers affecting data representation of femicide are related to definitions, data collection, coding, comparability, access, and systemic challenges. Key recommendations include establishing a nationwide consensus on the definition of femicide, updating training modules for medicolegal professionals, improving pathology reporting processes, ensuring quality assurance in documentation, refining coding practices, developing new analytic methods, and providing deidentified access to cases still under investigation.

Cruz S.S., Margerison C., Gemmill A., Ha S., Hurd T., Jensen J., Goldman-Mellor S.

Chen Y., Zhang L., Zhou Y., Zhang J., Yu H., Li Q., Xu J.

Abstract Introduction Health care workers represent a substantial demographic whose welfare and work efficiency are crucial to public health and societal well-being. However, the prevalence of sexual dysfunction within this group is often overlooked, despite its significant occurrence. Objective To evaluate the worldwide prevalence of sexual dysfunction among health care workers. Methods A comprehensive systematic review and meta-analysis of observational studies ranging from 2003 to 2023 were performed to compile prevalence estimates of sexual dysfunction among health care workers. A random effects model was implemented to amalgamate the prevalence analysis. Study heterogeneity was discerned by I2 and χ2 statistics. To assess potential publication bias, an Egger’s test and a funnel plot were employed. Results This meta-analysis incorporated 39 studies from 16 countries, encompassing 44 017 health care workers. The pooled prevalence of sexual dysfunction among health care workers was 46.79% (95% CI, 38.09%-55.68%), with a slightly higher prevalence of 49.57% (95% CI, 38.18%-61.01%) among clinical health care workers. The most prevalent forms of sexual dysfunction identified were loss of libido (51.26%), erectile dysfunction (36.99%), sexual dissatisfaction (36.90%), pain during intercourse (28.23%), orgasmic disorders (25.13%), low sexual arousal (23.54%), and lubrication disorders (22.62%). Among various health care professions, nurses exhibited the highest prevalence of sexual dysfunction (56.29%), followed by doctors (37.63%) and other health care workers (24.96%). Additionally, female health care workers experienced a higher prevalence of sexual dysfunction (47.61%) as compared with their male counterparts (32.01%). Conclusion This study indicates that nearly half of health care professionals report experiencing sexual dysfunction, with loss of libido being the most common manifestation. Addressing this issue requires a multistakeholder approach.

Metheny N., Dusing G.J., Essue B.M., O'Campo P.

AbstractThis study investigated the impact of non-physical intimate partner violence (IPV), including emotional and verbal abuse, and coercive/controlling behaviors, on Ontario Health Insurance Plan costs, the universal healthcare provider in the province of Ontario, Canada. Women exposed to non-physical IPV alone had 17% higher healthcare costs over 10 years compared to those not exposed, translating to CA$686 million in additional annual costs, challenging the perception that non-physical IPV is less harmful than physical forms. We argue for prevention of non-physical IPV and improved screening in healthcare settings is vital to mitigate its long-term impacts on individuals and healthcare systems.

Dusing G.J., Essue B.M., O'Campo P., Metheny N.

AbstractIntimate partner violence (IPV) is a major global health issue, yet few studies explore its long-term public healthcare burden in countries with universal healthcare systems. This study analyzes this burden among Canadian women using data from the Neighborhood Effects on Health and Wellbeing survey and Ontario Health Insurance Plan (OHIP) records from 2009-2020. We employed inverse probability weighting with regression adjustment to estimate differences in cumulative costs and OHIP billings between those reporting exposure to IPV during the survey and those who did not. Our sample included 1,094 women, with 38.12% reporting IPV exposure via the Hurt, Insult, Threaten, Scream scale. Findings show a significant public healthcare burden due to IPV: women reporting IPV in 2009 had an average of 17% higher healthcare costs and 41 additional OHIP billings (0.1732;95% CI: 0.0578-0.2886; 41.23;95% CI: 12.63-69.82). Policies prioritizing primary prevention and integration of trauma-informed care among healthcare providers are vital to alleviate the long-term burden on public health systems.

Fadeeva A., Barbosa E.C., Walker A., McManus S.

Violence is recognised as a cause of health harm, but it is not consistently or adequately captured in healthcare data systems. While administrative health records could be valuable sources of information for measuring violence, they remain underutilised in violence-related research. The present research aims to examine the suitability of violence indicators in emergency care, primary care, and linked healthcare datasets. Descriptive analyses were conducted with the 2015/16 Hospital Episode Statistics Accident and Emergency (HES A&E) and the 2021/22 Emergency Care Data Set (ECDS). The potential of the Clinical Practice Research Datalink (CPRD) and the South Wales Violence Surveillance dataset (a police and emergency department (ED) dataset linked by Public Health Wales) were shown using available evidence. Among the discussed datasets, the South Wales Violence Surveillance dataset has the most detail about violent acts and their contexts, while the CPRD includes a more extensive range of socioeconomic factors about patients and extensive linkage with other datasets. Currently, detailed safeguarding information is routinely removed from the ECDS extracts provided to researchers, limiting its utility for violence research. In the HES A&E, only physical violence was consistently recorded. Addressing these issues has the potential to improve the use of health administrative data in research on violence.

Gibson C.J., Bahorik A., Xia F., Peltz C., Yaffe K.

A growing body of evidence suggests adverse health outcomes related to intimate partner violence (IPV), including traumatic brain injury (TBI). However, most research in this area has focused on reproductive-aged women. To examine relationships between IPV (with and without TBI), mental health, and aging-related health outcomes among men and women Veterans across the lifespan. Cross-sectional analysis of Department of Veterans Affairs (VA) administrative data from fiscal years 2000–2019. Descriptive statistics and chi-square analyses were used to compare key comorbidities in matched samples of Veterans with and without IPV (gender-stratified and matched 1:3 based on demographics and index date). Comparisons between those with IPV and TBI relative to IPV alone were also examined. Veterans aged 18 + with and without documented IPV in Department of Veterans Affairs (VA) electronic health records (n = 4108 men, 2824 women). ICD codes were used to identify IPV, TBI, and aging-related medical (sleep disorder, hypertension, diabetes, dementia) and common psychiatric (depression, posttraumatic stress disorder, alcohol use disorder, and substance use disorder) diagnoses. Demographic characteristics were reflective of VA-enrolled Veterans (men: mean age 66, SD 16; 72% non-Hispanic White; women: mean age 47, SD 13; 64% non-Hispanic White). Relative to Veterans without IPV, both men and women with IPV had higher rates of all examined medical (e.g., sleep disorders, men: 33% vs. 52%; women: 45% vs. 63%) and psychiatric diagnoses (e.g., depression, men 32% vs. 74%; women 59% vs. 91%; all ps < .001), with evidence of an additive effect of TBI on some psychiatric outcomes. IPV is broadly associated with aging-related and mental health, and TBI is a common correlate that may further contribute to psychiatric outcomes. Findings highlight the importance of trauma-informed care and recognizing the potential role of these exposures on men and women Veterans’ health across the lifespan.

Blom N., Fadeeva A., Barbosa E.C.

Violence reduction is a United Nations (UN) sustainable development goal (SDG) and is key to both public health and criminology. The collaboration between these fields has the potential to create and improve prevention strategies but has been hampered by the usage of different definitions and measurements. This paper explores the definitions and measurements of violence by the World Health Organization, UN, and Council of Europe to arrive at a harmonized framework aligned with the SDGs. Violence and abuse are defined by these organizations as intentional actions that (are likely to) lead to harm, irrespective of physicality or legality. When recording violence and abuse, health- and justice-based administrative systems use different codes which cannot directly be translated without resorting to broad overarching categories. Additionally, the identification of the number of victims, perpetrators, and events is challenging in these systems due to repeat victimization/offending, multiple victims/perpetrators, and multiple engagements with services associated with a single event. Furthermore, additional information on the victims (e.g., ethnicity) and events needs to be registered to evaluate progress toward the SDGs. We propose a framework to record violence that includes individual and event identifiers, forms of violence and abuse (including physical, sexual, and psychological), harm, and individual and event characteristics.

Kar A., Das N., Broadway-Horner M., Kumar P.

Intimate partner violence (IPV) has been a significant public health problem in same-sex relationships. However, health policies across the globe do not address IPV causing a massive gap in health and economic burden. In the last decade, crucial missing links have been established, and researchers tried to connect the dots of this severe health disparity. This intersectionality has found the impact of race, gender, class, physical ability, and legal framework of IPV in lesbian, gay, and bisexual (LGB) relationships. However, preventive strategies, training programs, and dialogues in the clinical field about IPV are from heteronormative lenses. This particular bias can perpetuate the issue and will remain one of the leading causes of health burden in the LGB population. This article reviews the lacunae in health policies regarding same-sex IPV, highlights its impact on minority mental health, and calls for attention to train health-care professionals regarding the same.

Kerr P.L., Bryant G.

Objectives: People experiencing trafficking often seek health care but are not identified. Although the Centers for Disease Control and Prevention added new International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes specific to human trafficking (hereinafter, HT ICD-10-CM codes) that could systematize the identification and documentation of human trafficking in US health care settings, the extent of their use is unknown. The objectives of this study were to investigate (1) the frequency of HT ICD-10-CM code use in US health care organizations (HCOs) and (2) demographic data associated with HT ICD-10-CM codes using a large clinical database. Methods: This retrospective study used deidentified data collected from October 1, 2018, through March 30, 2021, from a clinical database (N = 69 740 144 patients) network (TriNetX) of 48 collaborating US HCOs. Data included number of patients with ≥1 HT ICD-10-CM code, diagnoses, and demographic characteristics (age, sex, race, ethnicity, and region). Results: HT ICD-10-CM codes were associated with 298 patients in US HCOs, most of whom were young (mean [SD] age, 26 [16] y), White (53.0%; n = 158), and female (87.9%; n = 262). Thirty-seven of 48 (77.1%) participating HCOs used ≥1 HT ICD-10-CM code. The most frequently used HT ICD-10-CM codes were “forced sexual exploitation, suspected” (32.2%; n = 96) and “personal history of forced labor or sexual exploitation” (27.1%; n = 81). Labor trafficking codes were noted in approximately 3.7% of cases. Conclusions: HT ICD-10-CM codes are being used by health care professionals, as confirmed by large databases. Further research is needed to understand variation in code use and risk factors associated with human trafficking.

Rebbe R., Adhia A., Eastman A.L., Chen M., Winn J.

Intimate partner violence (IPV) is challenging to measure yet systematic surveillance of IPV is critical to informing public health prevention and response efforts. Administrative medical data provide opportunities for such surveillance, and often use the International Classification of Diseases (ICD). The primary purpose of this systematic review was to document which ICD codes have been used in empirical literature to identify IPV, understand the justification used to select specific codes to develop IPV case definitions, and identify the data sources and types of research questions addressed by the existing literature. We searched 11 databases and of the initial 2182 results, 21 empirical studies from 2000 to 2020 met the study inclusion criteria including using ICD codes to measure IPV. The majority of these studies (90.5%) used either national samples of data or population-based administrative data from emergency departments (52.4%) or inpatient hospitalizations (38.1%). We found wide variation of ICD diagnostic codes to measure IPV and categorized the sets of codes used based on the number of codes. The most commonly used ICD-9 codes were E967.3, 995.81, 995.80, 995.85 and the most common ICD-10 codes were T74.1 and Z63.0. Few studies validated the ICD codes used to measure IPV. Most included studies (81.0%) answered epidemiological research questions. The current study provides suggestions for future research, including justifying the selection of ICD codes and providing a range of estimates based on narrow and broad sets of codes. Implications for policy and practice, including enhanced training for healthcare professionals in documenting IPV, are discussed.

Kishton R., Sinko L., Ortiz R., Islam M.N., Fredrickson A., Sheils N.E., Buresh J., Cronholm P.F., Matone M.

Introduction: Violence against women (VAW) can result in long-term and varied sequela for survivors, making it difficult to evaluate healthcare intervention. This study seeks to improve understanding of the healthcare experiences of women survivors prior to a violence-related diagnosis, allowing healthcare systems to better design strategies to meet the needs of this population. Methods: Using population-based data from 2016 to 2019, this cross-sectional observational study presents healthcare spending, utilization, and diagnostic patterns of privately insured women, age 18 or older, in the 10-months prior to an episode of care for a documented experience of violence (DEV). Results: Of 12 624 764 women meeting enrollment criteria, 10 980 women had DEV. This group had higher general medical complexity, despite being 10 years younger than the comparison group (mean age 32.7 vs 43.5). These relationships held up when comparing participants in each cohort by age. Additional key findings including higher numbers of medical visits across clinical settings and higher total cost ($10 138-$4585). Conclusions: The study utilized population-based data, to describe specific areas of health and medical cost for women with DEV. Increased medical complexity and utilization patterns among survivors broaden the understanding of the health profiles and healthcare touchpoints of survivors to inform and optimize strategies for medical system engagement and resource allocation for this public health crisis.

Rowe R.K., Murphy S.M., Handmaker H., Lifshitz J.

Domestic violence (DV) is a chronic societal epidemic that often involves physical assault to the head, neck, and face, which increases the risk of traumatic brain injuries (TBIs) in DV victims. However, epidemiological data on the extent of TBI-DV at the population scale remain sparse. We performed a statewide, multi-institution, retrospective review of all medical records for patients diagnosed with a concussion, the most common type of TBI, at health care facilities in Arizona, USA, that were licensed by Arizona Department of Health Services (ADHS) during 2016-2018. De-identified records were extracted from discharge data reported to ADHS, which we decoded and transformed to spatiotemporal demographic data of patients who were diagnosed with concussion concurrent with DV. Among 72,307 concussion diagnoses, 940 were concurrent with DV. Sixteen patients died as a result of TBI-DV injuries, where TBI is defined as concussion. Although females were most of the TBI-DV diagnoses, median ages for males and females were 1 and 32 years, respectively, demonstrating that males were predominantly child abuse victims. Whites and Hispanics were victims most diagnosed with concussion and DV, but Native Americans and Blacks comprised a much greater proportion of diagnoses compared with the representative state demographics. Although likely underreported, approximately half of the cases were inflicted by intimate partners, which corresponded closely to marital status. Surprisingly, 61% of victims sought medical treatment for non-concussion injuries and then concussion was entered as a primary diagnosis. The demographic and health care facility disparities demand TBI/concussion screening in suspected DV patients, education and training of care providers, and potential redistribution of resources to select health care facilities.

Koohestani D., Chobrutskiy B.I., Janjua H., Velanovich V.

To assess 4 measures of the accumulating deficits model of frailty for postoperative mortality and readmissions including their stability over time.Frailty has been assessed by multiple methods. It is unclear whether variation in how frailty is measured is important and would be stable over time.Rockwood's 57-item frailty index was mapped onto 14,568 ICD9 diagnosis codes from Healthcare Cost and Utilization Project State Inpatient Database for the state of Florida (HCUP-SID-FL) for calendar years 2011 to 2015, inclusive, with 962 ICD9 codes matching onto 42 items. This became the modified frailty index (mFI) used. Three measures of the mFI were differentiated: the number of admission diagnoses, number of chronic conditions upon admission, and number of increased deficits accumulated during the admission. The Charlson Co-Morbidity Index was a fourth measure of frailty. The mFI of patients who survived or died and were readmitted or not were compared.Across all years, 4,796,006 patient observations were compared to the number of diagnoses matched on the 42 items of the mFI. The median mFI scores for each method was statistically significantly higher for patients who died compared those that survived and for patients readmitted compared to patients not readmitted for all years. There was little-to-no variation in the year to year median mFI scores.The 4 methods of calculating frailty performed similarly and were stable. The actual method of determining the accumulated deficits may not be as important as enumerating their number.