Intimate Partner Violence Injuries --- Oklahoma, 2002

Intimate partner violence (IPV) is a serious public health problem in the United States and a common cause of injury. Prevalence rates of IPV vary by the surveillance methods and definitions used (1). National data from the 1995 National Violence Against Women Survey indicate that 22.1% of women and 7.4% of men experience IPV during their lifetimes and that 1.3% of women and 0.9% of men experience IPV annually (2). IPV results in an estimated $4.1 billion each year in direct medical and mental health-care costs, including $159 million in emergency department (ED) treatments for IPV physical assaults (3). IPV might constitute as much as 17% of all violence-related injuries treated in EDs (4). To determine the magnitude of the IPV problem in Oklahoma, including IPV-related injuries and medical service utilization, researchers analyzed injury surveillance data from ED medical records and data from the Oklahoma Women's Health Survey (OWHS). This report summarizes the findings, which indicated that, during 2002 in Oklahoma, approximately 16% of all ED visits for assaults were for IPV injuries, including 35% of assault visits among females and 3% of assault visits among males. In addition, results of the OWHS for 2001--2003 indicated that 5.9% of surveyed Oklahoma women aged 18--44 years sustained an IPV injury during the preceding year. Overall, IPV resulted in a substantial number of injuries, particularly to women, many of whom required treatment in EDs. Medical recognition and documentation of IPV are important for identification of persons in need of services.

IPV Injury Surveillance in EDs, 2002

IPV injuries* became a reportable condition to the Oklahoma State Department of Health (OSDH) in January 2000 for the purposes of a 5-year study. After a pilot project in the Oklahoma City metropolitan statistical area (MSA) during July 1, 2000--December 31, 2001, IPV injury surveillance was conducted statewide during 2002. Data were collected via a random sample of 118 hospital EDs (N = 20), stratified by hospital size (large: >100 beds; small: <99 beds) to ensure a representative sample of Oklahoma hospitals. All ED medical records for assaults (external cause of injury codes,^† E960--E968.9) and adult abuse/maltreatment (ICD-9-CM^§ codes 995.81--995.85) were reviewed to identify IPV injuries; an assault was determined to be IPV if the medical record indicated that the perpetrator of the injuries was an intimate partner. Intimate partners included current and former marital and nonmarital partners, dating partners, and same-sex partners. Males and females aged >15 years were included. Multiple ED visits for IPV injuries sustained during the same assault incident were counted once. Weighted population estimates and 95% confidence intervals (CIs) were derived from the sample data using hospital size and total number of annual ED admissions reported by hospitals in the state's annual health-care utilization survey. Rates were calculated using U.S. Census bridged-race population estimates for 2002 for persons aged >15 years.

A total of 3,988 ED medical records for assaults from the sampled hospitals were reviewed. Of these, 648 (16%) were documented as IPV assaults. Among females, 575 (35%) of all ED assault records reviewed were IPV-related, whereas 73 (3%) of ED assault records among males were IPV-related. For 1,939 (49%) of the assaults (31% of assaults on females and 61% of assaults on males), the perpetrator was not specified. After exclusions were applied (persons who died or were hospitalized, out-of-state residents, and multiple treatments for the same assault), 594 (15%) IPV injury cases were identified. The sample data were weighted, yielding an estimated 2,457 (CI = 2,188--2,726) IPV cases treated in EDs statewide (rate: 88.6 per 100,000 population aged >15 years). Ninety-one percent of cases were among females (mean age: 32 years, range: 16--66 years), and 9% were among males (mean age: 36 years, range: 18--68 years). Ninety percent of females treated for IPV injuries in EDs were aged 18--44 years.

IPV injury rates varied by race. The rate of IPV injuries per 100,000 population aged >15 years among black females (546.2) was 2.8 times higher than the rate for American Indian/Alaska Native females (192.3) and 4.7 times higher than the rate for white females (116.1). Black females had the highest rate of IPV injury across all age groups (Table 1). Among males, the rate per 100,000 population aged >15 years for blacks (94.8) was more than five times higher than that for American Indians/Alaska Natives (18.2) and nearly 12 times higher than that for whites (8.5).

A total of 1,351 injuries for 576 IPV injury cases were documented and classified by injury type and anatomic site of injury. The majority (83%) of persons with IPV injuries had soft-tissue injuries; 16% had strains/sprains, 10% had fractures/dislocations, 7% had brain injuries, 1% had eye injuries, 1% had stab wounds, and 2% had other injuries. The most frequently injured body regions were the head, neck, and face (48% of injuries), followed by the upper extremities (25%), chest and back (12%), lower extremities (10%), and abdomen/pelvic region (3%) (Table 2).

IPV Data from OWHS, 2001--2003

OWHS data were collected during 2001--2003 in a random-digit--dialed telephone survey of 6,163 Oklahoma women aged 18--44 years who were married or had a romantic relationship or date during the preceding year. The sampling scheme and survey administration followed Behavioral Risk Factor Surveillance System (BRFSS) methodology (5), with changes made to account for survey differences in study inclusion criteria. All analyses were weighted for the sampling design. Definitions of IPV used in the survey were derived from CDC-recommended definitions (1). Survey respondents who reported at least one occurrence of physical IPV or forced sexual IPV by any current or former partner during the preceding year were asked about resulting injuries. Women who reported any preceding-year IPV injury were asked about their need for and use of medical services. The CASRO response rate was 65.5%.

Among 6,163 respondents to the OWHS, 330 (weighted percentage: 5.9%; CI = 5.0%-- 6.8%) women reported IPV injuries during the preceding year. Nearly one third (31.6%) of injured women reported that they needed medical attention for their injuries; 13.2% reported never receiving medical attention when needed, 12.2% sometimes received medical attention when needed, and 6.3% reported always receiving medical services when needed (Table 3). A total of 18.4% (CI = 13.6%--24.5%) of women with IPV injuries received at least one type of medical treatment during the preceding year. Treatment for IPV injuries was received in hospital EDs by 9.8% of injured women; 2.1% were hospitalized overnight, and 3.3% received emergency medical services, including ambulance or paramedic services. Eleven percent of injured women received treatment at a private doctor or dental office, and 5.7% received treatment in an urgent care or other health clinic.

Reported by: S Brown MPH, Oklahoma State Dept of Health. LH Malcoe, PhD, EA Carson, MS, Dept of Family and Community Medicine, Univ of New Mexico School of Medicine.

Editorial Note:

In 1992, the American Medical Association issued diagnostic and treatment guidelines for IPV and a call for routine screening (6). Since that time, the practice of screening women for abuse has come under question (7). Screening has been effective for identifying abuse but has not been demonstrated to reduce violence (8). Evidence that screening is beneficial or, at least, not harmful, is lacking (9). However, the health and mental health consequences of IPV are well documented and sufficient to warrant identification, treatment, and service referral for IPV in the medical setting (10).

Data in this report demonstrate that IPV has a substantial impact on health-care systems in Oklahoma, with implications for provision of medical, social, and judicial services, particularly for minority women. The prevalence of IPV injury among black women treated in EDs was substantially higher than the prevalence among American Indian/Alaska Native or white women, some of which might be accounted for by racial differences in ED utilization patterns, patient disclosure of IPV, or provider query about IPV. The OWHS data further suggest that ED treatment for IPV injuries represents only about 10% of women injured by a partner each year.

The findings of this report are subject to at least five limitations. First, inclusion of IPV injury cases depended on documentation in ED medical records, which were often incomplete. The perpetrator was not specified and IPV status could not be determined for nearly half of the assaults noted in ED records. Thus, the reported rates of ED treatment for IPV injuries are likely underestimates. Second, the sampled hospitals might not have used standard practices for identifying IPV, which would also affect rate estimation. Third, the total number of IPV assaults was used to calculate rates per 100,000 population; however, 18 (3%) persons were treated for more than one assault during the study period and were counted more than once, which also affected rate estimation. Fourth, the survey data might also underestimate IPV injury prevalence because women experienced the most severe IPV might not have been able to participate in a telephone survey. Finally, injury rates from the survey data might not be generalizable to the target population because of nonresponse.

Medical tracking systems depend on recognition and documentation. A separate study conducted by OSDH in the Oklahoma City MSA revealed that only 43% of IPV hospitalizations were identified by specific IPV codes: external cause of injury code for partner/spouse perpetration (E967.3) and/or the ICD-9-CM code for adult physical abuse (995.81) (OSDH, unpublished data, 2005). For the ED data presented in this report, case ascertainment was not possible in nearly half of the ED assault records reviewed because the perpetrator of the assault was not specified. Because of the nature and stigma of IPV, a proportion of cases will never be recognized as IPV. However, improving medical recognition and documentation of IPV through continued training and policy is warranted, not only for surveillance purposes but also to identify persons in need of services. OSDH is providing training for hospital personnel and health-care providers on IPV screening, recognition, documentation, and service referral. The findings of this report will also be used in strategic planning to determine priorities for prevention of IPV in Oklahoma.

Acknowledgments

The findings in this report are based, in part, on contributions by C Smith-Edwards, MA, YWCA of Oklahoma City; S Mallonee, MPH, P Archer, MPH, Oklahoma State Dept of Health; B Skipper, PhD, Univ of New Mexico School of Medicine; P Mariolis, CDC; and Oklahoma medical records directors, ED nurse managers, ED medical directors, and hospital administrators.

References

1. Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta, GA: CDC, National Center for Injury Prevention and Control; 1999. Available at http://www.cdc.gov/ncipc/pub-res/ipv_surveillance/intimate.htm.
2. Tjaden P, Thoennes N. Full report on the prevalence, incidence, and consequences of violence against women. Washington, DC: US Department of Justice; 2000. Publication no. NCJ-183781. Available at http://www.ojp.usdoj.gov/nij/pubs-sum/183781.htm.
3. CDC. Costs of intimate partner violence against women in the United States. Atlanta, GA: US Department of Health and Human Services, CDC; 2003. Available at http://www.cdc.gov/ncipc/pub-res/ipv_cost/00_preface.htm.
4. Bureau of Justice Statistics. Violence-related injuries treated in hospital emergency departments. Washington, DC: US Department of Justice; 1997. Publication no NCJ-156921. Available at http://www.ojp.usdoj.gov/bjs/abstract/vrithed.htm.
5. CDC. Behavioral Risk Factor Surveillance System: survey data and technical information. Atlanta, GA: US Department of Health and Human Services, CDC. Available at http://www.cdc.gov/brfss/technical_infodata.
6. Flitcraft A, Hadley S, Hendricks-Matthews M, McLeer S, Warshaw C. Diagnostic and treatment guidelines on domestic violence. Chicago, IL: American Medical Association; 1992. Available at http://www.ama-assn.org/ama/pub/category/3548.html.
7. US Preventive Services Task Force. Screening for family and intimate partner violence: recommendation statement. Ann Intern Med 2004; 140:382--6.
8. Wathen C, MacMillan H. Interventions for violence against women: scientific review. JAMA 2005;289:589--600.
9. Ramsay J, Richardson J, Carter Y, et al. Should health care professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314.
10. Campbell JC. Health consequences of intimate partner violence. Lancet 2002;359:1331--6.

* For injury surveillance purposes, IPV injuries were defined as intentional injuries inflicted by an intimate partner. Cases included only Oklahoma residents.

^† Available at http://www.cdc.gov/nchs/about/otheract/ice/matrix10.htm.

^§ International Classification of Diseases, Ninth Revision, Clinical Modification.

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Date last reviewed: 10/19/2005