The Group Health Study Group
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1 A Hidden Pandemic: Intimate Partner Violence in Healthcare Amy E. Bonomi, PhD, MPH The Ohio State University The Group Health Study Group Robert S. Thompson, MD Frederick P. Rivara, MD, MPH Amy E. Bonomi, PhD, MPH Melissa L. Anderson, MS Robert J. Reid, MD, PhD Paul Fishman, PhD David Carrell, PhD Jane Dimer, MD Funding: Agency for Health Research & Quality & Group Health Foundation 2 Presentation Agenda. Overview of Group Health s Intimate Partner Violence (IPV) study 2. Prevalence 3. Medical Diagnoses 4. Healthcare Utilization & Costs 5. Responding in Healthcare 3
2 Study Objectives Describe the burden of intimate partner violence: Prevalence Type Frequency Duration Severity Health Effects Resulting Health Care Utilization & Costs 4 Study Sample 3,429 women & 42 men randomly sampled from Group Health membership files Age 8+ Insured by Group Health for at least 3 years Participated in telephone survey Current health status IPV victimization in adult lifetime Permission to consult medical records 5 Sample Characteristics Women n=3429 Men n=42 Age, mean 46 years 53 years White/Caucasian 83% 86% Education, some college 88% 89% Children living in home 34% 23% Currently in relationship 82% 84% 6 2
3 Abuse Definition Actual or threatened physical, psychological, and sexual violence used by an intimate partner to cause harm or trauma (Centers for Disease Control) 7 Abuse Assessment Women s Experience with Battering Scale ( questions) Behavioral Risk Factor Surveillance System (5 questions) Physical Partner ever hit, slapped, shoved, choked, kicked, k shaken, or physically hurt you? Forced you to participate in a sex act against your will? Threatened, coerced, physically forced you into sexual contact that didn t result in intercourse? Non-physical Put you down, called you names repeatedly, or controlled your behavior? Been frightened for your safety, or that of your family/friends, because of anger/threats? 8 Abuse Question Administration Behavioral Risk Factor Surveillance System questions Ever, in past 5 years, in past year Year it started and stopped Number of incidents, severity 9 3
4 Diagnoses and Health Care Utilization & Costs Medical Diagnoses Abstracted from health records Health Utilization & Costs Used health records to construct -year utilization trajectories Primary care Specialty Pharmacy Mental health Assigned costs to each service unit used Presentation Agenda. Overview of Group Health s study 2. Prevalence 3. Medical Diagnoses 4. Healthcare Utilization & Costs 5. Responding in Healthcare Prevalence BRFSS questions Perce ent Past year Past 5 years Lifetime Men Women 2 4
5 Lifetime Abuse Types Perc cent Physical Nonphysical Any IPV Men Women 3 IPV Frequency - Men time 2-5 times 6 + times Non-physical Physical Percent 4 IPV Duration - Men 5. Non-physical Physical 4. Years 5 5
6 IPV Severity - Men Not/slightly violent Moderately/extremely violent Non-physical 8 2 Physical Percent 6 IPV Frequency - Women time 2-5 times 6 + times Control Threats Sex cont Rape Physical Percent IPV Duration Women Control Threats Forced sex Sexual contact Physical Years 8 6
7 IPV Severity Women Not/slightly violent Moderately/extremely violent Threats Forced sex Sexual contact Physical Control Percent 9 Prevalence - Summary Intimate partner violence affects in 2 women in4men Women & men experience physical and nonphysical types of violence Abuse often not an isolated incident Abuse more severe in women 2 Presentation Agenda. Overview of Group Health s study 2. Prevalence 3. Medical Diagnoses 4. Healthcare Utilization & Costs 5. Responding in Healthcare 2 7
8 Diagnoses Women Only Used health records to examine 4 diagnoses occurring in at least 5% of women Estimated risk of diagnoses in abused relative to nonabused women during the year abuse exposure occurred Analyses adjusted for women s age 22 Exposure Groups N=3429 women 242 with past year IPV (exposed) 686 with no lifetime IPV (reference) 5 with IPV but not in past year (EXCLUDED) 23 Medical Diagnosis Groupings Allergy Cardiovascular Ear, nose and throat Endocrine Eye Female reproductive Gastrointestinal General signs/symptoms General surgery Genitourinary Infections Musculoskeletal Neurologic Nutrition Psychosocial/mental Reconstructive Respiratory Skin 24 8
9 Relative Risk Psychosocial Dx.* Anxiety Depression Family problems IPV *Adjusted for women s age 5.89 Substance abuse 25 Musculoskeletal Fractures Sprains Cervical pain Back pain Arthritis IPV 26 Trauma-related Conditions Lacerations Joint trauma Contusions IPV 27 9
10 Reproductive & Genitourinary Genital sx. Vaginitis UTIs Menstrual disorders IPV 3.5 STDs 28 Miscellaneous Symptoms Cardio. Sx. Abdominal pain Chest pain Headaches GERD IPV 29 Medical Diagnoses - Summary Many diagnoses more common in women with a history of intimate partner violence Conditions naturally related to IPV Contusions Depression But also conditions that don t immediately come to mind Chest pain Arthritis 3
11 Presentation Agenda. Overview of Group Health s study 2. Prevalence 3. Medical Diagnoses 4. Healthcare Utilization & Costs 5. Responding in Healthcare 3 IPV-related Health Care Utilization &Costs in Women 32 Exposure Groups 3,333 women,546 with IPV,789 no IPV (Comparison Group) Utilization during IPV IPV ended <5 yrs (Recent) IPV ended >5 yrs (Remote) 33
12 Analysis Health Care Use Analyses adjusted for age, education, dx., calendar year Commonly used health services (incident rate ratios) Primary care Specialty services Pharmacy (Rx) fills Less commonly used services (relative risks) Mental health Substance abuse Emergency department Inpatient 34 Health Services - Women tio Rate rat Primary care Specialty Pharmacy During Recent Remote 35 Health Services - Women risk Relative r Mental health ED Inpatient During Recent Remote 36 2
13 Analysis Health Care Costs Unadjusted health care costs What does the actual dollar amount look like? Adjusted health care costs (cost ratios), accounting for: Women s age Educational level Calendar year Diagnoses Total overall costs What is intimate partner violence costing Group Health? 37 Unadjusted Costs - Women Annual Do ollars $23 Primary care Pharmacy Total $2945 During Recent Remote 38 Adjusted Cost Ratios - Women tio Cost rat Primary care Pharmacy Total During Recent Remote 39 3
14 So What? If health care costs are 9% higher in abused women and IPV affects 44 percent of women it accounts for $9.3 million annually for every, women! 4 Bonus Analysis Was it just physical violence that led to inflated health care costs? 4 Physical IPV (Physical/sexual) tio Cost ra Total annual costs During Recent Remote 42 4
15 Non-physical IPV only (Threats/control) tio Cost ra Total annual costs During Recent Remote 43 Bonus Analysis When do health care costs for abused women return to looking like health care costs for non-abused women? 44 Abuse Costs Don t Return to Normal Until 4 Years Out! 4 Total Health Care Costs Over Time by IPV Exposure $3,342 $3, Total Health Care Costs in 24 US Dollars $3,86 $3,2 $2,849 $2,264 $2,293 $2,289 $2,29 Differences marked by arrow are signficant at p <. 5 $2,583 $2,845 $2,489 $2,357 $2,36 $2,347 $2,397 $2,373 $2,34 $2,63 $2,45 $2,46 $2,235 Not Exposed 5 Exposed Exposed st Year Post Exposure 2nd Year Post Exposure 3rd Year Post Exposure 4t h Year Post Exposure 5th Year Post Exposure 6t h Year Post Exposure 7th Year Post Exposure 8t h Year Post 9t h Year Post Exposure Exposure 45 th Year Post Exposure Year Relative to IPV Exposure 5
16 What Do IPV-related Health Care Use and Costs Look Like in Men? 46 Exposure Groups N=399 men (Reference) Utilization during IPV Utilization after IPV (- years) 47 Health Services - Men tio Rate rat Primary care Specialty Pharmacy During IPV After IPV * Adjusted for age, education, dx., calendar year 48 6
17 Health Services - Men risk Relative r Mental health Inpatient ED During IPV After IPV 49 And now men s health care costs attributable to intimate partner violence 5 Unadjusted Costs - Men Annual Do ollars $2329 Primary care Pharmacy Total $357 During IPV After IPV 5 7
18 Adjusted Cost Ratios - Men tio Cost rat During IPV After IPV Primary care Pharmacy Total * Adjusted for age, education, dx., calendar year 52 So What? If health care costs are 23% higher in abused men and IPV affects 28 percent of men it accounts for $5 million annually for every, men! 53 With 5, enrollees, intimate partner violence is costing Group Health $47 million annually for women & $37 million for men or $84 million annually 54 8
19 Responding in Health Care Settings 55 Women - Targeted Screening Women presenting with diagnoses & symptoms known to be associated with IPV Depression / anxiety UTIs / STDs Injuries & pain-related conditions Women with mental health, ED and substance abuse service use Also target women in primary care settings 56 Women s Comfort With Screening Negligible adverse outcomes associated with IPV screening in health care settings Nelson et al. / U.S. Preventive Services Task Force. Annals of Internal Medicine 24. MacMillan et al. / McMaster Violence Against Women Study Group. JAMA 29. Very few women (<5%) find IPV screening unacceptable in health care settings In Group Health s study, 87% of women said they would do the interview if they had known what it would be like in advance 57 9
20 Men - Targeted Screening Men presenting in mental health and primary care settings Those with high prescription drug use 58 Men s Comfort With Being Asked About Abuse In Group Health s study, 84% of men said they would do the interview if they had known what it would be like in advance 59 Study References Bonomi AE, Anderson M, Reid RJ, Rivara FP, Carrell D, Thompson RS. Medical and psychosocial diagnoses in women with a history of intimate partner violence. Archives of Internal Medicine 29;69(8): Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs associated with physical and non-physical intimate partner violence. Health Services Research 29;44(3): Fishman P, Bonomi AE, Anderson ML, Rivara FP, Reid RJ. Changes in health care costs over time following the cessation of intimate partner violence. Journal of General Internal Medicine 2;Sep;25(9):92-5. Reid RJ, Bonomi AE, Rivara FP, Anderson ML, Fishman PA, Carrell DS, Thompson RS. Intimate partner violence in men: prevalence, chronicity, and health effects. American Journal of Preventive Medicine 28 Jun;34(6): Rivara FP, Anderson M, Fishman P, Bonomi AE, Reid RJ, Carrell D, Thompson RS. Healthcare utilization and costs for women with a history of intimate partner violence. American Journal of Preventive Medicine 27; Feb;32(2): Thompson RS, Bonomi AE, Rivara FP, Anderson M, Reid RJ, Dimer JA, Grothaus L, Carrell D. Intimate partner violence: prevalence, types and chronicity in adult women. American Journal of Preventive Medicine 26;3(6):
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