Nonbattering presentations to the ED of women in physically abusive relationships

Nonbattering Presentations to the ED of Women in Physically Abusive Relationships ROBERT L. MUELLEMAN, MD,* PATRICIA A. LENAGHAN, RN, MS, CEN,~r RUTH A. PAKIESER, RN, PHD~: To determine which diagnoses in the emergency department (ED), apart from battering injuries, were more common among women who were living in physically abusive relationships than among women who were not, a study was conducted in 10 hospital-based EDs in two cities serving inner city, urban, and suburban populations. A total of 9,057 women between the ages of 19 and 65 years presenting to the EDs were eligible for the study. Medical records were reviewed, and a written questionnaire was used. The questionnaire was completed by 4,501 (73% of those asked, 59% of those eligible, and 50% of those presenting). Two hundred sixty-six (5.9%) were currently in a physically abusive relationship but not in the ED for battering injuries, and 3,969 (88.2%) were not currently in a physically abusive relationship. An additional 266 (5.9*/0) were positive, probable, or suggestive for battering injuries and excluded from diagnosis comparisons. Women in physically abusive relationships were more likely to be diagnosed with urinary tract infections, neck pain, vaginitis, foot wound, suicide attempt, and finger fracture. However, these represented only 19.8% of diagnoses in this group. The use of this knowledge alone to predict the presence of intimate violence in individual patients in the ED will not identify the majority of women at risk. These results suggest the use of routine inquiry for abuse in all women. (Am J Emerg Med 1998;16:128-131. Copyright o 1998 by W.B. Saunders Company)

violence presented to the ED for care for reasons other than trauma. 6 It has been observed that physicians generally do a poor j o b of identification and documentation of intimate violence, especially if no injury is present. 6-9 Identification of a violent relationship when women who do not have battering injuries present to the ED may be important because if appropriate identification and referral occurs, perhaps future battering episodes could be prevented. Guidelines provided to clinicians often list c o m m o n medical conditions found in battered women, but this information is usually based on expert opinion or limited studies. The purpose of this study was to determine which diagnoses in the ED, apart from battering injuries, were more common among women who were in physically abusive relationships than among women who were not.

METHODS

Study Sites Intimate violence against women continues to receive increased attention from the medical community. 1 Annually in the United States, 4 million women are assaulted and 2 million w o m e n are seriously injured 2 by their partners. Women injured by intimate violence often seek help from physicians, s and it has been estimated that 14 to 1.45 million women seek emergency department (ED) care for battering injuries. Although injury is the most obvious manifestation of intimate violence, many women in violent relationships also seek medical care for symptoms directly or indirectly related to the stress of the relationship. A recent prevalence study indicated that 77% of women subjected to acute intimate

From the *Department of Emergency Medicine, Truman Medical Center, University of Missouri-Kansas City School of Medicine, Kansas City, MO; and -j-Emergency Department, Methodist Hospital, and :~University of Nebraska Medical Center, College of Nursing, Omaha, NE. Manuscript received December 9, 1996; accepted January 21, 1997. Supported in part by grants from the Nebraska Methodist Hospital Foundation and the Omaha Community Foundation, Omaha Women's Fund. Address reprint requests to Dr Muelleman, Department of Emergency Medicine, Truman Medical Center, 2301 Holmes St, Kansas City, MO 64108. Key Words: Domestic violence, emergency services, partner abuse. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1602-000658.00/0 128

The study was conducted at 10 EDs in two Midwest cities (6 in Omaha, NE and 4 in Kansas City, MO). The study sites serve diverse populations. Two hospitals are located in inner city areas, 5 in other urban areas, and 3 in suburban areas. The percentage of serf-pay/Medicaid-insured patients in the payor mix ranged from 9% to 79% at the 10 hospitals. Patient volumes ranged from 15,000 to 42,000 visits annually.

Protocol The study was approved by the Institutional Review Boards at both the University of Nebraska Medical Center and the University of Missouri-Kansas City, as well as the appropriate committee at each participating community hospital. A study investigator oriented the ED staff at each institution about the study and provided education on interviewing women in a safe, confidential manner about domestic violence. This information was disseminated in a standardized manner at staff meetings and by written protocol. The progress of the study at each ED was monitored by a site coordinator. Each ED was asked to enroll 1,000 consecutive women between the ages of 19 and 65 years who presented to the ED for any reason. All enrolled women had their medical records reviewed and there were no exclusion criteria, other than age, for this portion of the study. After initial assessment and triage, the patient was invited, after she was alone, to participate in a "study regarding violence." She was assured that the answers would remain confidential. If she was interested, the treating nurse or physician explained the study and obtained written informed consent. The woman was then left alone to complete the questionnaire. All enrolled women were offered the opportunity to obtain information about community resources for domestic violence.

MUELLEMAN ET AL • NONBATTERING PRESENTATIONS

Medical Record Review Information regarding age, time of arrival, diagnosis, and disposition was abstracted from the medical record for all enrolled women by the site coordinator or designee. If the woman was injured, the cause of injury and the location and specific types of injuries in each body region were also recorded. Injury was defined as any intentional or unintentional damage to the body resulting from exposure to thermal, mechanical, or chemical energy, or the absence of such essentials as heat or oxygen. H Results of the injury analysis have been reported elsewhere. 12 The primary diagnosis for each visit was abstracted from the medical record by the site coordinator or designee who was blinded to the results of the questionnaire. These diagnoses were then assigned an ICD code ~3by one investigator (PL). All injured women were categorized as positive, probable, suggestive, or negative for battering by each site coordinator or designee, using the Flitcraft criteria. 14Women were categorized as follows: (1) positive, if there was a definite statement that injuries were caused by an intimate male partner; (2) probable, if she was intentionally injured but the person inflicting the injury was not identified; (3) suggestive, if the stated etiology of the injury did not account adequately for the injury; and (4) negative, if nothing in the record of the injury raised suspicion of battering.

Questionnaire A 1-page, 4-item written questionnaire was developed and reviewed by local experts in domestic violence. Three of the questions were: (I) Have you ever been in a relationship and intentionally injured by an intimate male partner? (2) Are you currently in a relationship in which you have been intentionally injured by your male partner? (3) Was your visit today due to an intentional injury by your intimate male partner? A woman was categorized as positive for battering (even if the medical record review was negative) if she answered yes to the third question. Exclusion criteria for participation in the questionnaire were as follows: (1) patients who were too ill, or otherwise unable to provide informed consent; (2) patients who were unable to speak or read English; (3) patients who left before treatment or against medical advice; (4) patients who previously completed the survey; and (5) patients with male partners who would not leave the room.

Data Analysis Women categorized as positive, probable, or suggestive for battering by medical record review or positive by questionnaire were excluded from the diagnosis analysis. The remaining women who answered the questionnaire were divided into two groups based on their response to the second and third questions: (1) women currently in a physically abusive relationship but not in the ED for battering injuries (+DV), and (2) women not currently in a physically abusive relationship (-DV). Comparisons between the two groups were made for age, time of presentation, and primary diagnosis. The frequency of diagnosis between the two age groups was compared with the comparison of proportions test (z test). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each diagnosis found more frequently in the +DV group. Age and time of presentation between the two groups were compared by X2 analysis. The alpha error rate was set at 0.05.

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study, 1,281 (14%) not approached because of high patient volume, and 194 (2%) with incomplete information on why the questionnaire was not completed. Of the remaining 6,142 patients, 4,501 (73% of those asked, 59% of those eligible, and 50% of those presenting) completed the questionnaire. Nonparticipants (those not asked and those who declined) were similar to participants in age (36 + 13 years v 34 + 13 years) and diagnosis of abdominal pain (9% each), chest pain (6% v 5%), vaginal bleeding (4% each), bronchitis (3% each), pharyngitis (3% v 4%), and urinary tract infections (3% v 4%). Nonparticipants were more likely than participants to have a diagnosis of suicide attempt (7% v 2%), and be admitted (16% v 6%), but less likely to have an injury (24% v 32%). Thirty-seven percent of the participants reported having ever been in a physically abusive relationship. Among the participants, but excluded from analysis, were 202 (4.5%) women positive for battering and 64 (1.4%) probable or suggestive for battering. There were 266 (5.9%) currently in a physically abusive relationship who reported their visit was not due to battering ( + D V ) and 3,969 (88.2%) who were not currently in a physically abusive relationship ( - D V ) . There was a diagnosis identified for 253 (95%) of the + D V group and 3,781 (95%) of the - D V group. The + D V group women were younger than the other women (Figure 1). There was no difference in time of presentation between the two groups (Figure 2). There were six diagnoses found to be more common in the + D V group: urinary tract infections, neck pain, vaginitis, foot wound, suicide attempt, and finger fracture. Although these diagnoses were found more commonly in the + D V group, they were present in only I9.8% of their visits. The six diagnoses found more often in cases had low sensitivities (1.2% for finger fracture to 6.7% for urinary tract infection) and positive predictive values (11.3% for urinary tract infection to 50% for neck pain) and high specificities (96.5% for urinary tract infection to 99.8% for finger fracture) and negative predictive values (93.7% for vaginitis to 94.1% for neck pain). Other common diagnoses in the + D V group included abdominal pain, pharyngitis, vaginal bleeding, bronchitis, chest pain, and headaches. However, there was no difference in frequencies between the two groups. 35 30i

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DISCUSSION Several studies have described medical or psychiatric symptoms of women in abusive relationships, 15-25 but have lacked the detail necessary to determine if the presence of these symptoms is sensitive or has a high positive predictive value in the clinical setting for the diagnosis of intimate violence. This is the largest ED-based study of women in physically abusive relationships that compares their diagnoses with those for women not currently in an abusive relationship. The large number of women enrolled from diverse socioeconomic backgrounds allowed for a detailed analysis of specific diagnoses. The 11.8% (5.9% positive, probable, or suggestive for battering and 5.9% without battering injury) prevalence of intimate violence among the participants of this survey is similar to the 1-month prevalence of 11.9% found in other ED settings using a different :means of detection. 6 The 37% lifetime prevalence of physical abuse in this study compares with 54% in another ED, 6 39% in a family practice clinic, 24 and 2t% in an internal medicine clinic. 25 The concept that nontrauma complaints are common reasons for physician visits by battered women has been reported by others. 6 We found six diagnoses more common in the + D V group than the - D V group. However, only 19.8% of the women in the + D V group had one of these diagnoses. Because of the low sensitivity and positive predictive value, the knowledge of these diagnoses would not be useful clinically in detecting a majority of women in violent relationships who do not present with battering injuries. This lack of sensitivity and positive predictive value is similar to the results of a study in a family practice setting. Saunders et a124 evaluated 394 women and found the diagnosis of depression as the only strong indicator of abuse. A classification analysis of all demographic and medical indicators in that study could predict violence in the previous year only about 20% of the time. In our study, the diagnoses found more common in the + D V group could have resulted from the violent relationships they were in. The increased rate of urinary tract infections and vaginitis could be related to the sexual abuse that often accompanies physical abuse. 26 The increased rate of suicide attempts could relate to the increased anxiety and

depression z2,24,25 commonly found in battered women. Others have described a high rate of suicide attempts by battered women. 27 It is uncertain whether the diagnosis of neck pain relates to stress or to the result of previous physical injury. The increased presence of finger fractures and foot wounds in women who stated on the questionnaire that it was not caused by an intimate male partner is difficult to explain. Perhaps some women were reluctant to divulge this information or were unsure of the intent. In another study, when women were asked on a questionnaire if their visit that day was due to injuries or stress related to their husband or boyfriend, many stated that they were unsure. 6 The notion that the stress of living in a violent relationship results in health problems is pervasive. An early study 15 of a group of battered women mentioned several symptoms that have become the basis for medical profiles describing battered women. That study, without a control group, found evidence of frequent visits by battered women for headaches, choking sensation, hyperventilation, asthma, chest pain, gastrointestinal symptoms, pelvic pain, back pain, and allergic phenomenon. Other studies have found that battered women are more likely to have chronic pain, 18 headaches, 17 gastrointestinal problems, 16 or chronic pelvic pain. 19These studies may have been limited by differing definitions of domestic violence and use of participants from specialty clinics. We found that the + D V group commonly were diagnosed with abdominal pain, pharyngitis, vaginal bleeding, bronchitis, chest pain, and headaches; however, the frequencies were not different from the - D V group. The results of this study call into question the utility of using symptoms or diagnosis alone as indicators of abuse. The concept that women with a "red flag" diagnosis should be asked about physical abuse may be useful if it alerts the clinician who does not routinely ask. However, if the inquiry is made only in "red flag" diagnoses, most cases of physical abuse will go undetected. The results of this study strongly support the use of routine inquiry about physical abuse as suggested by the American Medical Association. 28 Future studies will need to determine if the resources needed for battered women who present in crisis with battering injuries are different from the resources needed for those who do not. If there is a difference, then clinicians can tailor their referrals to the resources best suited to the patient's needs. We acknowledge the limitation of the current study. In an emergency care setting, many patients are not too sick to be excluded but are too sick to answer a questionnaire. Twenty-seven percent of the patients who were asked did not wish to participate. The nonparticipants were similar to participants in terms of age and most diagnoses, but had more severe illnesses as reflected by the higher admission rate, Also, the frequency of diagnosis in women presenting to the ED may be different than in those presenting to clinic settings. Also, the intermittently busy nature of emergency care often precluded the staff from administering questionnaires. Other limitations were that data were not collected on the socioeconomic status of the participants, and the gender-

MUELLEMAN ETAL • NONBATTERING PRESENTATIONS

specific questions prevented the detection of domestic violence in lesbian relationships.

CONCLUSION Women living in physically abusive relationships seek medical attention for battering injuries for symptoms directly or indirectly related to the stress of the relationship, or for routine medical care. This study identified six diagnoses found more frequently in women living in physically abusive relationships who presented to the El) for medical care. However, the use of this knowledge alone to predict the presence of intimate violence in individual patients in an ED setting will not identify the majority of women at risk. The results of this study strongly support the use of routine inquiry for abuse in all women.

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