Intimate partner violence-related hospitalizations in Appalachia and the non-Appalachian United

17 Pages·2017·0.88 MB·English

RESEARCHARTICLE
Intimate partner violence-related
hospitalizations in Appalachia and the non-
Appalachian United States
DanielleM.Davidov1,2*,StephenM.Davis1,MotaoZhu3¤a¤b,TracieO.Afifi4,
MelissaKimber5,AbbyL.Goldstein6,NicolePitre7,KellyK.Gurka3¤c,CarolStocks8
1 DepartmentofEmergencyMedicineandSocialandBehavioralSciences,WestVirginiaUniversity,
Morgantown,WestVirginia,UnitedStatesofAmerica,2 DepartmentofSocialandBehavioralSciences,West
a1111111111 VirginiaUniversity,Morgantown,WestVirginia,UnitedStatesofAmerica,3 DepartmentofEpidemiology,
a1111111111 WestVirginiaUniversity,Morgantown,WestVirginia,UnitedStatesofAmerica,4 DepartmentsofCommunity
a1111111111 HealthSciencesandPsychiatry,UniversityofManitoba,Winnipeg,Manitoba,Canada,5 Departmentof
PsychiatryandBehaviouralNeurosciences,McMasterUniversity,Hamilton,Ontario,Canada,6 Department
a1111111111
ofAppliedPsychologyandHumanDevelopment,OISE,UniversityofToronto,Toronto,Ontario,Canada,
a1111111111
7 FacultyofNursing,UniversityofAlberta,Edmonton,Alberta,Canada,8 AgencyforHealthcareResearch
andQuality,Rockville,Maryland,UnitedStatesofAmerica
¤a Currentaddress:CenterforInjuryResearchandPolicy,TheResearchInstituteatNationwideChildren’s
Hospital,Columbus,Ohio,UnitedStatesofAmerica
¤b Currentaddress:DepartmentofPediatrics,OhioStateUniversity,Columbus,Ohio,UnitedStatesof
OPENACCESS
America
Citation:DavidovDM,DavisSM,ZhuM,AfifiTO, ¤c Currentaddress:DepartmentofEpidemiology,UniversityofFlorida,Gainesville,Florida,UnitedStatesof
KimberM,GoldsteinAL,etal.(2017)Intimate America
*[email protected]
partnerviolence-relatedhospitalizationsin
Appalachiaandthenon-AppalachianUnitedStates.
PLoSONE12(9):e0184222.https://doi.org/
10.1371/journal.pone.0184222 Abstract
Editor:VirginiaJ.Vitzthum,IndianaUniversity,
ThehighlyruralregionofAppalachiafacesconsiderablesocioeconomicdisadvantageand
UNITEDSTATES
healthdisparitiesthatarerecognizedriskfactorsforintimatepartnerviolence(IPV).The
Received:February20,2017
objectiveofthisstudywastoestimatetherateofIPV-relatedhospitalizationsinAppalachia
Accepted:August21,2017
andthenon-AppalachianUnitedStatesfor2007–2011andcomparehospitalizationsin
Published:September8,2017 eachregionbyclinicalandsociodemographicfactors.DataonIPV-relatedhospitalizations
Copyright:Thisisanopenaccessarticle,freeofall wereextractedfromtheStateInpatientDatabases,whicharepartoftheHealthcareCost
copyright,andmaybefreelyreproduced, andUtilizationProject.Hospitalizationday,year,in-hospitalmortality,lengthofstay,aver-
distributed,transmitted,modified,builtupon,or
ageandtotalhospitalcharges,sex,age,payer,urban-rurallocation,income,diagnoses
otherwiseusedbyanyoneforanylawfulpurpose.
andprocedureswerecomparedbetweenAppalachianandnon-Appalachiancounties.Pois-
TheworkismadeavailableundertheCreative
CommonsCC0publicdomaindedication. sonregressionmodelswereconstructedtotestdifferencesintherateofIPV-relatedhospi-
talizationsbetweenbothregions.From2007–2011,therewere7,385hospitalizations
DataAvailabilityStatement:Thedatathatsupport
thefindingsofthisstudywereobtainedfrom relatedtoIPV,withone-third(2,645)occurringinAppalachia.Afteradjustingforageand
intramuralStateInpatientDatabases’filesatthe rurality,Appalachiancountieshada22%higherhospitalizationratethannon-Appalachian
AgencyforHealthcareResearchandQuality,but
counties(ARR=1.22,95%CI:1.14–1.31).Appalachianresidentsmaybeatincreasedrisk
restrictionsapplytotheavailabilityofthesedata,
whichwereusedunderlicenseforthecurrent forIPVandassociatedconditions.Exploringdisparitiesinhealthcareutilizationandcosts
study,andsoarenotpubliclyavailable. associatedwithIPVinAppalachiaiscriticalforthedevelopmentofprogramstoeffectively
Specifically,HCUPdataareLimitedDataSetsas
targettheneedsofthispopulation.
definedundertheHIPAAPrivacyRuleandcontain
protectedhealthinformationsuchascountyand
fullZIPCode.Datafromsomestatesparticipating
inHCUPrestrictpublicreleasebytheAgencyfor
PLOSONE|https://doi.org/10.1371/journal.pone.0184222 September8,2017 1/17
IntimatepartnerviolencehospitalizationsinAppalachia
HealthcareResearchandQuality(AHRQ).However Introduction
aggregatestatisticalresultsbasedonanalysesof
Intimatepartnerviolence(IPV)isapublichealthproblemthatinvolvesvictimizationbyacur-
therestricteddatasetareavailablefromtheauthors
uponrequestandwithpermissionfromtheAgency rentorformerspouseorpartnerthroughtheuseofphysicaland/orsexualviolence,psycho-
forHealthcareResearchandQuality.Intheevent logicalharm,andinsomecases,stalking[1].Recentestimatesdemonstratethatapproximately
thatverificationoffindingsisnecessary,arequest 37%ofwomenand31%ofmenintheUnitedStates(US)havereportedexperiencesofIPVin
foronsiteaccesstodatacanbesubmittedtocarol.
theirlifetime[2].AlthoughstudieshaverevealedsimilarpopulationratesofIPVbetweenrural
[email protected],orbymailtoHCUPProject
andnon-rurallocales[3],[4],[5],ruralIPVisperpetratedatahigherfrequencywithinrelation-
Officer,AgencyforHealthcareQualityand
shipsandwithgreaterseverity[6].Inruralareas,perpetratorsofIPVaremorelikelytouse
Research,5600FishersLane,Rockville,MD
20857.Asanalternative,requestscouldbemade weapons[7]andintimatepartnerhomicideratesaresignificantlyhighercomparedtothosein
directlytotheHCUPPartnerorganizations(https:// urbanandsuburbanlocales[8].Furthermore,thoseexperiencingIPVinruralareasaccess
www.hcup-us.ahrq.gov/partners.jsp).
medicalsystemsandutilizeformalandinformalresourceslessfrequently[9],[10].Socialand
Funding:Thisresearchwassupportedbythe geographicisolation,increasedtraveltimestoreceiveshelterandtreatment,andthepresence
CanadianInstitutesofHealthResearchInstituteof offewersocialandmedicalsupportsystemscreatesignificantchallengestotheprovisionof
GenderandHealthandInstituteofNeurosciences
adequateservicesforruralindividualsexposedtoIPV[5],[6],[11].
MentalHealthandAddictionstothePreVAiL
TheculturallyandgeographicallydefinedAppalachianregionhasoneofthelargestrural
PreventingViolenceAcrosstheLifespanResearch
populationsintheUS(42%ruralcomparedto20%ofUS).Appalachiaencompassesanareaof
Network)(CentreforResearchDevelopmentin
Gender,MentalHealthandViolenceacrossthe about205,000squaremilesstretchingalongthespineoftheAppalachianmountainrange
Lifespan,grant#RDG99326).DDissupportedbya fromsouthernNewYorktonorthernMississippi[12].Appalachiancommunitiesexperience
grantfromtheNationalInstituteOfGeneral higherlevelsofeconomicdistresscharacterizedbylowerincomeandeducationalattainment
MedicalSciencesoftheNationalInstitutesof
comparedtothoselivinginthenon-AppalachianUS[13].Further,Appalachianshavepoorer
HealthunderAwardNumberU54GM104942anda
healthstatus,includinghigherratesofmorbidityandmortalityfromchronicdiseases,com-
LoanRepaymentProgramGrantfromtheNational
paredtoindividualsresidingoutsideofthearea[14],[15],[16].Theregionalsofacessignificant
InstituteonMinorityHealthandHealthDisparities.
Thecontentissolelytheresponsibilityofthe disparitiesrelatedtomentalhealthdisordersandsubstanceuse[17]andhigherdeathrates
authorsanddoesnotnecessarilyrepresentthe fromprescriptiondrugabuse[18]andmotorvehiclecrashes[19].Whilethesedisparitiesare
officialviewsoftheNationalInstitutesofHealth, pronouncedwhencomparedtotherestoftheUS,thereissubstantialvariationthroughout
theAgencyforHealthcareResearchandQualityor
AppalachiawithcentralAppalachiacontinuingtofacesignificantdisparitiescomparedto
theU.S.DepartmentofHealthandHuman
northernandsouthernAppalachia[14].Appalachiaalsohasahistoryofanextremeshortage
Services.TAissupportedbyaResearchManitoba
EstablishmentAwardandaCanadianInstitutesof ofhealthcareprovidersandappropriatehealthservices[13],[20].Therefore,examiningsocial
HealthResearchNewInvestigatorAward.MKis andcontextualfactorsassociatedwithhealthbehaviorsandoutcomesamongAppalachian
supportedbyaWomen’sHealthScholarPost populations,inspecific,versusthosewithruralpopulationsingeneral,iscriticalforthedevel-
DoctoralFellowshipAwardfromtheOntario
opmentofacomprehensivepictureoflocalizedAppalachianhealthdisparitiestoguidethe
MinistryofHealthandLong-TermCare.
designandimplementationoffutureinterventionstoreduceIPV.
Competinginterests:Theauthorshavedeclared Unfortunately,limitedinformationisavailableregardingtheextentandnatureofIPVin
thatnocompetinginterestsexist.
AppalachiathatisseparatefromwhathasbeenpublishedaboutIPVinotherruralregions.A
recentpopulation-basedstudyoftheprevalenceofruralIPVconductedin16statesfoundno
significantdifferencein12-monthorlifetimeIPVprevalencebetweenthoselivinginruralver-
susnon-ruralareasoftheUS,butonlytwooftheincludedstateshavecountiesthatliewithin
theAppalachianregion[3].Furtherinvestigationiswarranted,asAppalachianpopulations—
andinparticularthoseresidinginruralareasofAppalachia—mayfacedoubleortripledisad-
vantageduetotheintersectionofgeographical,sociocultural,andeconomicconditionsunique
totheregion.Thesecompoundinglevelsofrisk,coupledwiththepresenceoffewerhealth
resources[3],[4],[5],mayleavethispopulationinherentlyvulnerabletotheacuteandlong-
termphysicalandmentalhealthconsequencesofIPV.
IPV-specificinformationisoftencapturedfromcommunity,criminaljustice,shelter,and
healthcaresettings.Althoughdatafromcommunitysamplesallowforepidemiologicalstudy
oftheprevalenceandincidenceofvariousformsofIPVamongthegeneralUSpopulationor
withinspecificcommunities,estimatesaretypicallyprovidedforsinglesitesoratstateor
nationallevels.Datacollectedfromcriminaljusticesurveillanceandsheltersettingsmay
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IntimatepartnerviolencehospitalizationsinAppalachia
includecasesofIPVthatinvolvelawenforcementorcriminalacts(eg,intimatepartnerhomi-
cide,useofweapons)andamongpopulationswhohaveleftabusiveorunsafesituations,
respectively,butmaynotbegeneralizabletoothersituationsinvolvingIPV.Furthermore,
thesesourceslackreliabledataonthehealthimpactsassociatedwithIPV.Individualsexposed
toIPVgenerallyhavemorefrequentcontactwiththehealthcaresystemandhighercostsfor
medicalandmentalhealthservicesthanthosewhohavenotexperiencedIPV[21–24].Infact,
abusedwomenareseeninthehealthcaresettingmoreoftenthaninsheltersorwithinthe
criminaljusticesystem,makinghospitalizationrecordsandsurveillancedatafromhealthsys-
temsanimportantsourceofinformationonIPV.
DataonIPV-relatedhospitalizations,specifically,canprovideabetterpictureofthedemo-
graphics,injuries,comorbidconditions,andcostsforindividualswhohaveexperiencedthe
mostseriousformsofIPV[25],[26].Onlyafewstudieshaveexaminedcharacteristicsassoci-
atedwithIPV-relatedhospitalizations,possiblyduetolimitationsofavailabledata,including
incompletemedicalrecorddata,misclassificationofIPVasotherformsoftraumaoraccidents
(possiblyasaresultofpatientsnotdisclosingabuse),andunderuseofIPV-specificbilling
codes,whichmayresultininsufficientsamplesizesthatprecludegenerationofreliableesti-
matesofhospitalizationsinvolvingIPV.RudmanandDavey[27]utilized1994Healthcare
CostandUtilizationProject(HCUP)datatoexaminetheincidenceofhospitalizationsrelated
toIPVfortheentireUSandreportedthatnon-whiteandyoungerindividualsweremorelikely
tobehospitalizedforIPVandhaveprimarydiagnosesrelatedtoacuteinjuriesfromviolence,
chronicdisease,andmentalhealthissues.Kernicandcolleaguesfoundthatwomenwhoexpe-
riencedIPVhadanincreasedrelativeriskofhospitalizationforassault,mentalhealthissues,
digestivesystemdiseases,injuriesandpoisonings,andsuicideattempts[28].Statewidesurveil-
lanceofinpatientdischargedataandsinglesitemedicalrecordreviewshavealsocontributed
toourknowledgesurroundinginpatienthealthcareutilizationpatternsassociatedwithIPV
[29],[30].OnestudyoftwoLevelItraumacentersinKalamazooCountyMichiganfoundIPV-
exposedindividualsweretentimesmorelikelytobehospitalizedforinjuriescomparedto
nationalage-matchedcontrols,andoverhalfofthecasesinvolveddrugsandalcohol[29].
AlthoughthesefewstudieshaveenhancedourunderstandingofIPV-relatedhospitaliza-
tions,verylittleisknownaboutinpatientcareprovidedtoindividualsexposedtoIPVresiding
inruralareasandnoinformationiscurrentlyavailableregardinghealthcareutilizationand
costsassociatedwithIPVinthehighlyruralAppalachianregion,despitethepresenceofmulti-
plevulnerabilitiesthatincreasetheriskforexperiencingsevereformsofIPVandassociated
healthconsequences[5].Currentresearchinthisareainvolvessamplesizestoosmalltomake
inferencesabouttheAppalachianregionasawholeorutilizesstateornationalleveldatathat
precludescounty-levelanalysesrequiredforexaminingtheentiretyofAppalachia.Datafrom
theHealthcareCostandUtilizationProject,managedbytheAgencyforHealthcareResearch
andQuality,provideanopportunitytoexaminecounty-levelhospitalizationevents,andpat-
ternsofhealthcareutilizationandcostsinAppalachia.Theobjectiveofthisstudywastocom-
parecounty-levelpopulationratesofIPV-relatedhospitalizationsacrossAppalachiaandnon-
AppalachianUScounties,andtodifferentiatesociodemographicandclinicalcharacteristicsof
thehospitalizationsbetweenthegeographicareas.
Methods
Thisstudyuses2007–2011datafromtheStateInpatientDatabases,whicharepartofHealth-
careCostandUtilizationProject.TheHealthcareCostandUtilizationProjectisafederal-
state-industrypartnershipsponsoredbytheAgencyforHealthcareResearchandQualitythat
compilesandprovideshealthdataforhealthcarepolicyandoutcomesresearch[31].TheState
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IntimatepartnerviolencehospitalizationsinAppalachia
InpatientDatabases’filescontainallinpatientrecordsfromcommunityhospitalsineachpar-
ticipatingstate.Collectively,thesefilescontainclinicalandnon-clinicaldataonapproximately
97%ofallhospitaldischargesintheUS.Thesedataarestandardizedtopermitmulti-stateand
geographicalcomparisons[32].IPV-relatedhospitalizationsinAppalachianandNon-Appala-
chiancountieswereidentifiedandextractedfromthe2007–2011intramuralStateInpatient
Databases’filesmaintainedbytheAgencyforHealthcareResearchandQualityaccordingto
themethodsdetailedbelow.WereceivedapprovalfromtheWestVirginiaUniversityInstitu-
tionalReviewBoardtocarryoutthisstudy.
Measures
Intimatepartnerviolencehospitalizations. OurselectionofcodestodenoteIPV-related
hospitalizationswithintheStateInpatientDatabaseswasguidedbypreviousresearchonthis
topic[30],[33].Specifically,weutilizedtheInternationalClassificationofDiseases,NinthRevi-
sion,ClinicalModification(ICD-9-CM)codesforthefollowingdiagnoses:abusebyspouse/
partner;adultmaltreatment,unspecified;adultphysicalabuse;adultemotional/psychological
abuse;adultsexualabuse;adultneglect–nutritional;otheradultabuseandneglect;observation
forabuseandneglect(S1Table).AhospitalizationwasconsideredtobeIPV-relatedifanyof
thesecodeswerelistedasaprimaryorsecondarydiagnosis.Primarydiagnosesarethosethat
aredeemedchieflyresponsibleforthepatient’shospitaladmissionwhilesecondarydiagnoses
areallconditionsthatco-existatthetimeofadmission.Somerecordsmayhaveincluded
codesusedforothertypesofmaltreatmentorabusethatmightnotbeconsideredIPV(eg,
elderabuse,sexualassaultoutsideofanintimaterelationship).However,althoughresearch
hasdemonstratedthatcodesspecifyingtheperpetratorofabuse(eg,9673–abusebyspouse/
partner)yieldahighpositivepredictivevalueintermsofidentifyingtruecasesofIPV,theyare
usedinfrequently[30].Thispresentsachallengeofneedingtobalanceincreasingsensitivityat
theexpenseofincludingfalsepositives.Schaferetalfoundvalueinutilizinga“provisional”set
ofcodesthatarenotdirectlyindicativeofIPVbutindeedmaybeusedincaseswhereIPVis
present.Whiletheyspanabroaderdefinitionthanwhatistypicallyusedtodescribeinstances
ofIPV,theyhavebeenshowntohavepositivepredictivevaluesrangingfrom40–97.6%.Thus,
weoptedtomaximizethesensitivityofidentifyingIPV-relatedhospitalizations,recognizing
thatthismayincreasethepossibilityofcapturinghospitalizationsthatmightnotberelatedto
IPV.
ClassificationofAppalachianandnon-Appalachiancounties. TheAppalachian
RegionalCommissionisafederal,state,andlocalgovernmentpartnershipthatwasestablished
byanactofCongressin1965.Inadditiontopromotingregionaleconomicdevelopment,the
AppalachianRegionalCommissioncreatesmapsandconductsresearchonfactorsthataffect
economicdevelopmentintheAppalachianregionandprovidesalistingofFederalInforma-
tionProcessingStandardcodes—fivedigitcodesthatuniquelyidentifycountiesandcounty
equivalentsintheUS—todesignateAppalachiancounties[34].Thereare420countiesand
eightindependentcitiesthatareconsidered“Appalachian”accordingtotheCommission’s
definition.AlabamadoesnotcontributedatatotheStateInpatientDatabases,thereforethe37
AppalachiancountiesinAlabama(approximately9%ofAppalachiaasdefinedbytheCom-
mission)wereexcludedfromtheanalysis,andthustheremaining391FederalInformation
ProcessingStandardcodeswereusedtoidentifyAppalachianCountiesintheStateInpatient
Databases.DatarestrictionssetforthbytheAgencyforHealthcareResearchandQualitypre-
cludedourabilitytocompareAppalachiancountieswithallremaining(non-Appalachian)
countiesintheUS,thereforeweusedsimplerandomsamplingtoselect391non-Appalachian
countiesasacomparisongroup.NorthDakota’s53countieswereexcludedfromtherandom
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IntimatepartnerviolencehospitalizationsinAppalachia
samplingprocedurebecausedatafromNorthDakotawerenotavailableduringtwoyearsof
thefiveyearstudyperiod.
Sociodemographiccharacteristics. Weexaminedthefollowingsociodemographicvari-
ables:age,sex,race,urban/rurallocationofpatientresidence,communityincomeandprimary
payer.Patientagewasmeasuredinyears.Sexwascodedasmaleorfemale.Racialcategoriesin
theStateInpatientDatabasesincludeWhite,Black,Hispanic,Asian/PacificIslander,Native
American,andOther.Duetosmallsamplesizes,wegroupedAsian/PacificIslanderandNative
AmericanintotheOthercategory.Patientresidencewasmeasuredusingthe2006six-category
urban-ruralclassificationschemeforUScountiesdevelopedbytheNationalCenterforHealth
Statistics.Largecentralmetropolitanareasare“central”countiesofmetropolitanareaswith(cid:21)1
millionpopulation;largefringemetroareasare“fringe”countiesofmetroareaswith(cid:21)1million
population;mediummetroareasarecountiesinmetropolitanareaswith250,000to999,999pop-
ulation;smallmetroareasarecountiesinmetropolitanareasof50,000to249,999population;
micropolitanareasarenon-metropolitancountieswith(cid:21)10,000populationbutlessthan49,999;
non-coreareasarenon-metropolitanandnon-micropolitancounties.Communityincomewas
measuredusingtheestimatedmedianhouseholdincomequartileforthepatient’szipcode(1st
quartile=(cid:20)$38,999;2ndquartile=$39,000-$47,999;3rdquartile$48,000-$63,999;4thquartile
(cid:21)$64,000).Theexpectedprimarypayersincludedthefollowingcategories:Medicare,Medicaid,
privateinsurance,andOther(includesWorker’sCompensation,CivilianHealthandMedical
ProgramoftheUniformedServices[CHAMPUS],CivilianHealthandMedicalProgramofthe
DepartmentofVeteransAffairs[CHAMPVA],TitleV,andothergovernmentprograms).
Hospitalizationcharacteristics. Variablesrelatedtohospitalstayincludedadmissionday
(weekdayvs.weekend),yearofhospitalization(calendaryear),averagelengthofhospitalstay
(days),in-hospitalmortality(yesvs.no),hospitalcharges,comorbiddiagnosesandprocedures.
Hospitalcharges(perhospitalizationaverageandtotal)weremeasuredinUSdollarsandrep-
resenttheamountthehospitalchargedfortheentirehospitalstay,notincludingprofessional
(physician)fees.Themostcommonlydiagnosedconditionslistedandproceduresperformed
duringthehospitalstaywereexaminedusingtheAgencyforHealthcareResearchandQual-
ity’sClinicalClassificationSoftware[35],whichclustersthousandsofICD-9-CMdiagnosis
andprocedurescodesintoasmallernumberofmeaningfulcategories.
Statisticalanalysis. Contingencytableanalyseswereusedtodenotedifferencesbetween
Appalachianandnon-Appalachiancountiesforthefollowingvariables:sex,race,urban/rural
locationofpatientresidence,communityincome,primarypayer,admissionday,yearofhos-
pitalization,in-hospitalmortality,anddischargediagnosesandproceduresperformedduring
hospitalization.Differencesintheaverageage,lengthofhospitalstay,andhospitalcharge
betweenAppalachianandnon-Appalachiancountiesweretestedusingthet-test.Tocalculate
IPV-relatedhospitalizationrates,populationcountsbycountyandagegroup(<18,18–34,
35–64,65+)fortheyears2007–2011wereextractedforallUScountiesfromtheUSCensus
[36],excludingAlabamaandNorthDakotacounties.Fromthisfinalcensusfile,weextracted
the391non-Appalachiancountiesidentifiedinourrandomsamplingproceduretocompare
withdatafromthe391Appalachiancounties(excludingcountiesinAlabamaandNorth
Dakota).Tocontrolfortheruralityofacounty,2013UrbanInfluenceCodeswererecoded
withcodes(cid:21)3indicatingnonmetropolitan(“rural”)countiesandcodeslessthan3indicating
metropolitan(“urban”)counties.Poissonregressionmodelswereconstructedtotestdiffer-
encesintherateofIPV-relatedhospitalizationsbetweenAppalachianandnon-Appalachian
counties.Negativebinominalmodelswereconstructediftherewasevidenceofoverdispersion
oriftheLagrangemultipliertestindicatedthatthenegativebinomialmodelwasabetterfit.A
two-tailedalphaof0.05wasselectedasthethresholdofstatisticalsignificance.Allanalyses
wereconductedusingSAS9.4(SASInstitute).
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IntimatepartnerviolencehospitalizationsinAppalachia
Results
Between2007and2011,therewere7,385IPV-relatedhospitalizations(2,645Appalachian,
4,740non-Appalachian).NostatisticallysignificantdifferenceswerefoundbetweentheAppa-
lachianandnon-Appalachiancountieswithregardtosex,hospitalizationadmissionday,
lengthofstay,andin-hospitalmortality(Table1).AppalachianpatientshospitalizedforIPV
wereslightlyolderthanthoseinnon-Appalachiancounties(53.4years[range=18–107]vs.
52.3years[range=18–104];p=0.04).Comparedtothenon-Appalachianregion,individuals
hospitalizedinAppalachiaweremorelikelytoidentifyasWhitewhereashospitalizedindivid-
ualsinthenon-AppalachianregionweremorelikelytoidentifyasBlackorHispanic.Almost
two-thirdsofpatientshospitalizedforIPVinAppalachialivedincommunitieswiththelowest
annualmedianincomequartile((cid:20)$38,999)comparedwith35%ofpatientsinnon-Appala-
chiancounties.Almost15%ofnon-AppalachianIPV-relatedhospitalizationsinvolvedpatients
fromneighborhoodsinthewealthiestincomequartile(>$64,000/year)versus3%ofAppala-
chianhospitalizations.AgreaterproportionofAppalachianpatientsutilizedMedicareor
Medicaidastheirprimarypayer,whilethoseinnon-Appalachiancountiesweremorelikelyto
payfortheirhealthcarethroughprivateinsurance.
Hospitalizationrates
TheIPV-relatedhospitalizationratewas14%higherinAppalachiancountiescomparedto
non-Appalachiancounties(3.09per100,000versus2.71per100,000,respectively).After
adjustmentforageandrurality,Appalachiancountieshada22%higherrateofhospitalization
relatedtoIPVcomparedtonon-Appalachiancounties(RR:1.22,95%CI:1.14–1.31)(Table2).
Thetop15mostfrequentdiagnosesandproceduresassociatedwithIPV-relatedhospitali-
zationsstratifiedbyAppalachianandnon-AppalachiancountiesarefoundinTables3and4.
Mooddisorderswereatopdiagnosisinbothgroups,butweretwiceasprevalentinAppalachia
(20.2%vs.10.0%).Substanceusedisordersandpoisonings,urinarytractinfectionsandpreg-
nancy-relatedissueswerealsoobservedinbothAppalachianandnon-Appalachiancounties;
however,intracranialandinternalinjurieswereamongthetop15diagnosesinnon-Appala-
chiancounties,only.Alcoholanddrugrehabilitation/detoxificationwasthemostcommon
primaryprocedureindicatedinbothAppalachianandnon-Appalachianregions,butoccurred
atahigherfrequencywithinAppalachia(16.5%vs.7.2%).Intubation,ventilationandblood
transfusionswerealsocommonproceduresperformedforpatientsadmittedtothehospitalfor
IPV.Pregnancy-relatedprocedures(deliveryassistance,Cesareansection,fetalmonitoring),
psychiatricandpsychologicalevaluation/therapyandtreatmentforwoundsandfractureswere
alsoreportedforpatientsinbothregions.
Discussion
Socioeconomicallydisadvantagedandruralcommunitiesareconsideredhealthdisparity
groupsbytheNationalInstitutesofHealth[36].Someareaswithinthelargelyruralregionof
Appalachiafaceconsiderabledisadvantageanddisparitiesrelatedtomentalhealth,chronic
disease,substanceabuseandinjuryandavailablepreventiveservicesandtreatmentforthese
conditions[14–20].Thecurrentstudyaddstotheliteraturebyprovidingnewinformation
abouthealthcareutilizationandcostsassociatedwithIPVinAppalachia.Tothebestofour
knowledge,thisisthefirststudytoexamineIPV-relatedhospitalizationsinAppalachiaand
makecomparisonswithnon-Appalachiancounties.Tosuccessfullycompletethisanalysis,it
wasnecessarytousetherestricted,intramuralStateInpatientDatabases’filesattheAgencyfor
HealthcareResearchandQualityduetovariablerestrictionsonthepubliclyavailabledata
files.
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IntimatepartnerviolencehospitalizationsinAppalachia
Table1. Sociodemographicvariablesandhospitalizationcharacteristicsa.
Appalachian Non-Appalachian
Variable (n=2,645) (n=4,740) p-value
n(%) n(%)
Ageinyears,Mean(SD) 53.4(21.1) 52.3(21.7) 0.04
Sex
Male 408(15.4) 737(15.6)
Female 2237(84.6) 4003(84.5) 0.89
Raceb
White 1713(88.9) 2508(60.9)
Black 162(8.4) 815(19.8)
Hispanic 26(1.5) 469(11.4)
Otherc 27(1.4) 326(7.9)
Missing 717 621 <0.001
Locationofpatientresidence
LargeCentralMetro 115(4.4) 2326(49.1)
LargeFringeMetro 210(7.9) 865(18.3)
MediumMetro 768(29.0) 639(13.5)
SmallMetro 455(17.2) 275(5.8)
Micropolitan 610(23.1) 396(8.4)
Non-core 487(18.4) 239(5.0) <0.001
Medianincomeforpatientzipcoded
Firstquartile((cid:20)$38,999) 1550(60.6) 1594(35.0)
Secondquartile($39,000-$47,999) 679(26.6) 1328(29.1)
Thirdquartile($48,000-$63,999) 252(9.9) 968(21.2)
Fourthquartile((cid:21)$64,000) 76(3.0) 668(14.7)
Missing 88 182 <0.001
PrimaryPayer
Medicare 1211(46.2) 1899(40.2)
Medicaid 756(28.8) 1224(25.9)
Privateinsurance 350(13.3) 807(17.1)
Self-pay 230(8.8) 488(10.3)
Nocharge 13(0.5) 36(0.8)
Other 63(2.4) 273(5.8) <0.001
AdmissionDay
Monday–Friday 1990(75.2) 3492(73.7)
Saturday–Sunday 655(24.8) 1248(26.3) 0.14
YearofHospitalization
2007 317(12.0) 828(17.5)
2008 710(26.8) 940(19.8)
2009 575(21.7) 889(18.8)
2010 495(18.7) 1056(22.3)
2011 548(20.7) 1027(21.7) <0.001
In-hospitalmortality
Yes 65(2.5) 104(2.2)
No 2579(97.5) 4625(97.8) 0.48
Missing 1 11
Lengthofstayindays,Mean(SD) 6.2(10.5) 6.5(12.2) 0.32
(Continued)
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IntimatepartnerviolencehospitalizationsinAppalachia
Table1. (Continued)
Appalachian Non-Appalachian
Variable (n=2,645) (n=4,740) p-value
n(%) n(%)
Hospitalcharge,Mean $19,866 $30,995 <.0001
aNumbersmaynotaddto100%duetorounding.
bSomestatesintheStateInpatientDatabasesdonotreportrace/ethnicityofdischarges.
cOtherincludesAsian/PacificIslander,NativeAmerican,Otherrace.
dEstimatedmedianannualhouseholdincomeofresidentsinthepatient’sZIPCode.
https://doi.org/10.1371/journal.pone.0184222.t001
OurprimaryfindingwasthatAppalachiancountieshadasignificantlyhigherrateofIPV-
relatedhospitalizationscomparedtoasampleofnon-Appalachiancounties.Theexplanation
forthedifferencebetweenthetworegionsislikelymultifactorial,thoughcharacteristicsassoci-
atedwithruralitymaypartiallyaccountforthefindings.Whilepreviousresearchhasshown
ratesofIPVtoberoughlyequivalentinurbanandruralareas[5],somestudieshavedemon-
stratedindividualslivingininner-cityurbanareastobeatincreasedriskforIPVandIPV-
relatedhealthconsequences[4],[37–40].WhileAppalachiaistwiceasruralasthenon-Appala-
chianUS,overhalfoftheregioniscomprisedofsuburbanorurbanareas.Inthecurrent
study,thehighestratesofIPV-relatedhospitalizationswerefoundinruralAppalachiancoun-
ties.Thus,itisplausiblethatruralareaswithinAppalachiaareinherentlydifferentfromthe
suburbanandurbanlocaleswithintheregion(non-ruralAppalachia)aswellasotherrural,
non-AppalachianareasoftheUS.Thishighlightstheimportanceofexaminingtheurban-
ruralcontinuumregionallyversussolelyatstateornationallevels.Edwards’recentcritical
reviewoftheIPVliteraturefoundruralIPVtobemorechronicandsevereandresultinworse
physicalandpsychosocialhealthoutcomesforindividualswhohaveexperiencedviolence[5],
andLoganandcolleaguesfoundthatperpetratorsofIPVinruralareasaremorelikelytouse
knivesorguns—injurieswhichmaynecessitatehospitalization[7].Additionally,rurallocales
havefewerIPVservicesandIPV-exposedindividualsinruralareasreportlesshelpseeking
behaviorsandmoredifficultyaccessingmedicalcare[5].Further,comparedwiththerestof
theUS,Appalachiancountiesreporthigheraggregatehealthcarecostsandmoredisparitiesin
accesstocare[41].Thus,thehigherIPV-relatedhospitalizationrateinAppalachiamightnot
Table2. IPV-relatedhospitalizationsforAppalachiaandnon-AppalachiancountiesintheUS,2007–2011.
Appalachia Non-AppalachianUS
Number Rate/100,000 Number Rate/100,000 RateRatio AdjustedRateRatio
(95%CI) (95%CI)
Total 2,645 3.09 4,740 2.71 1.14(1.09–1.20) 1.22(1.14–1.31)
Age
18–34 604 2.56 1237 2.24 1.14(1.04–1.26) 1.24(1.08–1.41)
35–64 1147 2.53 1993 2.20 1.15(1.07–1.24) 1.19(1.08–1.32)
65+ 894 5.34 1510 5.18 1.03(0.95–1.12) 1.23(1.10–1.37)
Rurality†
Rural 1,026 3.27 565 2.60 1.26(1.13–1.39) 1.26(1.12–1.41)±
Urban 1,619 2.98 4,175 2.72 1.09(1.03–1.16) 1.17(1.08–1.26)
†BasedonUrbanInfluenceCodes.
±PoissonregressionwithPearsonscalingfactor.
https://doi.org/10.1371/journal.pone.0184222.t002
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IntimatepartnerviolencehospitalizationsinAppalachia
Table3. TopfifteencomorbiddiagnosesforIPV-relatedhospitalizationsinAppalachiaandnon-AppalachiancountiesintheUS,2007–2011.
Rank Appalachia Non-AppalachianUS
Diagnosiscategory n(%) Diagnosiscategory n(%)
1 MoodDisorders 533 Otherinjuriesandconditionsduetoexternalcauses 616
(20.2) (13.0)
2 Otherinjuriesandconditionsduetoexternalcauses 233(8.4) MoodDisorders 476
(10.0)
3 Septicemia(exceptinlabor) 88(3.3) Alcohol-relateddisorders 174(3.7)
4 Urinarytractinfections 81(3.1) Othercomplicationsofpregnancy 168(3.6)
5 Fluidandelectrolytedisorders 69(2.6) Septicemia(exceptinlabor) 155(3.7)
6 Schizophreniaandotherpsychoticdisorders 67(2.5) Urinarytractinfections 149(3.4)
7 Poisoningbyothermedicationsanddrugs 63(2.4) Intracranialinjury 114(2.4)
8 Pneumonia(exceptthatcausedbytuberculosisorsexually 58(2.2) Poisoningbyothermedicationsanddrugs 111(2.3)
transmitteddisease)
9 Poisoningbypsychotropicagents 56(2.2) Fluidandelectrolytedisorders 98(2.1)
10 Chronicobstructivepulmonarydiseaseandbronchiectasis 53(2.0) Acuteandunspecifiedrenalfailure 97(2.1)
11 Substance-relateddisorders 51(1.9) Schizophreniaandotherpsychoticdisorders 92(1.9)
12 Delirium,dementia,andamnesticandothercognitivedisorders 50(1.9) Poisoningbypsychotropicagents 85(1.8)
13 Alcohol-relateddisorders 44(1.7) Crushinginjuryorinternalinjury 80(1.7)
14 Diabetesmellituswithcomplications 42(1.6) Diabetesmellituswithcomplications 77(1.6)
15 Othercomplicationsofpregnancy 42(1.6) Delirium,dementia,andamnesticandothercognitive 68(1.4)
disorders
https://doi.org/10.1371/journal.pone.0184222.t003
beafunctionofahigherprevalenceofIPV,butinsteadmayreflectoverutilizationofemer-
gencyorinpatientservicesduetoshortagesinpreventiveandIPV-specificservicesinthemed-
icallyunderservedregion.BecauseIPVfrequencyandseverityincreasesovertime,individuals
withoutadequatemeanstoaddressIPVmightremaininsituationsofescalatingabusethat
Table4. TopfifteenprimaryproceduresforIPV-relatedhospitalizationsinAppalachiaandnon-AppalachiancountiesintheUS,2007–2011.
Rank Appalachia† Non-AppalachianUS‡
Procedurecategory n(%) Procedurecategory n(%)
1 Alcoholanddrugrehabilitation/detoxification 169(16.5) Alcoholanddrugrehabilitation/detoxification 152(7.2)
2 Respiratoryintubationandmechanicalventilation 82(8.0) Respiratoryintubationandmechanicalventilation 133(6.3)
3 Bloodtransfusion 61(6.0) Bloodtransfusion 97(4.6)
4 Othervascularcatheterization;notheart 54(5.3) Othervascularcatheterization;notheart 94(4.5)
5 Uppergastrointestinalendoscopy;biopsy 34(3.3) Othertherapeuticprocedures 80(3.8)
6 Debridementofwound;infectionorburn 33(3.2) Otherprocedurestoassistdelivery 74(3.5)
7 Indwellingcatheter 32(3.1) Sutureofskinandsubcutaneoustissue 67(3.2)
8 Otherprocedurestoassistdelivery 32(3.1) Uppergastrointestinalendoscopy;biopsy 63(3.0)
9 Psychologicalandpsychiatricevaluationandtherapy 28(2.7) Debridementofwound;infectionorburn 58(2.8)
10 Cesareansection 26(2.5) Psychologicalandpsychiatricevaluationandtherapy 54(2.8)
11 Incisionofpleura;thoracentesis;chestdrainage 23(2.3) Computerizedaxialtomography(CT)scanhead 53(2.5)
12 Treatment;facialfractureordislocation 18(1.8) Cesareansection 47(2.2)
13 Othertherapeuticprocedures 18(1.8) Hemodialysis 42(2.0)
14 Hemodialysis 17(1.7) Fetalmonitoring 35(1.7)
15 Othernon-ORtherapeuticproceduresonskinandbreast 17(1.7) Treatment;facialfractureordislocation 33(1.6)
†Outof1,023hospitalizationsinwhichprocedureswereperformed.
‡Outof2,098hospitalizationsinwhichprocedureswereperformed.
https://doi.org/10.1371/journal.pone.0184222.t004
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IntimatepartnerviolencehospitalizationsinAppalachia
eventuallyrequireemergentinpatientcare.Thisdisparityinaccesstoresourcesmaybeespe-
ciallypronouncedamongAppalachianresidentslivinginthemostrural,isolatedareas.
Inadditiontorurality,sociodemographicdifferencesbetweenthetworegionsmayexplain
Appalachia’shigherrateofIPV-relatedhospitalizations.Appalachianpatientswereolderthan
theirnon-Appalachiancounterparts,weremorelikelytoidentifyasWhite,andhavepublic
versusprivateinsurance.Theywerealsomorelikelytoresideinthepoorestneighborhoods—
only3%ofAppalachianpatientshospitalizedforIPVlivedincommunitieswiththehighest
incomequartileof>$64,000peryear.ThesedataarereflectiveoftheAppalachianpopulation
asawhole:residentsofAppalachiaaremoreraciallyhomogenous(83%White)thanthetotal
USpopulation(63%White),significantlyolder(medianage=40yearsvs.37years),andhave
ahigherproportionofresidentsaged65yearsandolder(16%vs13%).Appalachiansarealso
lesslikelytohaveatleastabachelor’slevelofeducation(22%vs.29%)andtheyhavesignifi-
cantlylowerincomesthannon-Appalachianresidents.Moreover,thehouseholdswiththe
lowestincomesinAppalachiaarefoundwithinthemostruralcounties[42].Inarecentstudy,
Edwardsetal[43]foundthatruralcommunitieswithhighpovertyandlowcollectiveefficacy
(ie,socialcohesionamongcommunitymembersandwillingnesstointerveneforthecommon
good)[44]experiencedthehighestratesofIPV.Lowincomelevelsinparticularhavebeen
showntobeoneofthestrongestpredictorsofIPV,evenaftercontrollingforrace/ethnicity
[45].Inaddition,whilemanystudieshavefoundracial/ethnicminoritypopulationsdispro-
portionatelyexperienceIPV[40],[46–48]andaremorelikelytobehospitalizedasaresult
[28],lessisknownaboutIPVriskandoutcomesamongWhitepopulationslivinginpoor,pre-
dominatelyWhitecommunities[49].Whilelargeamountsofmissingdataonrace/ethnicity
withintheStateInpatientDatabasesprecludedourabilitytoreliablycontrolforrace/ethnicity
inourregressionanalyses,examiningIPVrisk,healthcareutilizationpatterns,andhealthand
psychosocialoutcomesacrossracial/ethnicgroupsinAppalachiaisanimportantnextstepfor
futureresearch.
WhileitisnotsurprisingthatAppalachianpatientswereslightlyolderthannon-Appala-
chiancounterparts,theolderageofpatientsinbothregionscontrastswithotherstudiesthat
havefoundyounger((cid:20)30)populationsareatincreasedriskforIPV-relatedhospitalizations
[27].However,ShaferetalreportedthatalthoughmostpatientsexposedtoIPVwhosought
emergencydepartmentserviceswerebetweenages20–29,those50yearsorolderweremore
frequentlyhospitalized[30].Thissuggeststhat,whileyoungergroupsmaybeatincreasedrisk
forIPV,olderpatientswhohaveexperiencedIPVmaybemorelikelytobehospitalizeddueto
comorbiditiesandotherchronicconditions(eg,osteoporosisthatcontributestomoresevere
fractures,anticoagulantsthatcontributetomoreextensivebleeding).
ThetopdiagnosesshowninTable3mirrorwhathasbeenreportedinotherstudiesofIPV-
relatedhospitalizations,whereinmentaldisorders,suicideattempts,traumaticinjuriesand
assault,drugaddictionandpoisonings,andpregnancycomplicationswerelistedastopdiag-
nosesamonghospitalizedpatients[27],[28],[30].Therewerenotabledifferencesincomorbid
diagnosesandproceduresbetweenAppalachianandnon-Appalachianpatients,however.Co-
morbiditiesrelatedtosubstanceuseandmentalhealthissuesweremorefrequentlyobserved
amongAppalachianpatientswhilenon-Appalachianpatientshadmorediagnosesandproce-
duresindicativeofacuteIPV-relatedinjuries(eg,intracranial,crushing,andinternalinjuries,
sutures,CTscans).Thehighprevalenceofcomorbiddiagnosesandproceduresrelatedtoboth
mentalhealthandsubstanceusedisordersamongAppalachianpatientswithhospitalizations
relatedtoIPVisnoteworthy,butnotunexpected,astheco-occurrenceofIPV,mentalhealth
issuesandsubstanceuseiswell-established[24],[50–53].Likewise,Appalachiafacessignificant
disparitiesrelatedtomentalhealthandsubstanceusedisorders,includingepidemicratesof
prescriptionopioidandheroinuse.Usingstate,sub-state,andcountyleveldatafrom2000to
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