Rural-Urban Disparities in Emergency Department Intimate Partner Violence Resources

INTRODUCTION

Intimate partner violence (IPV) includes any pattern of assaultive and coercive behaviors, including physical injury, psychological abuse, sexual assault, social isolation, stalking, deprivation, intimidation or threats perpetrated by someone who was or is in an intimate relationship with the victim.¹ It occurs in an estimated two million United States (U.S.) women each year and 26% of U.S. women over their lifetime.^2,3 However, partner violence is even more common among individuals visiting the emergency department (ED) for care; estimates range from past-year prevalence of 12 to 19% and lifetime prevalence of 44 to 54%.^4–8

The prevalence of IPV in rural settings appears to be similar to that in non-rural settings.^9–12 However, in rural areas, geographic and economic barriers to seeking healthcare are often greater and alternatives for follow up and referrals may be limited.^13,14 Therefore, the ED visit may be particularly important as an opportunity to identify and comprehensively address IPV. The objective of this study was to assess differences in IPV resource availability between urban and rural EDs.

METHODS

RESULTS

Fifty-five of 57 EDs (96%) participated in the survey, with 13 physician directors and 42 nurse managers responding. The director and nurse manager of one hospital could not be reached, and one ED declined participation. Table 1 compares characteristics of rural and urban hospitals. Thirty-four (63%) of the participating hospitals are classified as rural.

Figure 2 shows reported resource availability by practice setting. In univariate analysis, a smaller proportion of rural hospitals reported official IPV screening policies (p=0.01), standardized screening instruments (p=0.01), regular clinician training (p=0.02), and on-site IPV advocates (<0.001). Urban EDs more often reported availability of full-time on-site advocates than rural EDs (38% vs 6%, p<0.001). Use of public displays regarding IPV and standardized intervention checklists was greater in urban settings, although these differences were not statistically significant.

The total number of available IPV services differed significantly between urban and rural EDs (Figure 3) as well. Twenty-seven percent of rural services reported none of the six resources examined, while all urban hospitals reported two or more IPV resources and 65% had four or more (p=0.003).

Results based on reimbursement category are shown in Table 2. For every resource except use of public displays, a smaller proportion of Type A hospitals reported resource availability than Type B hospitals, and a smaller proportion of Type B hospitals reported resource availability than DRG hospitals. Fifty percent of Type A hospitals reported none of the examined resources, while all DRG hospitals reported at least two resources and 70% had four or more (p= <0.001).

In the comparison of hospitals by annual ED census, the only resource with a statistically significant difference was a written IPV policy, which was reported more frequently among hospitals with an annual ED census less than 10,000.

DISCUSSION

We describe differences in the reported availability of IPV resources between urban and rural EDs. Overall, rural EDs seem to have fewer resources to address partner violence, with less reported availability of all six types of studied IPV resources and fewer total number of IPV resources. Comparison of reported resource availability based on hospital reimbursement categories suggests that resource limitations were exacerbated by factors such as small size and remoteness. However, we did not find a correlation between ED volume and number of resources reported. It seems unlikely, therefore that need (i.e., number of IPV cases encountered) is what dictates availability of services.

In 1992, the Joint Commission (formerly known as the Joint Commission on the Accreditation of Healthcare Organizations, or JCAHO) defined basic standards for hospital policies and procedures to increase the identification of IPV within EDs and hospital-based ambulatory care centers.²² Updated in 2004, the standards include maintenance of specific criteria for identifying victims of IPV, identification of victims upon entry into the healthcare system (e.g., at ED triage), education of staff about the management of IPV, and appropriate assessment and referrals by staff. These recommendations are uniform for all hospitals and do not acknowledge potential resource differences between rural and urban hospitals, or hospitals of varying sizes.

There are a number of potential solutions to resource limitation in rural areas. Resources such as IPV management guidelines or patient educational posters and pamphlets are relatively inexpensive to develop and use, particularly with the increasing availability of free or low-cost materials from non-profit domestic violence groups and medical societies.^23,24 Existing leadership and continual medical education activities may be modified to include material on IPV and to emphasize skills that will allow individuals to train others within their institution. Statewide or county-wide collaborations may allow rural institutions to benefit from a variety of educational, research and community initiatives related to the management of IPV.²⁵ State and national hotlines are available 24/7 for counseling patients experiencing IPV. Telemedicine is providing intriguing new possibilities for counseling victims of IPV in rural locations.²⁶

LIMITATIONS

Resource availability was determined by the responses of surveyed ED staff. The studied resources may have been mistakenly reported as present when absent or reported as absent when actually present. Further, a resource may be technically present but not provided to patients meaningfully; for example, a written policy may exist but would have little effect on patient care if it was rarely referred to or if there was no quality assurance process to make sure it was adhered to rigorously. On the other hand, it may be that an ED does not have a formal policy in place yet in practice still delivers a service well. Our study was not able to measure actual ED practices.

Our findings may also be limited by recall bias. ED representatives may have been more likely to report having resources when unsure, particularly if they were aware that specific IPV resources are mandated for hospitals by the Joint Commission. Further, as a non-anonymous survey, respondents may not have felt free to answer honestly. However, there is no reason over-reporting or under-reporting of resources should have occurred differentially between rural and urban sites, so this bias, if present, would not explain our findings.

Because our study was limited to the state of Oregon, the findings may not be generalizable to the entire U.S. Oregon does not require reporting of IPV unless a weapon was used to inflict an injury. States without reporting requirements may have different resource utilization than those with these requirements. The hospitals surveyed did represent a broad range of practice settings, with varying bed and staff sizes and trauma capabilities, so are likely to be relevant to a broad range of practice types.

CONCLUSION

Rural EDs in our study reported limited resources for IPV management compared to urban EDs. Further research is needed to identify specific barriers to obtaining IPV resources. At the same time, further cost-effective means of improving the initial assessment and care of IPV victims in the ED should be identified and developed.