Intimate Partner Violence, Health Care Utilization and Insurance Status: Results from a Large Population-Based survey Kenneth J. Steinman, PhD, MPH Amy E. Bonomi, PhD, MPH Academy on Violence & Abuse April 25, 2009 Supported by a grant from the Ohio Family Health Survey

Background IPV (intimate partner violence) is associated with HCU (health care utilization) (Coker et al., 2004; Helweg-Larsen, 2003; Rivara et al, 2007) Few population-based studies Little consideration of insurance status

Goals Assess IPV-HCU association in a population-based sample Does association vary by insurance status?

Ohio Family Health Survey September 2008-January 2009 n=50,944 (23,083 women <65) Computer-Assisted Telephone Interviews Random Digit Dialing Over-sampling of ethnic minorities, select counties Representative of Ohio adults & households Response rate: 47%

Dependent Variables During the past 12 months, how many times were you a patient in… an urgent care center? a hospital emergency room? a hospital overnight?

IPV measure During the past 12 months, how many times, if any, has anyone hit, slapped, pushed, kicked or physically hurt you? Think about the time of the most recent incident involving a person or persons who hit, slapped, pushed, kicked or physically hurt you. What was that person’s relationship to you? (open-ended)

intimate partner violence classifying a case of intimate partner violence How many times…? Not a case 0 times 1+ times What was that person’s relationship to you? 01 Stranger 02 Coworker 03 Professional caretaker 10 S/he is my Child 11 S/he is my Stepchild 12 Another family member 13 Acquaintance/friend 97 OTHER 98 DK 99 REFUSED 04 Male/Female first date 05 Someone you were dating 06 Former boyfriend/girlfriend 07 Current boyfriend/girlfriend or fiancé 08 Spouse or live-in partner 09 Former spouse or live-in partner intimate partner violence Other violence

Other Variables Age, ethnicity, region Socioeconomic status Income, education, home ownership Insurance status Uninsured; Medicaid; Employer-based; Other

Data Analysis Bivariate association Generalized Linear Model Covariates with IPV IPV with dependent variables Generalized Linear Model Poisson distribution, log link Controlling for age, ethnicity, SES Weighted data; complex survey design

IPV prevalence n Weighted % 95%CI Total 351 1.9 [1.6-2.2] Age 18-24 75 5.3 [4.0-6.9] 25-34 93 2.1 [1.5-2.8] 35-44 85 1.8 [1.3-2.5] 45-54 72 1.1 [0.8-1.5] 55-64 26 0.4 [0.2-0.8] Race/Ethnicity white 259 1.7 [1.4-2.1] black 70 3.3 [2.4-4.5] Hispanic 22 2.7 [1.5-4.7] Asian --*

IPV prevalence (2) n Weighted % 95%CI Income as % of federal poverty level <100% 145 4.3 [3.4-5.5] 100-300% 133 2.1 [1.7-2.7] >300% 73 0.8 [0.5-1.1] Home ownership owns home 173 1.3 [1.6-2.2] does not own home 176 3.5 [2.8-4.3]

IPV prevalence (3) n Weighted % 95%CI Education < High school 44 3.8 [3.4-5.5] High school graduate 259 1.3 [1.7-2.7] College Graduate 48 0.2 [0.5-1.1]

IPV prevalence (4) n Weighted % 95%CI Insurance type Medicaid 127 5.2 [4.1-6.7] employer-based 105 0.7 [0.5-0.9] uninsured 83 4.5 [3.4-6.0] Other a 36 1.8 [1.1-2.9] a Other insurance types include: Medicare only, directly purchased, unknown

Association of IPV with Health Care Utilization: Prevalence Rate Ratio (unadjusted) 95% CI Prevalence Rate Ratio (adjusted)a Urgent care 2.1 [1.7-2.7] 1.6 [1.3-2.1] Emergency room 2.2 [1.9-2.6] 1.5 [1.3-1.7] Hospital Admission 1.7 [1.3-2.2] 1.3 [1.0-1.7] a Adjusted for age, ethnicity, income, education, home ownership, insurance status

Association of IPV with Hospital Admission: Variation by Insurance Status Uninsured Medicare Employer-Based Other (n=2,924) (n=2,998) (n=13,763) (n=2,395) PRR 95% CI Urgent care 2.3 [1.5-3.5] 1.4 [1.0-1.9] 1.3 [0.8-2.4] 1.9 [1.0-3.7] Emergency room 1.7 [1.3-2.3] [1.1-1.7] [0.9-2.2] [1.1-3.2] Hospital admission 1.2 [0.6-2.4] 1.1 [0.8-1.6] [0.6-2.0] 3.0 [1.7-5.2] PRR=Prevalence Rate Ratio (adjusted for age, ethnicity, income, education, home ownership)

Discussion IPV – HCU association holds in general population IPV prevalence varies by insurance status IPV – HCU association may vary by insurance status Smaller effects for among women with employer-based insurance (EBI)?

Implications Urgent care may be important source of care EBI samples may underestimate IPV-HCU association Include insurance as a component of SES Useful alternative measurement approach

Thank you