1. Health Care Use & Costs Associated with Child Abuse
Amy E. Bonomi, PhD, MPH
The Ohio State University

2. Collaborators Group Health Cooperative (Seattle, WA)
Melissa L. Anderson, MS
Robert S. Thompson, MD
Robert Reid, MD, PhD
Paul Fishman, PhD
University of Washington (Seattle)
Frederick P. Rivara, MD, MPH

3. Prior Studies of Child Abuse Costs
18% higher annual health care costs in women with sexual abuse history (Walker 1999)
93% higher for women with sexual & physical abuse (Tang 2006)
Costs & actual health care use associated with specific abuse types unknown

4. Study Objective
Estimate health care use & costs associated with child abuse
By type of child abuse (physical, sexual, or both)
Into late middle age

5. Study Design & Sample Retrospective cohort
3,333 women (enrolled for 3+ years)
Randomly sampled from Group Health Cooperative enrollment records
Participated in telephone survey to assess abuse history / health
Accessed automated health care use data

6. Child Abuse Assessment
Before you were 18, were you punched, kicked, choked, or did you receive more serious punishment
…anyone ever touch you in a sexual place or make you touch them when you did not want to…

7. Child Abuse Exposures Physical only Sexual only
Physical and sexual abuse
No physical or sexual (reference group)

8. Annual Health Care Use
Assembled from automated health plan data from 1 Jan 1992 to 31 Dec 2002
Services assessed
Primary care
Specialty care
Mental health
Pharmacy, laboratory & radiology
Inpatient
Emergency department

9. Annual Health Care Costs
Allocated for each unit of service delivered
Adjusted to 2004 U.S. dollars using Consumer Price Index for Seattle/Tacoma

10. Statistical Analysis Unadjusted annual health care costs
Multivariable analysis / generalized estimating equations
Costs (cost ratios)
Health care use
Any use (relative risks)
How much used (incident rate ratios)
Adjusted for age, education, calendar year

11. Women’s Characteristics
No abuse (2205)
Physical only (216)
Sexual only (671)
Both
(241)
Age, mean
46.7
47.3
48.0
45.8
White
83.1%
77.8% *
85.4%
76.8% *
HS grad or less
11.9%
12.0%
10.4%
11.6%
Depression
17.1%
27.3% *
21.2% *
38.2% *
BMI, mean
27.2
28.3 *
28.2 **
29.7 **
* p < 0.05, ** p < 0.01

12. Unadjusted Annual Costs (U.S. $)
No abuse (2205)
Physical only (216)
Sexual only (671)
Both
(241)
Primary care
508 (758)
569 (641)
562 (656)
657 (650)
Specialty care
355 (871)
367 (696)
406 (1110)
434 (894)
Pharmacy
394 (1001)
459 (731)
467 (960)
611 (1056)
Inpatient
380 (2724)
433 (2599)
405 (3182)
468 (2359)
Total
2413 (5550)
2915 (5406)
2795 (6183)
3203 (4928)

13. Adjusted Cost Ratios No abuse (2205) Physical only (216)
Sexual only (671)
Both
(241)
Primary care --
1.13
(1.02, 1.26)
1.10
(1.04, 1.18)
1.32
(1.20, 1.46)
Specialty care
1.05
(0.89, 1.23)
1.15
(1.03, 1.29)
1.25
(1.07, 1.47)
Pharmacy
1.18
(0.95, 1.48)
(1.00, 1.39)
1.61
(1.26, 2.07)
Inpatient
(0.79, 1.77)
1.12
(0.82, 1.51)
1.27
(0.90, 1.80)
Total
1.22 (1.04,1.44)
1.16
(1.04, 1.30)
1.36
(1.18, 1.57)

14. Primary Care Use (IRR)

15. Specialty Care Use (IRR)

16. Pharmacy Fills (IRR)

17. Mental Health Use (RR)

18. Emergency Use (RR)

19. Summary
Most pronounced health care use & costs observed for women with physical and sexual abuse
Yet women with a history of either abuse type also had elevated service use & costs across multiple areas
Concerning is mental health use by women with physical abuse histories

20. Limitations
Reliance on retrospective abuse reports may have underestimated effects
Did not ask about other types of abuse, which could confound findings
Generalizability may be limited due to employed / educated nature of sample

21. Clinical Implications
Primary prevention – parenting skills programs
Secondary prevention – evaluation by mental health professionals
Care in adulthood – screen high users of mental health services for child abuse history

22. Child Abuse History in Women
No abuse
Physical “only”
Sexual
“only”
Both
Our study
66.1%
6.4%
20.1%
7.2%
Bensley (2000)
75.2%
4.4%
13.8%
6.6%
Comprehensive abuse assessment
Tang (2006)
72.5%
14.1%
6.1%
7.4%
Walker (1999)
57.2%
14.2%*
18.4%* --
Pereda (2009)
Meta-analysis
19.7*