Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans

  • Mark W. Vander Weg
    Correspondence
    Correspondence to: Mark W. Vander Weg, PhD, Center for Access & Delivery Research and Evaluation (CADRE) Iowa City VA Health Care System, 601 Highway 6 West, Mail Stop 152, Iowa City, IA 52246. Phone: (319) 338-0581; fax: (319) 887-4932.
    Affiliations
    Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa

    Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa

    Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
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  • Anne G. Sadler
    Affiliations
    Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa

    Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Thad E. Abrams
    Affiliations
    Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa

    Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa

    Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Kelly Richardson
    Affiliations
    Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
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  • James C. Torner
    Affiliations
    Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa

    Departments of Neurosurgery and Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Craig H. Syrop
    Affiliations
    Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Michelle A. Mengeling
    Affiliations
    Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa

    Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa

    VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, Iowa
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      Abstract

      Background

      Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women Veterans’ lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans.

      Methods

      Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups.

      Results

      Sixty-four percent of participants visited a VA or non-VA ED during the previous 5 years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers.

      Conclusions

      Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.
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      References

        • Agarwal P.
        • Bias T.K.
        • Madhavan S.
        • Sambamoorthi N.
        • Frisbee S.
        • Sambamoorthi U.
        Factors associated with emergency department visits: A multistate analysis of adult fee-for-service Medicaid beneficiaries.
        Health Services Research and Managerial Epidemiology. 2016; 3 (2333392816648549)
        • American College of Obstetricians and Gynecologists
        Sexual assault.
        in: Special Issues in Women's Health. American College of Obstetricians and Gynecologists, Washington, DC2005: 189-202
        • American Medical Association
        Strategies for treatment and prevention of sexual assault.
        American Medical Association, Washington, DC1995
        • Anderson E.S.
        • Lippert S.
        • Newberry J.
        • Bernstein E.
        • Alter H.J.
        • Wang N.E.
        Addressing social determinants of health from the emergency department through social emergency medicine.
        Western Journal of Emergency Medicine. 2016; 17: 487-489
        • Baker D.W.
        • Stevens C.D.
        • Brook R.H.
        Determinants of emergency department use: Are race and ethnicity important?.
        Annals of Emergency Medicine. 1996; 28: 677-682
        • Barth S.K.
        • Kimerling R.E.
        • Pavao J.
        • McCutcheon S.J.
        • Batten S.V.
        • Dursa E.
        • Peterson M.R.
        • Schneiderman A.E.
        Military sexual trauma among recent veterans: correlates of sexual assault and sexual harassment..
        American Journal of Preventive Medicine. 2016; 50: 77-86
        • Booth B.M.
        • Mengeling M.
        • Torner J.
        • Sadler A.G.
        Rape, sex partnership, and substance use consequences in women veterans.
        Journal of Traumatic Stress. 2011; 24: 287-294
        • Breiding M.J.
        • Smith S.G.
        • Basile K.C.
        • Walters M.L.
        • Chen J.
        • Merrick M.T.
        Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization–national intimate partner and sexual violence survey, United States, 2011.
        MMWR Surveillance Summaries. 2014; 63: 1-18
        • Breiman L.
        • Friedman J.H.
        • Olshen R.A.
        • Stone C.J.
        Classification and regression trees.
        Wadsworth, Belmont, CA1983
        • Brignone E.
        • Gundlapalli A.V.
        • Blais R.K.
        • Kimerling R.
        • Barrett T.S.
        • Nelson R.E.
        • Fargo J.D.
        Increased health care utilization and costs among veterans with a positive screen for military sexual trauma.
        Medical Care. 2017; 55: S70-S77
        • Calhoun P.S.
        • Schry A.R.
        • Dennis P.A.
        • Wagner H.R.
        • Kimbrel N.A.
        • Bastian L.A.
        • Straits-Troster K.
        The association between military sexual trauma and use of VA and non-VA health care services among female veterans with military service in Iraq or Afghanistan.
        Journal of Interpersonal Violence. 2018; 33: 2439-2464
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        Journal of Chronic Disease. 1987; 40: 373-383
        • Cheung P.T.
        • Wiler J.L.
        • Lowe R.A.
        • Ginde A.A.
        National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries.
        Annals of Emergency Medicine. 2012; 60: 4-10.e12
        • Criner G.J.
        • Bourbeau J.
        • Diekemper R.L.
        • Ouellette D.R.
        • Goodridge D.
        • Hernandez P.
        • Stickland M.K.
        Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline.
        Chest. 2015; 147: 894-942
        • Dieleman J.L.
        • Baral R.
        • Birger M.
        • Bui A.L.
        • Bulchis A.
        • Chapin A.
        • Murray C.J.
        US Spending on Personal Health Care and Public Health, 1996–2013.
        JAMA. 2016; 316: 2627-2646
        • Dowd B.
        • Karmarker M.
        • Swenson T.
        • Parashuram S.
        • Kane R.
        • Coulam R.
        • Jeffery M.M.
        Emergency department utilization as a measure of physician performance.
        American Journal of Medical Quality. 2014; 29: 135-143
        • Eftekhari A.
        • Ruzek J.I.
        • Crowley J.J.
        • Rosen C.S.
        • Greenbaum M.A.
        • Karlin B.E.
        Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care.
        JAMA Psychiatry. 2013; 70: 949-955
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Medical Care. 1998; 36: 8-27
        • Foa E.B.
        • Riggs D.S.
        • Dancu C.V.
        • Rothbaum B.O.
        Reliability and validity of a brief instrument for assessing post-traumatic stress disorder.
        Journal of Traumatic Stress. 1993; 6: 459-473
        • Fontana A.
        • Rosenheck R.
        Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment.
        Psychiatric Services. 1998; 49: 658-662
        • Frayne S.M.
        • Skinner K.M.
        • Sullivan L.M.
        • Tripp T.J.
        • Hankin C.S.
        • Kressin N.R.
        • Miller D.R.
        Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military.
        Journal of Womens Health and Gender Based Medicine. 1999; 8: 835-845
        • Hastings S.N.
        • Smith V.A.
        • Weinberger M.
        • Schmader K.E.
        • Olsen M.K.
        • Oddone E.Z.
        Emergency department visits in Veterans Affairs medical facilities.
        American Journal of Managed Care. 2011; 17: e215-e223
        • Himmelfarb N.
        • Yaeger D.
        • Mintz J.
        Posttraumatic stress disorder in female veterans with military and civilian sexual trauma.
        Journal of Traumatic Stress. 2006; 19: 837-846
        • Katz D.A.
        • McCoy K.D.
        • Vaughan-Sarrazin M.S.
        Does greater continuity of veterans administration primary care reduce emergency department visits and hospitalization in older veterans?.
        Journal of the American Geriatrics Society. 2015; 63: 2510-2518
        • Kelly M.M.
        • Vogt D.S.
        • Scheiderer E.M.
        • Ouimette P.
        • Daley J.
        • Wolfe J.
        Effects of military trauma exposure on women veterans' use and perceptions of Veterans Health Administration care.
        Journal of General Internal Medicine. 2008; 23: 741-747
        • Kimerling R.
        • Gima K.
        • Smith M.W.
        • Street A.
        • Frayne S.
        The Veterans Health Administration and military sexual trauma.
        American Journal of Public Health. 2007; 97: 2160-2166
        • Kimerling R.
        • Pavao J.
        • Valdez C.
        • Mark H.
        • Hyun J.K.
        • Saweikis M.
        Military sexual trauma and patient perceptions of Veteran Health Administration health care quality.
        Womens Health Issues. 2011; 21: S145-S151
        • Kimerling R.
        • Street A.E.
        • Gima K.
        • Smith M.W.
        Evaluation of universal screening for military-related sexual trauma.
        Psychiatric Services. 2008; 59: 635-640
        • Kimerling R.
        • Street A.E.
        • Pavao J.
        • Smith M.W.
        • Cronkite R.C.
        • Holmes T.H.
        • Frayne S.M.
        Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq.
        American Journal of Public Health. 2010; 100: 1409-1412
        • Kintzle S.
        • Schuyler A.C.
        • Ray-Letourneau D.
        • Ozuna S.M.
        • Munch C.
        • Xintarianos E.
        • Castro C.A.
        Sexual trauma in the military: Exploring PTSD and mental health care utilization in female veterans.
        Psychological Services. 2015; 12: 394-401
        • Larsen M.L.
        • Hilden M.
        • Skovlund C.W.
        • Lidegaard O.
        Somatic health of 2500 women examined at a sexual assault center over 10 years.
        Acta Obstetrica et Gynecologica Scandinavica. 2016; 95: 872-878
        • Lowenstein S.R.
        • Koziol-McLain J.
        • Thompson M.
        • Bernstein E.
        • Greenberg K.
        • Gerson L.W.
        • Blanda M.
        Behavioral risk factors in emergency department patients: A multisite survey.
        Academic Emergency Medicine. 1998; 5: 781-787
        • Mengeling M.A.
        • Booth B.M.
        • Torner J.C.
        • Sadler A.G.
        Reporting sexual assault in the military: Who reports and why most servicewomen don't.
        American Journal of Preventive Medicine. 2014; 47: 17-25
        • Mengeling M.A.
        • Booth B.M.
        • Torner J.C.
        • Sadler A.G.
        Post-sexual assault health care utilization among OEF/OIF servicewomen.
        Medical Care. 2015; 53: S136-S142
        • Milbrett P.
        • Halm M.
        Characteristics and predictors of frequent utilization of emergency services.
        Journal of Emergency Nursing. 2009; 35 (quiz 273): 191-198
        • National Defense Research Institute
        Sexual assault and sexual harassment in the U.S. Military.
        Author, Rand Corporation: Santa Monica, CA2014
        • Nyweide D.J.
        • Bynum J.P.W.
        Relationship between continuity of ambulatory care and risk of emergency department episodes among older adults.
        Annals of Emergency Medicine. 2017; 69: 407-415.e403
        • Peterson C.
        • DeGue S.
        • Florence C.
        • Lokey C.N.
        Lifetime economic burden of rape among U.S. adults.
        American Journal of Preventive Medicine. 2017; 52: 691-701
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • Fong A.
        • Burnand B.
        • Luthi J.C.
        • Ghali W.A.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Medical Care. 2005; 43: 1130-1139
        • Rui P.
        • Kang K.
        National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables.
        (Available:)
        • Rust G.
        • Ye J.
        • Baltrus P.
        • Daniels E.
        • Adesunloye B.
        • Fryer G.E.
        Practical barriers to timely primary care access: Impact on adult use of emergency department services.
        Archives of Internal Medicine. 2008; 168: 1705-1710
        • Sadler A.G.
        • Mengeling M.A.
        • Booth B.M.
        • O'Shea A.M.
        • Torner J.C.
        The relationship between US military officer leadership behaviors and risk of sexual assault of Reserve, National Guard, and Active Component servicewomen in nondeployed locations.
        American Journal of Public Health. 2017; 107: 147-155
        • Sadler A.G.
        • Mengeling M.A.
        • Syrop C.H.
        • Torner J.C.
        • Booth B.M.
        Lifetime sexual assault and cervical cytologic abnormalities among military women.
        Journal of Womens Health (Larchmont). 2011; 20: 1693-1701
        • Santaularia J.
        • Johnson M.
        • Hart L.
        • Haskett L.
        • Welsh E.
        • Faseru B.
        Relationships between sexual violence and chronic disease: A cross-sectional study.
        BMC Public Health. 2014; 14: 1286
        • Skinner K.M.
        • Kressin N.
        • Frayne S.
        • Tripp T.J.
        • Hankin C.S.
        • Miller D.R.
        • Sullivan L.M.
        The prevalence of military sexual assault among female Veterans' Administration Outpatients.
        Journal of Interpersonal Violence. 2000; 15: 291-310
        • Smith S.G.
        • Chen J.
        • Basile K.C.
        • Gilbert L.K.
        • Merrick M.T.
        • Patel N.
        • Jain A.
        The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report.
        National Center for Injury Prevention and Control, Centers for Disease Control and Prevention:, Atlanta, GA2017
        • Stein M.B.
        • Lang A.J.
        • Laffaye C.
        • Satz L.E.
        • Lenox R.J.
        • Dresselhaus T.R.
        Relationship of sexual assault history to somatic symptoms and health anxiety in women.
        General Hospital Psychiatry. 2004; 26: 178-183
        • Suris A.
        • Lind L.
        Military sexual trauma: A review of prevalence and associated health consequences in veterans.
        Trauma, Violence, & Abuse. 2008; 9: 250-269
        • Suris A.
        • Lind L.
        • Kashner T.M.
        • Borman P.D.
        • Petty F.
        Sexual assault in women veterans: An examination of PTSD risk, health care utilization, and cost of care.
        Psychosomatic Medicine. 2004; 66: 749-756
        • Therneau T.M.
        • Atkinson E.J.
        An introduction to recursive partitioning using the RPART routines.
        (Available:)
        • U.S. Department of Health and Human Services
        Social determinants of health.
        (Available:)
        • Walker E.A.
        • Unutzer J.
        • Rutter C.
        • Gelfand A.
        • Saunders K.
        • VonKorff M.
        • Katon W.
        Costs of health care use by women HMO members with a history of childhood abuse and neglect.
        Archives of General Psychiatry. 1999; 56: 609-613
        • Werner R.M.
        • Canamucio A.
        • Marcus S.C.
        • Terwiesch C.
        Primary care access and emergency room use among older veterans.
        Journal of General Internal Medicine. 2014; 29: S689-S694
        • Young-Wolff K.C.
        • Sarovar V.
        • Klebaner D.
        • Chi F.
        • McCaw B.
        Changes in psychiatric and medical conditions and health care utilization following a diagnosis of sexual assault: A retrospective cohort study.
        Medical Care. 2018; 56: 649-657
        • Young G.P.
        • Wagner M.B.
        • Kellermann A.L.
        • Ellis J.
        • Bouley D.
        Ambulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group.
        JAMA. 1996; 276: 460-465
        • Zinzow H.M.
        • Grubaugh A.L.
        • Frueh B.C.
        • Magruder K.M.
        Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: A multi-site study.
        Psychiatry Research. 2008; 159: 226-236

      Biography

      Mark W. Vander Weg, PhD, is an Associate Professor, Internal Medicine and Psychological and Brain Sciences at the University of Iowa, and a Core Investigator with the Center for Access & Delivery Research and Evaluation with the Iowa City VA Health Care System.

      Biography

      Anne G. Sadler, PhD, RN, is Professor of Psychiatry at the University of Iowa and a Core Investigator with the Center for Access & Delivery Research and Evaluation with the Iowa City VA Health Care System.

      Biography

      Thad E. Abrams, MD, MS, is Clinical Associate Professor of Internal Medicine at the University of Iowa and a Core Investigator with the Center for Access & Delivery Research and Evaluation with the Iowa City VA Health Care System.

      Biography

      Kelly Richardson, PhD, is Director of the Statistics Core for the Center for Access & Delivery Research and Evaluation with the Iowa City VA Health Care System.

      Biography

      James C. Torner, PhD, is Professor of Epidemiology, Neurosurgery, and Surgery with the University of Iowa.

      Biography

      Craig H. Syrop, MD, MHCDS, is Professor Emeritus of Obstetrics and Gynecology with the University of Iowa.

      Biography

      Michelle A. Mengeling, PhD, is Assistant Professor, Internal Medicine, University of Iowa, and a Core Investigator with the Center for Access & Delivery Research and Evaluation and the Rural Health Resource Center – Iowa City, with the Iowa City VA Health Care System.