Multisite medical record review of emergency department visits for unspecified injury of head following the ICD-10-CM coding transition.

INTRODUCTION: In 2016, a proposed International Classification of Diseases, Tenth Edition, Clinical Modification surveillance definition for traumatic brain injury (TBI) morbidity was introduced that excluded the unspecified injury of head (S09.90) diagnosis code. This study assessed emergency department (ED) medical records containing S09.90 for evidence of TBI based on medical documentation. METHODS: State health department representatives in Maryland, Kentucky, Colorado and Massachusetts reviewed a target of 385 randomly sampled ED records uniquely assigned the S09.90 diagnosis code (without proposed TBI codes), which were initial medical encounters among state residents discharged home during October 2015-December 2018. Using standardised abstraction procedures, reviewers recorded signs and symptoms of TBI, and head imaging results. A tiered case confirmation strategy was applied that assigned a level of certainty (high, medium, low, none) to each record based on the number and type of symptoms and imaging results present in the record. Positive predictive value (PPV) of S09.90 by level of TBI certainty was calculated by state. RESULTS: Wide variation in PPV of sampled ED records assigned S09.90: 36%-52% had medium or high evidence of TBI, while 48%-64% contained low or no evidence of a TBI. Loss of consciousness was mentioned in 8%-24% of sampled medical records. DISCUSSION: Exclusion of the S09.90 code in surveillance estimates may result in many missed TBI cases; inclusion may result in counting many false positives. Further, missed TBI cases influenced by incidence estimates, based on the TBI surveillance definition, may lead to inadequate allocation of public health resources.

Multisite medical record review of emergency department visits for traumatic brain injury.

BACKGROUND: In 2016, the CDC in the USA proposed codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for identifying traumatic brain injury (TBI). This study estimated positive predictive value (PPV) of TBI for some of these codes. METHODS: Four study sites used emergency department or trauma records from 2015 to 2018 to identify two random samples within each site selected by ICD-10-CM TBI codes for (1) intracranial injury (S06) or (2) skull fracture only (S02.0, S02.1-, S02.8-, S02.91) with no other TBI codes. Using common protocols, reviewers abstracted TBI signs and symptoms and head imaging results that were then used to assign certainty of TBI (none, low, medium, high) to each sampled record. PPVs were estimated as a percentage of records with medium-certainty or high-certainty for TBI and reported with 95% confidence interval (CI). RESULTS: PPVs for intracranial injury codes ranged from 82% to 92% across the four samples. PPVs for skull fracture codes were 57% and 61% in the two university/trauma hospitals in each of two states with clinical reviewers, and 82% and 85% in the two states with professional coders reviewing statewide or nearly statewide samples. Margins of error for the 95% CI for all PPVs were under 5%. DISCUSSION: ICD-10-CM codes for traumatic intracranial injury demonstrated high PPVs for capturing true TBI in different healthcare settings. The algorithm for TBI certainty may need refinement, because it yielded moderate-to-high PPVs for records with skull fracture codes that lacked intracranial injury codes.

Assessment of Selected Overdose Poisoning Indicators in Health Care Administrative Data in 4 States, 2012.

OBJECTIVES: In 2012, a consensus document was developed on drug overdose poisoning definitions. We took the opportunity to apply these new definitions to health care administrative data in 4 states. Our objective was to calculate and compare drug (particularly opioid) poisoning rates in these 4 states for 4 selected Injury Surveillance Workgroup 7 (ISW7) drug poisoning indicators, using 2 ISW7 surveillance definitions, Option A and Option B. We also identified factors related to the health care administrative data used by each state that might contribute to poisoning rate variations. METHODS: We used state-level hospital and emergency department (ED) discharge data to calculate age-adjusted rates for 4 drug poisoning indicators (acute drug poisonings, acute opioid poisonings, acute opioid analgesic poisonings, and acute or chronic opioid poisonings) using just the principal diagnosis or first-listed external cause-of-injury fields (Option A) or using all diagnosis or external cause-of-injury fields (Option B). We also calculated the high-to-low poisoning rate ratios to measure rate variations. RESULTS: The average poisoning rates per 100 000 population for the 4 ISW7 poisoning indicators ranged from 11.2 to 216.4 (ED) and from 14.2 to 212.8 (hospital). For each indicator, ED rates were usually higher than were hospital rates. High-to-low rate ratios between states were lowest for the acute drug poisoning indicator (range, 1.5-1.6). Factors potentially contributing to rate variations included administrative data structure, accessibility, and submission regulations. CONCLUSIONS: The ISW7 Option B surveillance definition is needed to fully capture the state burden of opioid poisonings. Efforts to control for factors related to administrative data, standardize data sources on a national level, and improve data source accessibility for state health departments would improve the accuracy of drug poisoning surveillance.

"I didn't fight for my life to be treated like this!": The relationship between the experience of cancer and intimate partner abuse.

The current article seeks to further understanding of the high frequency of intimate partner abuse among cancer patients through qualitative analysis of semistructured interviews with 20 women and one man facing cancer and intimate partner abuse concurrently. Participants described a range of abusive and unsupportive behaviors by their intimate partners over the course of cancer treatment, which contributed to their reassessing and makinig changes in their relationships. Important factors in this process of change appear to be participants' increased focus on their own health, discovery of greater inner strength, and increased social support. Barriers to making changes in their relationships during their cancer treatment also were described. Participants who made significant changes in or left an abusive relationship usually did so after having recovered from cancer treatment. Implications of these findings for social workers in health care are discussed, as are directions for future research.

Perceived changes in health and safety following participation in a health care-based domestic violence program.

This descriptive study explores perceived changes in health and safety and the potential process by which these changes occur. Forty-nine women experiencing intimate partner abuse participated in a health care-based domestic violence (DV) advocacy program for 6 months or more. An analysis of structured interviews in English and Spanish found that the majority of participants perceived positive changes in their personal safety and emotional health because of their involvement in the program. Some participants also perceived improvements in their physical health, unhealthy coping behaviors (e.g., overeating and smoking), and health care following program involvement. Participants' responses suggest a process of change whereby DV advocacy services first contribute to improved safety and emotional health, which then facilitates behavioral changes. Behavioral changes may subsequently contribute to improvements in physical health, which may also benefit emotional health. Longitudinal evaluations are needed to evaluate the impact of DV advocacy and other interventions for partner abuse on women's health and safety over time.

Screening for domestic violence in an oncology clinic: barriers and potential solutions.

PURPOSE/OBJECTIVES: To evaluate the implementation of a domestic violence screening protocol in an oncology clinic. DESIGN: A retrospective review of a random sample of clinic medical records and qualitative surveys of nursing staff. SETTING: A gynecologic oncology clinic in a large teaching hospital. SAMPLE: 204 charts were abstracted and six oncology nurses completed surveys. METHODS: A random sample of patients from clinic appointment schedules was selected 6 and 12 months after the implementation of a domestic violence screening protocol. A brief written survey of nursing staff also was conducted. MAIN RESEARCH VARIABLES: Documentation of domestic violence screening, barriers to screening and documentation, and potential solutions to the barriers. FINDINGS: Sixty-three percent of the charts reviewed had a domestic violence screening record present, but only 12% of the charts with a screening record had documentation. Patients with domestic violence screening documentation were more likely to have had five or more clinic visits during the study period. The most frequent barriers to protocol implementation cited by nursing staff were forgetting to screen or document domestic violence screening. Nursing staff recommended adding domestic violence screening questions to forms and providing reminders to screen. CONCLUSIONS: Several barriers to successful implementation of a domestic violence screening protocol in a gynecologic oncology clinic, including documentation issues, were encountered. IMPLICATIONS FOR NURSING: Nurses interested in implementing a domestic violence screening protocol in their oncology clinic should consider reviewing the barriers to domestic violence screening and documentation and the potential solutions identified in this study.

Male partner pregnancy-promoting behaviors and adolescent partner violence: findings from a qualitative study with adolescent females.

OBJECTIVE: To examine the context of pregnancy and sexual health among adolescent females with a history of intimate partner violence (IPV). This paper reports on a subset of females who described abusive male partners' explicit pregnancy-promoting behaviors (ie, messages and behaviors that led females to believe their partner was actively trying to impregnate them). METHODS: Semistructured interviews were conducted with 53 sexually active adolescent females, with known history of IPV, about violence, sexual experiences, and related behaviors. Interviews were analyzed using a content analysis approach; 14 interviews in which females reported that partners were actively trying to impregnate them were further analyzed for pregnancy and contraceptive use. RESULTS: Participants (N = 53) were aged 15 to 20 years, with notable minority representation, 21% African American (n = 11) and 38% Latina (n = 20). Over half (n = 31, 58%) had experienced pregnancy. A key finding was that approximately one quarter of participants (26%, n = 14) reported that their abusive male partners were actively trying to get them pregnant. Females' stories revealed that abusive male partners desiring pregnancy manipulated condom use, sabotaged birth control use, and made explicit statements about wanting her to become pregnant. CONCLUSIONS: Pregnancy-promoting behaviors of male abusive partners may be one potential mechanism underlying associations between adolescent IPV and pregnancy. These findings suggest that exploring pregnancy intentions and behaviors of partners of sexually active adolescents may help to identify youth experiencing IPV. The frequency of birth control sabotage and explicit attempts to cause pregnancy in adolescent IPV needs to be examined at the population level.

How employment helps female victims of intimate partner violence: a qualitative study.

This exploratory, qualitative study documents ways in which being employed is helpful to victims of intimate partner violence (IPV). The authors conducted in-depth interviews with 21 women employed by a large health care organization in a major U.S. city. Through content analysis, the authors identified six ways in which employment was helpful to participants: by (1) improving their finances, (2) promoting physical safety, (3) increasing self-esteem, (4) improving social connectedness, (5) providing mental respite, and (6) providing motivation or a "purpose in life." Findings suggest that employment can play a critically important, positive role in the lives of IPV victims. The importance of flexible leave-time policies and employer assistance to IPV victims is discussed.

Social norms and beliefs regarding sexual risk and pregnancy involvement among adolescent males treated for dating violence perpetration.

The present study explored perceived sexual norms and behaviors related to sexual risk and pregnancy involvement among adolescent males (ages 13 to 20) participating in programs for perpetrators of dating violence. The purpose of this study was to generate hypotheses regarding the contexts and mechanisms underlying the intersection of adolescent dating violence, sexual risk and pregnancy. Six focus groups were conducted (N = 34 participants). A number of major themes emerged: 1) male norm of multiple partnering, 2) perceived gain of male social status from claims of sexual activity, 3) perception that rape is uncommon combined with belief that girls claiming to be raped are liars, 4) perception that men rationalize rapes to avoid responsibility, 5) condom non-use in the context of rape and sex involving substance use, 6) beliefs that girls lie and manipulate boys in order to become pregnant and trap them into relationships, and 7) male avoidance of responsibility and negative responses to pregnancy. The combination of peer-supported norms of male multiple partnering and adversarial sexual beliefs appear to support increased male sexual risk, lack of accountability for sexual risk, and rationalization of rape and negative responses to pregnancy. Further research focused on the context of male sexual risk and abusive relationship behaviors is needed to inform intervention with young men to promote sexual health and prevent rape, dating violence, and adolescent pregnancy.

Impact of partner abuse on women's reproductive lives.

OBJECTIVE: To increase our understanding of how intimate partner abuse may limit women's reproductive choices. METHODS: Findings were obtained from a larger study involving interviews with 38 women participating in a hospital-based domestic violence program. We asked participants whether and in what ways their abusive partners had limited their ability to choose whether or not to have children. Content analysis was used to identify main themes. RESULTS: Thirteen (34%) participants reported that partners had limited their ability to choose whether or not to have children. Seven of these women described tactics to try to get them to have children, and 7 reported being pressured or forced to have abortions (1 woman reported both). Two women underwent sterilization in response to the abuse. Four of the 13 women reported contradictory behaviors by their partners around family planning, such as not allowing birth control, then demanding that the participant terminate the pregnancy. CONCLUSION: Women described several ways in which their abusive partners controlled or attempted to control their reproductive lives that have received little or no prior attention. Further studies are needed to determine the prevalence and consequences of these behaviors, particularly the extent to which women in abusive relationships feel coerced into sterilization or abortion.