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

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

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

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

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

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…

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

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

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

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

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

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)

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)

Primary Care Use (IRR)

Specialty Care Use (IRR)

Pharmacy Fills (IRR)

Mental Health Use (RR)

Emergency Use (RR)

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

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

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

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*