A Description of Midlife Women Experiencing Intimate Partner Violence Using Electronic Medical Record Information

Abstract

Background:

Intimate partner violence (IPV) is an important health problem affecting women of all ages, but is often not addressed during healthcare visits.

Purpose:

To use electronic records of diagnoses and telephone advice calls to describe the clinical patterns of midlife women experiencing IPV.

Materials and Methods:

Using case–control methodology, women with an ICD9 diagnosis of IPV were chosen from those enrolled in 2005–2006 in Kaiser Permanente Northern California (KPNC) and matched on visit date, age, and facility with women without such a diagnosis. The study population was divided into subsets: ages 45–53 years (318 cases, 1588 controls); ages 54–64 years (200 cases, 1000 controls). Diagnoses and symptoms reported by phone that were significantly related to the cases compared with the controls were identified using multivariate logistic regression.

Results:

Among women aged 45–53 years, diagnoses of anxiety (odds ratio [OR] = 2.05) and of psychiatric problems (OR = 1.65) and calls for head injury (OR = 3.17), mental health problems (OR = 2.46), and sexually transmitted diseases (OR = 2.40) were associated with IPV. Among women aged 54–64 years, diagnoses of anxiety (OR = 1.74) and other psychiatric problems (OR = 1.76), injuries (other than head and neck) (OR = 1.57), urinary tract infection (UTI; OR = 2.31), headache (OR = 2.06), and calls for mental health problems (OR = 4.16) were associated with IPV. Among all women aged 45–64 years, history of prior IPV was strongly associated with subsequent diagnosis of IPV.

Conclusions:

Information available in the electronic health record of women who have been identified as experiencing IPV can be used to identify patterns of symptoms and diagnosis among midlife women. These patterns can potentially be used to improve identification of IPV in this age group. In addition to screening of all women for IPV, the presence of psychiatric problems, injuries, headache, and UTI and prior experience of IPV should prompt additional focused clinical inquiry about IPV in midlife women.

Introduction

Studies on prevalence of intimate partner violence (IPV) within the prior 6 months to 5 years consistently find lower rates of IPV among midlife and older women compared with women of childbearing age. In a study of women enrolled in a managed care organization, 4.1% of women aged 45–54 years and 1.2% of women aged 55–64 years reported experiencing physical IPV in the last 5 years compared with 6.7% of women aged 35–44 years and 6.7% for 25–34-year-old women.¹ Breiding,² in a 2008 analysis of Behavioral Risk Factor Surveillance System (BRFSS) data, found 12-month prevalence rates that steadily declined from 3.8% for women aged 18–24 years to 0.8% and 0.4% for women aged 45–54 and 55–64 years, respectively. More recent data from a 2010 the Centers for Disease Control national phone survey of IPV in the United States show that 4.1% of women aged 45–54 years and 1.4% of women aged 55 years and older had experienced physical violence, rape, or stalking by an intimate partner in the previous 12 months compared with 14.8% of women in the youngest (18–24 years) age cohort.³ Despite the lower prevalence among the older age groups, an understanding of the similarities and differences in the clinical presentation of IPV and associated conditions across the life course is necessary since IPV in midlife may have adverse health consequences for women in later years as well as in earlier years.^4,5

Although an analysis of data from the National Violence Against Women Survey on three age cohorts (18–29, 30–44, ≥45 years) found higher prevalence in the younger cohorts, these analyses also found that the duration of abuse, presence of chronic disease, chronic mental health conditions, and use of tranquilizers and antidepressants were much higher for the oldest cohort.⁶ Studies on the health status of midlife women exposed to IPV reveal the types of health problems associated with this abuse, including increased rates of clinically diagnosed depression and anxiety.^7,8 Increased reporting of bone or joint problems, digestive problems, chronic pain, and high blood pressure or heart problems⁹ and depressive symptoms^10,11 as indicated by significantly elevated odds ratios (ORs) were also detected in these studies. A review of literature found high incidence of trauma-related injuries and conditions related to musculoskeletal, gastrointestinal, and genitourinary disorders among older IPV victims.¹² The age groupings for research on this topic varied from study to study, ranging from women aged 45 to 50 years to later midlife and women over 50 years. The majority of these studies were based on general population surveys and involved self-reports of both diagnoses and symptoms.

The analyses presented in this case–control study aim to describe a clinical pattern using electronic medical records of diagnoses and advice call symptoms for midlife women (ages 45–64 years) who are experiencing IPV. The analyses will be using further subsets of women aged 45–53 years and women aged 54–65 years since issues such as menopause, chronic conditions, physiologic changes associated with declining health, changes in child rearing responsibilities, and less financial, social, and psychological flexibility¹³ may impact these two subsets differently. There is evidence to suggest that these two age groups may differ in prevalence of IPV as well as conditions found to be associated with IPV. A study of a national sample of midlife and older women found a higher prevalence of abuse in 45–59-year-old women compared with women 60 years and older¹⁴; it is not known if this indicates a difference in actual prevalence or differential reporting among age groups. For both groups, emotional/financial abuse was more common than physical/sexual abuse. The clinical pattern defined, which this study undertakes to find, may assist clinicians in identifying women who may benefit from further inquiry for IPV, disclosure, and intervention. Such an investigation will become increasingly crucial with the demographic shift in the US population toward an increasing proportion of older women.¹⁵

Materials and Methods

This study was reviewed and approved by Northern California Kaiser Permanente's IRB to ensure HIPAA compliance. Since the study utilized only electronic medical records, the Institutional Review Board waived the requirement for written consent from study subjects whose records were reviewed.

Practice setting

Kaiser Permanente Northern California is an integrated health organization serving more than 3.2 million members. During the study time period (2005–2006), Kaiser Permanente operated 49 outpatient facilities and hospitals. Its regional Appointment and Advice Call Center (AACC) operates 24 hours a day, 7 days a week, and receives more than 1 million calls per month from members seeking access to primary and specialty care. Calls are handled using symptom-specific scripts and protocols developed, approved, and updated by Kaiser Permanente physicians. Calls are initially answered by nonlicensed, nonprofessional teleservice representatives who follow highly structured scripts to set up appointments for members, send messages to members' healthcare providers, and provide nonmedical information. More complex calls are transferred to registered nurses who use advice and triage protocols to direct callers to the appropriate level of service, including emergency department (ED) care, appointments, provider messaging, or home care advice.

Study population

The study population included all women aged 45 through 64 years who were members of Northern California Kaiser Permanente in the 16-month study period from April 1, 2005, through July 31, 2006. Screening for IPV was provided in multiple ways, including (1) direct inquiry by clinicians (e.g., “Because domestic violence [DV] is so common, I ask all my patients whether they have been physically or emotionally hurt or threatened by their partner or spouse”), (2) questions on patient health history forms (e.g., “in the past year, has your partner hit, slapped, kicked, choked, or otherwise physically hurt you? Does your partner control where you go or make you feel afraid?), or (3) as part of ED triage (e.g., “Have you ever felt afraid of your partner? Are you in a relationship in which you have been physically hurt or threatened?”), or patients may disclose IPV without specific prompting. When IPV was identified, this was documented in the electronic medical record.

The study population included all women aged 45 through 64 years who were members of Northern California Kaiser Permanente in the 16-month study period from April 1, 2005, through July 31, 2006. All cases of newly identified IPV were found using electronic medical records of women who visited any of Northern California Kaiser Permanente's EDs or outpatient clinics (including primary care, family practice, urgent care, EDs, psychiatry, behavioral health, chemical dependency services, obstetrics/gynecology, and other specialty care) and who received an ICD-9 diagnosis specific to DV, including counseling for abusive partner relationships and injuries resulting from DV.

For each case, the date of initial IPV diagnosis entered in the electronic medical record in the study period, without any prior IPV diagnosis in the preceding year, was identified as the anchor date. Since the study was concerned with new diagnosis of IPV, women with prior IPV diagnosis (in the 365 preceding days) were excluded. However, women with remote history of IPV (between 1 and 5 years before anchor date) were included to determine if past IPV predicted recurrence. Controls were identified from members who had not received an IPV diagnosis within the study time period and who had visited a Northern California Kaiser Permanente outpatient clinic or ED within 1 month of the anchor date of the IPV case. A match of five controls was sought for each case on the basis of age (45–47, 48–50, 51–53, 54–56, 57–59, 60–62, and 63–64 years) and department or facility visited. Control selection excluded those who with a history of known IPV in the year preceding matched visit date.

Case and control selection was limited to members who had at least 365 days of continuous enrollment before the anchor date to ensure that data on calls to AACC and clinic/ED visits for the year preceding anchor date were available for each subject.

Data

Call data were extracted from electronic records of all calls to AACC in the 12-month period preceding case anchor dates. For the present study, advice calls about symptoms and concerns in the areas of adult medicine, mental health, obstetrics, and gynecology were compiled into 37 categories from the ∼300 scripts and protocols used at AACC.

Analysis of call frequency in the 12 months preceding case anchor visit revealed that call volume by the individual increased markedly in the 3 months before IPV diagnosis for the cases, while earlier months were associated with relatively low call volumes and little month-to-month call volume differences between cases and controls. Thus, final analysis of call data was limited to the 92 days preceding anchor visit.

Diagnostic codes from the ICD-9 were extracted from electronic medical records of visits at outpatient clinics, EDs, and counseling sessions for the year preceding anchor visit. To determine whether past IPV was associated with recurrence of IPV, clinical data between 1 and 5 years before anchor visit date were extracted to identify remote IPV diagnoses for both cases and controls. Using the Clinical Classification Software for ICD9-CM developed by the Agency for Healthcare Quality and Research Healthcare Utilization Project (HCUP), ICD-9 codes were aggregated into ∼200 clinically meaningful categories.¹⁶ These groupings were consolidated further into 22 mutually exclusive categories based on anatomic and physiological systems and symptom constellations (Appendix Table A1).

Each case and control was assigned a dichotomous value of 1 (presence) or 0 (absence) for each category of call and diagnosis; all diagnoses for each visit were considered. Data extraction, processing, and analysis were conducted in SPSS Version 16 for Windows and SAS software Version 9.1.3 for Windows.

Statistical analysis

Bivariate associations of each call and diagnostic variable with new IPV diagnosis for all women and each of the two age subsets were determined. Variables significant at the p < 0.05 level were entered into a logistic regression model, conditioned on the matching variables of age, visit date, and facility visited. Variables that were associated with the outcome of newly diagnosed IPV and were statistically significant (p < 0.05) were used in development of the multivariate models. Adjusted odds ratios (AORs), adjusted for those variables found to be significant at the bivariate level, were computed from the multivariate model and are presented in the findings.

Results

There were 518 cases of IPV among women aged 45–64 years (combined age group). Their characteristics are presented in Table 1. The 45–53-year-old subset included 318 cases and 1588 controls; there were 200 cases and 1000 controls in the 54–64-year-old subset. Prior History of IPV, defined as a diagnosis of DV that was entered in the electronic medical record more than 1 year before the anchor date diagnosis, was the predictor with the highest OR for the combined age group (AOR = 12.9; 95% confidence interval [CI]: 6.3–26.3). Other significant predictors for the combined age group (Table 2) were calls for mental health problems (AOR = 3.0), skin injuries (AOR = 2.7) sexually transmitted diseases (STDs; AOR = 2.1), chest pain (AOR = 1.7), and musculoskeletal injury (AOR = 1.6). Clinical diagnoses of anxiety (AOR = 1.9), psychiatric problems other than anxiety/depression (AOR = 1.7), head, neck, and jaw injuries (AOR = 1.6), and headache (AOR = 1.4) were also significantly associated with IPV.

Table 1.

Characteristics of Midlife Women with Intimate Partner Violence and Matched Controls

Women aged 45–64 years
Characteristic	Cases (N = 518)	Controls (N = 2588)	p
Mean calls in last 3 months	3.05	2.03	<0.001
Mean age, years	52.7 ± 5.3	52.3 ± 5.3	NS
Prior IPV%	37 (7.1)	12 (0.5)	<0.001
Department visited (site of diagnosis/matched visit), n (%)
Primary care/medicine	320 (61.8)	1605 (62.0)
Psychiatry/behavioral health	161 (31.1)	803 (31.0)
Emergency department	37 (7.1)	180 (7.0)

IPV, intimate partner violence; NS, not significant.

Table 2.

Association of Intimate Partner Violence with Diagnoses and Telephone Calls in Women Aged 45–64 Years (Multivariate Analysis)

Predictors	Adjusted odds ratio (95% CI)
ED and clinic diagnoses
Prior IPV	12.91 (6.34–26.29)
Anxiety	1.87 (1.48–2.37)
Psychiatric problems other than anxiety/depression	1.68 (1.30–2.19)
Head/neck/jaw injury	1.61 (1.07–2.42)
Headache	1.41 (1.05–1.89)
Telephone calls
Mental health problems	3.00 (2.00–4.44)
Skin injury	2.68 (1.41–5.07)
Sexually transmitted diseases	2.11 (1.33–3.64)
Chest pain	1.70 (1.27–2.56)
Musculoskeletal injury	1.56 (1.15–2.16)

CI, confidence interval.

In the younger age (45–53 years) group, 3.8% of the cases (n = 25) and 0.1% of controls (n = 11) had prior IPV; in the older age (54–64 years) group, 6.0% (n = 12) of the cases and 0.1% of the controls (n = 1) had prior IPV (Tables 3 –5). For both subsets, as for the combined age group, prior IPV emerged as the variable most strongly associated with current IPV (for ages 45–53. AOR = 9.0; 95% CI: 4.1–19.6; for ages 54–64. AOR = 51.2; 95% CI: 6.4–411.0) (Tables 6 and 7). Variables related to mental health were strongly associated with IPV for both age subsets and the combined age group. This included calls for mental health problems as well as diagnoses of anxiety and psychiatric problems other than depression or anxiety (AOR = 2.0) and psychiatric diagnoses other than anxiety and depression (AOR = 1.6). Women in the younger age group had fewer diagnoses that were statistically significant in the model: only anxiety (AOR = 2.0) and psychiatric diagnoses other than anxiety and depression (AOR = 1.6). Among the 54–64-year-old older women, for whom diagnosis of anxiety (AOR = 1.7) was also associated with IPV, urinary tract infection (UTI; AOR = 2.2), headache (AOR = 2.1), and psychiatric disorders other than anxiety and depression (AOR = 1.8) were significantly associated with IPV.

Table 3.

Variables Significant in Bivariate Analysis, Women Aged 45–64 Years

	Cases (N = 518), n (%)	Controls (N = 2588), n (%)	p
Prior IPV	37 (7.1)	12 (0.5)	<0.001
ED and clinic diagnoses in 12 months before visit
Anxiety	208 (40.2)	561 (21.7)	<0.001
Depression	207 (40.0)	748 (28.9)	<0.001
Injury other than HEENT	183 (35.3)	663 (25.6)	<0.001
Gastrointestinal disorder	172 (33.2)	731 (28.2)	0.027
Psychiatric disorders other than anxiety and depression	163 (31.5)	478 (18.5)	<0.001
Gynecological disorder	152 (29.3)	638 (24.7)	0.03
Smoking	97 (18.7)	356 (13.8)	0.006
Headache	89 (17.2)	246 (9.5)	<0.001
Chronic pain	64 (12.4)	186 (7.2)	<0.001
Chest pain	51 (9.8)	155 (6.0)	0.003
Urinary tract infection	50 (9.7)	136 (5.3)	<0.001
HEENT injury	44 (8.5)	108 (4.2)	<0.001
Substance/alcohol abuse	43 (8.3)	107 (4.1)	<0.001
Dizziness	33 (6.4)	89 (3.4)	0.004
Malaise/fatigue	33 (6.4)	103 (4.0)	0.026
Sleep disorder	31 (6.0)	82 (3.2)	0.005
Symptoms and concerns reported by telephone in 3 months before visit
Routine non-GYN	211 (40.7)	844 (32.6)	<0.001
Other	147 (28.4)	586 (22.6)	0.007
Musculoskeletal injury	66 (12.7)	210 (8.1)	0.002
Mental health problems	56 (10.8)	69 (2.7)	<0.001
Chest pain/injury	38 (7.3)	105 (4.1)	0.003
Abdominal pain/injury	36 (6.9)	120 (4.6)	0.045
Other gastrointestinal problems	34 (6.6)	112 (4.3)	0.047
Dizziness	33 (6.4)	81 (3.1)	0.001
Sexually transmitted diseases/exposure	33 (6.4)	75 (2.0)	<0.001
Neurological problems	20 (3.9)	53 (2.0)	0.028
Skin injury	16 (3.1)	33 (1.3)	0.009
HEENT injury	15 (2.9)	26 (1.0)	0.003

ED, emergency department; HEENT, head, ear, nose and throat.

Table 4.

Variables Statistically Significant in Bivariate Analyses, Women Aged 45–53 Years

	Cases (N = 318), n (%)	Controls (N = 1588), n (%)	p
Prior IPV	25 (3.8)	11 (0.1)	<0.001
ED and clinic diagnoses in 12 months before visit
Anxiety	132 (41.5)	347 (21.9)	<0.001
Depression	128 (40.3)	467 (29.4)	<0.001
Gastrointestinal	107 (33.6)	414 (26.1)	0.007
Psychiatric disorders other than anxiety and depression	101 (31.8)	292 (18.4)	<0.001
Headache	54 (17.0)	176 (11.1)	<0.006
Chronic pain	38 (11.9)	118 (7.4)	0.013
Substance abuse and alcohol	31 (9.7)	80 (5.0)	<0.003
Chest pain	29 (9.1)	84 (5.3)	0.003
Head injury	25 (7.9)	74 (4.7)	0.033
Prior IPV	25 (7.9)	11 (0.7)	<0.001
Dizziness	19 (6.0)	54 (3.4)	0.049
Symptoms and concerns reported by telephone 3 months before visit
Mental health problem	34 (10.7)	45 (2.8)	0.001
Abdominal pain/injury	26 (8.2)	72 (4.5)	0.016
STD/STD exposure	25 (7.9)	51 (3.2)	0.001
Dizziness/palpitations	21 (6.6)	49 (3.1)	0.008
Pregnancy-related problem	5 (1.6)	6 (0.4)	0.047

STD, sexually transmitted disease.

Table 5.

Variables Significant in Bivariate Analysis, Women Aged 54–64 Years

	Cases (N = 200), n (%)	Controls (N = 1000), n (%)	p
Prior IPV	12 (6.0)	1 (0.1)	<0.001
ED and clinic diagnoses in 12 months before visit
Depression	79 (39.5)	281 (28.1)	<0.001
Anxiety	76 (38.0)	214 (21.4)	<0.001
Injury other than head/neck/jaw	64 (32.0)	283 (28.3)	<0.001
Psychiatric disorder other than anxiety or depression	62 (31.0)	186 (18.6)	<0.001
Gynecological disorder	52 (26.0)	194 (19.4)	0.049
Smoking	37 (18.5)	106 (10.6)	0.004
Headache	35 (17.5)	70 (7.0)	<0.001
Urinary tract infection	29 (14.5)	52 (5.2)	<0.001
Chronic pain	26 (13.0)	68 (6.8)	0.007
Head/neck/jaw injury	19 (9.5)	34 (3.4)	<0.001
Sleep disorder	13 (6.5)	25 (2.5)	0.012
Substance/alcohol abuse	12 (6.0)	27 (2.7)	0.041
Symptoms and concerns reported by telephone 3 months before visit
HEENT symptoms, noninjury	29 (14.5)	54 (5.4)	0.014
Musculoskeletal injury	28 (14.0)	77 (7.7)	0.009
Mental health problem	22 (11.0)	24 (2.4)	<0.001
Chest pain or injury	18 (9.0)	46 (4.6)	0.030
Gastrointestinal problems other than abdominal pain	15 (7.5)	36 (3.6)	0.033
Urinary problem	15 (7.5)	37 (3.7)	0.035
Headache	11 (5.5)	21 (2.1)	0.020
Neurological problem	10 (5.0)	18 (1.8)	0.021

Table 6.

Association of Intimate Partner Violence with Diagnoses and Telephone Calls in Women Aged 45–53 Years (Multivariate Analysis)

Predictors	Adjusted odds ratio (95% CI)
Prior IPV	8.97 (4.09–19.64)
ED and clinic diagnoses
Anxiety	2.05 (1.53–2.73)
Psychiatric problems other than anxiety/depression	1.65 (1.19–2.29)
Telephone calls
Head Injury	3.17 (1.28–7.80)
Mental health problems	2.46 (1.48–4.07)
Sexually transmitted diseases	2.40 (1.41–4.11)

Table 7.

Association of Intimate Partner Violence with Diagnoses and Telephone Calls in Women Aged 54–64 Years (Multivariate Analysis)

Predictors	Adjusted odds ratio (95% CI)
Prior IPV	51.19 (6.38–410.92)
ED and clinic diagnoses
Urinary tract infection	2.31 (1.37–3.90)
Headache	2.06 (1.26–3.38)
Psychiatric disorders other than anxiety or depression	1.76 (1.13–2.75)
Anxiety	1.74 (1.17–2.58)
Injury other than head/neck/jaw	1.57 (1.11–2.21)
Telephone calls
Mental health problems	4.16 (2.12–8.16)

Discussion

This is the first study to describe the symptoms and medical conditions of women aged 45–64 years who visited outpatient clinics or EDs or made telephone calls about health concerns in a period of time before an ICD9 code for IPV. The information is presented for the entire group of 518 women diagnosed with IPV as well as the younger (aged 45–53 years) and older (ages 54–64 years) subsets of this group and highlights similarities and differences between these two subsets of midlife women. This information could be used to describe a clinical pattern of symptoms and clinical diagnoses that could assist clinicians in recognizing IPV among midlife women.

For the combined group, the results of this investigation identified several diagnoses (anxiety, psychiatric problems other than anxiety or depression, head/neck/jaw injury, and headache) that were significantly associated with a subsequent diagnosis of IPV. In addition, there was a significant association for calls regarding skin injury, chest pain, musculoskeletal injury, and STDs. Calls for mental health problems and prior IPV diagnosis were among the strongest predictors of current IPV among women in the study population with ages 45–64 years, consistent with what the authors found in a younger cohort aged 18–45 years.^17

–20 For the women of childbearing age, however, calls regarding reproductive health issues (abortion, pregnancy testing, and STDs) and clinical diagnosis of pregnancy complications were significantly associated with subsequent IPV diagnosis.¹⁷

Analysis of the subsets of midlife women aged 45–53 years and 54–64 years shows that mental health issues still comprise the largest number of symptoms/conditions among the factors associated with subsequent ICD9 code for IPV in the 45–53-year-old subset and comprise three of the six factors (other than prior IPV) significant in the model for the older subset.

The predominance of self-reported psychological problems as a strong correlate of IPV among midlife women aged 45–64 years in Kaiser Permanente Northern California is consistent with the findings of other studies. The California Women's Health Survey 2003–2004 found that 13% of Californian women responding to a phone survey had experienced some form of IPV. Of those individuals, between 25% and 35% reported frequent mental distress (at least 14 days in the last month with mental health self-reported as not good) compared with 12% of the population not reporting IPV. Forty-four to 56% reported a desire for mental health help compared with 19% of the population that did not indicate experiencing IPV.²¹ A cross-sectional survey conducted in Italy found that compared with women who reported no violence, women who reported violence both in the last 12 months and prior, only in the last 12 months, or only past violence were significantly more likely to report psychological distress. The relationship between current violence and self-reported mental health was independent of age.²²

The prominence of mental health issues as correlates of IPV suggests both a limitation of this study and implications for practice. Both IPV and mental health problems carry some stigma, so lack of disclosure of IPV could actually be even greater in this population of midlife women since many women may not seek medical help for psychological problems where they may have the opportunity to disclose IPV. In addition, under-recognition of IPV in the clinical setting may be due to the reluctance of older midlife women to disclose IPV and could reflect more traditional attitudes toward marriage and gender roles, lack of awareness that certain behaviors constitute abuse, and stigma and shame.²³ Issues related to cultural differences, limited financial resources, and social support may influence a woman's ability to end an abusive relationship and may also affect her willingness to disclose IPV.²⁴ These multiple barriers to disclosure of IPV among older midlife women increase the urgency of understanding what clinical symptoms and diagnoses are found to be associated with IPV so that clinicians can be more diligent in inquiring about IPV among women with a clinical profile similar to those found to be experiencing IPV.

In addition to lack of IPV disclosure by patients, many clinicians may not be aware of IPV as an important health issue for midlife women and fail to inquire.²⁵ Familiarity with clinical patterns associated with IPV may raise awareness and appropriate inquiry by clinicians. This study is also limited by the fact that cases represent individuals who had IPV identified in the clinical setting of an integrated healthcare organization and may have a different pattern of clinical diagnoses/and complaints than women whose IPV is identified in other health settings such as inner city clinics or services providing care for Medicaid recipients or immigrant populations. Finally, in this study, it was not possible to assess whether specific IPV diagnoses resulted from routine screening, a particular method of screening, or from spontaneous patient disclosure. Different disclosure contexts could affect patterns of clinical diagnoses. Future studies that include information on duration of abuse would be useful to further understand the issues presented by women who experience IPV.

The conviction that screening, assessment, and referral for IPV in later life should be an integral part of healthcare provision was repeated among the multiple authors in Roberto's review of IPV in later life.¹³ The implementation of the Affordable Care Act, which makes IPV screening a covered part of women's healthcare in many cases could help promote this. Focusing on a subpopulation of individuals receiving clinical care who are potentially at higher risk could contribute to the utility of screening as these individuals are manifesting symptoms identified as associated with IPV. Diagnosis and clinical symptoms found to be strongly associated with IPV could serve as red flags and trigger healthcare providers to inquire about IPV when an older or midlife patient presents with one of these conditions.

Conclusions

Diagnosed IPV was associated with a clinical pattern based on both telephone advice call data and clinical diagnoses. Along with a history of prior IPV, calls for mental health issues, diagnoses of anxiety, and other psychiatric problems are potentially red flag conditions, which might help identify women at risk of IPV. Along with these mental health/psychiatric concerns, diagnoses of injury other than head/neck/jaw injury and headache in midlife women, along with UTI diagnoses and calls regarding head injury or STDs, could be considered flags. Patterns determined from these combined sources can potentially be used to improve identification of IPV among midlife women in clinical settings by prompting focused clinical inquiry.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Appendix

Appendix Table A1.

Intimate Partner Violence Study Diagnostic Groupings

1	Anxiety
2	Depression
3	Other mental disorders
4	Systemic/other
5	Head/neck/jaw injury
6	Noninjury HEENT
7	Chronic pain
8	Dizziness
9	Malaise
10	Sleep disorders
11	Sexually transmitted diseases
12	Urinary tract infection
13	HIV/AIDS
14	Substance/alcohol abuse
15	Eating disorders
16	Gastrointestinal disorders
17	Gynecological disorders
18	Obstetrical problems
19	Injuries other than head injury
20	Smoking
21	Headache
22	Chest pain

HEENT, head, ear, nose and throat.

References

Thompson

, Bonomi

, Anderson

, et al. Intimate partner violence: Prevalence, types and chronicity in adult women. Am J Prev Med, 2006; 30:447–457.

Breiding

, Black

, Ryan

. Prevalence and risk factors of intimate partner violence in eighteen U.S. states/territories. Am J Prev Med, 2005; 34:1128.

Breiding

, Chen

, Black

. Intimate partner violence in the United States—2010. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2014.

Cook

, Dinnen

, O'Donnell

. Older women survivors of physical and sexual violence: A systemic review of the quantitative literature. J Womens Health, 2011; 20:1075–1081.

Cook

, Pilver

, Dinnen

, Schnurr

, Hoff

. Prevalence of physical and sexual assault and mental health disorders in older women: Findings from a nationally representative sample. Am J Geriatr Psychiatry, 2013; 21:877–886.

Wilke

, Vinton

. The nature and impact of domestic violence across age cohorts. Affilia, 2005; 20:316–328.

Loxton

, Schofield

, Hussain

. Psychological health in midlife among women who have ever lived with a violent partner or spouse. J Interpers Violence, 2006; 21:1092–1107.

Loxton

, Schofield

, Hussan

, et al. History of domestic violence and physical health in midlife. Violence Against Women, 2006; 12:715–731.

Fisher

, Regan

. The extent and frequency of abuse in the lives of older women and their relationship with health outcomes. Gerontologist, 2006; 46:200–209.

10.

Mouton

, Rodabough

, Rovi

, et al. Psychosocial effects of physical and verbal abuse in postmenopausal women. Ann Fam Med, 2010; 8:206–213.

11.

Humphreys

, Lee

. Interpersonal violence is associated with depression and chronic physical health problems in midlife women. Issues Ment Health Nurs, 2009; 10:206–213.

12.

Morgan Disney & Associates. Two lives–two worlds: Older people and domestic violence, Volumes 1 and 2. Canberra, Australia: Office of the Status of Women, 2000.

13.

Roberto

, McPherson

, Brossoie

. Intimate partner violence in late life: A review of the empirical literature. Violence Against Women, 2013:19:1538.

14.

Yon

, Wister

, Mitchell

, et al. A national comparison of spousal abuse in mid- and old age. J Elder Abuse Negl, 2014; 26:80–105.

15.

US Census Bureau. Percent distribution of the projected population by selected age groups and sex for the United States: 2015 to 2060. Washington, DC: US Census Bureau Population Division, 2012.

16.

Agency for Healthcare Quality and Research.. Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Qualify and Research, 2007. www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp

17.

Bhargava

, Temkin

, Fireman

, et al. A predictive model to help identify intimate partner violence based on diagnoses and phone calls. Am J Prev Med, 2011; 41:129–135.

18.

Coid

, Petruckevitch

, Chung

, et al. Abusive experiences and psychiatric morbidity in women primary care attenders. Br J Psychiatry, 2003; 183:332–339.

19.

Bonomi

, Thompson

, Anderson

, et al. Intimate partner violence and women's physical, mental and social functioning. Am J Prev Med, 2006; 30:458–466.

20.

Hegarty

, Gunn

, Chondros

, et al. Association between depression and abuse by partners of women attending general practice: Descriptive, cross sectional survey. BMJ, 2004; 328:621–624.

21.

California Department of Health Services Office of Women's Health. http://www.dhcs.ca.gov/dataandstats/reports/Documents/OWHReports/DataPoints2003-2004/OWH-DP29.03-04.pdf; 2006:28.

22.

Romito

, Molzan

, Turan

, Marchi

. The impact of current and past interpersonal violence on womens' mental health. Soc Sci Med, 2005; 60:1717–1727.

23.

Zink

, Jacobson

, Regan

, et al. Hidden victims: The healthcare needs and experiences of older women in abusive relationships. J Womens Health, 2004; 13:898–908.

24.

Beaulaurier

, Seff

, Newman

, et al. Internal barriers to help seeking for middle-aged and older women who experience intimate partner violence. J Elder Abuse Negl, 2005; 17:53–74.

25.

Tracy

, Speakman

. Intimate partner violence not just a concern of reproductive ages. Menopause, 2012; 19:3–5.