Trends in US Emergency Department Use After Sexual Assault, 2006-2019

IMPORTANCE Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality. OBJECTIVE To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation’s Uniform Crime Reporting Program, which includes annual crime data from more than 18000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022.


Introduction
Sexual assault (SA) is a disturbing and prevalent issue in the US, with a new assault occurring every 68 seconds. 1 Based on data from the Federal Bureau of Investigation (FBI), national reported rapes and SAs have increased from 93 000 in 2006 to 139 815 in 2019, peaking at 143 765 in 2018. 2 Studies have revealed that SA survivors are at greater risk for suicidal ideation, posttraumatic stress disorder,
ICD-9 codes were reported in NEDS from 2006 through the third quarter of 2015, whereas ICD-10 codes were reported from the fourth quarter of 2015 through 2019. 41,42Sample sizes smaller than 11 were excluded from the analysis per HCUP requirements.Visits with missing data or without an ICD-coded diagnosis of SA were excluded.The final sample of 120 to 130 million weighted visits annually was based on eligibility criteria.

Measures
Sexual assault was defined using ICD codes from NEDS data.There is 1 ICD-9 code for adult SA (995.83),whereas ICD-10 coding allows for suspected SA (T76.21XA),confirmed SA (T74.21XA), or forced penetration (T74.51XA).The FBI's definitions of rape and SA were used for UCRP data.In 2013, the FBI adapted its definition for SA from "the carnal knowledge of a female forcibly and against her will" to "penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim." 43The former is now known as the legacy definition and the latter as the revised definition.We included data from both FBI definitions in our analysis to account for this discrepancy.
Primary analysis measures for NEDS included ED visits and hospital admissions.Secondary analysis measures included age, sex, income quartile by zip code, and payment method.Race and ethnicity were analyzed for 2019 (the first year NEDS contained these data), given their relevance for highlighting potential racial disparities as they relate to ED use for SA.Per HCUP data collection, race and ethnicity categories were Asian or Pacific Islander, Black, Hispanic, Native American, White, or other. 44Other was defined as any individual identifying with multiple categories or with another group not delineated.Total annual and average annual inflation-adjusted hospital charges were also analyzed.

Statistical Analysis
Statistical analyses were conducted between January 2020 and June 2022.Descriptive statistics were calculated as counts and percentages for categorical variables and as means and SDs for continuous variables.χ 2 , t, and F tests were performed to assess for statistical significance.All-cause ED visits were added as a comparator to SA ED visits.Inflation-adjusted analysis of average annual and total annual hospital charge data for SA ED visits was performed relative to the 2019 US dollar.A joinpoint regression model was used to perform the trend analysis of hospital charge data.Average annual percentage changes (AAPCs) of charges were estimated by fitting trend data to a log-linear model.Missing data were handled by imputation for calculation of total charges, with age, region, income, and any SA-related diagnosis as covariates.Analyses were conducted using SAS, version 9.4 (SAS Institute) and Joinpoint, version 4.7.0.0 (National Cancer Institute) statistical software, and a 2-sided P < .05 was considered statistically significant.

Results
Our analysis revealed that US ED visits for SA increased by more than 1533.0%from 3607 visits in 2006 to 55 296 visits in 2019 (vs a 21.4% increase in all-cause ED visits) (Figure 1), with an AAPC rate of 23.0% (range, 14.5%-32.0%;P < .001).This increase was most notable from 2015 to 2016, when annual visits increased from 17 709 to 47 732.Analysis of ICD coding from October 2015 (after establishment of ICD-10) through December 2019 revealed that 50.7% (25 149-28 865 visits annually) of SA ED visits were coded as suspected adult rape/SA, 49.3% (22 584-29 542 visits annually) as confirmed adult rape/SA, and 0.05% (0-108 visits annually) as adult forced sexual exploitation.In 2014, under ICD-9, there were 10 133 SA ED visits.Total hospital charges for these

JAMA Network Open | Emergency Medicine
Trends in Emergency Department Use After Sexual Assault  Comparison of the NEDS and FBI databases revealed that ED visits for SA increased more than 1533%, whereas the FBI-reported legacy and revised definitions for SA increased by 7% and 23%, respectively (Figure 2).Data from 2019 revealed that there were still fewer survivors (55 296)   seeking ED care compared with reporting to LEAs (98 213 and 139 815 for legacy and revised definitions, respectively).

JAMA Network Open | Emergency Medicine
Trends in Emergency Department Use After Sexual Assault

Figure 1 .
Figure 1.Emergency Department (ED) Visits and Admissions for Adults Aged 18 to 65 Years With Any Diagnosis of Sexual Assault vs All Other Diagnoses, 2006-2019

Table 1 .
Trends in Emergency Department Use After Sexual Assault Despite the uptick in SA ED visits from 2006 to 2019, admission rates decreased by 8.3%, from 12.6% in 2006 to 4.3% in 2019 (P < .001)(Figure 1).The admission rate was lowest at 2.8% in 2015 (Figure 1) in contrast to the 11.0% admission rate for age-matched individuals with all other diagnoses.Older and Medicaid-insured individuals were overrepresented in admissions relative to total SA ED visits.Medicaid-insured individuals, including pregnant women and patients with low income, comprised 27.4% to 53.9% of the patients admitted, despite accounting for only 19.5% to Emergency Department Visits and Admissions Among Adults Aged 18 to 65 Years With Any Diagnosis of Sexual Assault by Age Group JAMA Network Open.2022;5(10):e2236273. doi:10.1001/jamanetworkopen.2022.36273(Reprinted) October 20, 2022 4/11 Downloaded From: https://jamanetwork.com/ on 09/27/2023

Table 3 .
Emergency Department Visits and Admissions Among Adults Aged 18 to 65 Years With Any Diagnosis of Sexual Assault by Payer Figure 2. Emergency Department (ED) Visits for Sexual Assault vs Federal Bureau of Investigation (FBI) Uniform Crime Reporting Program-Reported Sexual Assaults, 2006-2019