急診中的性侵害相關就診正在增加

海蒂·斯普利特 / 2022 年 10 月 28 日 / Medscape

根據美國國家醫院就診數據庫確定，從 2006 年到 2019 年，性侵害後急診科 (ED) 的就診次數增加了 15 倍。

來自聯邦調查局 (FBI) 的數據顯示，自 2006 年以來，報告的強暴和性侵害 (sexual assaults , SA) 事件有所增加，而對受害者的研究歞顯示，自殺意念、創傷後壓力症候群、抑鬱症、藥物濫用和慢性病，密歇根大學安娜堡分校的文學學士 Emily L. Vogt 及其同事寫道。

然而，他們說，尚未有探討在 SA 後尋求照護的成年人使用急診部門 (ED) 的趨勢和差異之研完。

對於發表在 JAMA Network Open 上的一項研究，研究人員審查了來自全國急診部樣本 (NEDS) 的數據，NEDS 是一個由醫療保健研究和質量機構管理的具有全國代表性的大型數據庫。該數據集包括從 2006 年到 2016 年每年報告的 1.2 億至 1.43 億次加權 ED 就診。研究人群包括 18 至 65 歲的成年人，他們進行了 NEDS 中記錄的 ED 就診並編碼為 SA。 SA 是使用 ICD-9 代碼定義的，直到 2015 年第四季度，ICD-10 代碼才開始使用。

總體而言，研究期間與 SA 相關的 ED 就診次數增加了 1533.0%，從 2006 年的 3,607 次增加到 2019 年的 55,296 次。平均年百分比變化為 23.0% (P < .001)。增幅最大的是 2015 年至 2016 年，年就診量從 17,709 人次增加到 47,732 人次。研究人員指出，這種增加可能反映了更新的 ICD-10 代碼，其中有疑似成人強暴、確認成人強暴和成人強迫性剝削的類別。

SA 後到 ED 就診的患者主要是女性（91.5%）。 18 至 25 歲的個人佔呈現結果的近一半。收入最低和第二低四分位數的個人也被過度代表。

研究人員指出，儘管出現在 ED個案有所增加，但 SA 的受理比率率從 12.6% 下降到 4.3%。年齡較大且通過 Medicaid 獲得保險的患者比其他人口統計群體的人更有可能被受理。

研究人員還發現，出現在ED 所報告的個案之增加超過了 SA 向執法部門報告個案的增加。他們將 2015 年至 2019 年的 ED 趨勢與 FBI 報告的強暴/性侵害 (rapes/SA) 進行了比較，發現在 ICD-9 和 ICD-10 代碼時期，分別增加了 7% 和 22%。然而，在 2019 年，尋求 ED 照護的 SA 倖存者人數仍低於向執法部門報告的人數（55,296 對 139,815，根據修訂的 SA 定義確定）。

研究人員寫道：「儘管編碼特異性的增加與 SA 文件之間的關聯仍不清楚，但 ICD-10 可能有助於增加 SA 的 ED 登錄」，但數據顯示穩定的增長獨主地與編碼之變化無關。

研究人員指出，研究結果受到幾個因素的限制，包括患者的多重表示的可能性、與 NEDS 數據庫相關的編碼錯誤，以及對 NEDS 和 FBI 數據集中的自願報告的依賴。他們說，由於樣本量大、樣本量大，以及納入住院和犯罪數據進行比較，結果得到了加強。

研究人員寫道：「只有 21% 的倖存者在 SA 後尋求醫療照護，這意味著本研究中捕獲的倖存者僅佔 SA 相關照護需求的一小部分」。他們總結說：「我們發現大多數 SA ED 就診是由年輕、女性和低收入倖存者進行的，這可以告知政策變化以更好地支持這些人」，這可能包括發展門診和縱向照護環境以更好地為這些人群服務。

綜合性照護需求遠超出 ED之服務

不僅要更好地了解 SA 報告的趨勢，而且還要了解在 SA 後尋求治療和評估的倖存者的人口統計數據，這一點至關重要，醫學博士 Robert Glatter 在接受採訪時說。

「能夠更好地了解社會上和社會運動如何影響患者在報告性侵犯上的舒適程度對於追查在急診部門 尋求照護上的人數至關重要」，在Northwell Health 的 Lenox Hill 醫院急診內科醫師和位於紐約 Hofstra/Northwell 的 Zucker 醫學院助理教授Glatter表示。

格拉特說，他對性侵害事件的顯著增加並不感到驚訝，特別是考慮到過去十年#MeToo 運動和其他社會正義運動的認識和影響力的提高。

他強調說：「雖然我相信性暴力的受害者現在可能覺得更有能力報告襲擊事件，但在美國和全球範圍內，未報告的 SA 數量仍然是一個嚴重的公共衛生問題和關注點」。

當前研究的一個關鍵信息是，需要投資「為所有 SA 倖存者提供富有同情心和全面的照護理」，格拉特說。「這包括認識到 SA 的廣泛心理健康後果，不僅會導致抑鬱、創傷後壓力症候群和焦慮，還會導致自殺意念和自殺。長期的醫療影響會改變生活，滲透到家庭和後代」，他強調。

作為一個社會，我們還必須非常重視照顧所有SA倖存者，尤其是那些來自經濟或社會弱勢背景且沒有保險或保險不足的人」，格拉特說。他補充說，還必須考慮SA倖存者的種族、性別認同和性認同等問題。

「我們需要更好地了解我們的醫療保健系統如何為門診環境中的倖存者提供更細緻入微的後續照護和通報」，格拉特說。「讓獲取更容易，同時確保機密性，將使更多的SA倖存者尋求治療和照護」，他說。格拉特指出：「我們還需要了解如何在這種量能上並能超越急診室以外場所使用法醫護士，才能更好地為少數族裔和種族多元化社區服務」，並增加此類專業護士的招聘和培訓，以照顧SA受害者。

該研究得到了密歇根大學和婦產科的內部資金支持。通訊作者 Erica C. Marsh 醫學博士已從 Myovant Sciences 和輝瑞公司收到與當前研究無關的個人費用。 Glatter 沒有披露任何相關的財務關係。                             JAMA 網絡上公開。 2022年10月20日線上發表。全文                                                      Heidi Splete 是一名擁有 20 年經驗的自由醫學記者。

Sexual Assault-Related Visits to the ED Are on the Rise

Heidi Splete / October 28, 2022 / Medscape

Visits to emergency departments (EDs) following sexual assault increased 15-fold from 2006 through 2019, as determined from a national database of visits to hospitals in the United States.

Data from the Federal Bureau of Investigation (FBI) show an increase in reported rapes and sexual assaults (SAs) since 2006, and studies of victims show an increased risk of conditions such as suicidal ideation, posttraumatic stress disorder, depression, substance use, and chronic conditions, write Emily L. Vogt, BA, of the University of Michigan, Ann Arbor, and colleagues.

However, trends and disparities in ED use by adults seeking care following SA have not been explored, they said.

For a study that was published in JAMA Network Open, researchers reviewed data from the Nationwide Emergency Department Sample (NEDS), a large, nationally representative database managed by the Agency for Healthcare Research and Quality. The dataset consisted of 120 million to 143 million weighted ED visits reported annually from 2006 through 2016. The study population included adults aged 18 to 65 years who had made an ED visit that was recorded in the NEDS and that was coded as an SA. SA was defined using ICD-9 codes until the fourth quarter of 2015, at which time ICD-10 codes came into use.

Overall, the number of SA-related ED visits increased by 1533.0% during the study period, from 3607 in 2006 to 55,296 in 2019. The average annual percentage change was 23.0% (P < .001). The greatest increase occurred from 2015 to 2016, when annual visits increased from 17,709 to 47,732. This increase likely reflected the updated ICD-10 codes, in which there are categories for suspected adult rape, confirmed adult rape, and adult forced sexual exploitation, the researchers note.

Patients presenting to the ED after an SA were mainly women (91.5%). Individuals aged 18 to 25 years accounted for nearly half of the presentations. Individuals in the lowest and second lowest income quartiles also were overrepresented.

Despite the increased presentation to EDs, admission rates for SA decreased, from 12.6% to 4.3%, the researchers note. Patients who were older and were insured through Medicaid were more likely to be admitted than persons of other demographic groups.

The researchers also found that increases in ED presentations outpaced increases in SA reports to law enforcement. They compared the ED trends with FBI-reported rapes/SAs from 2015 to 2019 and found increases of 7% and 22% during the times of ICD-9 and ICD-10 codes, respectively. However, in 2019, the number of SA survivors who sought ED care remained below the number who reported to law enforcement (55,296 vs 139,815, as determined on the basis of revised SA definitions).

“Although the association between increased coding specificity and documentation of SA is still unclear, ICD-10 likely contributed to increased ED documentation of SA,” but the data show steady increases that are independent of the coding change, the researchers write.

The study findings were limited by several factors, including the potential for multiple representations of patients, coding errors associated with the NEDS database, and the reliance on voluntary reports in the NEDS and FBI datasets, the researchers note. The results were strengthened by the large, diverse sample size and by the inclusion of hospital admissions and crime data for comparison, they say.

“As few as 21% of survivors seek medical care after SA, meaning that the survivors captured in this study represent a fraction of total SA-related care need,” the researchers write. “Our finding that most SA ED visits are by young, female, and low-income survivors can inform policy changes to better support these individuals,” which could include the development of outpatient and longitudinal care settings to better serve these populations, they conclude.

Comprehensive Care Extends Beyond the ED

Better understanding not only of the trends underlying SA reporting but also of the demographics of survivors who seek treatment and evaluation after SA is vital, said Robert Glatter, MD, in an interview.

“Being able to better understand how social and societal movements affect a patient’s comfort in reporting an SA is vital in tracking the numbers of people who seek care in the ED,” said Glatter, an emergency medicine physician at Lenox Hill Hospital at Northwell Health and an assistant professor at the Zucker School of Medicine at Hofstra/Northwell, New York.

Glatter said he was not surprised by the significant increase in sexual assault presentations, especially in light of increased awareness and the influence of the #MeToo movement and other social justice movements over the past decade.

“While I believe that victims of sexual violence may now feel more empowered to report an assault, the volume of SA that go unreported remains a serious public health issue and concern” in the United States and globally, he emphasized.

A key message from the current study is that there is a need for investment in “compassionate and comprehensive care for all survivors of SA,” Glatter said. “This includes recognition of the extensive mental health consequences of SA that can lead to not only depression, PTSD, and anxiety but also to suicidal ideation and suicide. The longer-term medical effects become life altering, permeating families and future generations,” he emphasized.

“As a society, we must also place a strong emphasis on caring for all SA survivors, but particularly those who come from economically or socially disadvantaged backgrounds who are uninsured or underinsured,” said Glatter. Issues of race, gender identity, and sexual identity among SA survivors also must be taken into consideration, he added.

“We need to better understand how our healthcare system can provide more nuanced follow-up care and reporting for survivors in outpatient settings,” said Glatter. “Making access easier, while ensuring confidentiality, will allow more survivors of SA to seek treatment and care,” he said. “We also need to understand how using forensic nurses in this capacity, and beyond the ED, can better serve minority and racially diverse communities” and to increase the recruitment and training of such specialized nurses to care for SA victims, Glatter noted.

The study was supported by internal funding from the University of Michigan and the Department of Obstetrics and Gynecology. Corresponding author Erica C. Marsh, MD, has received personal fees from Myovant Sciences and Pfizer unrelated to the current study. Glatter has disclosed no relevant financial relationships.

JAMA Netw Open. Published online October 20, 2022. Full text

Heidi Splete is a freelance medical journalist with 20 years of experience.