10974_The Care Of The Sexual Assault Patient

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School of Medicine
January 2019
The Care Of The Sexual Assault Patient
Eun Sook Choi
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Choi, Eun Sook, “The Care Of The Sexual Assault Patient” (2019). Yale Medicine Thesis Digital Library. 3483.
https://elischolar.library.yale.edu/ymtdl/3483

The Care of the Sexual Assault Patient

A Thesis Submitted to the
Yale University School of Medicine
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Medicine

by

Eun Sook Jennie Choi

2019

Acknowledgements

To my parents who have taught me compassion, dedication and sacrifice,
사랑해요.

To my mentors who have not only contributed their generous time and energy to support
my research endeavors but have also inspired me by example to become a
compassionate, motivated healthcare provider who strives for justice of the vulnerable
patient.

Dr. Shefali Ram Pathy
Dr. Kirsten A Bechtel
Dr. Sangini Sheth
Dr. Seth Guller

Funding

Research reported in this thesis was supported in part by

Yale School of Medicine Medical Student Research Fellowship
National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health
under award number T35AA023760.
The content is solely the responsibility of the author and does not necessarily represent
the official views of the National Institutes of Health.

CARE OF THE SEXUAL ASSAULT PATIENT.
Jennie E.S. Choi, Kirsten Bechtel, Shefali R. Pathy. Department of Obstetrics, Gynecology, and
Reproductive Sciences, Yale University, School of Medicine, New Haven, CT.

Survivors of sexual assault (SA) experience a range of physical and mental health consequences. Despite
universal agreement that follow-up care improves outcomes, studies demonstrate only one-third of
survivors receive assault related follow-up care. This study aims to describe the patient population
presenting after SA, characteristics of their acute care, and rates of follow-up within one-year at two sites of
the Yale New Haven Hospital, which includes an urban tertiary care hospital (York Street Campus, YSC),
and its satellite community hospital (St Raphael Campus, SRC). A retrospective medical record review was
conducted of patients older than 12 years presenting after sexual assault at emergency departments and
outpatient clinics from Jan 2014 to Feb 2017. Differences between groups based on assault characteristics,
such as assailant relation and substance use, were analyzed using Chi Square. Correlations with age were
analyzed with linear regression. Of the 466 patient encounters that met inclusion, the mean patient age was
25.5 years (s=12y); 95% were female; 46% were White and 35% were Black. The overall follow-up rate
within one year after index visit was 35% (165/466). Patients older than 18 years had significantly lower
rates of follow-up (23%, 73/318) than adolescents 13 to 18 years old (61%, 91/148) (p<0.05). Younger patients were more likely to receive recommended testing (p<0.05), and follow-up (p<0.001). Within adolescents, assault by a known individual significantly increases rates of follow-up (69% vs 41%, p<0.05), especially if by a family member (9/9, 100%). Follow-up after SA at our institution are low, consistent with the national average, and significantly lower in older survivors. Adolescent victims receive protocolized follow-up at a designated sex abuse clinic, are more likely to have the involvement of a case manager. Implementation of a standardized discharge protocol that involves follow-up at the Women’s Center—the ambulatory OBGYN clinic—and a designated care coordinator for navigation, may improve rates of follow-up of older survivors of SA. Table of Contents 1. Introduction ------------------------------------------------------------------------------ 1 i. Epidemiology 1 ii. Definitions 2 iii. Medical Examination 3 iv. Forensic Evaluation 5 v. Psychological Sequelae 8 vi. Follow Up Care 10 2. Statement of Purpose -------------------------------------------------------------------11 3. Materials and Methods -------------------------------------------------------------------12 i. Study Population 12 ii. Data Elements 16 iii. Data Analysis 22 4. Results ------------------------------------------------------------------------------ 23 i. Demographics 23 ii. Setting 25 iii. Assault Narrative 26 iv. Acute Care Team 31 v. Sexual Assault Evidence Collection Kit (SAECK) Completion 31 vi. Rates of Follow-Up Care within one-year 33 5. Discussion ------------------------------------------------------------------------------ 36 6. Future Directions -------------------------------------------------------------------- 37 7. References ------------------------------------------------------------------------------ 40 1 Introduction Epidemiology Sexual assault is a widespread public health issue; approximately 1.3 million sexual assaults occur annually against women1 with an estimated 19.3% of all women (23 million) reporting rape once in their lifetime2. The American Medical Association reported 1 in 5 women will experience sexual assault before the age of 21 years.3 Sexual assault against men is also significant; studies have found nearly 1.6 million men are raped at least once in their life.3 Teenagers and young adults are particularly vulnerable to sexual assault. The age group with the highest rate of sexual assault is 12 to 34 years old, according to one national survey.4 Another study showed that 18% of girls and 12% of boys reported an unwanted sexual experience in middle- or high-school.5 In the National Intimate Partner and Sexual Violence Survey (NIPSVS) national survey conducted by the CDC, nearly 80% of respondents reported their first rape as occurring before the age of 25 years old, and 42% of respondents before 18 years old.1 Another national survey of high school students found 11.3% of females and 3.5% of males reported unwanted sexual intercourse.6 The incidence and prevalence of sexual assault greatly depends on the definition employed as well as the methods of data collection. National surveys such as the NIPSVS conducted by the Centers for Disease Control and Prevention (CDC), and the National Crime Victimization Survey (NCVS) collected by the Bureau of Justice Statistics, attempt to overcome the reporting challenge by employing a uniform definition and large data source. Appropriate definitions of and statistics of sexual assault is extremely important in qualitative and quantitative research of this significant health issue. 2 Retrospective and prospective studies have been conducted in the medical setting to characterize the care provided to sexual assault survivors who interface with the healthcare system. The current understanding of the care of victims of sexual assault is the focus of the remainder of this section. Definitions The definition of sexual assault can vary from a crime of violence and aggression, ranging from sexual coercion—such as unwanted kissing, touching and fondling—to rape.7 In 2011, the Federal Bureau of Investigation (FBI) initiated a revision to the definition of rape to better characterize this important health issue for future national statistic reports in the Uniform Crime Report. The revised FBI definition was published in 2013, which now includes assault cases with male victims, female assailants, all forms of sexual contact such as anal and oral penetration, and penetration by an object in the designation of rape.7 In addition, physical force is no longer required to categorize an incident as sexual assault, thereby including events where individuals are unable to consent due to intoxications or mental or physical incapacity.7 More specific terms exist within the sexual assault umbrella, based on the assailant’s relationship to the victim (acquaintance rape, date rape, incest), and the victim’s age (child sexual abuse, statutory rape). Child sexual abuse is sexual assault of an individual under 13 years of age, and always necessitates the involvement of child- protective services and law enforcement. Classification of statutory rape based on age can vary by state, ranging from 14 to 18. In the state of Connecticut, the age of consent is 16 3 years old, but there are exceptions based on the assailant’s age and relationship to the patient.8, 9 • If the sexual activity involves a person of authority (i.e., teacher or coach), the age of consent rises to 18 years old. • If both individuals are under the age of consent, the “close-in-age exemption”, also known as the “Romeo and Juliet law” allows for legal consent in cases where both individuals are significantly close in age. This allowed age difference further varies based on individuals’ age. o Under the age of 13 years, sexual activity can be consensual with an age difference of 2 years or less. o Between ages of 13 and 16, parties can legally consent with another individual with an age different of 3 years or less. Healthcare professionals are commonly the first to interface with patients after sexual assault. Therefore, it is important for providers to have an understanding of the various nuances in the laws, as well as collaborate closely with social work and law enforcement professionals when caring for child and adolescent survivors of sexual assault. Sexual assault is both a medical concern as well as a legal concern; thus, promoting the wellbeing of a survivor requires recognizing the importance of both arenas. For example, the acute care of a patient presenting after sexual assault, discussed below, includes the timely collection of forensic evidence, which affects likelihood of perpetrator prosecution. As a result, medical providers must be aware of the legal implications of the forensics examination. 4 Medical Examination It is difficult to estimate the fraction of survivors who present to a health care provider after a sexual assault. Survivor reports suggest despite the significant prevalence of sexual assault, only 17% to 43% interface with the healthcare system for evaluation and treatment, 23% of female survivors seek care from a victim service agency, and only one-third disclose assault to their primary care provider.4, 10, 11 Of the 35% of females who reported suffering an injury from the sexual assault in 2005-2010, 20% received treatment at the scene or at a residence, as opposed to presenting to a hospital, doctor’s office or emergency room.4 Medical and forensic examinations after sexual assault have potential to retraumatize the patient; therefore, involvement of an experienced clinician is important to develop a therapeutic alliance with the patient while providing all necessary medical care while minimizing unnecessary ones. Immediate post-assault management can be a challenging balance for a provider, since medical, psychological, legal and social needs must be acknowledged and appropriately addressed. To aid the providers, recommendations for best practices of acute care of the sexual assault patient have been published by The Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American College of Emergency Physicians (ACEP).12-15 Many of the specialty-specific organizations reference the most recent (2015) CDC guidelines for the management of patients presenting after sexual assault. These guidelines provide recommendations for testing and treatment. Recommended testing includes pregnancy, hepatitis B, HIV, and syphilis. Treatment includes empiric treatment 5 for gonorrhea, chlamydia, and trichomonas (testing if treatment is refused), emergency contraception for pregnancy prevention, and considerations of hepatitis B, HPV vaccination, and HIV post-exposure prophylaxis based on risk stratification.12 The CDC recommendations do not address the topics of forensic evaluation and management of psychological trauma, physical injuries and potential pregnancy,12 possibly lending to the wide variation of care provided in these areas. Despite published recommendations, adherence to these guidelines is low.16, 17 Hoehn et al postulated that the variation in care is due to the lack of provider knowledge, and reported a 30% improvement in algorithm-adherent evaluation and management after implementing targeted education and an electronic order set.17 Another study in an urban hospital with an established Sexual Assault Nurse Examiner (SANE) program reported that patients evaluated by a trained SANE were more likely to have proper documentation (GU exam P<0.001, GU injury P<=0.001), and higher rates of STI testing (GC/CT P<=0.001, hepatitis B and C P=0.03, HIV P=0.03) than when a SANE was not involved.18 In addition to the challenges of clinical management, the process of testing, treatment, evidence collection and interviewing can be very lengthy, involving numerous parties including medical, legal, and social professionals. In the case of younger patients, care takers and case managers from the Department of Children and Families (DCF) are also involved in this exhausting process. Awaiting sobriety in drug facilitated sexual assault cases (DFSA) can further delay this process. The presence of a sexual assault crisis advocate (SAC) can be especially helpful in navigating the acute evaluation for all patients, but especially for the younger or more vulnerable patients. Resources for sexual 6 assault crisis support vary regionally. In Connecticut, there are 9 SAC Programs available to dispatch a certified sexual assault victim advocate for short term supportive counseling, case management, and accompaniment for medical, police and court attendance.19 Forensic Evaluation Though the process of forensic examination and evidence collection occurs in a medical setting, requiring the involvement of a healthcare professional, the purpose for such examination is strictly legal and for the prosecution of the perpetrator. For example, toxicology results from the forensic kit are not to be used for medical decision making, and independent tests should be conducted for recording in a medical chart. The forensic exam kit –also known as the rape kit, Sexual Assault Evidence Collection Kit (SAECK), Sexual Assault Forensic Exam (SAFE) kit, Sexual Offense Evidence Collection (SOEC) or Sexual Assault Nurse Examiner (SANE) kit—is provided by the state’s department of health. Policies on eligibility for forensic collection and best practices differs regionally, but the general components and the process are universally standardized. It involves a written narrative of the assault in the patient’s words, documentation of a physical exam, collection of swabs and clothing potentially containing DNA of the assailant, and toxicology samples. In the State of Connecticut, the General Assembly aims to standardize this process statewide. The general guidelines for forensic examination, as well as guidelines specific to Connecticut will be reviewed in the remainder of this section. The specific steps for collection and maintaining chain of custody are beyond the scope of this section. 7 It is ideal for qualified health care providers trained in this process to be involved with conducting a forensic exam, such as an emergency medicine physician, sexual assault nurse examiner (SANE), sexual assault forensic examiner (SAFE), a physician or nurse practitioner specializing in sex abuse. Maintaining a proper chain of custody and accurate documentation are imperative as this process has legal implications. There are several additional requirements for the proper collection of evidentiary data. For example, it is preferable for the survivor to not change their clothes, bathe/shower, eat/drink, urinate/defecate or douche until they have been examined. However, if they have done so, they should still be encouraged to seek care and undergo evidence collection, with proper documentation by the healthcare provider. In order for a forensic evidence kit to be legally admissible, it must be collected within a specific timeframe. In the State of Connecticut, the eligibility window for evidence collection is 120 hours (5 days) and varying time frames for toxicology collection, ranging up from 8-48 hours after suspected drugging. 19 Table 1 provides more details on the allowed windows for toxicology collection. Routine toxicology collection is not recommended but may be indicated if the patient has signs and symptoms of intoxication, or if the patient or accompanying individual suspect drug involvement. Table 1: Eligible Time Frames for Toxicology Collection through SAECK Kits Time frame Test Substance < 8 hours Blood test GHB (gamma-hydroxybutyric acid) < 12 hours Urine test GHB < 24 hours Blood/Urine Ethanol < 48 hours Blood Other substances < 120 hours Urine Other substances 8 While the forensic kit is secondary to providing exemplary health care, this time- sensitive collection has long term implications in the criminal investigation and legal proceedings. The Bureau of Justice Statistics reports only 36% of female victims of sexual assault from 2005 to 2010 reported to police. It is well recognized that sexual assaults are underreported to law enforcement, with several factors complicating the decision to pursue prosecution of the offender. Reasons for this include fear of reprisal or getting the offender in trouble (28%), feeling like sexual assault is a personal matter not requiring involvement of authority (20%), believing authority would not be able to help (13%), thinking it was not an important enough issue to report (6%), and a variety of other reasons (33%).11 According to the U.S. Department of Justice, the offender in approximately three-quarters of sexual violence is a family member, intimate partner, friend, or acquaintance.4 Therefore, patients often have difficulty committing to pressing charges against the perpetrator, particularly in the face of emotional and physical trauma during the acute phase after assault. It is important for healthcare providers to appropriately counsel patients about evidence collection and particularly the time restrictions for collection, and balance that with information that there is the “nonreport option,” in which completion of the evaluation does not require the patient to report or take legal action.14, 20 Furthermore, many law enforcement agencies will give the option to hold the forensic result for 2 or more years, providing the patient with time to decide their preferred course of legal action. Forensic evidence collection requires obtaining legal consent from the patient. This can be complicated by various factors including age, involvement of mental status altering substances, and capacity to consent such as cognitive delay. The age at which a 9 patient can consent for the forensic exam is state dependent, but regardless of the age, adolescents should never be coerced to undergo the evaluation. In the state of Connecticut, minors under the age of 18 require parental consent for forensic evidence collection. In the case of suspected child sexual abuse, the Department of Children and Families and law enforcement will be consulted and aid in consent. The patient may withdraw their consent and decline the exam or contacting of law enforcement at any point in the process. Upon initial medical evaluation, the provider may choose to place a referral for a formal forensic examination at a sexual assault specialty center with an interdisciplinary professional staff with expertise in treating adolescent assault patients. Such a team may include a medical provider, a social worker, and a detective. Psychological Sequelae The psychological effects after sexual assault can vary and can also be similar to those who have not experienced assault. Survivors of sexual assault are at increased risk for suicide as compared with the general population in addition to other psychological sequelae.21 It can be therapeutic for patients to be educated on the signs and symptoms of post-traumatic psychiatric sequelae, validate the significance of the trauma and be given psychosocial resources to support and counsel the patient. • Rape trauma syndrome is a disorder that may manifest in the weeks to several months following the incident. There can be behavioral, somatic, psychological disruptions resulting from the trauma.22 • Disorganized phase- Acutely, rape trauma syndrome manifests as a generalized lack of organization within the patient’s life. Fear and blame are prominent 10 components, contributing to the likelihood of the patient being lost to follow up. In this phase, patients are also likely to experience generalized physical pain, eating, mood, sleep disturbances.22 • Organized phase- The delayed phase is a more chronic state manifested by phobias, nightmares, flashbacks, somatic and gynecologic symptoms.22, 23 Though physical examination is most likely to yield normal findings24, it is important to validate and recognize the somatic complaints as part of the rape trauma syndrome. • Post Traumatic Stress Disorder- Approximately one-third of survivors suffer from PTSD. This psychiatric disorder is a state of hyperarousal, characterized by “re-living” the trauma. Patients affected by PTSD display avoidance behaviors and are at risk of chronic substance abuse.22, 23 Some groups suggest that interventions in the immediate post-trauma period may modulate the course of the aforementioned mental health dysfunctions. Resnick et al found that patients who watched an educational video on the potential long-term affects of their trauma, reported lower anxiety at their initial presentation than those who did not receive this intervention.24 Early interventions could lower the severity of psychopathology and risk of substance misuse. Follow Up Care Follow up examination and continued engagement in care is necessary for an opportunity to review results from serologic testing, assess tolerance of medications, examine for any new symptoms, address psychosocial needs, and provide counseling.12-14 11 Specifically, the CDC outlines the medical need for follow up visits starting within 1 week and up to 6 months to complete Hep B and HPV vaccinations if indicated, monitor for side effects and adherence to PEP medications, and repeat testing for pregnancy and STI if there was an initial negative test and infection in assailant cannot be ruled out.12 Furthermore, no matter the thoroughness of the care provided upon initial examination, a trauma survivor is likely to have difficulty remembering the information given to them. The follow-up provides an opportunity to re-address the medical testing and treatment provided, signs and symptoms for new or developing infections and psychological trauma, and medical and psychosocial resources available to the patient. Despite the well understood need for continued care, rates of follow up amongst survivors of sexual assault are low with studies reporting follow up rates ranging between 10-35%.24-26 Darnell et al reviewed patients ages 15 years and older presenting to an emergency department for rape or suspected rape, and found 28% attended the recommended medical/counseling follow-up appointment scheduled to take place 1 to 2 weeks after the ED visit.25 Holmes et al conducted a study of adolescent and adult patients referred to a specialty clinic called SAFE (Sexual Assault Follow-up Evaluation) and found a total of 31% (n=122) of sexual assault victims returned for follow up.24 Ackerman et al found 35.5% of their cohort of sexual assault patients ages 15 years and older presenting to an urban emergency department, attended follow-up.26 Herbert et al assessed follow up within 6 weeks of the index visit, and reported a rate of 10%.27 Statement of purpose It has been well documented that survivors of sexual assault are at risk for numerous immediate and long-term comorbidities both medically and psychologically, 12 necessitating appropriate acute care and follow-up adherence. Though studies report a wide range of follow-up rates, adherence and utilization of post-assault care are universally and historically low. The purpose of this study is to get an understanding of the care provided to patients presenting after sexual assault across two sites at the Yale New Haven Hospital (YNHH). By identifying specific characteristics of the patients, their assault narrative, the acute visit and follow-up care, the overall aim is to inform possible strategies for improved engagement and outcomes as well as encourage continued quality improvement study in the care of this vulnerable patient population. YNHH consists of two sites: York Street Campus (YSC), an urban tertiary care center, and its satellite community hospital, St. Raphael Campus (SRC). Both of the hospital sites included in this study has a referral system to the Child Sex Abuse Clinic, a comprehensive care program (medical, psychiatric, forensic) for pediatric and adolescent patients under 19 years of age. Currently no such referral protocol or system for exists for adult patients. It is possible that patients older than 19 years could benefit from a similar standardized referral protocol, and the YNHH Women’s Center—the ambulatory OB/GYN clinic located at the YSC site—could be an underutilized resource. Due to this difference in age-related resource, further analysis comparing the subgroup of adolescent patient encounters to the adult patient encounters will be conducted to investigate possible differences in outcomes due to variations in age. Specific Aims • Aim 1: Describe the population of patients presenting after sexual assault to Yale New Haven Hospital (YNHH) at its two campuses- the York Street Campus 13 (YSC), the urban tertiary care center, and its satellite community hospital at St. Raphael Campus (SRC). • Aim 2: Analyze patient encounters for characteristics of clinical management, reported assault narrative, medical and forensic documentation, involvement of various interdisciplinary professionals (SANE, social worker, law enforcement, DCF, sexual assault crisis advocate), and discharge planning. • Aim 3: Investigate the overall rate of assault-related follow-up care within one- year after index visit and identify associated factors. Materials and Methods Study Population After approval from the Institutional Review Board, the Joint Data Analytics Team (JDAT) compiled medical records for analysis of patient encounters with report of sexual assault. We conducted a retrospective medical record review of the encounters through Epic, the electronic medical record (EMR) system utilized at Yale New Haven Hospital (YNHH). We included patients older than 12 years of age, presenting to the emergency departments and outpatient clinics (primary care and OB/GYN), between January 2014 and February 2017. The encounters of interest were identified as first disclosures and initial presentations of sexual assault. Initially, a broad list of ICD (International Classification of Diseases) codes were used as the main inclusion criteria to identify all visits resulting in evaluation and care after sexual assault. Medical record review of the patients revealed that a subset of patients had multiple hospital encounters for evaluation after acute sexual assault, some 14 of which were not captured with the ICD criterion. At this point, the searchable “Chief complaint” field of the EPIC EMR system was employed as a second inclusion criterion and was used in conjunction with the ICD codes. The final data set is a collection of the data compiled from ICD codes and Chief Complaints. Table 2: International Classification of Diseases (ICD) Code List for Data Set Inclusion • ICD10 Description 1 Z04.4* Encounter for examination and observation following alleged rape 2 T74.* Adult and Child abuse, neglect, and other maltreatment, confirmed (including Sexual Abuse) 3 T76.* Adult and Child maltreatment, suspected (including Sexual Abuse) 4 T19 Effects of foreign body in genitourinary tract 5 T19.2 Foreign body in vulva and vagina 6 T19.8 Foreign body in other parts of the genitourinary 7 T19.9 Foreign body in genitourinary tract, part unspecified 8 S30 Superficial injury of the abdomen, lower back, pelvis and external genitals 9 S31 Open wound of abdomen, lower back, pelvis and external genitals 10 S37 Injury of urinary and pelvic organs 11 S39 Other and unspecified injuries of abdomen, lower back, pelvis and external genitals Table 3: “Chief Complaint” Field for Data Set Inclusion Sexual Assault Sexual Assault Exam Referral Possible Sexual Assault Sexual Problem Alleged child Abuse Sexual Dysfunction 15 A total of 1471 encounters were identified between January 2014 and February 2017 of patients ages 13 years and older, that were assigned a chief complaint of or ICD code related to sexual assault. From these encounters, only those visits to an emergency department or outpatient clinic for primary care or OB/GYN were considered, as disclosures of sexual assault would most likely result in a referral for evaluation by these departments. This filter yielded 844 unique encounters. We then performed a more in- depth medical record review of the notes linked to the encounter to validate the visit for initial evaluation of sexual assault, resulting in 466 encounters in the final data set. Of note, the ICD code criterion alone yielded 284 index visits after sexual assault. Adding the second, supplementary criterion of “chief complaint”, identified an additional 184 encounters for sexual assault, increasing the data set by 35%. Table 4 compares the demographics between these two subsets of data: the encounters captured by the ICD inclusion criterion, notated (+)ICD, and those only captured once the EMR’s “chief 1471 Encounters 844 Encounters 466 Encounters Filter by Department SA related visits in ED, Outpatient primary care & Women’s Clinic Figure 1: Data Set Filter Inclusion Criteria 1. Jan 2014 – Feb 2017 2. Ages 13+ 3. “Chief Complaint” Field or ICD codes related to sexual assault Medical record reviewed and confirmed as visit directly related to care of sexual assault patient* 16 complaint” field was used, notated (-)ICD. There was no significant difference in demographics of these two groups. Further investigation of the ICD(-) encounters revealed that these encounters had either (1) codes related to a second medical concern (e.g., alcohol intoxication, homicidal ideation), (2) a code that is not part of the ICD-10 directory (e.g., IMO code), or (3) a code that is broad and nonspecific to sexual assault (e.g., pelvic pain, anal pain, HIV exposure). All nonzero concern of sexual assault warranting a visit for forensic or medical evaluation were included in the final data set. For example, encounters in which the patient self-presents or accompanied by a parent requesting a Sexual Assault Table 4: Comparison Between Demographics of Data Subsets (+) ICD (-) ICD X2 SEX Female 268 95% 175 96% p=0.65 Male 15 5% 8 4% AGE Average, SD (y) 25.85 11.98 25.60 12.03 13-18 y 92 32% 57 31% p=0.76 19+ y 193 68% 127 69% ETHNICITY Non-Hispanic 225 79% 142 77% p=0.95 Hispanic or Latino 57 20% 38 21% Unknown 2 1% 1 1% PRIMARY RACE White or Caucasian 130 46% 85 46% p=0.82 Black or African American 99 35% 68 37% Not Listed 49 17% 26 14% LANGUAGE English 274 96% 169 92% p=0.08 Spanish 7 2% 9 5% Other or Not Listed 3 1% 6 3% 17 Evidence Collection Kit (SAECK) were always included, even if the patient denies having any memory of being assaulted nor any signs or symptoms of assault. These cases were most commonly in a setting of memory altering substance use. Excluded from the data set were: patient encounters with a distant history of sexual assault, sexual assault that has already previously been addressed by a healthcare provider, and assault that has been identified as nonsexual or nonphysical abuse. Cases of minors reporting consensual sexual activity were carefully reviewed for statutory rape, and those with age differences allowing for consent were excluded (see discussion of statutory rape in Definitions). In patient cases that resulted in a direct transfer of care between the two emergency departments in the study, the encounter providing more thorough care was included, and the other encounter excluded. For example, if a SANE nurse was not available at SRC, the community hospital, requiring a transfer of the patient to the emergency department at the larger tertiary care hospital (YSC), the first encounter was excluded and the encounter at the receiving department (where a SANE nurse was available) was included. Data Elements A total of 97 variables were identified by a combination of direct extraction from the EMR by JDAT, and manual review of provider notes and scanned documents. Variables of interest included those describing the patient demographics, medical, social and legal management at the index visit, forensic evaluation and kit collection, acute care team members, discharge planning and follow-up. 18 Dependent Variable The primary outcome of interest of our study is the attendance of outpatient visits providing sexual assault follow-up care within one year of index visit. Provider notes for all outpatient visits attended within one year, were manually reviewed through the EMR for documentation of clinical management or counseling related to the sexual assault. Providers included physicians, nurse practitioners, social workers, psychologists, and therapists. Though the majority of physician follow-up visits were provided by those in primary care and OB/GYN settings, specialty visits were also reviewed, as patients with chronic conditions, such as diabetes, interface frequently and reliably with their specialists, lending to an opportunity for intervention. Outpatient visits that did not address the sexual assault or refer to medical, psychiatric, social or legal management pertaining to the assault, were excluded. Certain special considerations are discussed below. In rare cases, documentation of electronic correspondence between the provider and the patient through the patient portal system called MyChart was identified and was considered potentially relevant for our study. Previous research of a piloted text- messaging intervention between nurses and sexual assault survivors in efforts to improve post-assault engagement of care found that this type of electronic communication was effective in relaying information such as signs of safety and well-being and information on non-occupational post-exposure prophylaxis.28 However, a large portion of their patients (42.5%) stopped responding after the third message, and they rarely utilized offers of assistance such as counseling and advocacy. Similarly, the MyChart electronic correspondences in this study consist mostly of unidirectional messages from the 19 provider or provider’s office to the patient as a reminder for an appointment or notification of testing results. While the unidirectional communication could be useful for sending visit reminders or patient education, bidirectional communication could indicate valuable post-assault medical advice from the provider such as responding to a question posed by the patient regarding testing results or medical/psychiatric concerns, and was considered a successful provision of follow-up care and a valuable opportunity for providers to track the survivor’s well-being. There are many psychosocial barriers to care, particularly following sexual trauma, and the availability of electronic communication with providers makes it easier for survivors to maintain contact with their providers. If a patient attended a follow-up visit after sexual assault, the provider type (e.g., primary care, OBGYN, psych, social work) and time lapse between the index visit and follow-up appointment were documented. In the case of multiple visits to a provider after the sexual assault, only the visit soonest after the index visit was recorded. Independent Variables • Patient demographics: Patient demographic information was extracted by the JDAT team directly from the EMR as recorded by ED providers (e.g., nurse, medical assistant, social worker) as reported by the patient. These variables include: sex (male/female), age at encounter (years), ethnicity (Hispanic/Latino, or Non-Hispanic/Latino), primary race (White/Caucasian, Black/African American, Asian, American Indian/Alaska Native, Other), and preferred language (English, Spanish, Sign Language, Other). 20 • Encounter setting: Variables describing the visit setting were also provided by the JDAT team and included: date and time of admission or appointment, discharge time for emergency department visits, encounter department (e.g., pediatric emergency department, adolescent primary care clinic, OBGYN clinic), and hospital campus (York Street Campus or St. Raphael’s Campus). These characteristics were gathered to analyze data for outcomes related to the visit setting. Of note, YSC (the tertiary care center of YNHH) has two separate emergency departments for pediatric and adult patient care while the community hospital of St. Raphael’s Campus (SRC) has one emergency department caring for patients of all ages. Prior to 2013, the SRC hospital housed its own OBGYN clinic, but in the time frame of this study, women’s health patients from both YSC and SRC were all referred to the Women’s Center ambulatory clinic at the YSC site. Each hospital has its own primary care outpatient clinics located at their respective sites. • Assault Narrative: Characteristics of the sexual assault narrative were extracted by manual review of all medical record documentation (medical provider, nursing, social work, SANE) pertaining to the index visit as available in the EMR. When assault narrative data was unavailable by review of the notes, the scanned forensic exam form was reviewed, if available. Variables included: time lapse (between assault and medical presentation), assailant relation to patient (known or unknown, biological or not, solo or multiple assailants), and substance use at time of assault. Time lapse (delay of presentation after sexual assault) is usually explicitly documented in the provider note. However, in cases where this was not