Management of Domestic Violence in the Healthcare Setting Jeffrey H. Coben, MD

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Management of Domestic Violence in the
Healthcare SettingJeffrey H. Coben, MD
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Identifying violence as a public health issue is
a relatively new idea. Traditionally, when
confronted by the circumstances of violence, the
health professions have deferred to the criminal
justice system. The professions of medicine,
nursing, and the health-related social services
must come forward and recognize violence as their
issue. C. Everett Koop, 1991
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Presentation Overview
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Definitions

• Domestic of or pertaining to the family or
  household
• Violence physical force exerted for the purpose
  of violating, damaging, or abusing
• Domestic violence might include spouse abuse,
  child abuse, sibling abuse, elder abuse.

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Definitions

• Inconsistent definitions have contributed to
  varied conclusions about incidence, prevalence,
  health effects.
• Presentation focus Intimate Partner Violence
  (IPV)
• CDC Uniform Definitions (1994-96 1999)

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Uniform Definitions - IPV

• Intimate Partners include
• current spouses (including common-law)
• current non-marital partners
• dating partners, including first date
  (heterosexual or same-sex)
• former marital partners
• former non-marital partners

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Uniform Definitions - IPV

• Violence includes
• Physical Violence intentional use of physical
  force
• Sexual Violence
• Use of physical force to compel a person to
  engage in a sexual act against his or her will,
  whether or not the act is completed

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Uniform Definitions - IPV

• Violence includes
• Threat of Physical or Sexual Violence
• Psychological/Emotional Abuse
• includes coercive tactics when there has also
  been prior physical or sexual violence.
• includes humiliation, property destruction,
  control.

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Prevalence

• General population estimates
• National Family Violence Survey (1985)
  cohabitating couples
• Telephone survey (n6002)
• 11.6 of women report past year physical
  violence.
• 3.4 of women report past year severe violence (gt
  slap).

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Prevalence (contd)

• National Violence Against Women Survey (2000) -
  CDC Definitions
• RDD survey (n16,000)
• 1.5 of women report past year rape and/or
  physical assault.
• 0.9 of men report past year rape and/or physical
  assault.

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Prevalence (contd)

• National Violence Against Women Survey
• 24.8 of women report lifetime rape and/or
  physical assault (gt50 if include childhood)
• 7.6 of men report lifetime rape and/or physical
  assault

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Prevalence (contd)

• Crime Statistics (Uniform Crime Reports)
• 1500 female homicides annually
• 1-2 million annual assaults

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Implications of Prevalence Data

• 1.5 million women and 835,000 men are physically
  or sexually assaulted annually.
• Many victims are victimized more than once -
  approximately 4.8 million assaults against women
  annually.
• gt500,000 women stalked annually.
• 41.5 of assaulted women injured, compared with
  19.9 of assaulted men.

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Prevalence in Healthcare Setting

• Psychiatry practice
• 25 of suicide attempts (Carmen, 1984)
• Internal Medicine
• 5.5 Annual, 21.4 Lifetime (McCauley, 1995)
• HMO Patients
• 4 Annual, 37 Lifetime (Jones, 1999)
• Abuse During Pregnancy
• 3.9 - 8.3 during current pregnancy

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Prevalence in Healthcare Setting

• Emergency Department studies
• Dearwater, Coben, Campbell, et al (n3455)
• 2.2 trauma from abuse
• 14 annual, 36 lifetime (44 CA, 31 PA)
• Abbott, Johnson, Koziol-McLain, et al (n418)
• 2.2 trauma from abuse
• 11.7 acute DV, 54.2 lifetime
• Muelleman, Lenaghan, Pakieser (ngt3000)
• 3.1 trauma from abuse for women aged 19-65.

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Healthcare Prevalence

• National Violence Against Women Survey
• 557,929 ED visits (87 female)
• 306,051 outpatient visits
• 388,335 overnights in hospitals
• 860,346 physician visits
• 216,955 dental visits
• 974,693 physical therapy visits

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Implications of Healthcare Studies

• Abused women are seen in the healthcare setting
  more often than in shelters or the criminal
  justice system.
• 550,000 - 670,000 acute injuries annually.
• Another 3 million seen in ED setting.
• 5-15 of women with past year violence.
• Abuse during pregnancy.

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Adverse Health Consequences

• Deaths
• 1200 to 1600 female homicides annually attributed
  to IPV
• 6000 female suicides annually (IPV role?)
• Acute Trauma
• 2 million injuries annually
• 500,000 ED visits for acute injury

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Adverse Health Consequences

• Chronic pain syndromes (back, abdominal, pelvic,
  headaches)
• Unintended pregnancy, STDs/HIV, UTIs, elective
  abortions more common

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Adverse Health Consequences

• Depression, anxiety, mood disorder, eating
  disorders
• Physically abused women 8 times more likely to be
  alcohol dependent than non-abused
• Strong association with PTSD

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Adverse Health Consequences

• Increased healthcare utilization
• HMO enrollee comparison. Annual difference of
  1775 for IPV victims, mostly mental health
  services.
• Poor compliance with treatment recommendations

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Role of the Healthcare System

• Potential role of early identification and
  intervention.
• Methods of early identification?
• How to structure interventions?

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Role of the Healthcare System

• Should healthcare providers screen for intimate
  partner victimization?

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Healthcare Screening for IPV

• Domestic violence and its medical and
  psychiatric sequelae are sufficiently prevalent
  to justify routine screening of all women
  patients in emergency, surgical, primary care,
  pediatric, prenatal, and mental health settings.
• American Medical Association, 1992

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Healthcare Screening for IPV

• American College of Obstetricians and
  Gynecologists recommends that physicians screen
  ALL patients at EVERY visit for both sexual
  assault and intimate partner violence.

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Healthcare Screening for IPV

• The Joint Commission on Accreditation of
  Healthcare Organizations has mandated that all
  emergency departments and ambulatory care
  facilities establish guidelines for the
  identification, evaluation, management and
  referral of adult victims of domestic violence.

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NIJ-CDC Findings from the National Violence
Against Women Survey

• The U.S. medical community treats millions of
  intimate partner rapes and physical assaults
  annually. To better meet the needs of intimate
  partner violence victims, medical professionals
  should receive training on the physical
  consequences of intimate partner violence and
  appropriate medical intervention strategies.

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U.S Preventive Services Task Force (USPSTF)

• There is insufficient evidence to recommend for
  or against the use of specific screening
  instruments to detect family violence, but
  recommendations to include questions about
  physical abuse when taking a history from adult
  patients may be made on other grounds.

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USPSTF Criteria

• Criteria for Effectiveness of a Screening Test
• Must be able to detect the target condition
  earlier than without screening and with
  sufficient accuracy to avoid producing large
  numbers of false-positive and false-negative
  results.
• Screening for and treating persons with early
  disease should improve the likelihood of
  favorable health outcomes compared with treating
  patients when they present with signs and
  symptoms of the disease.

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Systematic Evidence Review

• Several instruments have been developed for IPV
  screening some have demonstrated fair to good
  internal consistency and some have been validated
  with longer instruments. None, however, have
  been evaluated against measurable IPV outcomes

Systematic Evidence Review, Number 28 AHRQ
March, 2004
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Systematic Evidence Review

• Few intervention studies have been conducted and
  these focused on pregnant women. Outcomes were
  based on scores on questionnaires and suggest
  benefit, however study limitations restrict
  interpretation

Systematic Evidence Review, Number 28 AHRQ
March, 2004
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U.S Preventive Services Task Force (USPSTF)

• There is insufficient evidence to recommend for
  or against the use of specific screening
  instruments to detect family violence, but
  recommendations to include questions about
  physical abuse when taking a history from adult
  patients may be made on other grounds.

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Other Grounds

• High prevalence, adverse health consequences
• Diagnostic accuracy
• Opportunity to identify and assist patients
• The right thing to do

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Healthcare Goals

• Do no harm
• Assist our patients and their families
• Reduce morbidity mortality

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Healthcare IPV Assessment - Victim Perspectives

• Large majority of women and majority of victims
  support routine screening.
• Victims report wishing they had been asked by
  healthcare providers.
• Victims view providers as uncaring, uninterested,
  and not sympathetic.
• Safety issues are paramount.

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Healthcare IPV Assessment - Provider Perspectives

• Inadequate training, discomfort.
• What to do if the answer is yes?
• Lack of time, resources, reimbursement.
• Screening vs. targeted assessments vs. case
  finding vs. routine care

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Can a High Risk Clinical Population be Identified?

• Despite demographic and clinical associations,
  the sensitivity and positive predictive values of
  these risk factors individually and in the
  aggregate is low.
• Fanslow, et al 1998
• Zachary, et al, 2001

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Can a High Risk Clinical Population be Identified?

• 44 of women murdered by intimate partner seen in
  the ED within two years prior to their death -
  but only 42 there due to trauma.
• Muellemann, et al, 1998

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Other Grounds

• Screening insufficient evidence
• Targeted assessments poor sensitivity
• Case finding diagnostic accuracy
• Routine care the right thing to do

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Routine Inquiry for IPV in Healthcare Setting

• Combining acute and past year prevalence,
  7-15 of adult women are in abusive relationships
  and at greatest risk
• In comparison
• 7 of the general population are allergic to some
  drug
• 10-20 of hospitalized patients have an adverse
  drug reaction

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Are you allergic to any medications?

• 7 of population have a drug allergy
• (at least) 7 of women in abusive relationships
• 1500 deaths annually from anaphylaxis (all
  causes) in the United States
• 1500 female deaths from IPV annually in the
  United States

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But

• What if she says yes?

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Healthcare Goals

• Do no harm
• Assist our patients and their families
• Reduce morbidity mortality

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Healthcare-based IPV Interventions

• Healthcare-based IPV interventions are best
  viewed as programs, with numerous components,
  designed to promote systematic improvement in
  early identification and service provision

Improving the Health Care Response to Domestic
Violence Family Violence Prevention Fund April,
1998
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Specific Objectives of IPV Programs

• More knowledgeable, empathic providers
• User-friendly environment
• Early identification recognition
• Willingness to discuss
• Emotional support

• Provide information access to services
• Risk assessment
• Proper documentation
• Avoid causing harm
• Provide quality services

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• While we await the results of long-term
  prospective studies, how can we determine if we
  are providing quality care to the victims of IPV?

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Measuring the Quality of Healthcare

• Structure - is there a program?
• Process - what is it doing?
• Outcomes - what is the effect?

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Program Structure

• Structure refers to attributes of the settings in
  which care occurs. This includes the attributes
  of material resources (facilities, equipment,
  money), of human resources (number
  qualifications of personnel), and of
  organizational structure.

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Program Process

• Process refers to what is actually done in giving
  and receiving care. It includes the
  practitioners activities in making a diagnosis,
  documenting their findings, and implementing
  treatment.

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Program Outcome

• Outcome refers to the effects of the program on
  the outcomes of interest, which usually include
  morbidity, mortality, quality of life, healthcare
  utilization, and healthcare costs.

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Health Services Research Paradigm

• Programs with good structure in place will have
  an increased likelihood of good process of care,
  and good process increases the likelihood of good
  outcome
• Structure Process Outcome

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Health Services Research Caveats

• Having good structure in place is not sufficient
  - it must facilitate good process.
• Good structure and process do not guarantee
  success, but they increase the likelihood of
  successful outcomes.
• Inadequate structures and poor process is likely
  to result in poor outcomes.

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The Focus on Outcomes

• Health care produces only 10 of health outcome.
  Other factors such as lifestyle, genetics,
  stress, and environment are responsible for the
  other 90. So what should providers be held
  accountable for, in delivery of health care?

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The Focus on Outcomes

• ...Process is what should be paid for, not
  outcome. You should be paid for the probability
  of a better outcome through the process of health
  care
• Uwe Reinhart, PhD
• JAMA, 1/9/02

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Examples of Structure Process Assessments

• Joint Commission Standards
• Trauma System Standards
• HEDIS measures

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• Understanding the origins of health and health
  care disparities from a health services research
  perspective
• Kilbourne, AM, et al AJPH December 2006

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Hospital-based IPVPrograms - Common Features

• Training of healthcare providers
• Establishment of DV task force or team
• Establishment of DV-specific policies and
  procedures
• Environmental modifications
• Routine inquiry for victimization
• Intervention services

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Measuring the Quality ofIPV Services in
Healthcare Setting

• Structure - is there an IPV program?
• Process - what is the program and how well has it
  been implemented?
• Outcome - what are the effects of the program?
• Intermediate measures
• Long-term health and safety measures

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Process Program Implementation

• Example 1 - Training healthcare providers
• Qualifications of trainer?
• Quality of training material?
• Time devoted to training?
• Percentage of staff trained? Medical staff?
  Housestaff? New hires, all shifts?
• Evaluation of training?

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Process Program Implementation

• Example 2 - Environmental modifications
• Availability and visibility of DV -related
  posters, brochures, patient information, buttons,
  hotline numbers? Quantity, quality, and location
  of materials?
• Security procedures?
• Privacy of screening process?

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Process ProgramImplementation

• Example 3 - Intervention services
• who provides the intervention? Qualifications
  and experience? RN, social worker, advocate?
• On-site service provider? Hours of coverage?
• Standardized intervention protocol?
• Referral, counseling, advocacy, legal options,
  safety plan, shelter, transportation, etc.

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Hospital-based Domestic Violence Delphi Instrument

• Designed to measure the quality of DV program
  implementation in the hospital setting.
• 3 rounds, modified Delphi consensus method
• Structure and process measures operationalized to
  publicly available instrument

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Delphi Instrument - Purpose

• Can be used to provide benchmarks or objectives
  for program achievement.
• Measure and track site progress over time.
• Compare programs across sites.
• Can help determine most important program
  components, if linked to outcome data.

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Domains of Program Activities

• Policies Procedures
• Physical Environment
• Cultural Environment
• Training of Providers
• Screening Safety Assessment

• Documentation
• Intervention Services
• Evaluation Activities
• Collaboration

Coben, Academic Emergency Med 2002
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Examples of Use

• Statewide evaluation of Pennsylvania programs
• Kansas City Metro Hospitals
• New Zealand nationwide evaluation

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Delphi Results
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Total Score on Delphi Instrument by Duration of
Program

• All sites (n 34) mean score 50.6
• 1st year sites (n 17) mean score 46.6
• 3rd year sites (n 11) mean score 49.1
• gt 6th year sites (n 5) mean score 66.0

Coben Fisher, Fam Viol Prev and Health Prac 2005
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Status of Current Research on Healthcare-based
IPV Programs

• Goal 1 Do no harm.
• The existing literature suggests that the
  overwhelming majority of patients and IPV victims
  are satisfied or extremely satisfied with the
  services provided within hospital-based DV
  programs (94 in KC project)

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Status of Current Research on Healthcare-based
IPV Programs

• Goal 2 Assist patients and families (improve
  the structure process of care)
• Research has demonstrated
• Improvements in hospital environment and health
  system culture
• Improvements in provider knowledge attitude
• Improvements in assessment, identification, and
  referral rates

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Status of Current Research on Healthcare-based
IPV Programs

• Goal 3 Reduce morbidity mortality
• Long-term findings not available, but
• Studies among pregnant women have found favorable
  outcomes 6 12 months following an intervention
  in the healthcare setting
• And.

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Status of Current Research on Healthcare-based
IPV Programs

• The most promising intervention for IPV with good
  supporting evidence is the advocacy-based
  approach (Sullivan, et al) being adopted by the
  majority of hospital-based programs
• And.

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Status of Current Research on Healthcare-based
IPV Programs

• Recent research has demonstrated the protective
  effect of permanent restraining order
• Of 78 patients seen by medical advocates in the
  KC project, 50 were assisted in filing petitions
  for a restraining order

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Conclusions Recommendations

• There is strong rationale for the implementation
  of healthcare-based IPV interventions
• There is evidence to demonstrate programs can be
  successfully implemented
• These is evidence of short-term positive impacts
  upon patients and victims no evidence of
  negative consequences

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Conclusions Recommendations

• There is a lot more research that needs to be
  done
• To better serve our patients, we should
  understand the dynamics of IPV and provide them
  with the highest quality services available