A practice-centered intervention to increase screening for domestic violence in primary care practices

BMC Family Practice A practice-centered intervention to increase screening for domestic violence in primary care practices Denise E Bonds 2 Shellie D Ellis 1 Erin Weeks 2 Shana L Palla 0 Peter Lichstein 3 0 Department of Biostatistics and Applied Mathematics, University of Texas M.D. Anderson Cancer Center , Houston, Texas , USA 1 Duke Clinical Research Institute, Duke University , Durham, North Carolina , USA 2 Department of Epidemiology and Prevention, Division of Public Health Sciences, and Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine , Winston-Salem, North Carolina , USA 3 Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine , Winston-Salem, North Carolina , USA Background: Interventions to change practice patterns among health care professionals have had mixed success. We tested the effectiveness of a practice centered intervention to increase screening for domestic violence in primary care practices. Methods: A multifaceted intervention was conducted among primary care practice in North Carolina. All practices designated two individuals to serve as domestic violence resources persons, underwent initial training on screening for domestic violence, and participated in 3 lunch and learn sessions. Within this framework, practices selected the screening instrument, patient educational material, and content best suited for their environment. Effectiveness was evaluated using a pre/ post cross-sectional telephone survey of a random selection of female patients from each practice. Results: Seventeen practices were recruited and fifteen completed the study. Baseline screening for domestic violence was 16% with a range of 2% to 49%. An absolute increase in screening of 10% was achieved (range of increase 0 to 22%). After controlling for clustering by practice and other patient characteristics, female patients were 79% more likely to have been screened after the intervention (OR 1.79, 95% CI 1.43-2.23). Conclusion: An intervention that allowed practices to tailor certain aspects to fit their needs increased screening for domestic violence. Further studies testing this technique using other outcomes are needed. - Background Domestic Violence (DV) or Intimate Partner Violence is the physical, sexual, or psychological harm to another by a current or former partner or spouse [1]. Current estimates are that 5.3 million episodes of intimate partner victimization occur each year in the United States and nearly 25% of women have experienced some form of DV in their lifetime [2]. DV is associated with poor health outcomes. Women with a history of DV have a 60% higher rate of physical health problems [3] and are 46 times more likely to have depression [4]. Although the adverse health consequences of domestic violence have been widely documented, there is not consensus on the effectiveness of screening. While the United State Preventive Services Task Force recently found insufficient evidence to support routine screening for domestic violence [5], other physician organizations such as the American Medical Association [6], and the American College of Obstetricians and Gynecologists [7] have stated support for inclusion of screening or awareness in medical practice. When surveyed, patients also support physicians inquiring about violence in the home [8-10]. In concurrence with the practice organizations above and in support of patient findings, the Institute of Medicine published a report in 2001 calling for increased training of health care providers on family violence [11]. Interventions to increase screening for and awareness of domestic violence by health care professionals have had mixed success [12-16]. Several studies have explored the barriers to routine screening [17,18]. Lack of education and time, and fear of offending patients are frequently cited by health care providers [17,18] as barriers to routine screening. An additional barrier that may contribute to the failure of a targeted program to increase screening is the inability of the intervention to adapt to the individual characteristics of the health care practice or professional. If the educational mode or tool to be tested is too rigid to integrate with a clinic's existing routines, it may be discarded or not adopted, resulting in a failure to change. We hypothesized that a practice-centered intervention that is sensitive to the particular needs of the practice while still remaining true to the underlying principles of quality may be more successful in implementing change. To determine if a practice-centered intervention could successfully change practice patterns, we conducted a multifaceted intervention to increase screening for domestic violence. Methods Project PAAVE (Providers Asking About ViolencE) was a three year project designed to increase the rate of screening for domestic violence by primary care providers. Conducted in western North Carolina, PAAVE was a multimodality intervention that included both standardized educational sessions and components customized to the needs of participating practices. The intervention was evaluated through a pre/post telephone survey of female patients seen within the last 12 months at the practice. The study was reviewed and approved by the Institutional Review Board at Wake Forest University School of Medicine. Practices Primary care practices (defined as internal medicine, family medicine, or obstetrics and gynecology) with at least two providers located within 50 miles of Wake Forest University School of Medicine were invited to join. Both academic and community-based practices were eligible. Providers could be physicians, nurse practitioners, nurse midwives, or physician assistants. Practices agreed to send one staff member and one provider to a centralized training session and to allow these practice members to act as an on-site resource on domestic violence and local champion to increase screening (Domestic Violence Resource Persons). Primary care practices were contacted during a three month period. Several methods were used including letters, presentations at local meetings, cold calls to practice managers. Intervention The intervention for this study was multi-focal, consisting of training of two local resource persons (Domestic Violence Resource Persons), provider and staff education, audit of baseline rates and feedback of those rates back to the clinic, and ongoing educational visits (lunch and learn). Within this framework, clinics were allowed to customize specific aspects as described below. Each Domestic Violence Resource Person attended an all day training session conducted by a noted expert in the field (Dr. Elaine Alpert, MD, MPH). The training was modeled on the Massachusetts Medical Society Seminar Series on Domestic Violence and was supplemented with sessions on legal issues pertinent to the local area and su (...truncated)