Birth Outcomes in Relation to Intimate Partner Violence.

OBJECTIVES: Intimate partner violence (IPV)during pregnancy is a significant public health problem. Approximately 324,000 IPV victimizations occur during pregnancy each year. However, research on the impact of IPV on birth outcomes yields conflicting findings. This study examines the association of IPV with birth outcomes among pregnant women. STUDY DESIGN: We used a retrospective cohort study design to analyze data from chart reviews of a random sample of 1542 pregnant women. These women were seen between 2003 and 2009 at an urban university affiliated prenatal clinic and gave birth at the on-site hospital. Victims of IPV were defined as those who scored equal to or higher than 10 on an IPV screening tool: HITS (Hit, Insult, Threaten, and Scream). Three measures were included in birth outcomes. Preterm delivery was defined as gestational age less than 37 weeks. Low birth weight was defined as infants born weighing <2500 g. Neonatal intensive care was measured by prevalence of receiving intensive care. RESULTS: The prevalence of IPV was 7.5%. Compared to non-abused women, abused women were more likely to have preterm deliveries (18.3% vs. 10.3%; p = .016). Compared to infants of non-victims, infants of victims were more likely to have low birth weight (21.5% vs. 11.0%; p = .003) and to receive neonatal intensive care (23.4% vs. 7.8%; p = .000). Results from multivariate analyses indicated that victims were more likely to have preterm deliveries than non-victims (OR = 1.72; 95% CI: 1.22-2.95). More infants of victims had low birth weight (OR = 2.03; 95% CI: 1.22-3.39) and received neonatal intensive care than those of non-victims (OR = 4.04; 95% CI: 2.46-6.61). CONCLUSIONS: Abused pregnant women had poorer birth outcomes compared to non-abused pregnant women. Healthcare providers should be trained to screen and identify women for IPV, and interventions should be designed to reduce and prevent IPV and thereby improve health outcomes for victims and their children.

Relationship between medical student service and empathy.

BACKGROUND: Student participation in service activities during medical school is believed to enhance student professionalism and empathy. Yet, there are no studies that measure medical student empathy levels in relation to service activities. METHOD: Medical students from four classes (2007-2010) were surveyed at graduation using the Jefferson Scale of Physician Empathy-Student Version and questions about service activity during medical school. For two classes, empathy scores were also obtained at orientation. The data were analyzed using Statistical Package for the Social Sciences. Means comparison tests were performed. RESULTS: Mean empathy scores at graduation were higher for students who participated in service activities compared with those who reported no service (115.18 versus 107.97, P < .001). At orientation, students with no service had lower empathy scores, and those with any service had higher empathy scores. CONCLUSIONS: Student empathy and service activities during medical school are related. This may have implications for admissions committees.

Relationships between medical student burnout, empathy, and professionalism climate.

BACKGROUND: Medical student burnout is prevalent, and there has been much discussion about burnout and professionalism in medical education and the clinical learning environment. Yet, few studies have attempted to explore relationships between those issues using validated instruments. METHOD: Medical students were surveyed at the beginning of their fourth year using the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy-Student Version, and the Professionalism Climate Instrument. The data were analyzed using Statistical Package for the Social Sciences, and Spearman correlation analysis was performed. RESULTS: Scores indicative of higher medical student burnout were associated with lower medical student empathy scores and with lower professionalism climate scores observed in medical students, residents, and faculty. CONCLUSIONS: Investigators observed relationships between medical student burnout, empathy, and professionalism climate. These findings may have implications for the design of curriculum interventions to promote student well-being and professionalism.

Intimate partner violence and cancer screening among urban minority women.

PURPOSE: To evaluate the association of intimate partner violence (IPV) with breast and cervical cancer screening rates. METHODS: We conducted retrospective chart audits of 382 adult women at 4 urban family medicine practices. Inclusion criteria were not being pregnant, no cancer history, and having a partner. Victims were defined as those who screened positive on at least one of 2 brief IPV screening tools: the HITS (Hurt, Insult, Threat, Scream) tool or Women Abuse Screening Tool (short). Logistic regression models were used to examine whether nonvictims, victims of emotional abuse, and victims of physical and/or sexual abuse were up to date for mammograms and Papanicolaou smears. RESULTS: Prevalence of IPV was 16.5%. Compared with victims of emotional abuse only, victims of physical and/or sexual abuse aged 40 to 74 were associated with 87% decreased odds of being up to date on Papanicolaou smears (odds ratio, 0.13; 95% CI, 0.02-0.86) and 84% decreased odds of being up to date in mammography (odds ratio, 0.16; 95% CI, 0.03-0.99). There was no difference in Papanicolaou smear rates among female victims and nonvictims younger than 40. CONCLUSIONS: Because of the high prevalence of IPV, screening is essential among all women. Clinicians should ensure that victims of physical and/or sexual abuse are screened for cervical cancer and breast cancer, particularly women aged 40 or older. Cancer screening promotion programs are needed for victims of abuse.

Do state medical board applications violate the americans with disabilities act?

PURPOSE: To determine whether medical licensing board application questions about the mental or physical health or substance use history of the applicant violate the Americans with Disabilities Act (ADA) of 1990. METHOD: Content analysis of 51 allopathic licensing applications (50 states and District of Columbia) was performed at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in 2005. Questions referencing physical or mental health or substance use were identified by a team of physicians and reviewed and categorized based on the ADA and appropriate case law by legal counsel. RESULTS: Of the 51 applications reviewed, 49 (96%) contained questions pertaining to the physical or mental health or substance use history of the applicant. Thirty-four of the 49 (69%) state medical licensing applications contained at least one "likely impermissible" or "impermissible" item based on the ADA and appropriate case law. CONCLUSIONS: Most state medical licensing applications contain questions that ask about the physical or mental health and substance use of physician applicants. Many licensing applications appear to be in violation of the ADA, even 19 years after enactment of the regulation. These questions do not elicit responses by which professional competence can be judged. The presence of these questions on licensing applications may cause physicians to avoid or delay treatment of personal illness.

Relation of domestic violence to health status among Hispanic women.

Little research has addressed the association of domestic violence (DV) with physical and mental health in Hispanic women. We conducted a cross-sectional study with 146 Hispanic women patients in 2002 at an urban family medicine practice. Twenty-one percent of the women were identified as current victims of DV. Two-fifths of victims (41.9%) experienced physical and/or sexual abuse. Approximately two-thirds (64.5%) had depressive symptoms. Poorer mental health was associated with all forms of abuse. Relatively low socioeconomic status and acculturation level may lead to disparities in obtaining services for DV intervention. Culturally appropriate protocols are needed in primary care settings to prevent and intervene among Hispanic women at risk for DV.

Mapping the elder mistreatment iceberg: U.S. hospitalizations with elder abuse and neglect diagnoses.

PURPOSE: This study describes U.S. hospitalizations with diagnostic codes indicating elder mistreatment (EM). METHOD: Using the 2003 Nationwide Inpatient Sample (NIS) of the Healthcare Costs and Utilization Project (HCUP), inpatient stays coded with diagnoses of adult abuse and/or neglect are compared with stays of other hospitalized adults age 60 and older. RESULTS: Few hospitalizations (< 0.02%) were coded with EM diagnoses in 2003. Compared to other hospitalizations of older adults, patients with EM codes were twice as likely to be women (OR = 2.12, 95% CI = 1.63-2.75), significantly more likely to be emergency department admissions (78.0% vs. 56.8%, p < .0001), and, on average, more likely to have longer stays (7.0 vs. 5.6 days, p = 0.01). Patients with EM codes were also three to four times more likely to be discharged to a facility such as a nursing home rather than "routinely" discharged (i.e., to home or self-care) (OR = 3.66, 95% CI = 2.92-4.59). Elder mistreatment-coded hospitalizations compared to all other hospitalizations had on average lower total charges ($21,479 vs. $25,127, p < .001), with neglect cases having the highest charges in 2003 ($29,389). IMPLICATIONS: Knowledge about EM is often likened to the "tip of the iceberg." Our study contributes to "mapping the EM iceberg"; however, findings based on diagnostic codes are limited and should not be used to minimize the problem of EM. With the so-called graying of America, training is needed in recognizing EM along with research to improve our nation's response to the mistreatment of our elderly population.

Randomized comparison of 3 methods to screen for domestic violence in family practice.

PURPOSE: We undertook a study to compare 3 ways of administering brief domestic violence screening questionnaires: self-administered questionnaire, medical staff interview, and physician interview. METHODS: We conducted a randomized trial of 3 screening protocols for domestic violence in 4 urban family medicine practices with mostly minority patients. We randomly assigned 523 female patients, aged 18 years or older and currently involved with a partner, to 1 of 3 screening protocols. Each included 2 brief screening tools: HITS and WAST-Short. Outcome measures were domestic violence disclosure, patient and clinician comfort with the screening, and time spent screening. RESULTS: Overall prevalence of domestic violence was 14%. Most patients (93.4%) and clinicians (84.5%) were comfortable with the screening questions and method of administering them. Average time spent screening was 4.4 minutes. Disclosure rates, patient and clinician comfort with screening, and time spent screening were similar among the 3 protocols. In addition, WAST-Short was validated in this sample of minority women by comparison with HITS and with the 8-item WAST. CONCLUSIONS: Domestic violence is common, and we found that most patients and clinicians are comfortable with domestic violence screening in urban family medicine settings. Patient self-administered domestic violence screening is as effective as clinician interview in terms of disclosure, comfort, and time spent screening.

Screening for domestic violence in a predominantly Hispanic clinical setting.

BACKGROUND: Domestic violence is a public health problem that is common across ethnic groups. The utility of validated screening tools to detect abuse in diverse populations remains largely unknown. OBJECTIVE: The purpose of the study was to test the reliability and validity of a brief 4-question instrument, HITS, among predominantly Hispanic women. METHODS: We conducted a cross-sectional study in an urban clinical setting. Two hundred and two women completed HITS and two other previously validated tools, the Index of Spouse Abuse-Physical Scale (ISA-P) and the Woman Abuse Screening Tool (WAST). Instruments were prepared in English and translated to Spanish. Reliability and validity of HITS were compared with the ISA-P and WAST. Performance measures of HITS were compared with the ISA-P or WAST as a criterion standard. RESULTS: Cronbach's alphas were 0.76 and 0.61 for the English version and Spanish version of HITS, respectively. When administered first and analysed alone, the Spanish version of HITS had a reliability of 0.71. For both English and Spanish versions HITS was significantly correlated to ISA-P and WAST. The English HITS version had a sensitivity of 86% and a specificity of 99%. A cut-off score of 5.5 for Spanish HITS version achieved a sensitivity of 100% and a specificity of 86%. CONCLUSIONS: HITS demonstrated good reliability and validity with ISA-P in English speaking patients. The Spanish version of HITS showed moderate reliability and good validity with WAST in Spanish speaking patients. HITS may help physicians detect abuse in predominantly Hispanic clinical settings.

Mental health, family function and obesity in African-American women.

CONTEXT: African-American women are disproportionately affected by obesity and its related diseases. How psychological and psychosocial factors that affect this population differ across weight categories remains poorly understood. PURPOSE: To determine whether poor mental health and family functioning are associated with obesity in African-American women. METHODS: African-American women patients aged 21-65 years were interviewed at three primary care centers. Four well-established assessment tools were used to measure general mental and physical health status, family functioning, depressive symptoms and anxiety levels. Demographics, health behaviors and family and personal histories of overweight were assessed. RESULTS: Among 113 patients, after controlling for age and parity, obese women had significantly higher anxiety levels, poorer perception of their physical health, more often were overweight as a child, had overweight parents or siblings and experienced more psychosocial problems in their family growing up, compared to overweight and normal weight women. CONCLUSIONS: The observed findings of poor mental health, perception of physical health and family function in obese African-American women support a need for clinical attention and further study.

Collaboration Between Mental Health Professionals and Family Physicians: A Survey of New Jersey Family Physicians.

Background: Mental health problems are frequent in primary care, and there are many barriers to their detection and treatment. Clinical research protocols that include close collaboration between mental health professionals and primary care physicians have been found to be beneficial. This study explores the opinions of community family physicians regarding mental health professionals working directly in the primary care office.Method: Members of the New Jersey Academy of Family Physicians (N = 709) were sent a 25-item questionnaire about collaboration with mental health professionals. Three mailings were sent, with a 62% response rate. The surveys were mailed between May and July 1999.Results: Of family physicians included in the analysis, 13.5% reported having an in-office mental health professional. Of those who did not, 60.2% responded that they would consider having one. Compared with physicians who would not consider having an in-office mental health professional, physicians with a mental health professional and those without an in-office mental health professional but who would consider one were statistically more likely (p < .01) to respond that an in-office mental health professional would result in increased use of mental health services, improved acceptance of referrals to mental health professionals, and improved detection and treatment of mental health problems.Conclusion: Although few family physicians have an in-office mental health professional, many more would consider this arrangement and recognize the potential benefits of such collaboration.

The economic burden of hospitalizations associated with child abuse and neglect.

OBJECTIVES: This study assessed the economic burden of child abuse-related hospitalizations. METHODS: We compared inpatient stays coded with a diagnosis of child abuse or neglect with stays of other hospitalized children using the 1999 National Inpatient Sample of the Healthcare Costs and Utilization Project. RESULTS: Children whose hospital stays were coded with a diagnosis of abuse or neglect were significantly more likely to have died during hospitalization (4.0% vs 0.5%), have longer stays (8.2 vs 4.0 days), twice the number of diagnoses (6.3 vs 2.8), and double the total charges (19,266 vs 9513 US dollars) than were other hospitalized children. Furthermore, the primary payer was typically Medicaid (66.5% vs 37.0%). CONCLUSION: Earlier identification of children at risk for child abuse and neglect might reduce the individual, medical, and societal costs.

More harm than good? Diagnostic codes for child and adult abuse.

This study sought to understand the reasons for the lack of use of ICD diagnostic codes for child and adult abuse. New Jersey professionals were recruited to participate in three focus groups on child abuse, adult or primarily woman abuse, and elder abuse. Participants included health care providers, advocates from the community, and representatives of state agencies and the insurance industry. Concerns about coding abuse included further jeopardizing victims/patients, diagnostic uncertainty, and lack of resources. Members of the child abuse group were somewhat more receptive to coding abuse. Reasons to code, such as for documentation and reimbursement were discussed and rebutted. Most participants concluded that use of the abuse codes should be judicious because they have the potential to do more harm than good. More research is needed on the implications of coding for victims/patients along with medical education in the identification of abuse in general and coding abuse in particular.

Prophylaxis provided to sexual assault victims seen at US emergency departments.

OBJECTIVE: to report on prophylaxis provided to victims of sexual assault seen at hospital emergency departments in the United States. METHODS: Secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1994 to 1999. NHAMCS is a national probability sample of patient visits to US hospital emergency departments. Cases of sexual assault were identified using reason for visit, diagnostic, and injury codes. The medications provided for each case were examined. RESULTS: We identified 160 cases of sexual assault from 137 822 emergency department visits. None of these victims received the full regimen of antibiotics for sexually transmitted infections (STIs) recommended by the Centers for Disease Control and Prevention. Antibiotics for gonorrhea and chlamydia, 2 of the more frequently diagnosed STIs, were provided for only 24.8% of adults and adolescents. No antibiotics were ordered in 62.5% of all cases or in 51.3% of cases of patients 12 years and older. Twenty-one percent of those eligible received emergency contraception. Human immunodeficiency virus prophylaxis was amongthe medications ordered in one 1999 case. Roughly estimated, more than 60000 victims of sexual assault who visit US emergency departments annually may not be offered antibiotic treatment for the prevention of STIs. CONCLUSION: Even when data limitations are taken into account, our results suggest that emergency department staff may not be routinely providing antibiotic therapy for the prevention of STIs or emergency contraception to victims of sexual assault. A comprehensive national standard of care is needed for the medical treatment of victims of sexual assault along with more training for health care providers.