Are we ready for universal medical office screening for domestic violence The application of epidemi

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Are we ready for universal medical office
screening for domestic violence? The
application of epidemiological screening
principles to DV screening

• Desmond Runyan, MD, DrPHThe University of North
  Carolina

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Many Medical Organizations Recommend DV Screening

• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Emergency Physicians
• American College of Obstetrics and Gynecology
• American Medical Association
• American Dental Association
• American College of Nurse Midwives
• Emergency Nurses Association
• JACHO
• But not ACPM!

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Standards for Screening from Putting Prevention
Into Practice and USPSTF

• The condition must effect quality or quantity of
  life
• Acceptable methods of treatment must be available
• The condition must have an asymptomatic period in
  which detection Rx reduces mortality or
  morbidity
• Treatment in asymptomatic period yields a result
  superior to delaying treatment until symptoms
  appear
• Acceptable tests must be available, at reasonable
  cost, to detect the condition while asymptomatic
• The incidence of the condition must be sufficient
  to justify the costs of screening

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The condition must effect quality or quantity
of life

• Clear evidence that Domestic Violence is harmful
• gt1/3 of female homicide victims
• 6 of all Emergency visits
• Associated with depression, suicide, drug use,
  increased use of medical care, ...
• Doubles the risk of child maltreatment

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Acceptable methods of treatment must be
available

• Problematic (data from Thompson, et al. AJPM
  2000)
• lt20 of providers believe they have strategies
  that help
• lt30 of providers feel confident referring
  victims increased to 51 after training
• lt10 of providers report access to DV management
  information (after education 52)
• 65 of GHP charts had good management plan (no
  change with education intervention)

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Acceptable methods of treatment must be
available II

• MD Barriers to screening (Salber. AJMP 2000)
• I need to know how to do it
• I need to know what to do when a patient
  acknowledges abuse
• I need to know that my screening made a
  difference
• No studies of patient outcome after screening
• Womens beliefs re screening (Gielen, et al,
  AJPM 2000)
• 87 believe it would be easier to get help
• 43 believe it would put women at greater risk
• 95 would be glad someone took an interest

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The condition must have an asymptomatic period
in which detection treatment reduces mortality
or morbidity

• Difference between case finding and screening
• ER questioning with injury is case-finding
• No studies examine outcomes for women revealing
  abuse via screening vs. presentation with injury
• The reality is that, from a scientific point of
  view, we do not know what works to prevent DV or
  to keep women safe. (Gelles, AJPM, 2000)

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The condition must have an asymptomatic period
in which detection treatment reduces mortality
or morbidityII

• The medical workforce is unprepared to deal with
  domestic violence or child abuse
• Median medical school time on DV 2 hours
• Median medical school time on CAN 2 hours
• Median pediatric residency CAN caseload 15
• Little training on counseling and/or working with
  other agencies

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Treatment in asymptomatic period yields a
result superior to delaying treatment until
symptoms appear

• Can we prevent escalation by early
  identification?
• Unknown
• Does screening result in less subsequent harm?
• Unknown
• Duluth and Minneapolis Police Studies found fewer
  subsequent charges after incarceration
• Replications not so clearly successful
• Interventions are inadequate in 60-90 of cases
  (Thompson, et al. AJPM 2000)

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Acceptable tests must be available, at
reasonable cost, to detect the condition while
asymptomatic

• Providers dont rapidly accept screening
• Providers ask in 1-15 of primary care visits
• 22-39 of women report screening with prenatal
  care
• Only 13 of DV related visits to ED were asked
• 49 of women think women patients will be
  offended
• Education and structural practice efforts
  increased questioning to 20.5 in one HMO but
  many studies show little effect
• Screening is not expensive

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The incidence of the condition must be
sufficient to justify the costs of screening

• Evidence on incidence is clear
• 8-13 of women in the past year
• Prevalence in many countries similar
• In US 900,000 crimes a year by intimate partner

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Conclusions

• Established guidelines exist regarding screening
• Despite enthusiasm, routine DV screening is
  premature
• Research is needed to develop effective
  interventions
• Research is needed to show that intervention
  while asymptomatic is better than waiting
• Medical School residency teaching inadequate
• Medical education needs to prepare docs to
  respond
• Currently, no evidence that the average DV victim
  will benefit from screening by the average MD