Barbara Lent

Screening for Intimate Partner Violence in Health Care Settings: A Randomized Trial

CONTEXT Whether intimate partner violence (IPV) screening reduces violence or improves health outcomes for women is unknown. OBJECTIVE To determine the effectiveness of IPV screening and communication of positive results to clinicians. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted in 11 emergency departments, 12 family practices, and 3 obstetrics/gynecology clinics in Ontario, Canada, among 6743 English-speaking female patients aged 18 to 64 years who presented between July 2005 and December 2006, could be seen individually, and were well enough to participate. INTERVENTION Women in the screened group (n=3271) self-completed the Woman Abuse Screening Tool (WAST); if a woman screened positive, this information was given to her clinician before the health care visit. Subsequent discussions and/or referrals were at the discretion of the treating clinician. The nonscreened group (n=3472) self-completed the WAST and other measures after their visit. MAIN OUTCOME MEASURES Women disclosing past-year IPV were interviewed at baseline and every 6 months until 18 months regarding IPV reexposure and quality of life (primary outcomes), as well as several health outcomes and potential harms of screening. RESULTS Participant loss to follow-up was high: 43% (148/347) of screened women and 41% (148/360) of nonscreened women. At 18 months (n = 411), observed recurrence of IPV among screened vs nonscreened women was 46% vs 53% (modeled odds ratio, 0.82; 95% confidence interval, 0.32-2.12). Screened vs nonscreened women exhibited about a 0.2-SD greater improvement in quality-of-life scores (modeled score difference at 18 months, 3.74; 95% confidence interval, 0.47-7.00). When multiple imputation was used to account for sample loss, differences between groups were reduced and quality-of-life differences were no longer significant. Screened women reported no harms of screening. CONCLUSIONS Although sample attrition urges cautious interpretation, the results of this trial do not provide sufficient evidence to support IPV screening in health care settings. Evaluation of services for women after identification of IPV remains a priority. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182468.

What implementation interventions increase cancer screening rates? a systematic review

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests.MethodsOur first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo.ResultsThe update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions.ConclusionThe new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.

Abuse‐Related Injury and Symptoms of Posttraumatic Stress Disorder as Mechanisms of Chronic Pain in Survivors of Intimate Partner Violence

OBJECTIVE To examine the role of abuse-related injury and posttraumatic stress disorder (PTSD) symptom severity in mediating the effects of assaultive intimate partner violence (IPV) severity, psychological IPV severity, and child abuse severity on chronic pain severity in women survivors of IPV. METHODS Using data collected from a community sample of 309 women survivors of IPV, structural equation modeling was used to test a theoretical model of the relationships among the key variables. RESULTS The theoretical model accounted for almost 38% of the variance in chronic pain severity. PTSD symptom severity was a significant mediator of the relationships of both child abuse severity (beta = 0.13) and assaultive IPV severity (beta = 0.06) with chronic pain severity. Lifetime abuse-related injury was also a significant mediator of the relationships between both child abuse severity (beta = 0.05) and assaultive IPV severity (beta = 0.06) and chronic pain severity. Child abuse severity made the largest significant contribution to the model (beta = 0.35). Assaultive IPV severity had a significant indirect effect (beta = 0.12) on chronic pain severity while psychological IPV severity had a significant direct effect (beta = 0.20). CONCLUSIONS Management of chronic pain in IPV survivors requires attention to symptoms of PTSD, abuse-related injury, and lifetime experiences of violence. Ensuring that acute pain from injury is adequately treated and followed over time may reduce the extent of chronic pain in abused women. The results also support the importance of routine assessment for IPV and child abuse.

Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. Several high-quality systematic reviews and practice guidelines exist to inform the most effective screening options. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. We developed an implementation guideline to answer the question: What interventions have been shown to increase the uptake of cancer screening by individuals, specifically for breast, cervical, and colorectal cancers?MethodsA guideline panel was established as part of Cancer Care Ontarios Program in Evidence-based Care, and a systematic review of the published literature was conducted. It yielded three foundational systematic reviews and an existing guidance document. We conducted updates of these reviews and searched the literature published between 2004 and 2010. A draft guideline was written that went through two rounds of review. Revisions were made resulting in a final set of guideline recommendations.ResultsSixty-six new studies reflecting 74 comparisons met eligibility criteria. They were generally of poor to moderate quality. Using these and the foundational documents, the panel developed a draft guideline. The draft report was well received in the two rounds of review with mean quality scores above four (on a five-point scale) for each of the items. For most of the interventions considered, there was insufficient evidence to support or refute their effectiveness. However, client reminders, reduction of structural barriers, and provision of provider assessment and feedback were recommended interventions to increase screening for at least two of three cancer sites studied. The final guidelines also provide advice on how the recommendations can be used and future areas for research.ConclusionUsing established guideline development methodologies and the AGREE II as our methodological frameworks, we developed an implementation guideline to advise on interventions to increase the rate of breast, cervical and colorectal cancer screening. While advancements have been made in these areas of implementation science, more investigations are warranted.

Pathways of Chronic Pain in Survivors of Intimate Partner Violence

OBJECTIVE To examine the roles of lifetime abuse-related injury, posttraumatic stress disorder (PTSD) symptom severity, and depressive symptom severity in mediating the effects of severity of assaultive intimate partner violence (IPV), psychological IPV, and child abuse on chronic pain severity in women survivors of IPV. METHODS Structural equation modeling of data from a community sample of 309 women survivors of IPV was used to test partial and full theoretical models of the relationships among the variables of interest. RESULTS The full model had good fit and accounted for 40.2% of the variance in chronic pain severity. Abuse-related injury, PTSD symptom severity, and depressive symptom severity significantly mediated the relationship between child abuse severity and chronic pain severity, but only abuse-related injury significantly mediated the relationship between assaultive IPV severity and chronic pain severity. Psychological IPV severity was the only abuse variable with significant direct effects on chronic pain severity but had no significant indirect effects. CONCLUSIONS These findings can inform clinical care of women with chronic pain in all areas of healthcare delivery by reinforcing the importance of assessing for a history of child abuse and IPV. Moreover, they highlight the relevance of routinely assessing for abuse-related injury and PTSD and depressive symptom severity when working with women who report chronic pain.

Surgical culture in transition: gender matters and generation counts

BACKGROUND We sought to study the impact of the change in gender balance and the shift in generational beliefs on the practice of surgery. METHODS We used in-depth, individual, semistructured interviews to explore the ideas, perceptions and experiences of recently recruited academic surgeons regarding the role of gender and the influence of the changing attitudes of this generation on the work environment. All the interviews were audiotaped and transcribed verbatim. The data analysis was both iterative and interpretative. RESULTS Nine women and 8 men participated in the study. All participants stated that departmental expectations regarding their performance as clinicians and as academics were not influenced by gender. However, further exploration revealed how gender did influence the way they sought to balance their personal and professional lives. Women in particular struggled with attaining this balance. While maternity leave was endorsed by both men and women, the challenging logistics associated with such leave were noted. Our data also revealed a generational shift among men and women in terms of the importance of the balance between their personal and professional lives. Participants saw this priority as radically different from that of their senior colleagues. CONCLUSION Gender and the shift in generational attitudes are changing the culture of academic surgery, often described as the prototypical male-dominated medical environment. These changes may reflect the changing face of medicine.

Seeking balance: the complexity of choice-making among academic surgeons.

Purpose This study describes the experiences of academic surgeons in seeking a balance between their personal and professional lives. Method This phenomenological study, conducted in 2009–2010 at the University of Western Ontario, used in-depth individual semistructured interviews to explore the ideas, perceptions, and experiences of 17 recently recruited academic surgeons (nine women/eight men) about seeking balance between their personal and professional lives. All the interviews were audiotaped and transcribed verbatim. The data analysis was both iterative and interpretative. Results All the participants expressed a passion and commitment to academic surgery, but their stories revealed the complexity of making choices in seeking a balance between their personal and professional lives. This process of making choices was filtered through influential values in their lives, which in turn determined how they set boundaries to protect their personal and family time from the demands of their professional obligations. Intertwined in this process were the trade-offs they had to make in order to seek balance. Some choices, boundary-setting strategies, and trade-offs were dictated by gender. Finally, the process of making choices was not static; instead, the data revealed how it was both dynamic and cyclical, requiring reexamination over the life cycle, as well as their career trajectory. Thus, seeking a balance was an ever-changing process. Conclusions Understanding how members of an academic department of surgery navigate the balance between their personal and professional worlds may provide new insights for other disciplines seeking to enhance the development of the next generation of academics.

Better doctor efficiency is the real key to better productivity

The article ‘The feminisation of Canadian medicine and its impact upon doctor productivity’ focuses attention again on the ‘issue’ of women in medicine. Particular attention should be paid to the title’s last word: ‘productivity’. The authors measure productivity by calculating the number of hours doctors spend providing direct patient care. Using this definition, several assumptions are made which result in the ultimate conclusion that doctor productivity in Canada is suboptimal because of the increasing number of female doctors. However, is productivity, as defined in this article, really the best way to measure the provision of medical care in Canada? We believe the answer is no: by assuming the one-dimensional view that number of hours worked equals productivity, the authors fail to consider the significance of quality, efficiency and effectiveness in health care delivery. The cause of Canada’s doctor shortage will not be found in its gender demographic, nor will the solution be achieved by simply increasing medical school enrolment to accommodate the difference in hours spent on patient care by men and women doctors. Rather, we need to reorganise the way in which we deliver health care on a systemic level to improve overall doctor efficiency. Interprofessional collaboration is key to providing optimal medical care, for both doctors and patients. For example, integrated family medicine practices that feature a group of doctors working together with nurse practitioners, nurses, pharmacists, social workers and other allied health professionals provide faster and more efficient and continuous care. If we are to improve patient accessibility to doctors in Canada, we need to transform the ways in which we spend our working hours, not simply the number of hours we spend working.