Gene Feder

Relation between childhood sexual and physical abuse and risk of revictimisation in women: a cross-sectional survey

BACKGROUND Women who are physically and sexually abused in childhood are at increased risk of victimisation in adulthood. Research has concentrated on sexual revictimisation, and has not included investigation of other abusive experiences, nor examination of prevalence and effects of abuse on adult revictimisation. We aimed to examine the relation between childhood trauma and adult revictimisation, and identify confounding factors. METHODS We did a cross-sectional survey of 2592 women who were attending primary care practices in east London, UK, with self-administered anonymous questionnaires. We included questions on physical and sexual abuse in childhood; on domestic violence, rape, indecent assault, and other traumatic experiences in adulthood; and on alcohol and other drug abuse. We analysed associations between childhood and adulthood abuse with multiple logistic regression. FINDINGS 1207 (55%) of 2192 eligible women were recruited and completed the questionnaire. Abusive experiences co-occurred in both childhood and adulthood. Repetition and severity of childhood abuse were independently associated with specific types of adult revictimisation. Unwanted sexual intercourse (<16 years) was associated with domestic violence in adulthood (odds ratio 3.54; 95% CI 1.52-8.25) and with rape (2.84; 1.09-7.35); and severe beatings by parents or carers with domestic violence (3.58; 2.06-6.20), rape (2.70; 1.27-5.74), and other trauma (3.85; 2.23-6.63). INTERPRETATION Childhood abuse substantially increases risk of revictimisation in adulthood. Women who have experienced multiple childhood abuse are at most risk of adult revictimisation. Identification of women who have undergone childhood abuse is a prerequisite for prevention of further abuse.

Internal and external validity of cluster randomised trials: systematic review of recent trials

Objectives To assess aspects of the internal validity of recently published cluster randomised trials and explore the reporting of information useful in assessing the external validity of these trials. Design Review of 34 cluster randomised trials in primary care published in 2004 and 2005 in seven journals (British Medical Journal, British Journal of General Practice, Family Practice, Preventive Medicine, Annals of Internal Medicine, Journal of General Internal Medicine, Pediatrics). Data sources National Library of Medicine (Medline) via PubMed. Data extraction To assess aspects of internal validity we extracted data on appropriateness of sample size calculations and analyses, methods of identifying and recruiting individual participants, and blinding. To explore reporting of information useful in assessing external validity we extracted data on cluster eligibility, cluster inclusion and retention, cluster generalisability, and the feasibility and acceptability of the intervention to health providers in clusters. Results 21 (62%) trials accounted for clustering in sample size calculations and 30 (88%) in the analysis; about a quarter were potentially biased because of procedures surrounding recruitment and identification of patients; individual participants were blind to allocation status in 19 (56%) and outcome assessors were blind in 15 (44%). In almost half the reports, information relating to generalisability of clusters was poorly reported, and in two fifths there was no information about the feasibility and acceptability of the intervention. Conclusions Cluster randomised trials are essential for evaluating certain types of interventions. Issues affecting their internal validity, such as appropriate sample size calculations and analysis, have been widely disseminated and are now better addressed by researchers. Blinding of those identifying and recruiting patients to allocation status is recommended but is not always carried out. There may be fewer barriers to internal validity in trials in which individual participants are not recruited. External validity seems poorly addressed in many trials, yet is arguably as important as internal validity in judging quality as a basis for healthcare intervention.

The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice

BackgroundIntimate partner violence (IPV) including physical, sexual and emotional violence, causes short and long term ill-health. Brief questions that reliably identify women experiencing IPV who present in clinical settings are a pre-requisite for an appropriate response from health services to this substantial public health problem. We estimated the sensitivity and specificity of four questions (HARK) developed from the Abuse Assessment screen, compared to a 30-item abuse questionnaire, the Composite Abuse Scale (CAS).MethodsWe administered the four HARK questions and the CAS to women approached by two researchers in general practice waiting rooms in Newham, east London. Inclusions: women aged more than 17 years waiting to see a doctor or nurse, who had been in an intimate relationship in the last year. Exclusions: women who were accompanied by children over four years of age or another adult, too unwell to complete the questionnaires, unable to understand English or unable to give informed consent.ResultsTwo hundred and thirty two women were recruited. The response rate was 54%. The prevalence of current intimate partner violence, within the last 12 months, using the CAS cut off score of ≥3, was 23% (95% C.I. 17% to 28%) with pre-test odds of 0.3 (95% C.I. 0.2 to 0.4). The receiver operator characteristic curve demonstrated that a HARK cut off score of ≥1 maximises the true positives whilst minimising the false positives. The sensitivity of the optimal HARK cut-off score of ≥1 was 81% (95% C.I. 69% to 90%), specificity 95% (95% C.I. 91% to 98%), positive predictive value 83% (95% C.I. 70% to 91%), negative predictive value 94% (95% C.I. 90% to 97%), likelihood ratio 16 (95% C.I. 8 to 31) and post-test odds 5.ConclusionThe four HARK questions accurately identify women experiencing IPV in the past year and may help women disclose abuse in general practice. The HARK questions could be incorporated into the electronic medical record in primary care to prompt clinicians to ask about recent partner violence and to encourage disclosure by patients. Future research should test the effectiveness of HARK in clinical consultations.

Educational outreach to promote screening for tuberculosis in primary care: a cluster randomised controlled trial

BACKGROUND Tuberculosis is re-emerging as an important health problem in industrialised countries. Uncertainty surrounds the effect of public-health control options. We therefore aimed to assess a programme to promote screening for tuberculosis in a UK primary health care district. METHODS In a cluster randomised controlled trial, we randomised 50 of 52 (96%) eligible general practices in Hackney, London, UK, to receive an outreach programme that promoted screening for tuberculosis in people registering in primary care, or to continue with usual care. Screening was verbal, and proceeded to tuberculin skin testing, if appropriate. The primary outcome was the proportion of new cases of active tuberculosis identified in primary care. Analyses were done on an intention-to-treat basis. This study was registered at clinicaltrials.gov, number NCT00214708. FINDINGS Between June 1, 2002, and Oct 1, 2004, 44,986 and 48,984 patients registered with intervention and control practices, respectively. In intervention practices 57% (13,478 of 23,573) of people attending a registration health check were screened for tuberculosis compared with 0.4% (84 of 23 051) in control practices. Intervention practices showed increases in the diagnosis of active tuberculosis cases in primary care compared with control practices (66/141 [47%] vs 54/157 [34%], odds ratio (OR) 1.68, 95% CI 1.05-2.68, p=0.03). Intervention practices also had increases in diagnosis of latent tuberculosis (11/59 [19%] vs 5/68 [9%], OR 3.00, 0.98-9.20, p=0.055) and BCG coverage (mean BCG rate 26.8/1000 vs 3.8/1000, intervention rate ratio 9.52, 4.0-22.7, p<0.001). INTERPRETATION Our educational intervention for promotion of screening for tuberculosis in primary care improved identification of active and latent tuberculosis, and increased BCG coverage. Yield from screening was low, but was augmented by improved case-finding. Screening programmes in primary care should be considered as part of tuberculosis control initiatives in industrialised countries.

Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity

Context Can patient-specific appropriateness criteria developed by experts validly determine which patients with suspected angina should undergo coronary angiography? Contribution In this study, expert panels scored hundreds of patient-specific scenarios for coronary angiography as inappropriate, uncertain, or appropriate. Using a computer algorithm, researchers matched the devised appropriateness indications to 9356 clinic patients with recent-onset chest pain. They found that many patients judged as appropriate candidates did not undergo angiography and that this group had more subsequent coronary events than did patients who appropriately did have angiography. Implication Patient-specific appropriateness criteria are a promising tool for improving care of patients with suspected angina. The Editors The decision to perform diagnostic and prognostic investigations in clinical medicine is uncommonly supported by evidence from randomized trials, yet it has major consequences in terms of cost and clinical outcomes when treatments are contingent on investigation results. Deciding which patients with suspected chronic stable angina pectoris should undergo coronary angiography is an important example of this general phenomenon. Although broad conventional clinical guideline recommendations (1, 2) and patient-specific appropriateness criteria (3) have been developed, 3 key questions about their clinical value remain unanswered. First, are the recommendations for investigation reliable, in the sense of being reproducible by independent groups? Good levels of agreement are essential for clinical credibility and accurate measurement of the frequency of underuse. Second, are the recommendations graded? Although the decision to perform angiography is binary (it either is or is not done), many decisions in clinical medicine are made in the gray zone, where understanding thresholds of benefit is crucial (4). For revascularization, prognostically important underuse was found not only among patients rated as appropriate candidates for revascularization but also among patients with scores denoting uncertainty about the appropriateness of this procedure (5). Third, and most important, are the recommendations valid in terms of prognosis? If so, then coronary event rates should be higher among patients not undergoing the recommended procedure (reflecting underuse). This might occur if medical or invasive management were optimized (6) in patients with the more definitive diagnosis that angiography offers. Although some studies have reported that angiography for suspected angina is underused (79), they have not reported whether such underuse has prognostic consequences. In the setting of acute myocardial infarction, patients not undergoing angiography that was considered necessary had worse outcomes (4, 10), but studies among ambulatory patients with chest pain at the point of diagnosis are lacking. We sought to address these 3 questions in the ARIA (Appropriateness of Referral and Investigation of Angina) study, in which 2 independent panels rated the appropriateness of patient-specific clinical indications by using the RAND appropriateness method. These appropriateness ratings were then matched to a large consecutive ambulatory cohort of patients with first-presentation chest pain who were followed for coronary events. Methods Design The study involved 3 stages: development of new appropriateness ratings (on which full details are published elsewhere [11]), matching these ratings to a patient cohort, and following the cohort for clinical outcomes (Figure 1). Figure 1. Study flow diagram. ACS= acute coronary syndrome; CHD= coronary heart disease. Panel Members We convened 2 independent panels with different moderators, who at each stage were unaware of the others ratings. Twenty-two physicians from 9 centers in England, Ireland, and Scotland took part in these panels, rating the appropriateness of angiography by using the RAND appropriateness method (12). Only 1 of the 9 centers was also involved in the 6 centers for patient recruitment. We sought nominations within centers to reflect a balance of experience (years since qualification); sex; and, among specialists, invasive and noninvasive practice. Sixteen of the clinicians had published research on the management of coronary disease. Each panel consisted of 5 cardiologists, 5 family physicians, and 1 cardiothoracic surgeon. Indications for Angiography Panelists judged appropriateness of angiography on a 9-point scale, on which scores of 1 to 3 denoted inappropriate use (no benefit of angiography, possible harms), 4 to 6 denoted uncertainty about use (when harms and benefits were judged as approximately equal, or when the best available evidence did not support a judgment either way), and 7 to 9 denoted appropriate use (benefits were judged to outweigh harms). Combinations of routinely assessed clinical factors were used to define specific clinical indications (scenarios) spanning the range of pretest probability of coronary disease from very low (<5%) to very high (>95%). Eight clinical descriptors were identified that influence the decision to perform angiography in people with suspected angina (but in the absence of previous definite coronary disease); Table 1 shows how these descriptors were combined into clinical indications. The descriptors are age (<40, 40 to 49, 50 to 59, 60 to 74, or 75 to 84 years), sex, typicality of symptoms, severity of symptoms (Canadian Cardiovascular Society class), medication for symptoms (submaximal or maximal), coronary risk factors (low, medium, or high), resting electrocardiography (ECG) findings (normal or abnormal), and exercise ECG findings (none, normal, abnormal, or very abnormal). Indications were grouped in 3 broad clinical presentations: typical angina symptoms (900 indications), atypical angina symptoms (900 indications), and nonspecific chest pain (600 indications). Table 1. Most Frequent Indications for Angiography and Guideline Recommendations, by Angiography Appropriateness Rating and Symptom Typicality Appropriateness Scores We developed software for the panel members to enter and review their own scores for each patient indication and access definitions of terms. Panelists were invited to base their ratings on peer-reviewed research evidence and were given a literature review with evidence tables, narrative synopses, and graded strength of evidence (11). We identified key articles on the role of angiography in the diagnosis of coronary artery disease from existing guidelines, systematic reviews, and MEDLINE, and then performed forward citation tracking in the Science Citation Index until March 2003. Panel members did the first round of rating independently. Panels then met over 2 days in July 2003, during which they followed an identical protocol. Each panelist was given a personalized report containing their own first-round ratings; the medians of their whole panel; and the range, with areas of disagreement highlighted. Panel members had the opportunity to change their ratings in light of the panel discussion, but in accordance with the RAND appropriateness method (12); no attempt was made to force the panel to consensus. Table 1 shows the most frequently occurring indications according to symptom typicality and gives the appropriateness category and the nearest match recommendation from conventional broad guidelines. Patients Using a computer algorithm, we matched the ARIA indications and their associated ratings to 9356 consecutive patients attending rapid-access chest pain clinics in 6 urban centers in the United Kingdom (Oldchurch, Newham, Kingston, Manchester, Blackburn, and Burnley) between 1996 and 2002. The sample size was determined by the availability of baseline data in these clinics that were systematically collected by using the same electronic record system. Physicians made decisions about investigation on these patients independent of the ARIA appropriateness ratings. These ambulatory care clinics are run by cardiology teams and accept same-day referrals from family physicians of patients with recent-onset chest pain in whom stable angina pectoris is suspected. Patients who had previously undergone angiography or received a diagnosis of coronary disease and those in whom acute or unstable coronary syndromes were suspected were not eligible for referral to these clinics. Using a common database, each center recorded patient age, sex, and ethnicity (South Asian, white, black, or other); whether chest pain was typical, atypical, or nonspecific; smoking, hypertension, hypercholesterolemia, and diabetes status; whether the resting ECG was abnormal; the exercise ECG result; and medical therapy at discharge. Angina symptom severity was not recorded; we assumed that angina was mild when matching patients to indications and performed sensitivity analyses on this assumption. Ethical approval was obtained from a multicenter research ethics committee. Follow-up and Clinical Outcomes More than 99% of patients were successfully matched at the Office for National Statistics and the National Health Service (NHS)wide clearing system. The Office for National Statistics informed us of the date and cause of death or date of hospital discharge. Causes of death and hospitalization were coded according to the International Classification of Diseases, 10th revision. Median follow-up for the cohort was 3 years, until the end of 2003. Use of coronary angiography was obtained from the NHS-wide clearing system. Our a priori primary end point, used in all reports from this data set (1315), was death from coronary heart disease (codes I20 to I25) and hospitalizations due to acute myocardial infarction (codes I21 to I23) and unstable angina (codes I20.0 to I20.9, I24.0, I24.8, and I24.9). The primary discharge diagnosis after hospital admission was used to define nonfatal events in these analyses. To define a group of patients without majo

Feasibility of spirometry and reversibility testing for the -identification of patients with chronic obstructive pulmonary disease on asthma registers in general practice

There is renewed interest in the diagnosis of chronic obstructive pulmonary disease (COPD) within primary care. Primary care physicians have difficulty distinguishing asthma from COPD. We tested the feasibility of using spirometry and if appropriate, reversibility testing, to identify patients with COPD on asthma registers in primary care. We carried out a cross-sectional study in three inner-city group practices in east London. Three hundred and twenty-eight patients aged 50 years and over on practice asthma registers were invited to attend for spirometry and, if appropriate, a trial of oral corticosteroids. The main outcome measures were: feasibility of carrying out spirometry; lung function; severity of COPD; prior diagnosis of COPD; response to a corticosteroid trial; quality of life. One hundred and sixty-eight of 328 (51%) patients attended for spirometry. According to British Thoracic Society criteria, 58 (34%) patients had normal spirometry at the time of assessment; 40 (24%) had active asthma and 57 (34%) had COPD. Thirteen patients (8%) were unable to perform spirometry. Of 57 patients with COPD 30 (53%) had mild, 15 (26%) had moderate and 12 (21%) had severe disease. Twenty-three of 57 (40%) patients with COPD on spirometry had this diagnosis recorded prior to the study. New diagnoses of COPD were more likely in those with mild or moderate disease (P<0.05). Twenty-three of 57 (40%) patients with COPD completed a corticosteroid trial: one showed significant reversibility of lung function. Spirometry was feasible and helped identify patients with COPD on asthma registers in these inner-city practices. Patients aged 50 years and over on asthma registers had a wide spectrum of lung function with considerable diagnostic misclassification. Some patients with normal lung function when tested may have had well controlled asthma. New diagnoses of COPD were mainly in those with mild or moderate disease.

Sample size calculations for intervention trials in primary care randomizing by primary care group : an empirical illustration from one proposed intervention trial

Because of the central role of the general practice in the delivery of British primary care, intervention trials in primary care often use the practice as the unit of randomization. The creation of primary care groups (PCGs) in April 1999 changed the organization of primary care and the commissioning of secondary care services. PCGs will directly affect the organization and delivery of primary, secondary and social care services. The PCG therefore becomes an appropriate target for organizational and educational interventions. Trials testing these interventions should involve randomization by PCG. This paper discusses the sample size required for a trial in primary care assessing the effect of a falls prevention programme among older people. In this trial PCGs will be randomized. The sample size calculations involve estimating intra-PCG correlation in primary outcome: fractured femur rate for those 65 years and over. No data on fractured femur rate were available at PCG level. PCGs are, however, similar in size and often coterminous with local authorities. Therefore, intra-PCG correlation in fractured femur rate was estimated from the intra-local authority correlation calculated from routine data. Three alternative trial designs are considered. In the first design, PCGs are selected for inclusion in the trial from the total population of England (eight regions). In the second design, PCGs are selected from two regions only. The third design is similar to the second except that PCGs are stratified by region and baseline value of fracture rate. Intracluster correlation is estimated for each of these designs using two methods: an approximation which assumes cluster sizes are equal and an alternative method which takes account of the fact that cluster sizes vary. Estimates of sample size required vary between 26 and 7 PCGs in each intervention group, depending on the trial design and the method used to calculate sample size. Not unexpectedly, stratification by baseline value of the outcome variable decreases the sample size required. In our analyses, geographic restriction of the population to be sampled reduces between-cluster variability in the primary outcome. This leads to an increase in precision. When allowance for variable cluster size is made, the increase in precision is not as great as would be expected with equal cluster sizes. This paper highlights the usefulness of routine data in work of this kind, and establishes one of the essential prerequisites for our proposed trial and other trials using primary outcomes with similar between-PCG variation: a feasible sample size.

Ethnic differences in long-term improvement of angina following revascularization or medical management: a comparison between south Asians and white Europeans

BACKGROUND It is not known whether there are disparities in morbidity outcomes between south Asians and whites with established coronary disease. METHODS Six-year prospective cohort study to determine whether improvement of angina symptoms differs between 196 south Asians and 1508 whites following revascularization or medical management. RESULTS 43.9% of south Asians reported improvement in angina at 6 years compared with 60.3% of whites (age-adjusted OR 0.56, 95% CI 0.41-0.76, adjusted for diabetes, hypertension, smoking, number of diseased vessels, left ventricular function and social class OR 0.59, 95% CI 0.41-0.85). Similar proportions of whites and south Asians underwent percutaneous coronary intervention (PCI) (19.6% versus 19.9%) and coronary artery bypass surgery (CABG) (32.8% versus 30.1%). South Asians were less likely to report improved angina after PCI (OR 0.19, 95% CI 0.06-0.56) or CABG (OR 0.36, 95% CI 0.17-0.74). There was less evidence of ethnic differences in angina improvement when treatment was medical (OR 0.87, 95% CI 0.48-1.57). CONCLUSION South Asians were less likely to experience long-term improvements in angina than whites after receipt of revascularization. Further research is needed to identify why these ethnic groups differ in symptomatic prognosis following revascularization for coronary disease and how these differences may be mitigated.

Waiting for coronary angiography: is there a clinically ordered queue?

Among over 3000 patients undergoing coronary angiography in the absence of a formal queue-management system, we found that a-priori urgency scores were strongly associated with waiting times, prevalence of coronary-artery disease, rate of revascularisation, and mortality. These data challenge the widely held assumption that such waiting lists are not clinically ordered; however, the wide variation in waiting times within urgency categories suggests the need for further improvements in clinical queueing.

Zero tolerance for domestic violence

1 Mathews KA, Gump BB. Chronic work stress: and marital dissolution increase risk of posttrial mortality in men from the Multiple Risk Factor Intervention Trial. Arch Intern Med 2002; 162: 309–15. 2 Moller J, Hallqvist J, Diderichsen F, Theorell T, Reuterwall C, Ahlbom A. Do episodes of anger trigger myocardial infarction? A case-crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosom Med 1999; 61: 842–49.