Jean Ramsay

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

BACKGROUND Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services. METHODS In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786. FINDINGS We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded. INTERPRETATION A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services. FUNDING Health Foundation.

How effective are expert patient (lay led) education programmes for chronic disease

Considerable hyperbole has surrounded the UK expert patient programme, and it has received considerable funding—but will its impact meet expectations?

Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis.

Objective To examine the effectiveness of screening for intimate partner violence conducted within healthcare settings to determine whether or not screening increases identification and referral to support agencies, improves women’s wellbeing, decreases further violence, or causes harm. Design Systematic review and meta-analysis of trials assessing effectiveness of screening. Study assessment, data abstraction, and quality assessment were conducted independently by two of the authors. Standardised estimations of the risk ratios and 95% confidence intervals were calculated. Data sources Nine databases searched up to July 2012 (CENTRAL, Medline, Medline(R), Embase, DARE, CINAHL, PsycINFO, Sociological Abstracts, and ASSIA), and five trials registers searched up to 2010. Eligibility criteria for selecting studies Randomised or quasi-randomised trials of screening programmes for intimate partner violence involving all women aged ≥16 attending a healthcare setting. We included only studies in which clinicians in the intervention arm personally conducted the screening, or were informed of the screening result at the time of the consultation, compared with usual care (or no screening). Studies of screening programmes that were followed by structured interventions such as advocacy or therapeutic intervention were excluded. Results 11 eligible trials (n=13 027) were identified. In six pooled studies (n=3564), screening increased the identification of intimate partner violence (risk ratio 2.33, 95% confidence interval 1.39 to 3.89), particularly in antenatal settings (4.26, 1.76 to 10.31). Based on three studies (n=1400), we detected no evidence that screening increases referrals to domestic violence support services (2.67, 0.99 to 7.20). Only two studies measured women’s experience of violence after screening (three to 18 months after screening) and found no reduction in intimate partner violence. One study reported that screening does not cause harm. Conclusions Though screening is likely to increase identification of intimate partner violence in healthcare settings, rates of identification from screening interventions were low relative to best estimates of prevalence of such violence. It is uncertain whether screening increases effective referral to supportive agencies. Screening does not seem to cause harm in the short term, but harm was measured in only one study. As the primary studies did not detect improved outcomes for women screened for intimate partner violence, there is insufficient evidence for screening in healthcare settings. Studies comparing screening versus case finding, or screening in combination with therapeutic intervention for women’s long term wellbeing, are needed to inform the implementation of identification policies in healthcare settings.

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.

Primary care Identification and Referral to Improve Safety of women experiencing domestic violence (IRIS): protocol for a pragmatic cluster randomised controlled trial

BackgroundDomestic violence, which may be psychological, physical, sexual, financial or emotional, is a major public health problem due to the long-term health consequences for women who have experienced it and for their children who witness it. In populations of women attending general practice, the prevalence of physical or sexual abuse in the past year from a partner or ex-partner ranges from 6 to 23%, and lifetime prevalence from 21 to 55%. Domestic violence is particularly important in general practice because women have many contacts with primary care clinicians and because women experiencing abuse identify doctors and nurses as professionals from whom they would like to get support. Yet health professionals rarely ask about domestic violence and have little or no training in how to respond to disclosure of abuse.Methods/DesignThis protocol describes IRIS, a pragmatic cluster randomised controlled trial with the general practice as unit of randomisation. Our trial tests the effectiveness and cost-effectiveness of a training and support programme targeted at general practice teams. The primary outcome is referral of women to specialist domestic violence agencies. Forty-eight practices in two UK cities (Bristol and London) are randomly allocated, using minimisation, into intervention and control groups. The intervention, based on an adult learning model in an educational outreach framework, has been designed to address barriers to asking women about domestic violence and to encourage appropriate responses to disclosure and referral to specialist domestic violence agencies. Multidisciplinary training sessions are held with clinicians and administrative staff in each of the intervention practices, with periodic feedback of identification and referral data to practice teams. Intervention practices have a prompt to ask about abuse integrated in the electronic medical record system. Other components of the intervention include an IRIS champion in each practice and a direct referral pathway to a named domestic violence advocate.DiscussionThis is the first European randomised controlled trial of an intervention to improve the health care response to domestic violence. The findings will have the potential to inform training and service provision.Trial registrationISRCTN74012786

Screening women for intimate partner violence in health care settings

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society.Some governments and professional organisations recommendscreening all women for intimate partner violence rather thanaskingonly women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, andreferral to support agencies, or improve women’s subsequentwellbeing and not cause harm?

Components of the Anger-Hostility Complex and Symptom Reporting in Patients with Coronary Artery Disease: A Multi-Measure Study

Multiple anger and hostility variables were investigated for associations with coronary artery disease (CAD) symptoms and to examine if those relationships were different for disease severity.Atwo year follow-up study of97 men with stenosed coronary arteries was undertaken. Questionnaires measured: nine forms of anger and hostility; Type A behaviour; anxiety; depression; social support; and ninesymptom measures. CAD severity was derived from clinicians’ ratings of coronary angiograms. Results are four fold: anger-hostility variables are relatively unimportant predictors of symptoms compared with anxiety and depression; psychosocial measures (except for expressed anger) are uncorrelated with CAD severity, though correlate numerously with CAD symptoms; symptoms are not distinguishable empirically in terms of frequency, intensity and duration with regard to type (‘angina pain’, ‘tiredness’ and ‘breathlessness and restricted mobility’); finally, CADsymptoms are unrelated to CAD severity. In conclusion, components of the angerhostility complex are of limited use for predicting CAD symptoms. However, anger expression is of utility for differentiating between CAD symptoms and disease severity.

Effect of an Education Programme for SOuth Asians with Asthma and Their Clinicians: A Cluster Randomised Controlled Trial (OEDIPUS)

Background People with asthma from ethnic minority groups experience significant morbidity. Culturally-specific interventions to reduce asthma morbidity are rare. We tested the hypothesis that a culturally-specific education programme, adapted from promising theory-based interventions developed in the USA, would reduce unscheduled care for South Asians with asthma in the UK. Methods A cluster randomised controlled trial, set in two east London boroughs. 105 of 107 eligible general practices were randomised to usual care or the education programme. Participants were south Asians with asthma aged 3 years and older with recent unscheduled care. The programme had two components: the Physician Asthma Care Education (PACE) programme and the Chronic Disease Self Management Programme (CDSMP), targeted at clinicians and patients with asthma respectively. Both were culturally adapted for south Asians with asthma. Specialist nurses, and primary care teams from intervention practices were trained using the PACE programme. South Asian participants attended an outpatient appointment; those registered with intervention practices received self-management training from PACE-trained specialist nurses, a follow-up appointment with PACE-trained primary care practices, and an invitation to attend the CDSMP. Patients from control practices received usual care. Primary outcome was unscheduled care. Findings 375 south Asians with asthma from 84 general practices took part, 183 registered with intervention practices and 192 with control practices. Primary outcome data were available for 358/375 (95.5%) of participants. The intervention had no effect on time to first unscheduled attendance for asthma (Adjusted Hazard Ratio AHR = 1.19 95% CI 0.92 to 1.53). Time to first review in primary care was reduced (AHR = 2.22, (1.67 to 2.95). Asthma-related quality of life and self-efficacy were improved at 3 months (adjusted mean difference -2.56, (-3.89 to -1.24); 0.44, (0.05 to 0.82) respectively. Conclusions A multi-component education programme adapted for south Asians with asthma did not reduce unscheduled care but did improve follow-up in primary care, self-efficacy and quality of life. More effective interventions are needed for south Asians with asthma.

Authors’ reply to Whitehouse and Fabre

Unlike Whitehouse, we do not think that our findings will “discourage health professionals from identifying and signposting” as long as they receive regular and sustained training and resources on identification and appropriate responses.1 2 We are definitely not saying that clinicians should sit back and wait for disclosures of intimate partner violence. We agree with Fabre that case finding …