Louise-Anne McNutt

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

CONTEXTnWhether intimate partner violence (IPV) screening reduces violence or improves health outcomes for women is unknown.nnnOBJECTIVEnTo determine the effectiveness of IPV screening and communication of positive results to clinicians.nnnDESIGN, SETTING, AND PARTICIPANTSnRandomized 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.nnnINTERVENTIONnWomen 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.nnnMAIN OUTCOME MEASURESnWomen 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.nnnRESULTSnParticipant 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.nnnCONCLUSIONSnAlthough 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.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00182468.

Cumulative Abuse Experiences, Physical Health and Health Behaviors

PURPOSEnOur purpose was to investigate the complex relationship between a range of lifetime abuse experiences with current physical health and health behaviors.nnnMETHODSnBetween October 1998 and May 1999, interviews were conducted with 557 ethnically diverse women seen at two urban primary care centers. Seven forms of abuse were measured: childhood physical and sexual abuse, past physical and sexual intimate partner violence (IPV), and recent emotional, physical, and sexual IPV. Severity was measured for six of these forms. Multiple non-specific physical symptoms were measured with a modified PRIME-MD, and four health behaviors were ascertained.nnnRESULTSnApproximately 10% of women never experiencing abuse reported multiple non-specific physical symptoms, compared with 25.8% to 78.4% of women reporting a range of abuse experiences. Increases in recent IPV, past IPV, child abuse, and economic hardship were associated with increases in reported symptoms. Women who experienced IPV were more likely to report smoking cigarettes, binge drinking, and having poor nutritional habits.nnnCONCLUSIONSnRecent IPV is associated with physical symptoms and risky health behaviors beyond the effects of child abuse, past IPV, and economic disadvantage. Understanding a persons IPV experiences may inform interventions for health behaviors, such as smoking cessation programs.

Racial Disparity in Hypertensive Disorders of Pregnancy in New York State: A 10-Year Longitudinal Population-Based Study

OBJECTIVESnWe studied trends of hypertensive disorders of pregnancy by residential socioeconomic status (SES) and racial/ethnic subgroups in New York State over a 10-year period.nnnMETHODSnWe merged New York State discharge data for 2.5 million women hospitalized with delivery from 1993 through 2002 with 2000 US Census data.nnnRESULTSnRates of diagnoses for all hypertensive disorders combined and for preeclampsia individually were highest among Black women across all regions and neighborhood poverty levels. Although hospitalization rates for preeclampsia decreased over time for most groups, differences in rates between White and Black women increased over the 10-year period. The proportion of women living in poor areas remained relatively constant over the same period. Black and Hispanic women were more likely than White women to have a form of diabetes and were at higher risk of preeclampsia; preeclampsia rates were higher in these groups both with and without diabetes than in corresponding groups of White women.nnnCONCLUSIONSnAn increasing trend of racial/ethnic disparity in maternal hypertension rates occurred in New York State during the past decade. This trend was persistent after stratification according to SES and other risk factors. Additional research is needed to understand the factors contributing to this growing disparity.

Antihypertensive Medication Use During Pregnancy and the Risk of Cardiovascular Malformations

We used data from the National Birth Defects Prevention Study, a population-based, case-control study, to examine whether previously reported associations between antihypertensive medications and cardiovascular malformations could be confirmed and to explore whether new associations might be identified. Cases (n=5021) were ascertained through birth defects surveillance systems from 1997 through 2003 in 10 US states. Controls (n=4796) were live births without birth defects selected randomly from birth certificates or hospital discharge listings in the same geographic regions. Logistic regression was used to examine the relationship between antihypertensive medication treatment and the occurrence of cardiovascular malformations while controlling for confounding variables. First-trimester treatment with antihypertensive medication was associated with pulmonary valve stenosis (odds ratio [OR]: 2.6; 95% CI: 1.3 to 5.4), Ebstein malformation (crude OR: 11.4; exact 95% CI: 2.8 to 34.1), coarctation of the aorta (OR: 3.0; 95% CI: 1.3 to 6.6), and secundum atrial septal defects (OR: 2.4; 95% CI: 1.3 to 4.4). Treatment initiated after the first trimester was associated with pulmonary valve stenosis (OR: 2.4; 95% CI: 1.1 to 5.4), perimembranous ventricular septal defects (OR: 2.3; 95% CI: 1.2 to 4.6), and secundum atrial septal defects (OR: 2.4; 95% CI: 1.3 to 4.4). Untreated hypertension was associated with Ebstein malformation (OR: 2.1; 95% CI: 1.0 to 4.3) and secundum atrial septal defects (OR: 1.3; 95% CI: 1.0 to 1.6). Antihypertensive medication use and/or the underlying hypertension might increase the risk of having an infant with specific left and right obstructive and septal defects. Additional studies with adequate power will be needed to confirm these findings.

Human papillomavirus vaccine uptake and barriers: association with perceived risk, actual risk and race/ethnicity among female students at a New York State university, 2010.

Understanding human papillomavirus (HPV) vaccine uptake patterns is critical to improve vaccination levels. Approximately half (56%) of female undergraduate students surveyed at a large public university reported HPV vaccine series initiation, with 79% of initiators completing the three dose series. Predictors of series initiation included having a conversation with a health-care provider about the vaccine, reporting a history of sexual intercourse and receipt of the meningitis vaccine. Compared to whites, black/African-American women were 33% less likely to have initiated HPV vaccination. Common reasons for not receiving the HPV vaccine included concerns about vaccine safety and doctors not recommending vaccination.

Social Support Choices for Help with Abusive Relationships: Perceptions of African American Women

A recent national telephone study of the African American community found that over 90% of respondents would feel comfortable talking to a family member or friend who was being abused about the abuse, with the majority advising she get help from a domestic violence program. The purpose of this study was to understand how comfortable abused women would feel talking to members of her support system about the abuse and how comfortable women who have not experienced partner abuse would feel if they were abused. Over 70% of women who have experienced abuse reported at least some comfort getting assistance for abuse from a friend, clergy/spiritual leader, Black community member, family member their age, or physician. Women who reported never experiencing physical or sexual partner violence were less likely to perceive feeling comfortable getting assistance from their social support systems (both formal and informal) if they were abused. Implications of these findings are discussed.

Risk factors for coronary artery bypass graft chest surgical site infections in New York State, 2008

BACKGROUNDnAll hospitals in New York State (NYS) are required to report surgical site infections (SSIs) occurring after coronary artery bypass graft surgery. This report describes the risk adjustment method used by NYS for reporting hospital SSI rates, and additional methods used to explore remaining differences in infection rates.nnnMETHODSnAll patients undergoing coronary artery bypass graft surgery in NYS in 2008 were monitored for chest SSI following the National Healthcare Safety Network protocol. The NYS Cardiac Surgery Reporting System and a survey of hospital infection prevention practices provided additional risk information. Models were developed to standardize hospital-specific infection rates and to assess additional risk factors and practices.nnnRESULTSnThe National Healthcare Safety Network risk score based on duration of surgery, American Society of Anesthesiologists score, and wound class were not highly predictive of chest SSIs. The addition of diabetes, obesity, end-stage renal disease, sex, chronic obstructive pulmonary disease, and Medicaid payer to the model improved the discrimination between procedures that resulted in SSI and those that did not by 25%. Hospital-reported infection prevention practices were not significantly related to SSI rates.nnnCONCLUSIONSnAdditional risk factors collected using a secondary database improved the prediction of SSIs, however, there remained unexplained variation in rates between hospitals.

Identification of patients with Pseudomonas aeruginosa respiratory tract infections at greatest risk of infection with carbapenem-resistant isolates.

OBJECTIVEnTo create a clinical tool based on institution-specific risk factors to estimate the probability of carbapenem resistance among Pseudomonas aeruginosa isolates obtained from infected patients. By better estimating the probability of carbapenem resistance on the basis of patient-specific factors, clinicians can refine their empirical therapy for P. aeruginosa infections and potentially maximize clinical outcomes by increasing the likelihood of appropriate empirical antimicrobial therapy.nnnDESIGNnA retrospective, cross-sectional study.nnnSETTINGnTertiary care academic hospital.nnnPATIENTSnAll adult inpatients who had a respiratory tract infection due to P. aeruginosa between January 2001 and June 2005.nnnINTERVENTIONnData on demographic characteristics, antibiotic history, and microbiology were collected. Log-binomial regression was employed to identify predictors of carbapenem resistance among P. aeruginosa isolates and to devise the clinical prediction tool.nnnRESULTSnAmong 351 patients with P. aeruginosa infection, 44% were infected with carbapenem-resistant P. aeruginosa strains. Independent predictors of carbapenem resistance were prior receipt of mechanical ventilation for 11 days or more, prior exposure to fluoroquinolones for 3 days or more, and prior exposure to carbapenems for 3 days or more.nnnCONCLUSIONSnWith carbapenem resistance rates among P. aeruginosa isolates on the rise at our institution, the challenge was to identify patients for whom carbapenems would remain an effective empirical agent, as well as the patients at greatest risk for infection with carbapenem-resistant strains. The clinical prediction tool accurately estimated carbapenem resistance among this risk-stratified cross-sectional study of patients with P. aeruginosa infection. This tool may be an effective way for clinicians to refine their selection of empirical antibiotic therapy and to maximize clinical outcomes by increasing the likelihood of appropriate antibiotic treatment.

Maternal Hypertension, Medication Use, and Hypospadias in the National Birth Defects Prevention Study

OBJECTIVE: To investigate whether antihypertensive classes and specific medications in early pregnancy increase the risk of severe hypospadias and to assess prior associations detected for late-treated and untreated hypertension in the National Birth Defects Prevention Study. METHODS: Using telephone interviews from mothers of 2,131 children with severe hypospadias and 5,129 nonmalformed male control children for 1997–2009 births in a population-based case–control study, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) with multivariable logistic regression. We adjusted P values to account for multiple testing. RESULTS: Forty-eight (2.3%) case and 70 (1.4%) control mothers reported early pregnancy antihypertensive treatment, 45 (2.1%) case and 31 (0.6%) control mothers reported late treatment, and 315 (14.8%) case and 394 (7.7%) control mothers reported untreated hypertension. Selective &bgr;-blockers, centrally acting agents, renin–angiotensin system-acting agents, diuretics, and specific medications, methyldopa and atenolol, were not associated with hypospadias. Nonselective &bgr;-blockers (adjusted OR 3.22, 95% CI 1.47–7.05) were associated with hypospadias; however, P values adjusted for multiple testing were not statistically significant. We confirmed prior findings for associations between hypospadias and untreated hypertension (adjusted OR 2.09, 95% CI 1.76–2.48) and late initiation of treatment (adjusted OR 3.98, 95% CI 2.41–6.55). The increased risks would translate to severe hypospadias prevalences of 11.5, 17.7, and 21.9 per 10,000 births for women with untreated hypertension, nonselective &bgr;-blocker use, and late initiation of treatment, respectively. CONCLUSION: Our study suggests a relationship between hypospadias and the severity of hypertension. LEVEL OF EVIDENCE: II

Logistic Regression Analysis: When the Odds Ratio Does Not Work An Example Using Intimate Partner Violence Data

The odds ratio is one of the most common measures used to assess the relationship between exposure to violence and adverse health outcomes, adjusting for possible confounding factors. A reason for the odds ratios popularity is that it is relatively easy to calculate from the coefficients of a logistic regression model. For most etiologic studies of disease, the odds ratio is a suitable estimate of risk because incidence or prevalence of disease is rare (<10%). However, health outcomes studied in violence research are often more prevalent (e.g., fatigue, insomnia, stomach pain, and shortness of breath). In these cases, the odds ratio usually overestimates the strength of association, sometimes erroneously tripling the magnitude. Data from a study measuring the health effects of intimate partner violence are used to illustrate the problem of incorrectly using odds ratios. Methods to calculate relative risks and prevalence ratios from logistic regression models are presented.