Therese M. Zink

Systematic Review of Health Information Exchange in Primary Care Practices

Background: Unprecedented federal interest and funding are focused on secure, standardized, electronic transfer of health information among health care organizations, termed health information exchange (HIE). The stated goals are improvements in health care quality, efficiency, and cost. Ambulatory primary care practices are essential to this process; however, the factors that motivate them to participate in HIE are not well studied, particularly among small practices. Methods: We conducted a systematic review of the literature about HIE participation from January 1990 through mid-September 2008 to identify peer-reviewed and non–peer-reviewed publications in bibliographic databases and websites. Reviewers abstracted each publication for predetermined key issues, including stakeholder participation in HIE, and the benefits, barriers, and overall value to primary care practices. We identified themes within each key issue, then grouped themes and identified supporting examples for analysis. Results: One hundred and sixteen peer-reviewed, non–peer-reviewed, and web publications were retrieved, and 61 met inclusion criteria. Of 39 peer-reviewed publications, one-half reported original research. Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented. Conclusions: The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation.

Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation

BACKGROUND We undertook a study to understand how women who are victims of intimate partner violence (IPV) want physicians to manage these abusive relationships in the primary care office. METHODS Thirty-two mothers in IPV shelters or support groups in southwestern Ohio were interviewed to explore their abuse experiences and health care encounters retrospectively. The interviews were taped and transcribed. Using thematic analysis techniques, transcripts were read for indications of the stages of change and for participants’ desires concerning appropriate physician management. RESULTS Participants believed that physicians should screen women for IPV both on a routine basis and when symptoms indicating possible abuse are present, even if the victim does not disclose the abuse. Screening is an important tool to capture those women early in the process of victimization. When a victim does not recognize her relationship as abusive, participants recommended that physicians raise the issue by asking, but they also warned that doing more may alienate the victim. Participants also encouraged physicians to explore clues that victims might give about the abuse. In later contemplation, victims are willing to disclose the abuse and are exploring options. Physicians were encouraged to affirm the abuse, know local resources for IPV victims, make appropriate referrals, educate victims about how the abuse affects their health, and document the abuse. Participants identified a variety of internal and external factors that had affected their processes. CONCLUSIONS In hindsight, IPV victims recommended desired actions from physicians that could help them during early stages of coming to terms with their abusive relationships. Stage-matched interventions may help physicians manage IPV more effectively and avoid overloading the victim with information for which she is not ready.

Cohort, Period, and Aging Effects A Qualitative Study of Older Women’s Reasons for Remaining in Abusive Relationships

To understand women’s reasons for continuing long-term abusive relationships, inter-views were conducted with 36 women who were over the age of 55. These women matured during times of sweeping social changes with the feminist, battered women’s, and elder abuse movements. Reasons for remaining were organized into three categories: cohort, period, and aging effects. Cohort effects included reasons similar to those of younger women such as lacking education or job skills. Period effects related to efforts to seek help early in the abusive relationship and receiving little assistance from society’s social institutions. Finally, aging effects dealt with how the health challenges of physical age limited options.

A Lifetime of Intimate Partner Violence Coping Strategies of Older Women

Little is known about how older women cope in long-term abusive intimate relationships. Understanding their coping strategies may give insight into how to further support their effective coping efforts. Interviews were conducted with 38 women older than age 55 years. Grounded theory analysis demonstrated that women who remained in their abusive relationships employed mainly cognitive (emotion-focused) strategies to find meaning in a situation that was perceived as unchangeable. By reappraising themselves, their spouses, and their relationships they refocused energies in certain roles, set limits with their abusers, and reached out to others (friends, family, and community organizations). Some women appeared to thrive, others merely survived, but all maintained the appearance of conjugal unity.

The prevalence and incidence of intimate partner violence in older women in primary care practices

AbstractOBJECTIVE: Identify the incidence and prevalence of intimate partner violence (IPV) in women over 55 years of age in primary care offices. DESIGN: Telephone survey conducted between March and June 2003 by trained female interviewers who gathered self-report information about health and abuse. PATIENTS: A total of 3,636 women over 55 years of age had at least 1 visit in the past 12 months to primary care offices affiliated with an academic center in Southwestern Ohio were contacted by phone; 995 were deemed competent and completed the interview. INTERVENTION/INSTRUMENT: Thirty-eight page instrument that explored health, history of psychological (controlling behavior and threat of physical harm), physical, and sexual abuse since age 55 years. Interviews lasted 20 to 45 min. MAIN RESULTS: The mean age was 69 years (SD 8.35). Physical abuse in intimate relationships was reported by 1.52% since age 55 years (prevalence) and 0.41% in the past year (incidence). Prevalence and incidence rates for sexual abuse were 2.14% and 1.12%, threat of physical harm 2.63% and 1.62%, respectively. Less than half of the victims told someone else about the abuse. The mean number of health conditions was 3.84 for victims and 3.21 for nonvictims (P<.055) with significantly larger percentages of IPV victims reporting problems with chronic pain and depression. CONCLUSIONS: Physical and sexual abuse by an intimate partner does occur in women over 55 years, but rates are lower than those of younger women. Health care providers are reminded to think about IPV in older women and to ask about abuse as disclosure is rare.

Recruitment and Retention of Rural Physicians: Outcomes From the Rural Physician Associate Program of Minnesota

CONTEXT Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. PURPOSE To examine RPAP outcomes in recruiting and retaining rural primary care physicians. METHODS The RPAP database, including moves and current practice settings, was examined using descriptive statistics. FINDINGS On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. CONCLUSION RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.

Older Women’s Descriptions and Understandings of Their Abusers

Thirty-eight women who were in abusive relationships since age 55 years were interviewed to understand their abuse stories, ways of coping, and health care experiences. In responding to these questions, women described the nature of the abuse perpetrated by their elderly partners and tried to “make sense” of what they had experienced and to define “who” these men were. This took various forms, from personal theories about aging, to labels (ethnic stereotyping, demonizing, pathologizing) to characterizations of the abuser’s private versus public behaviors. The authors explore the implications these findings have for assisting the elderly victim and perpetrator.

Efforts to graduate more primary care physicians and physicians who will practice in rural areas: Examining outcomes from the university of Minnesota-Duluth and the rural physician associate program

Purpose To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN–Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. Method In 2008, the authors analyzed outcomes for four student groups: (1) UMN–Duluth and (2) UMN–TC medical students who participated in RPAP and (3) UMN–Duluth and (4) UMN–TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. Results The UMN–Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN–TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. Conclusions RPAP and UMN–Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

The Development of a Sexual Abuse Severity Score: Characteristics of Childhood Sexual Abuse Associated With Trauma Symptomatology, Somatization, and Alcohol Abuse

Childhood sexual abuse (CSA) is common and is associated with both mental and physical health problems in adulthood. Using data from an age- and sex-stratified population survey of 600 Olmsted County, Minnesota, residents, a Sexual Abuse Severity Score was developed. The abuse characteristics of 156 CSA respondents were associated with self-reported trauma, somatization, and alcohol use. Characteristics included age of first sexual abuse, more than one perpetrator, degree of coercion, severity of abuse (i.e., attempted intercourse is more severe than fondling), and the number of occurrences. This is one of the few reports to develop a risk summary that quantifies the severity of CSA.

Abuses Against Older Women: Prevalence and Health Effects

A clinical sample of 995 community dwelling women aged 55 and older were surveyed by telephone about their experience with psychological/ emotional, control, threat, physical, and sexual abuse. Nearly half of the women experienced at least one type of abuse since turning 55. Sizable proportions were victims of repeated abuse, and many experienced co-occurring abuse. Women who experienced any type of abuse were more likely to self-report negative health effects than those who were not abused. Health care and social service providers should routinely screen older women for psychological/emotional abuse at it often co-occurs with more severe forms of abuse.