June 1, 2009 — Domestic abuse is a serious health issue for many women, but there are barriers in many healthcare settings to detecting and discussing intimate-partner violence. Women may be hesitant to admit they are involved in a relationship where violence has occurred, and in acute healthcare settings, physicians are often pressed for time and uncomfortable with initiating discussions about domestic abuse. However, these barriers may be addressed and overcome by computer-based screening — an innovation that may eventually find its way to healthcare clinics and hospitals in the United States.
In a new study published online June 1 in the Annals of Internal Medicine, Canadian researchers found that interactive computer-based screening for domestic violence increased the detection rate for this health risk and enhanced doctor-patient communication about intimate-partner violence or control.
In the randomized trial of 293 women in partner relationships, researchers tested computer-based screening against usual care in a busy urban, academic, hospital-affiliated family-practice clinic in Toronto, Ontario. They found that intimate-partner violence or control was more often detected by computer-based assessment (18% vs 9%; adjusted relative risk [RR], 2.0; 95% CI, 0.9 – 4.1) than in the usual-care group.
Physicians provided with a printout detailing the women's health risks also discussed intimate-partner violence more often in the computer-screened group than the usual-care group (35% vs 25%; adjusted RR, 1.4; 95% CI, 1.1 – 1.9). The overall rate of domestic violence or control for both groups was 22%, with no statistical difference between the computer-based-screening and usual-care groups (20% vs 23%). The prevalence of physical or sexual violence was 11% in both groups.
"While we know that patients are often very reluctant to spontaneously disclose domestic violence, it's very important for healthcare providers to ask about these health risk factors," said study investigator Farah Ahmad, PhD, from the Dalla Lana School of Public Health at the University of Toronto.
"At the same time, we know that in healthcare settings today, acute care is a priority, and many physicians are not comfortable with talking about psychosocial issues. So computerized-based screening is a very innovative way to address barriers to the detection and discussion of intimate-partner violence," she told Medscape Psychiatry.
Well-Received by Physicians and Patients
Each patient in the computer-based screening group completed a touch-screen test with questions about domestic violence as well as a range of other psychosocial and health issues, such as depression; alcohol, tobacco, and street-drug use; and risk for sexually transmitted infection. Eleven participating physicians then received a 1-page health-risk report attached to the patient's medical record during her clinic visit.
Any "yes" answer to questions about intimate-partner violence was included in the physician reports, and these were also labeled "Possible partner abuse — assess for victimization."
After completing the test, all women received a computer-generated recommendation sheet about their reported health risks, including domestic violence, with the contact numbers of appropriate community agencies. The computer-generated reports given to physicians also included relevant community referral.
Dr. Farah noted that the computer-generated reports were tailored to report each woman's health risks, particularly domestic abuse, and helped each doctor probe for more details about intimate-partner violence.
"They knew that the patient was ready to disclose, and it was an easy issue to address because it was printed right in front of them. They also didn't have to take time to look for referrals but just had to deal with management of their patients' health risks," she said.
In general, patients also thought the computer-based screening had benefits — many liked the anonymity of completing a test via computer touch screen. "Some patients had some concerns about privacy — about having information about themselves on a computer — and others worried that using a computer-based test might cause loss of personal time with their doctors," Dr. Ahmad said.
A Lot of Potential
"Computer-based screening has a lot of potential; it makes it easier for practitioners because domestic violence is a very uncomfortable subject," said Harise Stein, MD, from Stanford University Medical Center, in California, and cochair of the Family Abuse Prevention Council there.
"As well as enhancing patient-physician discussion, it's anonymous. Computer-based tools could also be used for people who speak a different language or have disabilities — so it has tremendous potential," Dr. Stein told Medscape Psychiatry.
At the same time, she cautioned that patients should be informed of the limits of confidentiality surrounding issues of domestic violence. Some states in the United States, for instance, have mandatory reporting requirements for physicians who learn of domestic violence, and patients would need to be informed of this fact, she said.
"The computer-based survey in this study is really not that different from paper-based questionnaires, except that the providers got the information in a more synthesized way. Some patients may also view it as more anonymous," added Brigid McCaw, MD, medical director of the family violence-prevention services for Kaiser Permanente in northern California.
Yet Dr. McCaw noted that as the United States moves toward electronic medical records, computer-based screenings for domestic violence are likely to become part of routine patient assessments. While Kaiser Permanente still uses paper-based screenings for domestic violence, the health plan will soon include domestic-violence questions on a volunteer online health assessment available to its members, Dr. McCaw said.
"In the future, domestic-violence information is likely to be linked to the patient's electronic medical record. In this way, you have the opportunity for the patient to receive continuity of care when they see different clinicians," she said.
Source : http://www.medscape.com/viewarticle/703650?sssdmh=dm1.480032&src=nldne
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