Primary Care Providers with More Experience and Stronger Self-Efficacy Beliefs Regarding Women Veterans Screen More Frequently for Interpersonal Violence

Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status

Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.

Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans

IMPORTANCE

Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described.

OBJECTIVE

To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA).

DESIGN, SETTING, AND PARTICIPANTS

This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019.

EXPOSURES

Risk of hospitalization and assignment to general vs specialized primary care.

MAIN OUTCOME AND MEASURES

High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care).

RESULTS

The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall.

CONCLUSIONS AND RELEVANCE

The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.

Implementation of an intimate partner violence screening program in a university health care clinic

Objectives: To examine whether an intimate partner violence (IPV) screening program is related to a positive change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening. Participants: Eleven health care providers at a university health care clinic participated in the IPV screening program. Methods: A one-group pretest-posttest design was used to examine whether an IPV screening program was related to a change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening. Results: Findings indicated that there was a significant difference (p < 000) between the posttest scores and the pretest scores on the Domestic Violence Healthcare Provider Survey Scale. Domain analysis of the scale revealed a significant difference in perceived self-efficacy (p = .001), system support (p = <.002), victim provider safety (p = .015), and beliefs of blaming victims (p = <.004). No statistical difference was found in professional role resistance/fear of offending (p = .158). Conclusions: A university health care clinic IPV screening program was related to a positive change in health care providers' knowledge, attitudes, and self-efficacy of IPV screening.

Understanding Gender Sensitivity of the Health Care Workforce at the Veterans Health Administration

BACKGROUND

Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff.

METHODS

We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff.

RESULTS

PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff.

CONCLUSIONS

Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

When user-centered design meets implementation science: integrating provider perspectives in the development of an intimate partner violence intervention for women treated in the United States' largest integrated healthcare system

BACKGROUND

Intimate partner violence (IPV) against women is a global health problem that is a substantial source of human suffering. Within the United States (US), women veterans are at high risk for experiencing IPV. There is an urgent need for feasible, acceptable, and patient-centered IPV counseling interventions for the growing number of women treated in the US's largest integrated healthcare system, the Veterans Health Administration (VHA). Implementation science and user-centered-design (UCD) can play an important role in accelerating the research-to-practice pipeline. Recovering from IPV through Strengths and Empowerment (RISE) is a flexible, patient-centered, modular-based program that holds promise as a brief counseling intervention for women veterans treated in VHA. We utilized a UCD approach to develop and refine RISE (prior to formal effectiveness evaluations) by soliciting early feedback from the providers where the intervention will ultimately be implemented. The current study reports on the feedback from VHA providers that was used to tailor and refine RISE.

METHOD

We conducted and analyzed semi-structured, key-informant interviews with VHA providers working in clinics relevant to the delivery of IPV interventions (n = 23) at two large medical centers in the US. Participants' mean age was 42.6 years (SD = 11.6), they were predominately female (91.3%) and from a variety of relevant disciplines (39.1% psychologists, 21.7% social workers, 17.4% physicians, 8.7% registered nurses, 4.3% psychiatrists, 4.3% licensed marriage and family therapists, 4.3% peer specialists). We conducted rapid content analysis using a hybrid inductive-deductive approach.

RESULTS

Providers perceived RISE as highly acceptable and feasible, noting strengths including RISE's structure, patient-centered agenda, and facilitation of provider comfort in addressing IPV. Researchers identified themes related to content and context modifications, including requests for additional safety check-ins, structure for goal-setting, and suggestions for how to develop and implement RISE-specific trainings.

CONCLUSIONS

These findings have guided refinements to RISE prior to formal effectiveness testing in VHA. We discuss implications for the use of UCD in intervention development and refinement for interventions addressing IPV and other trauma in health care settings globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03261700; Date of registration: 8/25/2017, date of enrollment of first participant in trial: 10/22/2018. Unique Protocol ID: IIR 16-062.

Adoption, penetration, and effectiveness of a secondary risk screener for intimate partner violence: Evidence to inform screening practices in integrated care settings

OBJECTIVE

Veterans Health Administration (VHA) has implemented screening for past-year intimate partner violence (IPV) in some healthcare facilities along with secondary screening of risk for severe violence among those screening positive in order to facilitate follow-up care for high-risk patients. We evaluated the adoption, penetration, and effectiveness of secondary screening as a tool to facilitate timely follow-up services.

METHODS

Retrospective review of medical records (screening and healthcare use) of 774 women screening positive for past-year IPV (IPV+) at 11 facilities nationwide from April 2014-April 2016. Chi-square and t-tests examined factors related to secondary screening.

RESULTS

Three of eleven (27.3%) facilities that implemented primary IPV screening adopted secondary screening. At adopting sites, 56.4% eligible (i.e., IPV+) women received secondary screening. Among 185 IPV+ women who completed secondary screening, 33.0% screened positive for severe IPV. Screening positive during secondary screening was associated with higher rate of psychosocial care within 60 days (73.8% vs. 54.0% of IPV+ patients screening negative; p < .05), posttraumatic stress disorder diagnosis (31.1% vs. 15.3%; p < .05), and being physically threatened or harmed (>50% vs. <15%; p < .001).

CONCLUSIONS

Secondary risk assessment following IPV screening may expedite access to psychosocial follow-up care in integrated healthcare settings. However, program uptake needs to be enhanced.