702 OCTOBER 2018 • VOL. 50, NO. 9 FAMILY MEDICINE BRIEF REPORTS I ntimate partner violence (IPV) is a silent epidemic affecting one in three women during their lifetime.1 IPV leads to injuries and death from physical and sexual as- sault, sexually transmitted infec- tions, pelvic inflammatory disease, unintended pregnancy, chronic pain, posttraumatic stress disorder, depression and anxiety, substance abuse, and suicide.2 The US Preven- tive Services Task Force (USPSTF) recommends that clinicians routinely screen women of childbearing age for IPV (“B” recommendation),3 but research shows that actual rates of screening in primary care settings are low.4 In addition, there is a wide range of screening strategies across different medical practices, with some clinics assigning nonphysi- cian personnel (ie, nurse/midwife, social worker, medical assistant) to do screening, while others rely on physicians.5 There is no consensus on the optimal screening protocol. A randomized trial of three screening protocols (self-administered survey, nonphysician personnel interview, and physician interview) showed similar rates of IPV disclosure in a controlled environment.6 However, in real-world settings where lack of office protocols and limited time are common barriers for physicians,7-10 results are inconsistent and contra- dictory on the optimal way of deliv- ering IPV screening.11-12 With violence against women in the national spotlight due to the #MeToo movement,13 we set out on a quality improvement initiative to identify opportunities to enhance IPV screening within our university- based network of primary care clin- ics. Our objectives were to determine (1) how often IPV screening was be- ing documented, and (2) whether screening initiated by nonphysician staff or physicians resulted in more documented screens. Methods Setting We examined IPV screening prac- tices in five primary care clinics within a university-based network in Northern California. Collectively, these clinics provide care for 40,000 people and have 52 providers, includ- ing family physicians and general BACKGROUND AND OBJECTIVES: Intimate partner violence (IPV) is a si- lent epidemic affecting one in three women. The US Preventive Services Task Force recommends routine IPV screening for women of childbearing age, but actual rates of screening in primary care settings are low. Our objectives were to determine how often IPV screening was being done in our system and whether screening initiated by medical assistants or physicians resulted in more screens. METHODS: We conducted a retrospective chart review to investigate IPV screening practices in five primary care clinics within a university-based net- work in Northern California. We reviewed 100 charts from each clinic for a total of 500 charts. Each chart was reviewed to determine if an IPV screen was documented, and if so, whether it was done by the medical assistant or the physician. RESULTS: The overall frequency of IPV screening was 22% (111/500). We found a wide variation in screening practices among the clinics. Screening initiated by medical assistants resulted in significantly more documented screens than screening delivered by physicians (74% vs 9%, P<0.001). CONCLUSIONS: IPV screening is an important, but underdelivered service. Using medical assistants to deliver IPV screening may be more effective than relying on physicians alone. (Fam Med. 2018;50(9):702-5.) doi: 10.22454/FamMed.2018.311843 Identifying Opportunities to Improve Intimate Partner Violence Screening in a Primary Care System Laurel Sharpless, BS; Cathina Nguyen, RN, MPH; Baldeep Singh, MD; Steven Lin, MD From the Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA. FAMILY MEDICINE VOL. 50, NO. 9 • OCTOBER 2018 703 BRIEF REPORTS internists. Among the participat- ing clinics, one had an established protocol of medical assistants doing screening, while the other four loca- tions had an established protocol of physicians doing screening. All five clinics subscribed to a policy of IPV screening consistent with the 2013 USPSTF guidelines. Standard proce- dures to support IPV screening and follow-up in the event of IPV dis- closure were identical across clin- ics. The clinics were within 20 miles of one another and served a simi- lar patient population (ie, insured, working, upper middle class, racial- ly diverse). Physician characteris- tics were similar across the clinics (ie, gender, average years of clinical experience). Design We conducted a retrospective chart review in the electronic health re- cord. Our inclusion criteria were: (1) female patient of childbearing age (defined as 18 to 49 years), (2) pre- ventive exam as the reason for visit, and (3) charts completed on or af- ter May 1, 2017. We reviewed 100 charts from each study clinic for a total of 500 charts. Charts were re- viewed in chronological order until the target was achieved. Each chart was reviewed to determine if an IPV screen was documented. If a screen was completed, the reviewer deter- mined whether it was done by the physician or the medical assistant, and what questions were asked. Data were also collected on the pa- tients’ age and the screeners’ gender. The chart review was conducted by a trained clinical scribe (L.S.) using a checklist/spreadsheet developed for the project under the supervision of a faculty mentor (S.L.). Data Analysis Descriptive statistics were used to examine the frequency distribu- tion of patients screened, patients’ age, and screeners’ gender. Pearson χ2 test and Fisher exact test were performed to discover associations between the number of patients screened by clinic site, screener type (physician or medical assistant), pa- tient age, and screener gender. A bi- nary logistic regression model was performed to predict patient screen- ing based on patient age as a con- tinuous variable. All analyses were done using SPSS (IBM SPSS Sta- tistics for Windows, Version 24.0, Armonk, NY: IBM Corp). The Insti- tutional Review Board of Stanford University School of Medicine grant- ed this study a formal exemption. Results Patient and screener characteristics are shown in Table 1; these were similar across the five study clinics. The overall frequency of IPV screen- ing across five primary care clinics within our academic medical cen- ter was 22% (111/500; Table 1). We identified a wide variation in the fre- quency of screening documentation between clinics, ranging from 0%- 74% (Table 2). Screening performed in the clinic where the screener was a medical assistant resulted in sig- nificantly more documented screens than in clinics where the physician was the screener (74/100 [74%] vs 37/400 [9%], P<0.001, Table 3). The most commonly used screening ques- tions were: (1) “Because difficult rela- tionships can cause health problems, we are asking all of our patients the following question: ‘Does a part- ner, or anyone at home, hurt, hit, or threaten you?’” and (2) “Is anyone at home hurting you, threatening you, or making you afraid?” Male screeners were associated with more documented screens than female screeners (16/46 [35%] vs 95/454 [21%], P=0.031), though there was a heavy skew in our female-to- male ratio (Table 4). Patient age was associated with documented screens (age 18-29 years: 24/136 [17%]; age 30-39 years: 36/194 [19%]; age 40-49 years: 51/170 [30%]; P=0.011, Table 5). Binary logistic regression showed that patient age was a significant predictor of being screened for IPV (χ2=8.311, df=1 and P=0.004). Discussion Our study identified opportunities to improve IPV screening in our prima- ry care system—lessons we believe might be helpful to other systems. First, we found a wide variation in the frequency of screening docu- mentation (0%-74%) among clinics within the same primary care net- work. This is despite the fact that standard policies and guidelines to support screening and follow-up in the event of disclosure were identical across clinics. This suggests that pol- icies alone are insufficient and that a universal workflow, training, and screening protocol might be needed to help eliminate disparities in care quality and adherence to evidence- based screening guidelines within a system. Second, we found that IPV screening performed in the clinic where the screener was a medical assistant resulted in significantly more documented screens than in the clinics where the screener was Table 1: IPV Screening Frequency and Characteristics of Patients/Screeners Characteristics n (%) (n=500) Patient Screened Yes 111 (22.2%) No 389 (77.8%) Patient Age 18-29 136 (27.2%) 30-39 194 (38.8%) 40-49 170 (34.0%) Screener Gender Female 454 (90.8%) Male 46 (9.2%) 704 OCTOBER 2018 • VOL. 50, NO. 9 FAMILY MEDICINE BRIEF REPORTS a physician. Though previous stud- ies have shown no difference in the rates of IPV screening and disclosure between physician and nonphysician methods in a controlled setting,6 in our real-world setting, a medical as- sistant protocol was more effective in completing screens. Nonphysician screening has been shown in a recent randomized con- trolled trial to be superior to a phy- sician-only approach for another USPSTF recommendation, namely alcohol abuse screening.14 In a study of 54 primary care clinics in an in- tegrated health care system (Kaiser Permanente Northern California), screening rates were highest in the nonphysician provider and medi- cal assistant arm (51%), followed by the primary care physician arm (9%), and the control arm (3.5%). Their study and ours together add to a growing body of literature suggest- ing that screening by medical assis- tants with intervention and referral by physicians as needed can be a fea- sible model for increasing evidence- based screenings. Our study is limited by its retro- spective, nonrandomized design fo- cused on a single institution. Our chart review methodology may not have captured the true frequency of screening across the system; our re- ported screening frequency of 22% is probably driven by the clinic with a medical assistant screening protocol. Although we found associations be- tween screener gender and patient age with IPV screening, the study was insufficiently powered to exam- ine the clinical significance of screen- er and patient factors. Lastly we only measured the frequency of screening documentation and not the rates of IPV disclosure. Conclusions IPV screening is an important, but underdelivered service. Using medical assistants to perform IPV screening may be a more effective real-world strategy than relying on physicians alone. ACKNOWLEDGMENTS: The authors thank Dr Harise Stein for her contributions to this work, as well as her many years of research and advocacy on the topic of intimate partner violence. Previous presentations: Part of this manuscript was presented as a poster at the STFM Annual Spring Conference in Washing- ton, DC, May 5-9, 2018. CORRESPONDING AUTHOR: Address cor- respondence to Steven Lin, MD, 211 Quar- ry Road, Ste 405, MC 5985, Palo Alto, CA 94304. 650-725-7966. Fax: 650-498-7750. stevenlin@stanford.edu. References 1. Smith SG, Chen J, Basile KC, et al. The Na- tional Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. At- lanta, GA: National Center for Injury Preven- tion and Control, Centers for Disease Control and Prevention; 2017. https://www.cdc.gov/vio- lenceprevention/pdf/NISVS-StateReportBook. pdf. Accessed January 24, 2018. 2. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a sys- tematic review to update the U.S. Preventive Services Task Force recommendation. Ann In- tern Med. 2012;156(11):796-808, W-279, W-280, W-281, W-282. 3. Moyer VA; U.S. Preventive Services Task Force. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;158(6):478- 486. 4. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and at- titudes of primary care physicians. JAMA. 1999;282(5):468-474. Table 2: Association Between IPV Screening and Clinic Patient Screened Clinic (Screener) P Value Pearson χ2 Clinic 1 (MA) Clinic 2 (MD) Clinic 3 (MD) Clinic 4 (MD) Clinic 5 (MD) Yes (n=111) 74 31 4 2 0 <0.001 No (n=389) 26 69 96 98 100 Total 100 100 100 100 100 Table 3: Association Between IPV Screening and Screener Type Patient Screened Screener P Value Pearson χ2 MA MD Yes (n=111) 74 37 <0.001 No (n=389) 26 363 Total 100 400 Abbreviation: MA, medical assistant. Table 4: Association Between IPV Screening and Screener Gender Patient Screened Screener Gender P Value Pearson χ2 Female Male Yes (n=111) 95 16 0.031 No (n=389) 359 30 Total 454 46 Table 5: Association Between IPV Screening and Patient Age Patient Screened Patient Age P Value Pearson χ2 18-29 30-39 40-49 Yes (n=111) 24 36 51 0.011 No (n=389) 112 158 119 Total 136 194 170 FAMILY MEDICINE VOL. 50, NO. 9 • OCTOBER 2018 705 BRIEF REPORTS 5. Sprague S, Slobogean GP, Spurr H, et al. A scoping review of intimate partner violence screening programs for health care profession- als. PLoS One. 2016;11(12):e0168502. 6. Chen PH, Rovi S, Washington J, et al. Random- ized comparison of 3 methods to screen for domestic violence in family practice. Ann Fam Med. 2007;5(5):430-435. 7. Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatrics. 2001;108(1):98-102. 8. Cummins A, Little D, Seagrave M, Ricken A, Esparza V, Richardson-Nassif K. 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