:':? *:gRS1.2..t :RS!:4'. 4w .t^r'@t,.pSv5NX t:$..:sm.5.s'..X".}p...'...g.-X.'.ts.'S".......'5S... .......S'.t ....'.:.St:4CgNwaW Utility of STaT for the Identification of Recent Intimate Partner Violence Anuradha Paranjape, MD, MPH; Kimberly Rask, MD, PhD; and Jane Liebschutz, MD, MPH Atlanta, Georgia and Boston, Massachusetts for Disease Control and Prevention report on IPV defi- Financial support: Funding for this study was made possible nitions-are physical violence; sexual violence; threat by a grant from the Emory Medical Care Foundation. Pre- of physical or sexual violence; and psychological or sented at the American Public Health Association Annual emotional abuse, including coercive tactics.' Patients Meeting, San Francisco, CA, November 2003. Dr. Paranjape who are victims ofviolence may have experienced these was supported by the Emory Mentored Clinical Research four forms of IPV together or separately in >1 relation- Scholars Program (National Institutes of Health/National ship over their lifetime. The lifetime prevalence of IPV Center for Research Resources K12 RR 017643). Dr. Lieb- ranges from 26-54% among patients in different med- schutz was supported by a grant through the Generalist ical settings,29 while the one-year incidence of IPV Physician Faculty Scholars Program of the Robert Wood ranges from 10-15%.569 In one emergency room study, Johnson Foundation (RWJF #045452). 13% of all women seeking care did so for injuries and Intimate partner violence (IPV) is an important issue with far- illnesses related to IPV2 Patients who report IPV have reaching health consequences. This study investigates the been shown to suffer from a variety of pain syndromes, utility of STaT, a three-question IPV screening tool, for recent including headaches'0 and chronic abdominopelvic IPV identification in a sample of adult women in an inner- complaints,""2 and report higher rates of posttraumatic city urgent care clinic. STaT score was calculated as the stress disorder, depression,"'," substance abuse'5-'7 and total number of affirmative responses to the three questions. suicidality.'3 They also report overall poorer health sta- Efficacy of STaT as an IPV screen was estimated by comput- tus,'8-20 and utilize and cost healthcare systems more.2'-25 ing the sensitivity and specificity at possible cut points, Thus, not only is IPV very common in women, but it based on participant's STaT score, and using Index of also is associated with significant morbidity. Spouse Abuse scores as a comparison standard. The sensi- Due to the high prevalence of IPV in women seen in tivities of STaT were 94.9%, 84.8% and 62% with the cut points healthcare settings, healthcare visits are an excellent set at scores of 1, 2 and 3, respectively. Thus, with the criteri- window of opportunity to screen patients for IPV Uni- on for a positive screen set at a cut-point score of 1, STaT versal IPV screening by physicians has been recom- can be used to facilitate the identification of abused mended since 1992 by the American Medical Associa- women in busy public healthcare settings. tion26 27 and other professional societies.28-29 While systematic reviews of the literature on IPV have yet to Key words: violence U screening U women's health yield evidence for the efficacy ofIPV screening,30'3' sev- eral factors still support empiric inquiry about IPV in © 2006. From the Division of General Medicine, Emory University School of female patients by healthcare providers, including the Medicine (Paranjape, assistant professor) and Rollins School of Public Health, substantial prevalence of IPV, its repetitive nature, and Emory University (Rask, associate professor), Atlanta, GA; and Section of General Medicine, Boston University School of Medicine, Boston, MA its high medical and societal costs.32'33 Current detection (Liebschutz, assistant professor of medicine). Send correspondence and rates for IPV have improved overall, yet providers still reprint requests for J Natl Med Assoc. 2006;98:1 663-1669 to: Dr. Anuradha do not screen their patients routinely.34 38 Researchers Paranjape, Associate Professor, Section of General Internal Medicine, Tem- have identified several barriers to screening, including ple University School of Medicine, Jones Hall, First Floor, 1316 W. Ontario St., perceived lack of time; lack of resources; reluctance on Philadelphia, PA 19140; phone: (215) 707-1800; fax: (215) 707-3699 the part of physicians to screen due to personal beliefs that caring for IPV victims is difficult, low-paying and BACKGROUND stressful; or due to a personal history of trauma.3814' A ntimate partner violence (IPV) is a constellation of challenge to identification of IPV is the paucity of clini- intentional violent or controlling behaviors, which cally useful screening tools. A clinically useful screen- occur within the context of an intimate relationship. ing tool for IPV would safely and reliably identify the Four separate aspects of IPV as defined in a Centers majority of those patients affected by IPV.42 To do so, JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 98, NO. 10, OCTOBER 2006 1663 IDENTIFICATION OF RECENT INTIMATE PARTNER VIOLENCE such a screening tool should have a high sensitivity; in METHODS the context of IPV in healthcare settings, the specificity ofthe screening tool may be less important than its sen- Participants sitivity. Sensitivity rates are available for only a few We recruited a sample of 240 women for this study published screening questions or tools for IPV detec- from patients seeking medical services at the urgent care tion, and not all tools have sensitivity rates high enough center of a large inner-city public hospital in the south- to maximize IPV detection. Furthermore, not all exist- eastern United States. The urgent care center serves as a ing screening tools for IPV are sufficiently validated, safety net providing primary care to a largely indigent nor are these tools able to detect most forms of IPV and uninsured population, and also delivers acute medical Some are too cumbersome to use in practice.4348 care. Approximately 50,000 patient visits are made to the In a prior study, to address this gap in research, we urgent care center per year. To be eligible for the study, developed a three-question screening tool-STaT women had to be 18-65 years of age, English speaking [slapped, threatened and throw (things)] that is short and had to have seen a medical provider in the urgent care and sensitive for the identification of lifetime IPV Sen- center on that day. Patients who could not be interviewed sitivity of STaT was estimated to be 96% for the detec- alone were excluded. tion oflifetime IPV using an affirmative response to any one of the three questions as the cut-off for a positive Data Collection screen.49 Identification of patients who are currently Trained research interviewers systematically being abused or have been abused in their most recent approached all women in the discharge area of the relationship is of value, as such patients are potentially urgent care center to ask them about their interest in par- at greater risk for harm or ill effects from the abuse.50'51 ticipating in a study on women's health and screened This paper reports the results of a study that examines interested women for eligibility (Figure 1). Research the utility of STaT for recent IPV interviewers used a private room to obtain informed consent and to conduct the study interview. Each partic- Table 1. Participant characteristics (n=240) Demographic Characteristics IPV (+) N (%7) IPV (-) N () pValue Age (Years), Mean (Standard Error) 37.2 (0.8) 39.7 (1.1) 0.08 Currently in Relationship 37 (46.8) 116 (72 ) 0.0001 Children Living with Patient 30 (38) 72 (44.7) 0.058 Housing Status Rent or own 52 (65.8) 113 (70.2) 0.148 Live with relatives or in shelter 26 (32.9) 44 (27.3) Other 1 (1.3) 4 (2.5) Marital Status 0.34 Ever married 38 (48.1) 67 (41.61) Never married 41 (51 .9) 94 (58.39) Education 0.53** Eighth grade or less 2 (2.5) 5 (3.1) Some high school 22 (27.8) 32 (19.9) High-school grad or more 44 (55.7) 95 (59) Other (include technical school) 11 (13.9) 29 (18) Work Status 0.27 Full- or part-time 31 (39.2) 80 (49.7) Disabled 12 (15.2) 19 (11.8) Unemployed 29 (36.7) 43 (26.7) Other 7 (8.9) 19 (11.8) Insurance Status 0.62** None 52 (65.8) 106 (65.8) Medicare or Medicaid 17 (21.5) 33 (20.5) Private 8 (10.1) 12 (7.4) Other 2 (2.5) 10 (6.2) Number of Children Median (Range) 2 (0-9) 2 (0-9) 0.17 Current Relationship Length in Years, Median (Range)*** 2 4 0.26 Monthly Income, Median (Range) $800 $800 0.21 $0-$3,200 $0-$6,000 ** Fisher's exact; ***Of those in a current relationship, n=153; IPV: intimate partner violence 1664 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 98, NO. 10, OCTOBER 2006 IDENTIFICATION OF RECENT INTIMATE PARTNER VIOLENCE ipant was interviewed by one-half trained interviewers, possible scores that could be selected as a cut-offlevel (cut using a questionnaire developed and piloted prior to point) for a positive STaT screen for IPV At a cut point of data collection. The study questionnaire included demo- 1, participants who had a STaT score of .1 would be IPV graphic questions, the screening questions to be tested screen positive. Similarly, with the cut point set at a STaT (including STaT) and the scale used as the comparison score of 2, participants with scores of .2-that is, those standard.