CONTEXT: Domestic violence has an estimated 30% lifetime prevalence among women, yet physicians detect as few as 1 in 20 victims of abuse. OBJECTIVE:To identify factors associated with physicians' low screening rates for domestic violence and perceived barriers to screening. DESIGN:Cross-sectional postal survey. PARTICIPANTS:A national systematic sample of 2,400 physicians in 4 specialties likely to initially encounter abused women. The overall response rate was 53%.MAIN OUTCOME MEASURE: Self-reported percentage of female patients screened for domestic violence; logistic models identified factors associated with screening less than 10%. RESULTS:Respondent physicians screened a median of only 10% (interquartile range, 2 to 25) of female patients. Ten percent reported they never screen for domestic violence; only 6% screen all their patients. Higher screening rates were associated with obstetrics-gynecology specialty (odds ratio Lower screening rates were associated with emergency medicine specialty (OR, 1.72; CI, 1.13 to 2.63), agreement that patients would volunteer a history of abuse (per Likertscale point, OR, 1.60; CI, 1.25 to 2.05), and forgetting to ask about domestic violence (OR, 1.69; CI, 1.42 to 2.02).CONCLUSIONS: Physicians screen few female patients for domestic violence. Further study should address whether domestic violence training can correct misperceptions and improve physician self-confidence in caring for victims and whether the use of specific intervention strategies can enhance screening rates.
Abstract. Objectives:To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. Methods: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. Results: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. Conclusions: Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life. Key words: emergency services; aging; drugs; pharmacology; outcomes; quality of care. ACADEMIC EMER-GENCY MEDICINE 1999; 6:1232-1242 A DVERSE drug reactions are common and expensive. For example, a recent meta-analysis estimated that 6.7% of hospitalized patients have serious adverse drug reactions.1 In the outpatient setting, rates of adverse drug reactions have ranged from 1.7% to 50.6%.2 Costs associated with adverse drug events in a typical tertiary care hospital have been approximated to be $1.1-5.6 million per year, 3,4 and drug-related morbidity and mortality have been estimated to cost $76.6 billion annually in the ambulatory setting.5 Therefore, clinicians, administrators, and policymakers have become interested in what system factors contribute to adverse drug reactions and how provider practices around medication prescribing can be improved. 6,7 Several factors place older persons at especially high risk for iatrogenic complications of medication use. The normal aging process is associated with ...
Wide variation exists in the attitudes of older African Americans toward their diabetes and treatment. Patients frequently expressed ambivalence toward the care of their illness. Providers should explore these issues and help patients resolve their ambivalence if patient preferences are to be respected in the overall treatment plan.
Endocrinologists had the most aggressive, complex diabetes treatment regimens, although geriatricians had older patients with more dementia and lower prevalence of microvascular complications. Average hemoglobin A1c levels and blood pressures were higher than recommended among patients of all three specialties. Screening for diabetic complications and hyperlipidemia was lower than advised.
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