Case-management by the GP of domestic violence

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1 Case-management by the GP of domestic violence an example of results from a sentinel network of general practitioners Nathalie Bossuyt Sentinel network of general practitioners

2 Outline Introduction Research questions Methods Results Conclusions

3 Introduction: WHO classification violence selfdirected interpersonal collective selfabuse family / partner community social suicidal behaviour adult victim acquaintance political elderly victim stranger economic child victim

4 Introduction: WHO classification violence selfdirected interpersonal collective selfabuse family / partner community social suicidal behaviour adult victim acquaintance political elderly victim stranger economic child victim

5 Outline Introduction Research questions Methods Results Conclusions

6 Research Questions Characteristics of cases of domestic violence seen by the GP Case-management of domestic violence by the GP Practice variation in case-management

7 Outline Introduction Research questions Methods Results Conclusions

8 The sentinel network of GPs a network of practices or community based physicians who monitor one or more specific health problems on a regular basis representative for all general practitioners in the country (age, sex, geographical distribution) operational for 30 years coordinated at IPH voluntary participation regular participation small financial compensation + (individual) feedback +/- 8 health problems registered / year weekly registration / paper forms anonymity of patients

9 Data collection & study population Data collection: 01/01/ /12/2004 Inclusion: all cases of interpersonal violence Topics: Socio-demographics victim, perpetrator, p household GP: Socio-demographics + practice organisation Nature of violence (physical, psychological, sexual) Place of violence Reporter of complaint Provision of care by GP: interventions / referrals (long term) consequences for victim

10 Paper form

11 Statistical analysis For each (binary) intervention or referral: Multilevel logistic regression analysis Random effects model Why? Data on patients are clustered by GPs Multilevel analysis takes into account clustering valid estimates of regression parameters correct confidence intervals & inferences Random effects model: estimates variation between GPs

12 Dependent variables: interventions / referrals Interventions Next appointment Prescription psychotropic medication Certificate of injury Certificate of incapacity of work Hospitalisation No immediate interventions Referrals Child abuse centre Guidance centre Shelter / safe house Social services Police / juridical services Psychologist / psychiatrist Other GP / specialist Any referral (incl. hospitalisation)

13 Independent variables: individual & GP characteristics Individual characteristics Socio-demographics victim Socio-demographics perpetrator Socio-demographics household Nature of violence Place Reporter of complaint Other interventions/referrals GP characteristics + region Region Age & sex GP Group/solo practice Size of practice Trainee Organisation patient s t record

14 Outcome measures for each intervention Frequency of occurrence: % calculated on basis of parameters of random effects model Variation between GPs: Median Odds Ratio: median of all odds ratios resulting from every comparison of two persons with the same covariates but from randomly chosen different GPs always > 1 the higher the MOR, the larger the variability between clusters

15 Outline Introduction Research questions Methods Results Conclusions

16 Size of the network Number of GP practices Population covered % 1.5% % % Registered cases of interpersonal violence N = 1745 Registered cases of domestic violence N = 963 Incidence of GP consult. for intrafamilial violence: 2 / 1000

17 Number of registered cases violence interpersonal (N = 1745) collective selfdirected selfabuse family / community partner (N = 733) (N = 963) social suicidal behaviour adult victim (N = 776) acquaintance (N = 403) political elderly victim (N = 86) stranger (N = 330) economic child victim (N = 73)

18 Demographic characteristics Male victims Female p-value victims N(%) N (%) Age group victim 17y 34 (19) 47 (6) 18-64y 117(65) 648 (86) 65y 29(16) 57 (8) < Sex perpetrator t man 95(66) 609 (95) woman 49 (34) 34 (5) < Self-reported complaint yes 146 (78) 693 (90) < history of domestic violence Previous episodes 89 (48) 492 (64) First episode 96 (52) 274 (36) <

19 Characteristics of the violence Male Female p-value victims victims N (%) N (%) Nature of the violence Physical violence 150 (80) 586 (76) 0.25 Psychological violence 134 (71) 636 (82) Sexual violence 8 (4) 53 (7) 0.24 Physical injuries No injury 20 (11) 67 (9) 0.41 Open wound 41 (22) 86 (11) Haematoma 80 (43) 387 (51) 0.05 Fracture 7 (4) 26 (3) 0.82 Burn wound 3 (2) 5 (1) 0.20 Contusion 38 (20) 196 (26) Concussion 6 (3) 15 (2) 0.28 Psychological violence Emotional pressure 68 (37) 398 (53) Verbal violence 104 (57) 480 (64) 0.08 Extorsion 12 (7) 101 (13) Neglect 7 (4) 34 (5) 0.84

20 Circumstances Male Female p-value victims victims N(%) N (%) Substance abuse acute abuse alcohol victim 13 (7) 21 (3) 0.01 chronic abuse alcohol victim 26 (14) 61 (8) 0.01 Place of the violence home 141 (75) 686 (89) < Other house 15 (8) 43 (6) 0.21 institution 0 (0) 6 (8) 0.60 Public place 27 (14) 47 (6) work 4 (2) 8 (1) 0.27 other 1 (1) 5 (1) 1.00 Long-term consequences Mental problems 53 (28) 321 (42) absence from work or school 19 (10) 91 (12) 0.52

21 Case-management of domestic in adults by the GP Interventions Frequency of Variation occurrence between GPs (%) (MOR) Next appointment Prescription psychot. med Certificate t of injury Certificate of incapacity of work Hospitalisation ti 4 3 /

22 Case-management of domestic in adults by the GP referrals Frequency of Variation occurrence between GPs (%) (MOR) Psychosocial services / 2.4 Police / juridical services Other health professional / medical service

23 Conclusions GP is frequently consulted for interpersonal violence Considerable practice variation for most interventions / referrals

24 Questions?

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