**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**Clinical Utility of an Intimate Partner Violence Screening Tool for Female VA Patients**

**Presenter: Katherine M. Iverson, Ph.D.**

**February 13, 2013**

**Clinical Utility of an Intimate Partner Violence Screening Tool for Female VA Patients**

**February 13, 2013**

Moderator:And we are at the top of the hour, so at this time I would like to introduce our presenter for today. We have Dr. Katherine Iverson. She is a Clinical Research Psychologist in the Woman’s Health Sciences Division of the National Center for PTSD, located in the Boston Health Care System. She is also an Assistant Professor of Psychiatry at Boston University. And Dr. Iverson, are you ready to share your screen?

Dr. Iverson:Yes I am. Okay, my slide should be up, great thank you. Alright, thank you Molly. Hello everyone, I am very excited to be here today to talk with you about some of my work on identifying intimate partner violence or IPV among female VA patients. The bulk of my presentation today is focused on findings from a study I recently conducted in VISN1, Evaluating the Clinical Utility of an Intimate Partner Violence Screening tool for use of female VA patients. This is part of my HSR&D Career Development Award. And I am hoping that my presentation today will stimulate some discussion on the topic of caring for women Veterans who are impacted by IPV and informed conversations regarding best practices for detection, and coordination of care.

But before I begin, I would like to recognize my co-authors on the research paper that I am presenting today which include Drs. Matt King, Patricia Resick, Megan Gerber, Rachel Kimerling, and Don Vogt. 

And I would also like to acknowledge my funding sources, which include HSR&D as well as the Executive Division of the National Center for Post-Traumatic Stress Disorder. And I would also like to say a special thank you to Drs. Errol Baker and Mark Meterko who are investigators at my HSR&D Center... that is COLMR. They have provided me with a lot of methodological and statistical consultation while I have been working on this project, and it is just so appreciated. And I would like to really thank the hundreds of women Veterans who were willing to participate in the project I am presenting on today. They shared their experiences and their opinions with me and my research team.

So it would be helpful for me to understand a little bit about who you are. So please tell me, which category best describes your current role in working with women Veterans. 

Moderator:Thank you Dr. Iverson, we do have answers streaming in at this time. About half of our audience has voted, so we will leave it open for a few more seconds and give everyone else a chance to answer. So the option, which category describes your current role in working with women Veterans, Primary Care Provider, Mental Health Provider, Substance Use or other Counselor, Social Worker or Case Manager, Administrator or Researcher. Simply click the square next to your answer choice and it will – and then click the button submit. And it looks like about 70% of our audience has answered but the responses are still streaming in, so we will give people a few more seconds. Okay, so it looks like the answers have stopped streaming in so I am going to go ahead and close the poll and share the results. And Dr. Iverson, can you see those on your screen?

Dr. Iverson:Yes, they just popped up. Great, so it looks like we have a really nice variety of audience members. So this is great, because we are all are working together to inform best care for our women Veterans. Great, so moving on to our next poll question, building off of that last question. I am curious to find out how often you currently screen your female patients for experiences of partner violence.     

Moderator:Alright, it looks like about half of our audience have voted so we will give people just a few more seconds. Okay, and responses have stopped streaming, so at this time I am going to close the poll and share the results. 

Dr. Iverson:Okay, great, I see the results up. So it looks like almost 40% are doing it some of the time and most of the time, which is great. And another 18% are doing it rarely but on occasion, and so hopefully, I am going to talk about an IPV Screening tool today, so that will encourage you to think about the kinds of questions you are asking, or even possibly use the screening tool, which brings us to our next question. So for those of you who do screen for – do ask your patients about experiences of intimate partner violence, how often do you use an empirically validated screening tool to facilitate this process?

Moderator:Okay, so for our final audience poll, we have had about 40% of our audience vote, so we will give our respondents just a little bit more time. Okay, the responses have stopped streaming in so I am going to go ahead and close this out and share the results. 

Dr. Iverson:Okay, so we have just under 20% who are using an empirically supported screening tool for IPV at least some of the time or most of the time. And then a bunch that are never or rarely using one. So hopefully today we can stimulate some discussion on the end about the utility of empirically validated screening tool for detecting Intimate Partner Violence among women patients and I am hoping on my presentation today will give us some food for thought on that issue. 

Moderator:And Dr. Iverson, you should have a popup that says show my screen, go ahead and click that button.

Dr. Iverson:Yes, I am not seeing it at the moment. 

Moderator:Alright I will turn it over to you again, you should see a popup right now.  

Dr. Iverson:Not seeing it.

Moderator:Okay, click on down at the bottom of your screen you should see the blue go to webinar icon. If you click on that window, it should pop up for you. If you need to, you can escape out of full screen mode for your slides. I will go ahead and try it one more time, you should see a popup right now. 

Dr. Iverson:Unfortunately, I am not.

Moderator:Okay, thank you to our attendees for your patience. We will get this sorted out. Okay, I see the issue, so I am going to solve the problem right now.

Dr. Iverson:Great.

Moderator:Okay, you will see the popup now.

Dr. Iverson:Okay, showed me a screen, so hopefully we are back in business. 

Moderator:We are, thank you.

Dr. Iverson:Alright, so moving on, sorry about that. So some of you may already be aware of this but within the past year, a national VHA Domestic Violence Taskforce was convened whose task was developing recommendations regarding how the VA can more systematically provide care for male and female Veterans who use and/or experience intimate partner violence. The taskforce felt strongly that the VA is well positioned to be a leader in the field in terms of detection of IPV and provision of high quality healthcare for Veterans who use and experience intimate partner violence. 

The Task Force co-chairs are currently in the process of making a number of recommendations to VA leadership, including the Secretary of Health. And in direct relevance to this presentation is that one of the task force’s recommendations is for routine screening of women for experiences of intimate partner violence. So what is typically referred to as IPV Victimization, so physical, sexual or psychological aggression from a former or current intimate partner.

My research presentation today will provide a rationale for that recommendation, and provide you with some information on one screening tool that is being considered for that purpose. And we do have some pretty good information regarding the scope of intimate partner violence among female service members and Veterans that indicates pretty clearly, that IPV is a critical woman’s health issue faced by our patients. At least 19% of women report physical or sexual IPV prior to enlisting in the military. And we know that at least 22% of women report physical or sexual IPV during their military service. And this percentage actually jumps to 36% when psychological IPV is included.

Moreover, female Veterans have been found to be significantly more likely to report physical or sexual IPV relative to their non-Veteran counterpart, with Veterans having a nearly 10% higher lifetime prevalence than non-Veterans. 

Now data from VA settings suggest that female VA patients are at particular risk for IPV. For example, a study of female VA patients conducted in the Midwestern United States, found that nearly on quarter of women, under the age of 50, reported past year IPV. And lifetime IPV is as high as 74% among VA primary care patients. And I know with our own Women’s Stress Disorder Treatment Team here in Boston, we find that about three out of every four patients report some form of intimate partner violence during her lifetime. And unfortunately, data on IPV specifically among LGBT Veterans and VA patients is lacking at this time. This is an important area for future research. Because we know from nationally represented civilian data, that IPV appears even more common among this population. And we know that women make up a high proportion of our active duty LGBT Service members. 

So I have been talking with Dr. Jillian Shepherd who is one of our national LGBT Program Coordinators about this issue, and she is in agreement that this is something we really need to look more into in our research and clinical efforts. So I provided a link to the recent Center for Disease Control Report on the results from the National Intimate Partner and Sexual Violence Survey by sexual orientation. So those of you who are interested in learning more about IPV among lesbian, gay, and bi-sexual individuals. 

IPV is one of the most serious and complex public health problems in the U.S. today. Not only because it is so rampant, but because it is associated with numerous and costly health consequences. The most obvious physical health outcomes are obviously physical injury such as concussion or bruising. But IPV also directly and indirectly leads to numerous chronic physical health conditions and stress related illnesses. So in primary care we would often see headaches, chronic pain, these kind of bodily symptoms related to having so much stress associated with IPV. 

And IPV also leads to or exacerbates a whole host of mental health problems such as PTSD, depression, suicidality, self-harm, just to name a few. Re-victimization, including re-abuse from a previous or new partner is something I see a lot of clinically and is an all too common experience for IPV survivors, even among those who have left abusive partners. For example, I recently found that 46% of the women in the community who were seeking help from an abusive partner, reported physical IPV re-victimization within six months of seeking help for the abuse. So this is something I think we really need to pay attention to in our process and research effort.

Finally, IPV survivors utilize health care at rates that are two to four times higher than non-abused women, even many years after the abuse has ended. And it has estimated that upwards of ten billion dollars are spent annually in the U.S. on direct health care cost and lost work productivity associated with IPV. The health consequences and cost of IPV really underscore the importance of being able to detect IPV in our health care setting, including the need for early detection.   

A recent vigorous review of the intimate partner violent screening literature sponsored by the U.S. Preventative Task Force concluded that intimate partner violent screening not only allows for accurate detection of women who have experienced IPV, but can result in an important benefit in terms of women’s physical and mental health and safety with minimal adverse effects. As a result, the U.S. Preventative Task Force, now recommends routine screening women of childbearing age. Similarly, for the reasons I have mentioned, the Institute of Medicine now recommends routine screening of all women for IPV as part of standard preventative health care. Now these recommendations dovetail well with the timing of the National Domestic Violence Task Force, and guidance that is coming in the near future. I know that many of us have been anxiously awaiting guidance on these issues, so please know that we have an excellent multidisciplinary team of policy makers, researchers, administrators and clinicians, working on this even as we speak. 

So given how common IPV is among female Veterans and the substantial health consequences, it is critical to identify feasible, non-evasive and accurate methods for detecting IPV among our female VA patients. Some VA clinics have implemented various screening tools and strategies. We saw some of that in our poll answers. But at this point, most are not routinely screening for IPV, which actually, makes a lot of sense with the U.S. Preventative Task Force just changing their recommendation about screening. 

It is important the tools and procedures we use in our VA settings are formerly evaluated specifically with female VA patients. We cannot assume that a tool that was established with non-Veterans will work the same way or be as sensitive with women VA patients. We know that woman VA patients are different in important ways from their civilian counterparts, including trauma exposure, especially in a personal violence, and they tend to have poor health. So this graph depicts work by Dr. Susan Frayne and really illustrates this point. So this graph shows self-reported physical and mental health of female VA patients, which is the gray bar, and female civilians, which is the black bar. So these are scores on the SF-36, which is a well-validated measure of physical and mental health. Higher scores are better, so what you see here is female VA patients have worse physical and mental health relative to women in the general population. Thus, we must ensure that tools and strategies are sensitive, effective and acceptable to women Veteran’s prior to and during our implementation effort. 

As the largest provider of healthcare for women Veterans, the VA has a strong commitment to improving the health and healthcare of women. And we have seen the VA make tremendous strides in terms of the provision of comprehensive and gender sensitive healthcare for women. It has just been a really exciting time to be in the VA. And as I am sure you are aware, the number of women Veteran’s using VA services has doubled over the past decade. So we, as VA providers, have an important opportunity to detect IPV, provide appropriate support and ensure a high standard of care to meet the multifaceted needs of women impacted by past or recent IPV. 

Although the VA is well positioned to implement IPV screening, relatively little is known about VA provider’s perspective with regards to IPV screening. In a 2011 publication, Edwardsen and colleagues found in a sample of VA providers, the providers thought IPV was an important topic, but they generally did not feel very knowledgeable about it. So in an attempt to further understand VA provider concerns and needs, as part of my Career Development award, I conducted a small, qualitative study of VA primary care providers throughout VISN 1 to assess their practices and perceived barriers and facilitators to IPV screening within the VA. Although only a small portion of the participants indicated that they currently screen their patients for IPV, the majority of participants strongly supported screening for IPV as a standard part of medical care for women. And in terms of barriers, providers indicated general lack of awareness, knowledge and comfort with respect to identifying IPV as major hindrances to screening among the VA clinicians that they knew. 

In addition, they expressed desire for educational training, especially those that are interactional with opportunities with role-play to teach them how to best identify and address IPV including calls for a screening tool with an associated clinical reminder to make screening easy and systematic. Although as I am sure you can imagine, participants were not thrilled with the idea of yet another clinical reminder, the general sense was that the VA has a culture in which clinical reminders get done, and they get done in a reasonable way. So this was brought up as a one-way to make implementation of IPV screening protocols effective within the VA and to facilitate documentation. 

Fortunately, there are a number of IPV screening tools in existence, several of which have reasonable psychometric properties. However, none of these tools have been evaluated in a published paper for use of female VA patients. And according to the standard for educational and psychological testing, precision and accuracy are not simply properties of a particular measure, but rather psychometric properties differ by population type. Therefore, prior to investing in a large-scale implementation of an IPV screening tool into VA, I felt that it was imperative to first evaluate this clinical utility in the population of interest. So I selected a tool called the HITS, which I will show you in a moment, and I selected this tool for several reasons. I reviewed the various screening tools that were in existence, their evidence and their respective strengths and weaknesses. And I found that the HITS was one of the most widely studied tools and had been validated in diverse population which seemed really important giving the diversity of female Veterans we see here at the VA. Additionally, it was one of the only tools that had preliminary data in the sample of female Veterans. This is work by Dr. Rachel Latta, of the Bedford VA that is currently in submission. Moreover, in the general literature, the HITS has been shown to have good psychometric properties and is relatively easy to score. And it is worth noting that many tools I considered did not include an assessment of psychological IPV. And I thought that was really problematic, because psychological IPV is strongly and independent associated with adverse health outcomes. So even in the absence of physical or sexual IPV, psychological forms of IPV really have a negative impact on women’s mental and physical health.   

Moreover, for some women, they have not experienced physical IPV from their partner in many years, but it is that constant threat of physical aggression that dramatically alters the balance of power in the relationship and erodes women’s health. They felt it was really critical to be able to identify psychological IPV. 

So here you can see the HITS screening tool and response options. HITS stands for Hurt, Insult, Threaten, Scream. The timeframe is the past 12 months and response options range from never to frequently. Responses are summed to form a total score ranging from four to twenty. Previous studies have found a cutoff score off eleven to have good sensitivity and specificity in identifying women who are experiencing IPV in different health care settings. But it should be noted that support for a lower cut score of six has been found in some diverse populations. Now I will give you a moment to just kind of study the items. But some of you may notice that this tool does not include a sexual aggression item. And this seemed to me like it could be an important limitation of the tool So I look at this issue more closely in my study. 

So let us go ahead and talk about the study details. In preparation for the development and implementation of national guidelines for IPV screening within the VA, my co-authors and I investigated the accuracy of the HITS in direct comparison with the reference standard among a sample of female VA patients. We evaluated accuracy primarily through examining the sensitivity and specificity of the tool which are statistical measures of the performance of the screening tool relative to a binary criterion standard. So just as a quick reminder, sensitivity measures the proportion of actual positive which are correctly identified as positive, and specificity measures the proportion of negative cases which are correctly identified. 

And then additionally in this study was to evaluate the concurrent validity of the HITS in terms of the screening tools association with measures of current psychiatric distress. So to do this, we conducted a paper and pencil mail survey of a random selection of women drawn from the pool of all female VA patients in VISN-1 focused on women’s interpersonal relationship and health. So the women in this study had received VA medical and mental health care at least one visit in the New England area between January 1 and December 31, 2011. We contracted with a survey firm and used a multiple mailing strategy modified from the well-supported Tillman approach.

At the first contact, women received the informed consent fact sheet, a survey packet, and a $10 bill incentive. Two weeks later, all potential participants received a thank you/reminder post card, encouraging them to complete the survey if they had not already done so. And approximately two weeks later, those women who had not yet responded or declined participation, received a second survey packet, informed consent fact sheet, and another $10 bill incentive. 

So this figure gives you a sense of participant response going from left to right. There were 700 potential participants on the roster provided to the survey firm of which we were able to locate 585 using address searches such as Nexus Lexus. Of these 585 potential participants, 369 women responded resulting in an overall response rate of about 64% which I thought was pretty decent considering we only did two ways of survey administration due to budgetary constraints. Now of the responders, 179 women reported that they had been in an intimate relationship in the past year, and that 160 had completed both the IPV screening tool and the reference standard. So these folks comprised my final sample. 

For measures, I have already described the HITS screening tool so I will not discuss it in great detail here other than to say that the tool demonstrated adequate and internal consistency and reliability in the sample. Now when selecting a reference standard, it is important that the measure is credible, replicable, and clear. To this end, I selected the Revised Conflict Tactics Scales as it meets all these criteria and is the most commonly used criterion standard in the IPV screening literature. The CTS-2 includes 39 statements that assess how partners resolve conflict including physical, sexual and psychological aggression experienced by the respondent. For each statement, participants indicate how frequently a behavior happened in the past year using a seven-point scale ranging from zero to six. The CTS-2 has well established psychometric properties including good test/retest reliability as well as good construct, convergent, discriminant and factorial validity. 

And consistent with VA recommendations for a broadly inclusive IPV screening program to promote early detection, a relatively liberal criterion was used for identifying IPV in order to avoid missing exposed women. On line with several other previous studies evaluating IPV screening tools, women were considered IPV positive on this measure if they scored greater than zero on the physical, sexual, and/or severe psychological IPV scale. And I also want to note that the order of the screening tool and criterion standard were counter balanced during survey administration such that half the participants received the screening tool first followed by the criterion measure and vice versa to control for potential presentation effect. 

In order to examine the associations between past-year IPV on the HITS and current psychological distress, I looked up probably PTSD as measured by the PTSD checklist and probably depression as measured by the Center of Epidemiologic Study Depression Scale. These are both well-validated self-report measures of PTSD and depressive symptoms. 

Okay, so first I took a look at some sample characteristics by IPV status as measured on the Conflict Tactic Scale. As you can see, women look pretty similar between the two groups in some respect. However, consistent with the literature, women who experience past year IPV’s tended to be younger on average than women who did not report past year IPV. We also see differences between the groups in terms of race such that women with past year IPV’s were more likely to identify the racial or ethnic minority than non-abused women. Again, this is pretty consistent with the larger IPV literature. 

Okay, so here you see results in terms of past year IPV experiences as reported on the criterion standard, the Conflict Tactic Scale. We see that nearly 29% of the women in the sample reported some physical, sexual, and/or severe psychological IPV in the past year. You can see the breakdown for different types of abuse. Consistent with the general IPV literature, I saw that about half of the women who experienced IPV reported more than one type of aggression in the past year, which probably will not surprise you very much.

Okay, so now let us take a look at the diagnostic accuracy findings. What you see here are the results from the receiver operating characteristic analysis. The ROC curve is plot of true positive rate, or sensitivity over the false positive rate at different cut points for the screening tool. The area under the curve can be interpreted as the measure of agreement. These typically want an AUC or area under the curve, a point 8.0 or higher. So for this study, an area under the curve of .85 tells us that overall, the screening tool is performing pretty well relative to the Conflict Tactic Scale. 

To make it easier to identify the optimal cut point of the HITS listed in the sample, we will look at the coordinates of this differently. Okay, so this table summarizes the accuracy of the HITS at different cutoff scores and demonstrates that a cut score of six optimizes both sensitivity and specificity in this sample of female VA patients. Specifically at the cut point of six, the tool has a sensitivity of 78% and a specificity of 80%. And it is notable that a cut score of five is associated with a higher sensitivity, but at a cost of specificity, such that a score of five results in a substantial proportion of false positive. So when we are thinking about IPV screening within the VA, we can tolerate some false positives but certainly we do not want too many. As this is associated with cost per patient in terms of their time and their energy, for providers certainly in terms of their time, and cost of the health care system at large, because it uses resources. 

And as I mentioned earlier, the HITS does not include an item that specifically assesses sexual IPV. And I wanted to know whether the HITS accurately detect women who experience sexual IPV as measured on the Conflict Tactic Scale. The findings were similar albeit more modest than when detecting any IPV. Here you see the ROC curve for detecting sexual IPV laid over the ROC curve for general IPV so we can make comparisons. For this analysis, the area under the ROC curve was .79 indicating that the HITS had moderate agreement with the CTS-2 sexual IPV subscale. The valuation of different cut points on the HITS again, demonstrate that a cut score of six optimizes both sensitivity which is 87% and specificity in the detection of sexual of IPV in the sample. So these findings tell us that case of the sexual IPV do not go undetected or missed at any higher rates than physical or severe psychological forms of IPV. So this was really reassuring to me. 

Okay, well finally, you not only want a screen to be accurate in terms of its ability to detect IPV among women, but it is also useful if the screening tool identifies patients with significant health symptoms. I tested this by using logistic regression with probably PTSD and probably depression as my outcome, and a positive screen on the HITS with my predictor variable. What I found was, as expected, women who screen positive on the HITS were 2.7 times more likely to report probable PTSD’s and 3.5 times more likely to report probable depression than women who screen negative on the HITS. So these are pretty big odds ratio and really help to demonstrate the concurrent validity of the HITS for use of female VA patients.

The HITS accurately identified female Veterans experiencing past year IPV. Findings indicated that a cut point of six on the four-question tool accurately detected 78% of women identified as abused within the past year by the lengthy and behaviorally specific Conflict Tactic Scale. This is a good level of diagnostic accuracy for a relatively low burden screen. Moreover, we saw that even in the absence of an item assessing sexual IPV, the HITS can identify a high proportion of female VA patients who experience past year sexual IPV. The need to establish the clinical utility of a brief screening tool among female VA patients is really underscored by the high proportion of women who reported IPV in the sample, about 29%. This finding is in the upper range of what has been reported in other samples of female healthcare patients and provides additional support that IPV is a pervasive and serious health issue among women Veterans. 

Clearly, it will be important to replicate the current findings in the national sample of female VA patients, and test the tool as administered in different clinical contexts like self-report format versus clinician administered, versus computerized methods. But the current findings are promising and suggest that combining this tool with an interdisciplinary approach to screening and intervention, will help make it possible for the VA to provide high quality care for women who have been impacted by IPV. 

And this is really important to remember that screening for IPV is just one part albeit a really critical part, but it is one part of a comprehensive health care response to IPV. As my colleague and friend, Dr. Megan Gerber always says, screening starts a process. The screening is a way to let our patients know that we think IPV is an important health issue and that help is available regardless of whether they choose to disclose a view. By simply asking the questions, we are engaging in important awareness campaign and helping to educate our patients and build a culture of safety. And, screening allows us to start a more open-ended assessment and make referrals for those who acknowledge abuse. 

You want to remember your social workers and your women Veteran program managers in this regard. In addition to their expansive knowledge of relevant VA services, they are really the experts at also connecting patients with the excellent resources that are often available in the community for IPV. I know I love ours here at the VA Boston, Carolyn, and she is just very well dialed into the various resources for the IPV within our community.       

And it is always important to provide education about IPV and the health consequences, and provide options and resources such as the Domestic Violence Hotline Number which I provided on the screen. We want to be empathic and empower our patients and let them know what their options are, but we do not want to tell them what to do. We do not want to be another person who is taking away their power, even if it is inadvertent. So always ask them first if they would like a referral. So tell them what it was, what would the benefit of talking with a social worker, for example, be. And see if they would be interested in that rather than just facing one without discussing it with them first.  

It is also good to let patients know that mental health providers are readily available within the VA. Mental health treatment is often an important component of recovery from abuse. And there is evidence that reducing psychiatric distress such as reducing PTSD and depression symptoms, helps reduce women’s risk of re-victimization. 

Provision of psychotherapy for trauma related symptoms is something we have a really rich history of doing within the VA. And it is something that we do very well. So this is something we can really capitalize on in our IPV programming implementation effort. 

And of course, if we are going to assess for IPV, it is critical that we know our own state’s mandated reporting requirements. Mandated reporting requirements differ across states and by discipline. Many states do not mandate reporting for IPV, but some do. For example, those of you in California are probably aware of this already. So if you are practicing in a state where you are required to report, then I am of the mind that you should let patients know what you are required to report ahead of time so they can decide whether it is safe for them to disclose. 

In focus groups I have been conducting, I have also learned from women Veterans, the things they would really like us to talk to them about what we document in their medical record. And they would like us to invite them to have some say in what we document. They really appreciate this and helps make the process really transparent for them. This can be a very vulnerable experience disclosing abuse, and so helping them understand what will be in their medical records and who has access to them, helps make that process more clear and transparent, and helps ease some of their anxiety. 

IPV is just one of those areas that can be complicated at times. So encourage you to talk with your team. For those of you working in a pact team, you already have an ideal format from which to do this kind of work. And for those of you who are not working in as much of a team, do not be shy about consulting with your colleagues about your clinic’s procedures or how to handle specific situations, even just as things come up on a case by case basis. And I can tell you that although my research focus is on IPV, and I specialize clinically in treating IPV survivors, I still have times when I am not exactly sure what the best action is in a given situation, or I might have questions about mandate or reporting of something meets criteria from time to time. So I find it so helpful to be able to talk to my colleagues when these kinds of issues come up. And I do think there will be a good chance that we will have more opportunities for consultation on this issue at a national level in the very near future. 

And again, know that VA guidance and the development of formal guidelines, protocols and trainings are in the works and we will likely be hearing about them soon. 

I am personally very excited about the possibility of implementing more systematic IPV screening and responding programs within the VA, because such programs have been shown to have a number of positive effects in non-VA health care settings. First, if we can detect IPV’s, then we can provide more accurate diagnoses and targeted care for a major underlying cause of health problems among our population of female Veterans. And when done well, so when done in a sensitive, genuine and empathic way, IPV screening and response programming can be therapeutic for women. And such work can lead to improvements in women’s safety, their physical and mental health, but also improvement in women’s satisfaction with healthcare. I think this is something is particularly relevant to the treatment of women Veterans. As we are working to understand why some women discontinue care with the VA, or prefer to get some of their care outside of the VA. And research also is shown that providers expressed increased job satisfaction and lower burnout when they have clear guidelines and procedures for addressing IPV. So this makes a lot of sense because they are typically getting a lot more support around caring for this issue when leadership is also on board. 

Additionally, although such programming would likely be costly to get up and running, the accurate detection of IPV and treatment of IPV related problems, may lead to significant reductions in health care costs in the long run through more accurate diagnoses and appropriate treatment that leads to improvement in women’s health. This is something that I am very interesting in collaborating with others to study in the future. 

And I want to end by highlighting a few helpful resources. So for more information about IPV in general and more specifics about assessment practices, including the steps you can take when a woman screens positive for IPV, you might be interested in listening to Dr. Megan Gerber’s archived Cyberseminar entitled “IPV, An Overview for VA Clinician”. So you can get this archived seminar, it is the one that I have listed here. Also, “Futures Without Violence” is an excellent resource. This website has many clinical tools and delineates best practices for working with men and women who experience violence. And for some of the women’s Veteran programs on the call as well as other types of providers, I encourage you to check the site out as you can order safety cards, posters and other helpful awareness materials that you may want to put around your clinic. 

And finally, the National Center for PTSD, who has also developed a website that includes helpful safety planning tips, as well as advice for male and female Veterans who are wonder whether the behaviors in the relations are unhealthy. So I have included the link there, if you want to check that out or refer your Veteran patients to that website.

Finally, I did want to let you know that there is also a National IPV Research Work Group comprised of researchers and clinicians who are interested in researching IPV within the VA. I chair this group along with Dr. Melissa Dichter from the Philadelphia PA. You will see contact information in a moment about how to join this group and other relevant women’s health research groups that are going on. 

Okay, and I would like to just really thank you for taking the time to tune into my presentation today. Hopefully the information I presented today was useful and I look forward to hearing your comments, and we have plenty of time for questions.

Moderator:Thank you very much. We do have some pending questions, so we will get right to those. And Dr. Iverson, can I ask you to scroll down the final slide in your slide deck, great, thank you. Okay, the first question we have, somebody at the beginning of the session wanted to know, is this a clinical reminder? 

Dr. Iverson:Currently there is not a national clinical reminder for intimate partner violence screening. Some clinics may have implemented this type of clinical reminder, but that is on a case-by-case basis and most have not. There is talk of a clinical reminder but there is not a formal policy on this. So we should be hearing more about this in the near future. Certainly, as I mentioned earlier in my qualitative study of VA primary care providers, they did bring up clinical reminders that one possible way for the screening tool to get done in a reasonable way. So this may happen in the future, but that remains to be seen. 

Moderator:Excellent, thank you. I just want to make an announcement to those of you that joined us after the top of the hour. If you want to submit a question or a comment, just simply type it into the question section of your go to webinar dashboard on the right hand side of your screen, and then press submit. 

Somebody would like to know, what is the National DV Task Force working on?

Dr. Iverson:That is a great question, so the National VHA Domestic Violence Task Force was convened in June. And it is a group of researchers, administrators, clinicians and policy makers through various departments and areas of the VA that have really tried to come up with an agenda and potential policy for the VA as a health care system to better address intimate partner violence, both experiences of victimization and perpetration among our male and female Veterans. And so this is a large group that started meeting in June and has worked very hard to come up with a number of recommendations to VA leadership about how the VA can provide good care in terms of detection and treatment of both men and women who are impacted by IPV. And so this task force is currently ongoing, but we do have a number of recommendations that are being considered by the leadership. So we should be hearing more in the future about whether some of these recommendations are going to move forward.

Moderator:Thank you very much. We do have a number of questions streaming in now. The next one, what is the official title of the National Multidisciplinary Team currently working on this issue?

Dr. Iverson:My understanding and the documents I have seen, I cannot swear that it is the official title, but it is the National VHA Domestic Violence Task Force. 

Moderator:Thank you. Somebody asked, is not the CTS the work of Marie Strauss?

Dr. Iverson:Yes, Strauss is one of the developers of this Conflict Tactic Scale, both the original and the revised version.

Moderator:Great, I was correct. How do you anticipate your findings will affect healthcare policy?

Dr. Iverson:Well, that is a really good question. As I mentioned, I think a lot of us have been interested in doing more inquiry in our clinical work, that we have a sense that certainly we are seeing a lot of women patients who experience intimate partner violence. And when we ask about it in direct ways, we are uncovering even more experiences of intimate partner violence. And so we really have seen some of the literature that a number of screening tools can make it really kind of efficient and effective for us to identify intimate partner violence. And I think what my work here has shown is that there is a previously validated screening tool that now has data specifically with women Veterans. And, it speaks to – my findings speak to a specific cut point which we might want to consider using. 

I found in my sample, that a cut point of six on the HITS has done reasonably well in identifying women who reported past year physical, sexual, or severe psychological IPV. And you know, I think we should take that kind of cut point into consideration. Because if we had just ruled out the screening tool and used some of the cut points, I mentioned the cut point of eleven that has been used in some settings, I think we would be missing an awful lot of women which would have been a shame. So if the VA does consider ruling out universal screening that includes material supported screening tool, I think the HITS would be a reasonable option.

Moderator:Thank you for that reply. Can I ask you to refresh your screen real quick. There you go. The next question, is this tool currently being used. 

Dr. Iverson:Again, this has not been rolled out at a National level at this point. I certainly know individuals that are using this tool, I use this tool in my clinical work. I am aware of several clinics that have used the tool outside of the VA. There are an awful lot of health care settings and emergency departments, primary care, offices etc., that routinely use this tool. But there is just a lot of variability at this point within the VA. So it is hard to say exactly how many clinics are using this tool, but it is a handful. 

Moderator:Thank you for that reply, the next question we have, how is your work group collaborating with non-VA work groups?

Dr. Iverson:Well that is a great question. There has been – one of the things the task force had a number of specific work groups, for example I was part of a screening work group, and we consulted with several experts in the field that are not within the VA. For example, we reached out to Dr. Jacqueline Campbell who consulted with us about screening tools. I know that in other work groups we have consulted with others on best practices in terms of treatments or individuals who use aggression in their relationship to try to get a good understanding of what is available out there and how the data actually supports it. So there has been – we have reached out to quite a few experts outside of the VA to get insight into our recommendations. 

Moderator:Next question we have, when do you plan on expanding the study nationally, and how can I participate.

Dr. Iverson:Oh, thank you for your enthusiasm. I would love to do that as soon as possible, I have to start thinking about how to get the funding to do that kind of work. But anyone who is interested and possibly collaborating or being a site, could contact me or I would love to stay in touch, and I am just very grateful that there is enthusiasm for it. 

Moderator:Great, do any facilities have a template-screening tool based on the HITS that they could share with us all?

Dr. Iverson:You know, that is a really good question. I will ask around and try to find out. I am not aware of one that is specifically for the HITS. I know that some clinics have developed their own templates because we are able to do that at the facility level, but I am not sure how many specifically use the HITS. Because I think a lot of clinics will find, they are trying to use really brief questions, so they may include one or two questions in a template, and they may or may not be taking from validated tools. So I wish I could say I knew exactly which clinic already has a template for this, but I cannot at this point. But I love the idea.

Moderator:Thank you. Given findings of under detection of IPV among men, is there consideration of using the screener among all Veterans?

Dr. Iverson:That is a really thoughtful question that there has been a lot of discussion about. You know, we are following in some ways, the guidelines of the US Preventative Task Force at this point, which based on who was at the greatest risk for being harmed by intimate partner violence. They identify women as being most at risk at this point. Certainly we have such a better understanding of intimate partner violence experience, but men experiences intimate partner violence at high rates too. One thing we do not have the same amount of foundational research on screening men for intimate partner violence. There have been a couple of studies here or there, I am certainly not aware of any specifically with the male Veteran population, although I think that is an important area for us to do more work in. But I think until we get a better understanding of kind of understanding more of the IPV dynamics experience by men, how they feel about using a screening tool. One thing that is nice is because there has been such a long history of studying IPV among women, we have had a lot of qualitative and quantitative studies showing that women think they should be asked. They want their health care providers to ask them about experiences with intimate partner violence. And we know that we have tools that can reasonable do this. And unfortunately, we do not have that same level of foundational research for men. So I think that will be a necessary first step. But I do think that it is an extremely important line of inquiry that is being considered, and may happen sometime down the road.

Moderator:Thank you, can I trouble you to refresh your screen again.

Dr. Iverson:Oh yes.

Moderator:Thank you. Do you have recommendations for IPV screening in pregnant Veterans, frequency of screening, and any other suggestions?  

Dr. Iverson:Well I can just speak, I cannot to speak to policy on this matter, but clinically a lot of – it is a really great question, so a lot of different medical associations have come out with guidelines. And typically they recommend that you definitely screen women during pregnancy, and that you screen, basically at least once per trimester, and thereafter. And I think a number of different tools have been found to be effective with pregnant women. I think the HITS would be reasonable, if that person wants to back channel me, I can do a quick search to see if the HITS has been validated specifically with pregnant women, but in terms of the frequency, the experts recommend once per trimester at least.

Moderator:Great, the final question we have, do you think cutoff for the HITS in transgendered Veterans will be radically different?

Dr. Iverson:Oh, that is such a good question, I think it remains an empirical question, I would love to talk to whomever wrote that question. It is hard to say without looking at it empirically, because I did not come into this work thinking that we needed a lower cut off point for women Veterans. I thought it might need a different cut off point, but I wanted to kind of let the data tell me where the best cut point was. And so I think it is possible they may need a different cut point, but until we do the research, we will not really know. So I think that is the really important area for us to look into more. 

Moderator: Thank you, we do have one more question that just came in. If we do have a HITS positive test, whom shall we contact, social worker or mental health provider?

Dr. Iverson:Well I think either of those are great options. I mean I think whoever is doing the asking can do a lot of validation and support in the moment. And then, I do not know if you have a social worker as part of your team, or that is readily accessible, but they are often a great resource because they often have more training and safety assessments and planning and helping to determine what a woman’s kind of comprehensive needs are. So that is definitely a good option for referral. Certainly mental health providers can be a good referral source as well. I think what, you know, if the VA is talking more about intimate partner violence, we are seeing a lot more trainings and kind of cyber seminars on this issue. I think a lot of us will be receiving more training and have more comfort and expertise in dealing with addressing the needs of women who have experienced intimate partner violence.    

Moderator:Thank you for that reply. That is the final question, so I would like to give you a moment to make any concluding comments.

Dr. Iverson:Again, I just want to thank everybody for tuning in today and thank you for this interest in this topic. It is a topic that is close to my heart and I just wanted to give, ask you to take a look real quick at that last slide. I had mentioned at the end of my talk that there are a number of women’s health workgroups that tends to meet either by phone either monthly or bi-monthly. And they are comprised of people that are interested in researching various topic areas within one’s health scene, and you might want to take a look at that list. And you can contact Ruth Clauss if you are interested in joining one of the work groups. 

Moderator:Great.

Dr. Iverson:Ruth’s contact information is at the bottom of the slide by the way. 

Moderator:Great, I also would like to thank our attendees for joining us and also thank Dr. Iverson for lending her expertise to the field. This session has been recorded and you will receive a follow-up email with a link to the recording so you can pass it on to any colleagues that were unable to join today’s live presentation. And with that, I am going to ask that as you exit today’s session, please wait just a moment while a feedback survey populates on your screen. We do take your opinions into consideration when planning future topics or cyber seminars. So thank you once again to our presenter and to our attendees, and this does conclude today’s HSR&D Cyberseminar.  

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