The medical and legal risks of the electronic fetal monitor

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound. Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.     

Intimate Partner Violence During Pregnancy and 1-Year Post-Partum

Using data on a nationally representative cohort of pregnant women in US cities, this study examines the prevalence and correlates of interpersonal violence (IPV)—physical, emotional, and coercion-control—during pregnancy and 1 year after birth. Overall, 33% of mothers and 40% of fathers experience some form of IPV during or after pregnancy. Hispanic women and those no longer romantically involved with their children’s fathers were most likely to experience IPV during pregnancy. Less educated women, women who reported that they or their spouses used substances (i.e., alcohol or illicit drugs), and women who reported that their pregnancy was unwanted were at high risk of IPV both during and after their pregnancy. Violence during pregnancy strongly predicted violence after pregnancy. Recent immigrants were among the least likely to leave a violent relationship 1-year post-partum. US-born women who were employed during their pregnancy were among the most likely to leave an abusive relationship 1-year post-partum. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

No room at the inn: a snapshot of an American emergency room

The emergency rooms of American hospitals have frequently become the principal suppliers of nonurgent primary care to the under- and uninsured. Canvassing published reports and using original data obtained from a representative urban hospital, Erik Olson examines the demographics of the American emergency room and analyzes its finances. The costs of providing primary care are shifted, to the extent possible, to those who can pay. The result is escalating health care costs and a deterioration of quality of care due to overcrowding, leading some hospitals to close their emergency rooms and others to turn away ambulances or "dump" patients who still require critical care. Mr. Olson explains that state antidumping laws and the federal COBRA statute have been ineffective at stemming these practices in the face of severe economic pressure to continue them. Pointing out that emergency rooms are an excessively expensive method of treating uninsured nonemergency patients, he proposes a system of primary care clinics created through a public/private partnership between municipalities and existing private health care providers. The partnership is designed to maintain a high standard of care at the clinics. As an incentive to stimulate the appearance of such clinics, a tax would be imposed on private health care providers; the tax on a given provider would be reduced to the extent that provider subsidizes a local primary care clinic that offers universal coverage, regardless of insurance status. Because the existence of such clinics would reduce inefficient use of hospital emergency rooms, in the long run hospitals should find it less expensive to finance local primary care clinics than to continue to sustain unreimbursed expenses due to improper use of their emergency departments.     

Mental disorder in violent women in secure settings: Potential relevance to risk for future violence

The relevance to women of common violence risk factors identified in men has in many instances yet to be established. Consequently, there is a reluctance to accept without question the application to women of practices relating to violence risk assessment and management developed from research into men. This study examines mental disorder in women who are violent in order comment on its relevance to the practice of violence risk assessment and management. A sample of 95 violent women in high secure prison and forensic psychiatric care were assessed. Structured assessments of Axis I and II mental disorders and psychopathy were undertaken on all women and conviction histories were recorded. Very high levels of psychiatric morbidity were noted and patterns in comorbidity were detected. Among Axis I conditions, psychotic disorders and disorders of mood co-occurred at a very high rate. Among the Axis II conditions, dimensional ratings of borderline personality disorder (PD) correlated with dimensional ratings of avoidant, dependent and paranoid PDs while ratings of antisocial PD correlated with those of narcissistic, histrionic and obsessive–compulsive PDs. Women who had been incarcerated for a major violent offence were four times more likely to have a diagnosis of borderline PD than women whose index offence was one of minor violence. A number of the findings reported are in contrast to those reported in similar studies of men. Findings suggest that practitioners are right to question the application to women of knowledge derived from research into men. The practice of violence risk assessment and management with women should emphasise the development of individual risk formulations and responding to psychiatric comorbidity should be the rule rather than the exception with this population.     

A comparison of women of color and non-Hispanic White women on factors related to leaving a violent relationship

This study compares women of color and non-Hispanic White women regarding the influence of socioeconomic status, family investment, and psychological abuse on leaving a violent relationship. It was found that most women who left stayed away for less than a month. Women of color and non-Hispanic White women did not differ in their length or rate of leaving, although women of color left more frequently when they did leave. Factors associated with leaving for both groups were threat with a weapon, psychological abuse, being single, and having fewer adults in the household. Women of color with higher socioeconomic status were less likely to leave, which was not the case for non-Hispanic White women. Non-Hispanic White women were more likely to leave if they had lived with their partners less than 5 years and had children at home.     

Help-Seeking Behavior of Female Victims of Intimate Partner Violence in Ghana: The Role of Trust and Perceived Risk of Injury

Although several studies have investigated the socio-cultural underpinnings of intimate partner violence (IPV) in Ghana, few explore the help-seeking behavior of the victims. This study examined the help-seeking behavior of female victims of IPV in Ghana. Specifically, it explored the role of perceived risk of injury and trust in determining whether and where victims seek help and their likelihood of seeking help in the event of future abuse. The study used nationally representative cross-sectional data (N =?1689) and logit regression techniques to address these research objectives. The majority of respondents who had suffered IPV had not sought help after experiencing violence. However, of these, a substantial proportion said they would do so in the future. Respondents with high perceived risk of injury from physical and emotional violence were significantly more likely to seek help from both formal and informal support networks than those who saw themselves at no risk. Those with high levels of trust in formal and informal institutions were more likely to seek help from these networks. Compared to those who did not, respondents who thought IPV should be kept private were less likely to seek help, especially in future abuse. Finding suggest policy makers should educate women about IPV, especially their risk of violence.     

Helping women understand their risk in situations of intimate partner violence

Only approximately one-half of the 456 women who were killed or almost killed by a husband, boyfriend, or ex-husband or ex-boyfriend in a recent national study of homicide of women accurately perceived their risk of being killed by their abusive partner. Women are unlikely to overestimate their risk; however, many will underestimate the severity of the situation. From the same study, it was found that relatively few of the victims of actual or attempted intimate partner femicide were seen by domestic violence advocates during the year before they were killed; they were far more likely to be seen in the health care system. Implications are drawn as to innovative ways that women who are abused can be identified and with skilled assessment of the danger in their relationship helped make more informed plans for their safety.     

Leading the health policy orchestra: the need for an intergovernmental partnership

The past decade provides a useful window through which to examine whether states are likely to provide health care leadership. During this era, states were given increased discretion to set health care policy, they had the financial resources to encourage innovation, and their administrative capacity was at its strongest ever. Despite the favorable conditions, however, states were reluctant to spend their own funds on programs for the uninsured, their efforts to make private insurance more affordable for the small business community were disappointing, and their efforts to regulate the managed care industry fell short. At the same time, though, the most promising innovations over the past decade were in programs financed primarily with federal dollars, administered primarily by state officials, and advanced by an intergovernmental partnership in which administrators at different levels of government prod each other to try and do more. This sort of intergovernmental partnership provides the best model for innovative health policy leadership.     

Qui tam claims: threat to voluntary compliance programs in health care organizations

The Department of Justice (DOJ) reports that after violent crime, health care fraud is the department's top priority. The number of health care fraud investigations pending at the DOJ increased from 270 cases in 1992 to more than 4,000 in 1997. The DOJ's primary weapon in prosecuting health care fraud is the federal False Claims Act (FCA) of 1863 (31 U.S.C. secs. 3729-3733). Almost unique among federal antifraud provisions, the FCA may also be used by "private prosecutors" to file lawsuits on behalf of the federal government charging organizations with submitting false claims to the government. The FCA rewards such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers. It also requires defendants to pay the costs and attorneys fees of successful claimants. Although the private "bounty hunter" features of the FCA data back to the Civil War, these so-called qui tam claims were nearly dormant until 1986, when Congress amended the FCA to revive their use. Following the 1986 amendments, and paralleling the rapid increase in federal reimbursements for health care costs, private qui tam claims have far expanded beyond their traditional purview of defense contracts into the field of health care. By 1997, health care providers were the targets of 54 percent of the 530 private qui tam lawsuits field that year.     

Identification of violence in Turkish health care settings

This study sought to investigate the contributing factors to and frequency of violence against health care workers (HCWs) working in western Turkey. The population is composed of a random sample of 1,209 HCWs from 34 health care workplaces. Written questionnaires were given to HCWs at all sites, where staff were instructed to register all types of violence they had experienced. In all, 49.5% of HCWs reported having experienced verbal, physical, or verbal and physical violence, with this total being made up of 39.6% men and 60.4% women. A larger percentage (69.6%) of general practitioners reported experiencing verbal abuse and physical violence by patients and patients' family members or friends. Younger workers, inexperienced staff, and those in emergency services were more likely to report violence. Violence directed toward HCWs is a common occupational hazard. Public health authorities should plan preventive interventions based on the findings of this study.     

One Step at a Time: A Latent Transitional Analysis on Changes in Substance Use,Exposure to Violence,and HIV/AIDS Risk Behaviors among Female Offenders

The aim of this analysis is to identify latent subgroups of women based on substance use, exposure to violence, and risky sexual behaviors and quantify discrete stages of behavior change over time. Data comes from 317 women recruited from a Municipal Drug Court System in the Midwest. All participants were interviewed regarding their substance use and sexual behaviors, as well as their exposure to violence at baseline, a 4th-month follow-up, and an 8th-month follow-up. A latent transitional analysis (LTA), a longitudinal extension of a latent class analysis (LCA), was used to quantify discrete stages of behavior change. The results of our analyses revealed 4 distinct behavioral profiles in our sample: 1) women with high probabilities of risky sexual behaviors, exposure to violence, and crack/cocaine use, 2) women with a high probability of exposure to violence, and moderate sexual risk taking, 3) women characterized solely by a high probability of crack/cocaine use, 4) women with low probabilities of all factors. The proportion of women in latent statuses characterized by a high probability of crack/cocaine use did not substantially decrease over time. Women who experienced child sexual abuse, had a greater number of lifetime arrests, were older, and believed they had risky drug using behavior that needed changing at baseline were significantly more likely to be in higher-risk latent statuses. Targeted interventions tailored to crack/cocaine users, as well as a wide-spread need for trauma-informed interventions among females involved in the criminal justice system, are needed.     

Reform and remembrance: the place of the private sector in the future of health care policy

Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak: that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system. there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.     

Partner killing by men in cohabiting and marital relationships: a comparative, cross-national analysis of data from Australia and the United States

Using a national-level U.S. database, T. K. Shackelford (2001) calculated rates of uxoricide (the murder of a woman by her romantic partner) by relationship type (cohabiting or marital), by ages of the partners, and by the age difference between partners. Women in cohabiting relationships were 9 times more likely to be killed by their partner than were married women. Within marriages, the risk of uxoricide decreases with a woman's age. Within cohabiting relationships, middle-aged women were at greatest risk of uxoricide. The risk of uxoricide increased with greater age difference between partners. We sought to replicate the findings of Shackelford (2001) using a national-level database that includes information on more than 4,400 homicides that occurred in Australia between 1989 and 2002. Despite the higher rate of partner killing in the United States, and despite other cultural differences between the two countries, we replicated key patterns with the Australian data.     

Severity of intimate partner violence and occurrence and frequency of police calls

This article evaluates whether female victims of severe physical, psychological, or sexual intimate partner violence (IPV) call police more often than other abused women. Abused women (431) reported frequency of contacting police (dependent variable), nature and severity of IPV experienced, and characteristics of themselves and their perpetrator (explanatory variables). A two-part regression model estimated likelihood of police contact among all participants and rate of contact among callers. Women with severe physical or psychological IPV or injury were more likely to call police than were other abused women. Among callers, women made 96% more calls if a weapon was involved, 58% more if they were severely sexually abused, and 40% more if they were severely physically abused. Women with children at home made 32% more calls. These results delineate the level and types of IPV and other characteristics of homes that make single and repeat calls to police.     

Estimating the extent of Medicaid spend-down in nursing homes

Although it is commonly thought that a very high proportion of private-pay nursing home patients become eligible for Medicaid during their stay, few national studies have been conducted to determine the extent of Medicaid "spend-down." The discharged resident survey of the 1985 National Nursing Home Survey was analyzed to determine the extent of spend-down among elderly nursing home patients during a single nursing home episode, the proportion of patients who remained Medicaid or private payers throughout their stay, and how the measures varied by patient characteristics. Overall, during a single nursing home episode only 10 percent of nursing home patients who entered as private payers received Medicaid at discharge. Roughly one-third of nursing home patients remained on Medicaid throughout their stay, and another third remained private payers throughout their stay.     

Optimal methods to screen men and women for intimate partner violence: results from an internal medicine residency continuity clinic

Contradictory data exist regarding optimal methods and instruments for intimate partner violence (IPV) screening in primary care settings. The purpose of this study was to determine the optimal method and screening instrument for IPV among men and women in a primary-care resident clinic. We conducted a cross-sectional study at an urban, academic, internal medicine residency continuity clinic in Connecticut among English or Spanish speaking adult patients. One group of patients ( n = 340) received a self-administered questionnaire (SAQ) containing the partner violence screen (PVS) and the Hurt, Insulted, Threatened or Screamed at Questionnaire (HITS). A second group (n = 126) was screened with PVS and HITS by their primary care providers during face-to-face (FTF) clinical encounters. Multivariable logistic regression models were used to determine the association between IPV prevalence and screening method (SAQ or FTF) after adjusting for socio-demographic effects. The overall IPV prevalence was 17.3% using the SAQ and 9.0% with FTF screening (p = .008). Patients receiving the SAQ were more likely to report IPV than those who were screened FTF (adjusted odds ratio [AOR]: 2.6, 95% confidence interval [CI]: 1.2-5.6). This effect persisted for women, who had a higher odds of IPV when screened through a SAQ than when screened FTF (AOR: 3.5, 95% CI: 1.4-8.6). Men did not differ in reporting IPV between methods: 11% with SAQ versus 9.4% FTF (p = .69). In internal medicine residency continuity clinics, a SAQ for IPV may result in higher disclosure and completion rates among female patients compared to FTF screening. Unique screening instruments and methods may be needed for men.     

Special report on liability and insurance. An update on assignment of patient benefits under ERISA

While the holdings in Davidowitz and Arkansas Blue Cross & Blue Shield arose in different contexts, they both reflect the courts' increasing willingness to consider the importance of cost containment in the health insurance arena, even though patient accessibility to health care may be restricted as a result. If the holding in Davidowitz is not successfully appealed, providers may need legislative relief in order to retain their ability to take valid assignments of patient claims for payment from ERISA plans. It is uncertain whether such legislation can be sought at the state level or must instead come from Congress due to ERISA preemption of state legislation. Clearly, the district court decision on remand in Arkansas Blue Cross & Blue Shield will be closely watched for any light it may shed on this question. On a pragmatic note, providers who have not entered into "participation" agreements with insurers or other private payors may now have a greater incentive to do so, and "nonparticipating" providers who continue to obtain assignments from patients in order to collect directly from insurers or other private payors should determine on a case-by-case basis whether the source of the patient's benefits is a group health plan--which is likely to fall under ERISA and may contain nonassignment provisions--or some other form of coverage. For an additional perspective on insurers' responses to copayment waivers, see Newsletter, Vol. 6, No. 10, October 1991, at 7.     

Comparing Women and Men Arrested for Domestic Violence: A Preliminary Report

This study uses criminal justice data to compare women and men arrested for domestic violence on their levels of violence, reported victimization, general criminality, and substance abuse. Participants were 45 women and 45 men convicted of domestic violence between 1996 and 1998. Results indicate that women were less likely than men to have a history of domestic violence offenses and nonviolent crimes. They were also more likely to report that they had been injured or victimized by their partner at the time of their arrest. However, in other ways, women and men were similar: they were equally likely to have used severe violence and inflicted severe injuries on their victims; to have previously committed violence against nonintimates; and to have been using drugs or alcohol at the time of their arrest. The implications for treatment for women arrested for domestic violence are discussed.     

Secure pathways for women in the UK: lessons from the women’s enhanced medium secure services (WEMSS) pilots

Abstract

Women’s enhanced medium secure services (WEMSS) is a model of care aimed at providing a more appropriate level of security for women and, in so doing, reducing the number of women in high secure psychiatric services. In 2007, three Department of Health commissioned WEMSS pilots became operational. This study compared the clinical outcomes of women in WEMSS with control women in six standard medium secure services and one high secure service matched on key clinical and risk characteristics, in order to examine their pathways of care. Our findings confirm that the WEMSS pilots were successful in transitioning women from high secure services who had previously been thought unsuitable for medium secure services. However, WEMSS showed no additional clinical benefit, suggesting that these women could be cared for equally well within standard medium secure services. We make recommendations about WEMSS and the future shape of women’s secure care in England.