Time to Screen Routinely for Intimate Partner Violence?

PRACTICE CHANGER
Use a validated tool to screen women of childbearing age for intimate partner violence (IPV) and follow up with any woman with a positive screen.¹

STRENGTH OF RECOMMENDATION
B: Based on a systematic review of 10 randomized controlled trials (RCTs), 11 prospective cohort and cross-sectional studies, and 13 diagnostic accuracy studies.

ILLUSTRATIVE CASE
A healthy 27-year-old woman schedules a visit to discuss birth control options. Should you screen her for IPV, and if so, what instrument should you use?

Each year in the United States, an estimated 5.3 million women ages 18 and older are affected by IPV, resulting in nearly 2 million injuries and more than $4 billion in direct medical and mental health costs.² In addition to the immediate effects, which include death as well as injuries from physical and sexual assault,² IPV has long-term consequences, such as chronic physical and mental illness and substance abuse.³

Too little evidence of benefit?
In 2011, the Institute of Medicine (IOM) recommended for the first time that all women of childbearing age be screened for IPV and identified IPV screening as one of a number of preventive services that are important to women’s health.⁴ The IOM’s recommendation is in line with positions held by the American Medical Association’s National Advisory Council on Violence and Abuse⁵ and the American College of Obstetrics and Gynecology.⁶ These recommendations differ from that of the US Preventive Services Task Force (USPSTF), which determined in 2004 that there was insufficient evidence for or against screening women for IPV.⁷ In issuing its I rating, the USPSTF cited a lack of studies evaluating the accuracy of screening tools for identifying IPV and a lack of evidence as to whether interventions lead to a reduction in harm.

The 2012 systematic review detailed below was undertaken on behalf of the USPSTF to assess the latest evidence and update its recommendation. The USPSTF and the Agency for Healthcare Research and Quality (AHRQ) determined the focus and scope of the review.

STUDY SUMMARY
USPSTF issues a B recommendation for IPV screening
Thirty-four studies of women who sought care in either primary care settings or emergency departments (EDs) but had no complaints related to IPV were included in the review, which addressed four key questions.

Question 1: Does screening women for current, past, or increased risk for IPV reduce exposure to IPV, morbidity, or mortality? No, according to one large RCT whose validity was compromised by high dropout rates. The researchers reviewed a multicenter RCT with 6,743 participants ages 18 to 64 to answer that question. (The study was deemed to be of fair quality because of the high percentage of dropouts from both the screened and unscreened groups.)

The women, recruited from primary care, acute care, and obstetrics and gynecology clinics in Canada, were randomly assigned to either screening with the Woman Abuse Screening Tool (WAST)—an eight-question, self-administered and validated tool—or no screening. Primary outcomes were exposure to abuse and quality of life in the 18 months after screening; secondary outcomes included both mental and physical ailments.

Those in the intervention group underwent screening before seeing their clinicians, who received the positive results before the patient encounter but were not told how, or whether, to respond. Women in both the screened and unscreened groups had access to IPV resources, including psychologists, social workers, crisis hotlines, sexual assault crisis centers, counseling services, and women’s shelters, as well as physician visits. In addition, all participants completed a validated Composite Abuse Scale, a broader (30-question) self-administered measure of IPV, at the end of the visit. Those with positive scores were followed for 18 months.

At follow-up, women in both the screened and unscreened groups had accessed additional health care services. Both groups also had reduced IPV, posttraumatic stress disorder, depression, and alcohol problems, as well as improved quality of life and mental health. There was no statistical difference in outcomes between the groups.

Question 2: How effective are the screening techniques? The efficacy of at least five tools has been demonstrated. Fifteen diagnostic accuracy studies, using cross-sectional and prospective data, evaluated a total of 13 screening instruments.

Five of the 13 screening tools—the face-to-face Hurt, Insult, Threaten, and Scream (HITS) tool, the self-administered Ongoing Violence Assessment Tool (OVAT), the face-to-face Slapped, Threatened and Throw (STaT) instrument, the self-administered Humiliation, Afraid, Rape, Kick (HARK) tool, and the WAST—were at least 80% sensitive and 50% specific in identifying IPV in asymptomatic women.

Question 3: How well do the interventions reduce exposure to IPV, morbidity, or mortality in women with positive screens? Interventions improve outcomes, according to several studies.