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. Stength of recommendation: B: Based on a systematic review of 10 randomized controlled trials, 11 prospective cohort and cross-sectional studies, and 13 diagnostic accuracy studies

Kottenstette, Jennifer Bello

Stulberg, Debra

English

PubMed

University of Missouri: MOspace

90 The Journal of family PracTice  |   february 2013  |   Vol 62, no 2Priority updates from the research literature from the family Physicians inquiries networkPURLs®Jennifer Bello Kottenstette, MD; Debra Stulberg, MD The University of ChicagoP U R L s  E D i t o RAnne Mounsey, MD Department of Family Medicine, University  of North Carolina  at Chapel Hill Time to routinely screen   for intimate partner violence?Yes, according to the USPSTF, which says a systematic review has tipped the scale in favor of regular screening. Practice changerUse a validated tool to screen women of childbearing age for intimate partner vio-lence (IPV) and follow up with any woman with a positive screen.1StREngth of REcoMMEnDAtionB: Based on a systematic review of 10 ran-domized controlled trials, 11 prospective cohort and cross-sectional studies, and 13 di-agnostic accuracy studies.Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the US Preventive Ser-vices Task Force Recommendation. Ann Intern Med. 2012;156:796-808.illustrative casea 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 es-timated 5.3 million women ages 18 and older are affected by IPV, result-ing 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) rec-ommended 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 recommen-dation 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 stud-ies 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 systemic review detailed below was undertaken on behalf of the USPSTF to assess the latest evidence and update its rec-ommendation. The USPSTF and Agency for Healthcare Research and Quality (AHRQ) de-termined the focus and scope of the review. study summaryUSPStf issues a B recommendation  for iPV screening   Thirty-four studies of women who sought care in either primary care settings or emer-gency departments (EDs) but had no com-plaints related to IPV were included in the review, which addressed 4 key questions. Question 1: Does screening women for cur-rent, past, or increased risk of iPV reduce exposure to iPV, morbidity, or mortality? z no, according to one large Rct whose AcKnowLEDgEMEnt The Purls Surveillance System is supported in part by Grant number ul1rr024999 from the na-tional center for research resources, a clinical Trans-lational Science award to the university of chicago. The content is solely the re-sponsibility of the authors and does not necessarily represent the official views of the national center for research resources or the national institutes of health.conTinuedvalidity was compromised by high dropout rates. The researchers reviewed a multi-center RCT with 6743 participants ages 18 to 64 years 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 8-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 under-went 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 wom-en’s shelters, as well as physician visits. In ad-dition, all participants completed a validated Composite Abuse Scale, a broader (30-ques-tion) 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 ac-cessed additional health care services. Both groups also had reduced IPV, posttraumatic stress disorder, depression, and alcohol prob-lems, and improved quality of life and mental health. There was no statistical difference in outcomes between the groups.  Question 2: how effective are the screen-ing techniques?z the efficacy of at least 5 tools has been demonstrated. Fifteen diagnos-tic 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 mor-tality in women with positive screens? z interventions improve outcomes, according to several studies. One good-quality RCT comparing prenatal behavioral counseling by psychologists or social workers with usual care found that the intervention led to decreased IPV up to 10 weeks’ postpartum and improved birth outcomes. These included a reduction in preterm births, increased mean gestational age, and decreased rates of very low birth weight, although the difference for very low birth weight was not statistically significant. One fair-quality trial comparing home visitation by paraprofessionals with usual care for postpartum women led to lower rates of IPV for those in the home visitation group 3 years after the intervention. Another study compared a counseling intervention with usual care for women who had reported recent IPV. The intervention led to a decrease in pregnancy coercion—being physically or verbally threatened with preg-nancy or prevented from using contracep-tion—and an increase in the likelihood of ending an unsafe relationship. Two trials evaluating counseling vs wallet-sized referral cards and nurse manage-ment vs usual care during pregnancy showed improved outcomes in both the intervention and control groups, with no statistically sig-nificant difference between them.  Question 4: what are the adverse effects of screening for iPV and interventions to reduce harm?z there are few—if any—adverse ef-fects, according to 3 Rcts and several de-scriptive studies. The RCTs found no adverse effects of screening or IPV interventions. De-scriptive studies showed low levels of harm among a wide range of study populations and a variety of methods. However, some women experienced loss of privacy, emotional dis-tress, and concerns about further abuse.91JfPonline.com Vol 62, no 2  | february 2013  |  The Journal of family PracTice92 The Journal of family PracTice  |   february 2013  |   Vol 62, no 2PURLs®What’s neWB recommendation is finalized Given the relative safety of screening, the po-tential benefits of interventions for women who have positive screens, and the availabil-ity of accurate screening instruments, the USPSTF disseminated a draft recommen-dation that health care providers screen all women between 14 and 46 years old for IPV.At presstime in late January, the recommen-dation was finalized.8caveats Universal screening questions remainWhile the findings from this systematic review led the USPSTF to upgrade its recommenda-tion for IPV screening from an I (insufficient evidence) to a B (moderate to substantial benefit of screening), additional high-quality studies are needed to definitively reveal the benefit of screening. The validity of the large multicenter RCT that found no benefit from IPV screening was compromised by high dropout rates and, po-tentially, by the fact that women in the control group had access to materials that increased IPV awareness. Overall, the trials included in this systematic review ranged from fair to good quality and had relatively high and differential rates of loss to follow-up, enroll-ment of dissimilar groups, and concern for the Hawthorne effect (in which participants change their behavior simply as a result of be-ing involved in a study). What’s more, some trials used narrowly defined populations, which could limit ap-plicability. And, while some earlier studies had found higher rates of IPV disclosure us-ing self-administered instruments compared with face-to-face questioning, more research is needed to identify the optimal screening method.9challenges to imPlementationthe right screen—and reliable follow-upFive of the screening instruments used in studies included in this systematic review ac-curately identified women with past or pres-ent IPV. Three of these are suitable for use in primary care:•   HARK, a self-administered screen available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1•   HITS, a face-to-face screen •   WAST, a self-administered screen (more information about these screens is available at http://www.cdc.gov/ncipc/pub-res/images/ipvand svscreening.pdf).After deciding which instrument to use, family physicians still must determine how to incorporate screening into a busy practice. Finally, physicians should not screen for IPV until reliable procedures and resources for follow-up of patients who screen positive have been identified. Resources are readily avail-able through local and national hotline num-bers. The number of the National Domestic Violence Hotline is 800-799-SAFE.               JFPcopyright © 2013. family Physicians inquiries network.all rights reserved. 1.   Nelson HD, Bougatsos C, Blazina I. Screening women for inti-mate partner violence: a systematic review to update the US Pre-ventive Services Task Force recommendation. Ann Intern Med. 2012;156:796-808. 2.   National Center for Injury Prevention and Control. Costs of in-timate partner violence against women in the United States. March 2003. Available at: http://www.cdc.gov/violencepreven-tion/pdf/IPVBook-a.pdf. Accessed November 7, 2012. 3.   Coker AL, Davis KE, Arias I, et al. Physical and mental health ef-fects of intimate partner violence for men and women. Am J Prev Med. 2002;23:260-268. 4.   Committee on Preventive Services for Women, IOM. Clinical preventive services for women: closing the gaps. July 2011. Avail-able at: http://www.iom.edu/Reports/2011/Clinical-Preventive- Services-for-Women-Closing-the-Gaps.aspx. Accessed Novem-ber 7, 2012 . 5.   AMA, National Advisory Council on Violence and Abuse. Policy compendium. April 2008. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/386/vio_policy_comp.pdf. Acces-sed November 7, 2012. 6.   American College of Obstetricians and Gynecologists. Screening tools—domestic violence. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Violence_Against_Women/Screening_Tools__Domestic_Violence. Accessed November 7, 2012. 7.   US Preventive Services Task Force. Screening for family and intimate partner violence. 2004. Available at: www.uspreventi-veservicestaskforce.org/3rduspstf/famviolence/famviolrs.htm. Accessed November 7, 2012. 8.   US Preventive Services Task Force. Screening for intimate part-ner violence and abuse of elderly and vulnerable adults. Avail-able at: http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderfinalrs.htm. Accessed January 29, 2013.  9.   Kapur NA, Windish DM. Optimal methods to screen men and women for intimate partner violence. J Interpers Violence. 2011;26:2335-2352.referencesAt least  3 screening  instruments for intimate partner violence are  suitable for use in primary care.

Time to routinely screen for intimate partner violence?

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Time to routinely screen for intimate partner violence?

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