Heidi D. Nelson, MD, MPH; Christina Bougatsos, MPH; Ian Blazina, MPH
Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Tracy Dana, MLS, from Oregon Health & Science University, who conducted literature searches; and Shelley Selph, MD, MPH, from Oregon Health & Science University, and Laurie Hoyt Huffman, MS, provided who additional contributions to the report.
Grant Support: By AHRQ under contract HHSA-290-2007-10057-I-EPC3, Task Order 3. This work was contracted by AHRQ and used by the U.S. Preventive Services Task Force to determine its recommendation.
Potential Conflicts of Interest: Dr. Nelson: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ. Ms. Bougatsos: Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Other (money to institution): AHRQ. Mr. Blazina: Grant (money to institution): AHRQ. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2667.
Requests for Single Reprints: Heidi D. Nelson, MD, MPH, Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098; e-mail: firstname.lastname@example.org.
Current Author Addresses: Dr. Nelson, Ms. Bougatsos, and Mr. Blazina: Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: H.D. Nelson.
Analysis and interpretation of the data: H.D. Nelson, C. Bougatsos, I. Blazina.
Drafting of the article: H.D. Nelson, C. Bougatsos, I. Blazina.
Critical revision of the article for important intellectual content: H.D. Nelson.
Final approval of the article: H.D. Nelson, C. Bougatsos.
Provision of study materials or patients: H.D. Nelson.
Statistical expertise: H.D. Nelson.
Obtaining of funding: H.D. Nelson, C. Bougatsos.
Administrative, technical, or logistic support: H.D. Nelson, C. Bougatsos, I. Blazina.
Collection and assembly of data: H.D. Nelson, C. Bougatsos, I. Blazina.
Nelson HD, Bougatsos C, Blazina I. Screening Women for Intimate Partner Violence: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2012;156:796-808. doi: 10.7326/0003-4819-156-11-201206050-00447
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Published: Ann Intern Med. 2012;156(11):796-808.
In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to support screening women for intimate partner violence (IPV).
To review new evidence on the effectiveness of screening and interventions for women in health care settings in reducing IPV and related health outcomes, the diagnostic accuracy of screening instruments, and adverse effects of screening and interventions.
MEDLINE and PsycINFO (January 2002 to January 2012), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through fourth quarter 2011), Scopus, and reference lists.
English-language trials of the effectiveness of screening and interventions, diagnostic accuracy studies of screening instruments, and studies of any design about adverse effects.
Investigators extracted data about study populations, designs, and outcomes and rated study quality by using established criteria.
A large fair-quality trial of screening versus usual care indicated reduced IPV and improved health outcomes for both groups, but no statistically significant differences between groups. Fifteen fair- and good-quality studies evaluated 13 screening instruments, and six instruments were highly accurate. Four fair- and good-quality trials of counseling reported reduced IPV and improved birth outcomes for pregnant women, reduced IPV for new mothers, and reduced pregnancy coercion and unsafe relationships for women in family-planning clinics. Fourteen studies indicated minimal adverse effects with screening, but some women experienced discomfort, loss of privacy, emotional distress, and concerns about further abuse.
Trials were limited by heterogeneity, lack of true control groups, high loss to follow-up, self-reported measures, and lack of accepted reference standards.
Screening instruments accurately identify women experiencing IPV. Screening women for IPV can provide benefits that vary by population, while potential adverse effects have minimal effect on most women.
Agency for Healthcare Research and Quality.
Analytic framework and key questions for screening women for IPV.
ED = emergency department; IPV = intimate partner violence.
* Including reduction in the level of violence or abuse and leaving an unsafe situation.
† Including physical trauma (fractures, dislocations, and brain injury); unwanted pregnancy and sexually transmitted diseases; mental trauma and its repercussions, such as depression, anxiety, and posttraumatic stress; social isolation; quality of life; and chronic medical conditions, among others.
Summary of evidence search and selection.
RCT = randomized, controlled trial.
* Cochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Identified from reference lists and suggested by experts.
‡ Includes search results for child, adult, and elderly populations. Studies of children and elderly populations are included in separate reports.
§ Studies that meet inclusion criteria for key questions, some studies apply to more than 1 key question.
Appendix Table 1.
Measures of Diagnostic Accuracy
Studies of Diagnostic Accuracy of Screening Instruments for IPV
Appendix Table 2.
Instruments Used in Studies of IPV Screening
Randomized Trials of IPV Interventions
Studies of Harms of IPV Screening
Summary of Evidence for IPV Screening
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Harriet L., MacMillan, Professor, Gene Feder, Professor
McMaster University and University of Bristol
May 18, 2012
Link between evidence and conclusion unclear in USPSTF IPV screening systematic review
As two clinician-researchers involved in the intimate partner violence (IPV) screening trial (1) that featured prominently in the recent US Preventive Services Task Force (USPSTF) systematic review on screening women for IPV (2), we were perplexed by the authors' conclusion that IPV screening can provide benefits that vary by population. This was the only trial identified as meeting the inclusion criteria to address question 1 of the review: "Does screening asymptomatic women in health care settings for current, past, or increased risk for IPV reduce exposure to IPV, physical or mental harms, or mortality?" Given that the trial results showed no differences between groups and the overall quality of the study was considered "fair", presumably the answer to question 1 would be "no" - which is what the trial authors concluded. Even taking into account the limitations of the trial, at most one would expect the answer to be "unknown". Yet the review authors concluded that IPV screening can provide benefits, extrapolating from trials of IPV interventions recruiting all participants via screening. These trials do not provide evidence for the effectiveness of screening in comparison to other methods of identifying survivors of IPV, such as clinical enquiry or case finding. Educational interventions in primary care that increase IPV disclosure rates and referral for advocacy support do not require implementation of screening (3).
We were concerned by the recent recommendation on IPV screening from the Institute of Medicine (4), given the lack of evidence of screening effectiveness and even more so by the conclusions of this USPSTF review. Previous systematic reviews have consistently found that there is insufficient evidence to justify screening women for IPV in health care settings. One of the most recent UK reviews assessed research findings against nine criteria for a public health or health care based screening program (5). The IPV screening trial that formed the basis for answering question 1 of the updated USPSTF review has provided further evidence that IPV violence screening is not justified. This is not simply an intellectual debate; the over-emphasis on means of identifying women experiencing abuse and the promotion of screening distracts attention and resources from further development of safe and effective interventions for women after disclosure of violence. We hope that the USPSTF Recommendation statement on IPV screening that is presumably forthcoming will reflect the scientific evidence and acknowledge the lack of evidence to support IPV screening.
(1) MacMillan HL, Wathen CN, Jamieson E, Boyle MH, Shannon HS, Ford- Gilboe M et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA 2009;302:493-501.
(2) Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendations. Ann Int Med 2012;156: May 7 [Epub ahead of print].
(3) Feder G, Davies RA, Baird K, Dunne D, Eldridge S, Griffiths C et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378:1788- 1795.
(4) National Research Council. Clinical Preventive Services for Women: Closing the Gaps. Washington DC: National Academies Pr; 2011.
(5) Feder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess 2009;13:iii-iv, xi-xiii, 1-113, 137-347.
H MacMillan (as principal investigator) and G Feder (as Chair of Data Monitoring Committee) were both involved in a trial of IPV screening included in the review. Both are involved in the WHO Policy and Clinical Practice Guidelines for Responding to Violence against Women (G Feder as Chair and H MacMillan as a member) and G Feder chairs the UK National Institute of Health and Clinical Excellence Domestic Violence Program Development Group.
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