Doctors urged to screen women for domestic abuse

By Monte Morin, Los Angeles Times

January 21, 2013, 8:02 p.m.

 

Asking standard questions of female patients of childbearing age shows a 'moderate net benefit' and little risk, a federal advisory panel says.

Women of childbearing age should undergo screening for domestic violence and other forms of abuse while visiting their doctor or clinic, according to a recommendation published online Monday by an influential panel of medical experts that advises the federal government.

 

That recommendation, published in the Annals of Internal Medicine, marks a significant change from 2004 when the U.S. Preventive Services Task Force found insufficient evidence to support screenings for so-called intimate partner violence, or IPV.

 

Now, citing new evidence, the task force said that screening women for IPV with a list of standard questions showed a "moderate net benefit," while the risks associated with disclosing abuse were small.

"The bottom line is that more research is needed on how primary-care clinicians can effectively screen and protect all populations, including older and vulnerable adults, middle-aged women, men and children from abuse and violence," said Dr. David Grossman, a Seattle pediatrician and task force member.

The guidelines apply only to women aged 14 to 46 who do not show obvious signs of physical or sexual abuse that would otherwise prompt questions from healthcare providers. Though the report acknowledged that women of childbearing age were not the only people who suffered abuse at the hands of former or current intimate partners, evidence was still insufficient to recommend broader screenings, the authors said.If abuse is confirmed, physicians should provide patients with, or refer them to, intervention services, the panel said. Such services include counseling, home visits, information cards, community service referrals and mentor programs.

 

In a separate draft statement addressing child maltreatment, task force members said there wasn't enough evidence to recommend how clinicians could prevent abuse among children who lacked obvious symptoms.

 

Intimate partner violence includes physical violence, sexual abuse, psychological abuse, stalking and reproductive coercion — intimidation that increases the risk of unplanned pregnancy. The Centers for Disease Control and Preventionestimates that nearly 31% of women and 26% of men have experienced IPV in their lifetimes. Immediate health consequences include injury, death, sexually transmitted diseases, unintended pregnancy, psychological distress and premature births.

 

Screening for domestic violence is recommended by the American Congress of Obstetricians and Gynecologists for women of all ages. Other organizations, such as the American Medical Assn., encourage physicians to inquire about abuse in all patients as part of medical history, but do not recommend a specific screening format or list of questions.

 

Monday's recommendation by the task force could possibly steer organizations toward adopting a more standardized protocol, according to some healthcare providers.

 

"This is very significant," said Eric Ferrero, a Planned Parenthood spokesman who was not involved in the study. "It's just good practice to know a patient's health history, and we have been conducting screenings for a number of years. Hopefully, with this recommendation, it will be done more broadly."

In the case of Planned Parenthood, which treats about 3 million patients in 800 facilities, IPV screenings were sometimes the first time that patients spoke of or even acknowledged abuse, Ferrero said. "We know, at least anecdotally, that this first discussion has led some women to leave an abusive relationship."

 

The task force recommendation was based on a review of dozens of studies and interviews with more than 30,000 people. Screenings were conducted several ways. Some women were questioned face to face by their healthcare provider and others performed self-screenings, answering questions on either a computer or a printed questionnaire.

monte.morin@latimes.com

MEDICAL NEWS: No Benefit Seen in Routine Screening for Domestic Abuse

MedPage Today
No Benefit Seen in Routine Screening for Domestic Abuse

By John Gever, Senior Editor, MedPage Today
Published: August 04, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Screening all women in medical clinics for intimate partner violence in a randomized trial did not reduce rates of abuse or improve their quality of life, researchers said. Among those for whom the screening revealed a history of abuse, recurrence of partner violence during 18 months of follow-up was reduced by a nonsignificant 18% (odds ratio 0.82, 95% CI 0.32 to 2.12) compared with control participants, according to Harriet L. MacMillan, MD, of McMaster University in Hamilton, Ontario, and colleagues. The study randomized more than 6,700 eligible and consenting women at 26 Ontario medical clinics to either screening before their medical evaluation, so that interventions could be recommended to women exposed to partner violence, or to completing the screening questionnaires after the clinic visit. Writing in the Aug. 5 Journal of the American Medical Association, the researchers found that quality of life scores improved somewhat more at the 18-month follow-up in the screened group -- from 52.1 to 58.5, compared with an increase from 50.6 to 52.7 in the control group (P<0.05). Depression scores were also modestly reduced. But when MacMillan and colleagues imputted outcomes for the more than 40% of participants in both groups who dropped out of the study during follow-up, these differences shrank to insignificance. The screened women also showed no reduction in after-effects of domestic violence, such as post-traumatic stress disorder and drug and alcohol problems, compared with the unscreened group. "These results do not provide sufficient evidence to support universal IPV screening in healthcare settings in the absence of an effective intervention to prevent or reduce intimate partner violence," the researchers concluded. The trial did not employ a specific intervention for those with positive screening results. Clinicians were informed of available local services for victimized women, but they provided referrals at their own discretion. In fact, the researchers said, "fewer than half [44%] of the screened-positive women reported having a discussion about violence with their clinician during their visit." MacMillan and colleagues said it may be argued that even small improvements in outcomes justify screening, particularly as the trial did not identify any specific harms to participants from the screening. For example, other researchers suggested last year that performing such screens on mothers bringing their children to pediatric clinics would be beneficial. (See Pediatricians Should Screen Moms for Domestic Violence) But the researchers pointed out that 87% of participants were not exposed to partner violence, suggesting a significant amount of wasted effort in the screening. They also noted that the screening had a false-positive rate of 11%, requiring additional clinical effort and opportunity costs to identify those with positive results who actually needed no intervention. In an accompanying editorial, Kathryn E. Moracco, PhD, MPH, of the University of North Carolina in Chapel Hill, N.C., and Thomas B. Cole, MD, MPH, a contributing editor at JAMA, suggested that the effectiveness of medical screening for partner violence can't be properly evaluated until there are clinic-based interventions with proven efficacy. "Specific interventions to prevent the recurrence of abuse for women at risk of violence should be implemented and rigorously tested, preferably in randomized trials, without further delay," they wrote. "The results of the [current study] should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships," they contended. In the study, women presenting at 11 emergency departments, 12 family practice centers, and three ob/gyn clinics during an 18-month period beginning in July 2005 were nominally eligible to participate. Those younger than 18 or older than 64 were excluded, as were women who did not make their own appointments or who did not have a male partner in the past year. Participation was also limited to those who spoke English, were able to be alone, and were not seriously ill. These exclusions meant that, of more than 120,000 women presenting at these clinics, about 87,000 were ineligible. Another 13,000 either refused to provide information to determine eligibility or were missed by the investigators. About 1,500 more who were eligible declined to participate. That left about 6,700 to be randomized. The investigators designated certain days as "screening days" during which all eligible and consenting female patients were asked to complete the screening questionnaire before they saw clinicians. An equal number of days provided the nonscreened control, with participants completing the questionnaire after the clinic visit. The screening instrument was the Woman Abuse Screening Tool, with the Composite Abuse Scale used to determine exposure to violence during follow-up. Other outcomes such as PTSD, depression, and substance abuse were measured with standard instruments such as the Short Form-12 and Short Form-36. Quality of life was evaluated with the World Health Organization Quality of Life (WHOQOL)–Bref questionnaire. Of 2,733 screened patients, 347 had positive results. A similar proportion of the 2,948 patients in the control group who completed the questionnaires also had positive results. Those in the unscreened group could also be asked about domestic violence if the clinician chose. Participants were interviewed every six months afterward through the 18-month follow-up period. Attrition was steady, reaching 43% in the screened group and 41% in the control patients at the end of follow-up. Growth trajectories were calculated with a logistic model for abuse recurrence and with a linear model for quality of life. A secondary analysis used imputed observations based on partial follow-up data to compensate for the high attrition. The researchers found that, among the screened-positive women still in the study at 18 months, 8% had called a crisis hotline, while 9% had contacted a counseling or advocacy center for abused women, and 4% had sought refuge at a shelter during the follow-up period. Some 26% had talked with a psychologist or social worker. These figures were very similar to those in the control group whose screening results were positive. MacMillan and colleagues said it was notable that absolute improvements in most outcomes were seen in both groups relative to baseline. They speculated that participation in the study -- being asked about intimate partner violence and its effects -- may have been beneficial in itself. Every participant was given an information card with details on services for abused women in their communities. The authors also noted that the study began during a period when crime statistics indicated violence was at a high point, and "was likely to decrease over time regardless of any intervention." Besides the high loss to follow-up, limitations to the study included the reliance on participant self-report for baseline and follow-up data, as well as the carefully controlled trial conditions that would probably not occur in ordinary medical practice. They also noted that significant costs were involved to support the highly trained research assistants who ensured that women filled out the written screen and that positive results were delivered immediately to the clinicians. In addition, each clinician received specific training. Also, the study was conducted in Canada where women have universal access to most healthcare services. The study was funded by a grant from the former Ontario Women's Health Council (Ontario Ministry of Health and Long-Term Care).  MacMillan reported holding a Canadian Institutes of Health Research (CIHR) New Emerging Team grant from the Institutes of Gender and Health.

Primary source: Journal of the American Medical Association Source reference: MacMillan H, et al "Screening for intimate partner violence in health care settings: a randomized trial" JAMA 2009; 302: 493-501. Additional source: Journal of the American Medical Association Source reference: Moracco K, et al., "Preventing intimate partner violence: screening is not enough" JAMA 2009; 302: 568-69.