Screen All Women of Childbearing Age for Partner Violence, Say USPSTF, AAFP

Both the AAFP and the U.S. Preventive Services Task Force (USPSTF) have updated their positions on screening for intimate partner violence (IPV), calling on physicians to screen all women of childbearing age, regardless of whether symptoms are present, and provide or refer women who screen positive to intervention services.

According to family physician and USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., the USPSTF was able to issue its new recommendation, which was published Jan. 22 in the Annals of Internal Medicine, because of the volume of research conducted on partner violence since the previous recommendation was released in 2004.

"Since the last time the task force looked at this (topic), we have new evidence that supports the ability to screen and the effectiveness of intervention when people are identified as experiencing intimate partner violence," LeFevre told AAFP News Now. "The task force holds fairly high standards of evidence, and the last time we looked at this, we felt that there was not enough (good-quality evidence) to make a recommendation about screening women for IPV."

At that time, the USPSTF "found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse."

The AAFP's own 2004 recommendation statement mirrored that of the USPSTF, although it also noted that "The AAFP recognizes that all family physicians should be alert to physical and behavioral signs and symptoms associated with abuse or neglect."

According to LeFevre, the task force's 2004 statement disappointed some in the advocacy community, who said it did not reflect the importance of the topic. Now, however, "We feel that we have adequate evidence to make that recommendation," said LeFevre. "And the main message for family physicians now is that screening women of reproductive age for intimate partner violence can have a positive influence on their health."

LeFevre said that in his Columbia, Mo., practice, screening for IPV primarily is incorporated into regular wellness visits.

"We actually have a self-completed questionnaire that asks about personal and family history, as well as current symptoms, and we include on that (questionnaire) a question about whether (the patient) feels threatened," LeFevre said. "There are a number of screening tests referenced in the recommendation statement itself, some of which are fairly simple. The other obvious time to screen is at the first prenatal intake visit, since pregnant women are certainly at risk."

Regarding which screening tests are most effective to use in a family medicine setting, AAFP Director Wanda Filer, M.D., M.B.A., of York, Pa., talks about the efficacy of certain screening tools in her recent AAFP Leader Voices blog on domestic violence.

As for legal issues involved with screening for IPV, LeFevre said that, as a family physician, he does not have any legal concerns with regard to the new recommendation.

"For adults, you have no legal obligation to report," he said. "Your job is to either counsel or provide resources for the woman who feels threatened or has experienced intimate partner violence to optimize her chances of not being harmed by that individual in the future."

Unfortunately, not all women who experience IPV are willing to pursue recommended interventions that might benefit them, LeFevre said.

"Certainly, in my experience, the best I can do for (women who choose not seek intervention) is give them a phone number to call if they, in fact, reach a point where they feel they need or are willing to call," he said. "On the other hand, some women are certainly looking for an out (from a violent relationship), and giving them a way to do that is important care."

In addition to the current recommendation on screening women of childbearing age for IPV, both the Academy and the USPSTF indicated insufficient evidence exists to recommend for or against screening elderly or vulnerable adults (i.e., those with mental or physical disabilities) for abuse and neglect if symptoms are not present.

"While elderly abuse is common and may be underreported, adequate evidence is currently lacking," LeFevre said. "We just didn't have the same strength of evidence (as in the childbearing cohort) for the task force to recommend for intervention in elderly or venerable adults who don't present with symptoms of abuse.

"We do believe elderly maltreatment is happening, but the evidence just isn't there that says we have a reliable tool to screen for it."

In a separate draft recommendation on child maltreatment, the USPSTF said evidence remains insufficient to recommend a primary care intervention to prevent abuse among children with no signs or symptoms of maltreatment.

"This is unfortunate, because child maltreatment is a very important cause of health problems in children," LeFevre said. "I believe it was the CDC that estimated that in 2011, about 680,000 children in the United States were the victims of maltreatment, and 1,570 died. So if there was a way to detect children at risk in the asymptomatic stage and then (implement) interventions that would prevent maltreatment, this could be an important improvement to child health."

The draft recommendation will remain open for public comment until Feb. 18.