Intimate partner violence (IPV) -- or domestic/dating violence -- affects more than one in three women in their lifetimes.
Most seriously, it can result in injury and death, but IPV also can leave lasting effects such as mental illness, substance abuse, suicidal behavior, sexually transmitted infections and unintended pregnancy.
Women are at increased risk for IPV if they were exposed to violence as a child, are young or unemployed, abuse substances, or have marital difficulties or economic hardships.
On April 24, in an effort to re-examine what can be done to help treat IPV, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening for IPV, elder abuse and abuse of vulnerable adults.
- On April 24, in an effort to re-examine what can be done to help treat intimate partner violence (IPV), the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement and draft evidence review on screening for IPV, elder abuse and abuse of vulnerable adults.
- Based on its review of the evidence, the USPSTF recommended clinicians screen all women of reproductive age for IPV and provide or refer those who screen positive to ongoing support services that provide a range of emotional, social and behavioral support -- a "B" recommendation.
- Additionally, the USPSTF concluded that current evidence was insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults.
Based on its review of the evidence, the USPSTF recommended that clinicians screen all women of reproductive age for IPV and provide or refer those who screen positive to ongoing support services that provide a range of emotional, social and behavioral support -- a "B" recommendation.(www.uspreventiveservicestaskforce.org)
"Clinicians can make a real difference for women suffering from intimate partner violence by helping identify them and getting them the support they need," said task force member and family physician John Epling Jr., M.D., M.S.Ed., in a news release.(www.uspreventiveservicestaskforce.org) "The task force found that screening tools can help detect intimate partner violence among women, and ongoing support services can reduce physical and sexual violence and psychological abuse."
The USPSTF said IPV is also a serious issue in men, but research is significantly lacking on screening and interventions for these patients. In turn, the task force called for more research on IPV and men.
Additionally, the USPSTF concluded that current evidence was insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older (ages 60 or older) or vulnerable adults (those who are physically or mentally dysfunctional) -- an "I" recommendation.
"Unfortunately, the task force was unable to make a recommendation about elder abuse and abuse of vulnerable adults due to a complete lack of evidence," said USPSTF member Melissa Simon, M.D., M.P.H., in the release. "Until more research is available, clinicians should continue to use their clinical judgment and connect patients who they suspect may be the victims of abuse with resources as appropriate."
This draft recommendation statement is consistent with the USPSTF's 2013 final recommendation statement,(www.uspreventiveservicestaskforce.org) which the AAFP supported at the time.
Draft Recommendation Details
The USPSTF commissioned a systematic evidence review to update its 2013 recommendation on screening for the prevention of IPV, elder abuse and abuse of vulnerable adults. The scope of the recent review was similar to that of 2013, but for this draft recommendation, the task force also examined the evidence on men and adolescents as victims of IPV.
This evidence review identified 15 fair-quality studies assessing the accuracy of 12 screening tools for IPV.
All studies enrolled adults, with most including only women or a majority of women, while one study included only men.
The B recommendation was issued for women of reproductive age because that was the age range in most of the studies reviewed -- from around ages 12-49 years.
These studies recruited from a variety of settings: five recruited from emergency departments, four from primary care practices, one from urgent care, and three recruited women by telephone or mail survey.
Most of these studies assessed a tool designed to identify patients exposed to IPV in the past year.
"However, six studies reported on the accuracy of a tool for identifying current (ongoing) abuse, two assessed the accuracy of detecting lifetime abuse and one assessed the accuracy of a tool for predicting future (three to five months) abuse," the draft recommendation said.
The draft recommendation statement highlighted screening instruments that had reasonable accuracy to detect IPV in the past year in adult women:
- Humiliation, Afraid, Rape, Kick (HARK);
- Hurt/Insult/Threaten/Scream (HITS);
- Extended Hurt/Insult/Threaten/Scream (E-HITS);
- Partner Violence Screen (PVS); and
- Woman Abuse Screening Tool (WAST).
Across all screening tools, sensitivity ranged from 64 percent to 87 percent and specificity ranged from 80 percent to 95 percent.
One study that enrolled only men from an emergency department reported on the accuracy of the PVS and HITS for detecting past-year IPV. Sensitivity was low for both tools for detecting psychological abuse (30 percent and 35 percent, respectively) and physical abuse (46 percent for both).
For identifying ongoing, current relationship violence in populations enrolled from emergency departments, two studies reported on the accuracy of screening tools not previously mentioned.
The first study found a sensitivity of 86 percent and specificity of 83 percent for the Ongoing Violence Assessment Tool (OVAT) compared with the Index of Spouse Abuse.
The second study found relatively poor accuracy for the Abuse Assessment Screen (AAS) and Ongoing Abuse Screen (OAS) tools.
The evidence review identified one fair-quality study assessing the accuracy of screening for abuse in older adults; no studies were available on the effectiveness of screening questionnaires or tools in identifying abuse and neglect of vulnerable adults.
Screening was conducted using the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST), which includes 15 items.
Compared with the Conflict Tactics Scale (violence/verbal aggression scales combined), the H-S/EAST had a sensitivity of 46 percent and specificity of about 73 percent.
The USPSTF found no valid, reliable screening tools to identify abuse of older or vulnerable adults in the primary care setting.
Family Physician's Perspective
Jennifer Frost, M.D., medical director for the AAFP's Health of the Public and Science Division, told AAFP News that family physicians can use accurate screening tools, such as HARK and HITS, to screen their female patients of childbearing age for IPV.
"Physicians can ask the screening questions directly, or the questions can also be given in written form," she said. "It's important that women are screened in private, and if there is a language barrier, it's not appropriate to use family or friends to translate."
And while there may be signs and symptoms of abuse, Frost said, more often there are not.
"Family physicians may think they 'know' their patients, but intimate partner violence is relatively common, affecting women of all races, education levels and socioeconomic status," she said.
If there is suspicion of abuse, Frost said no matter the age or sex of the patient, family physicians should evaluate the patient and offer services or report the abuse, as appropriate.
"When a woman screens positive for intimate partner violence, it's important to provide her with ongoing support," she said. "Services for victims of IPV vary by community, so it's important for family physicians to know what support systems are available and how to contact them."
As for screening elderly patients for abuse, Frost said that while there isn't sufficient evidence that screening this population affects outcomes, it's still very common for older adults to be victims of violence and neglect.
"How we manage these situations depends on several variables, such as the patient's age, health status, living situation and support system," she said. "If abuse is suspected, Adult Protective Services may be able to help."
The USPSTF is inviting comments on its draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review.(www.uspreventiveservicestaskforce.org) The public comment window is open until 8 p.m. EDT on May 21. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.
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