Intimate partner violence against women: To screen or not to screen in the emergency department?

Commentary

CJEM 2004;6(1):38-39

The Recommendation Statement from the Canadian Task Force on Preventive Health Care (CTFPHC) on the prevention of violence against women was published in the Sept. 16, 2003, issue of the Canadian Medical Association Journal.¹ It does not recommend for or against screening for intimate partner violence (IPV), due to insufficient evidence. Although this may seem like a blow to women's advocacy groups and health organizations, the CTFPHC recommendation gives emergency physicians and nurses some direction based on existing evidence; it suggests we should not expend limited emergency department (ED) resources on IPV screening until it is clear that such screening does more good than harm.

Partner violence is a serious heath and social problem but, for a variety of reasons, EDs deal with it less effectively than with other health problems. There are many IPV screening tools -- some are even validated in ED settings -- but like most screening tests, these have false- positives and false-negatives that may lead to adverse consequences.² In addition, studies have shown that universal screening for IPV is not universally accepted by women who present to the ED for treatment, nor universally applied by ED staff.^3-6 In settings where ED staff compliance with IPV screening has been high, this compliance has been short-lived.^4-7 There is also evidence that when patients provide information suggesting IPV it is not always acted upon by ED staff.⁴ Most important is the fact that there is insufficient evidence of effective treatment for IPV victims.⁸ Hence the CTFPHC recommendation.

The difference between screening, case finding and diagnosis must be understood. Screening is applied universally to a convenient population; for example, all adult women attending the ED. Case finding refers to the application of diagnostic tests to patients who belong to a high-risk group but present for (apparently) unrelated illness. To illustrate, an ED might "case-find" in patients with suspicious or high-risk presentations. Diagnosis involves identifying the cause of the problem that triggered the ED visit; so, although emergency staff should consider IPV in the differential diagnosis for any adult female patient who presents with evidence of assault, this would not be considered screening or case finding. Therefore, while the task force does not advocate "screening" all ED patients, their recommendations do not preclude "case finding" among patients with suspicious or high-risk presentations, or treating victims of IPV.

If there is insufficient evidence for or against IPV screening, why do leading medical organizations advocate for it? Most important, the prevalence of IPV in women attending EDs in the US is high, and the outcome is sometimes fatal.^3,9 Not screening might be construed as lack of concern about an important woman's health and emergency medicine issue. It is important, however, to consider the potential harm related to inaccurate or ineffective screening.⁷ Patients whose screening results are false-negative may believe they do not meet some defined criteria and are ineligible for assistance. They may, therefore, remain at risk without further attempts to seek help. Similarly, false-positive results of screening might lead to conflict within the relationship or unnecessary separation. Furthermore, the time and resources spent on IPV screening are time and resources taken away from other investigations and treatment for which there is good evidence.

In short, IPV screening policies lack evidence of effectiveness and are not well supported by ED providers. If and when randomized controlled trials provide evidence that the ED is an appropriate site for IPV screening and that effective treatment exists, screening policies can be implemented with the necessary supporting resources. Until then the best and perhaps safest course of action is to recognize that IPV is a serious health problem with a measurable mortality rate, that many of these victims will present to the ED for help, and that health practitioners are obligated to provide the best available care for all identified IPV victims. This should generally include a social work consultation (if available), identification of children at risk, information about available community resources, and assistance in finding a safe shelter. In the interim, emergency physicians can serve IPV victims best by collectively lobbying for funding to support high quality, ED-based studies to discover the most accurate IPV screening methods and the most effective interventions.

References

1. Wathen CN, MacMillan HL, with the Canadian Task Force on Preventative Health Care. Prevention of violence against women. Recommendation statement from the Canadian Task Force on Preventative Health Care. CMAJ 2003;169(6):582-4.
2. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277(17):1357-61.
3. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women. Incidence and prevalence in an emergency department population. JAMA 1995;273(22):1763-7.
4. Rhodes KV, Lauderdale DS, He T, Howes DS, Levinson W. "Between me and the computer": increased detection of intimate partner violence using a computer questionnaire. Ann Emerg Med 2002;40(5):476-84.
5. Larkin GL, Hyman KB, Mathias SR, D'Amico F, MacLeod BA. Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors. Ann Emerg Med 1999;33(6):669-75.
6. McGrath ME, Bettacchi A, Duffy SJ, Peipert JF, Becker BM, St. Angelo L. Violence against women: provider barriers to intervention in emergency departments. Acad Emerg Med 1997;(4):297-300.
7. Heron SL, Kellermann AL.Screening for intimate partner violence in the emergency department: Where do we go from here? Ann Emerg Med 2002;40(5):493-5.
8. Wathen CN, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289(5):589-600.
9. Muelleman RL, Lenaghan PA, Pakieser RA. Nonbattering presentations to the ED of women in physically abusive relationships. Am J Emerg Med 1998;16:128-31.