Cochrane in CORR ®: Screening Women for Intimate Partner Violence in Healthcare Settings (Review)

Importance of the Topic The orthopaedic surgeon's role in the identification and care of patients experiencing intimate partner violence (IPV) has gained considerable interest in the surgical community during the last few years. With the publication of the Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation (PRAISE) study [9] that determined the global prevalence of IPV in orthopaedic clinics, and a series of subsequent studies specifically focusing on IPV in orthopaedic settings [7, 11, 12], orthopaedic surgeons are becoming aware that IPV affects a staggeringly large number of the women whom they treat. One in six women in fracture clinics has experienced IPV in the past year and one in 50 women present to fracture clinics with IPV-related injuries [9]. More than one in four women (28%) in IPV-therapy programs who have experienced abuse have musculoskeletal injuries requiring medical attention [2]. Since 45% of women who are killed by their intimate partner present to emergency departments within 2 years before their death [10], physicians and orthopaedic surgeons have an important opportunity to prevent further injuries and death for their patients. In recent years, a number of IPV screening and assistance programs have been implemented and tested in medical settings. These screening programs typically aim to ask every woman presenting for treatment a set of standardized questions to elicit disclosure of IPV. Assistance programs take this concept one step further by processes of referral, advocacy, or counseling once patients disclose IPV in order to reduce the health, social, economic and/or psychological consequences of IPV. Despite the availability of published randomized trials, recommendations about screening for IPV from health organizations have been conflicting [8, 13] and the value of screening is highly debated [4]. This Cochrane review evaluated the efficacy of screening programs for IPV in clinical settings. Based on evidence from 13 randomized trials (14,959 women) the authors concluded that there is insufficient evidence to recommend screening all women for IPV in clinical settings. It should be noted that the review did not evaluate IPV screening programs that also included a counseling, advocacy, or social services intervention. It should also be noted that, although domestic violence can affect men and women and is harmful to all persons affected, the review focuses only on interventions directed at women who have experienced IPV. Upon Closer Inspection While IPV screening programs demonstrated a considerable improvement in IPV identification, there were no major differences in referring patients to social services or counselling. The review also evaluated reduction of IPV, physical health, psychosocial health, and resource use. The authors were unable to pool these outcomes, but none showed significant differences between groups in individual trials. The authors concluded that these IPV screening programs that focus on identification of patients who have experienced IPV only are ineffective. Although this meta-analysis was thorough and of high quality, identification and referral rates, the focus of the study, are not patient-important outcomes. Studies that evaluate the effects of patient-important outcomes such as physical and mental health outcomes would be more valuable in reporting efficacy of IPV interventions. Indeed, there was little data on outcomes that could be classified as patient-important. Additionally, patients in these studies were only asked about IPV once. It is important to ask patients about IPV multiple times during the course of their care, since patients may need to establish a relationship with the healthcare professional before they feel ready to disclose [12]. This is part of the reason that orthopaedic surgeons have an advantage compared to emergency physicians when it comes to discussing IPV with patients. It should also be noted that no trials were conducted in an orthopaedic setting (the PRAISE study was not interventional), so applicability to orthopaedic clinics is unclear. Further research is recommended evaluating interventions specifically for orthopaedic settings. Take-home Messages The conclusion from the authors that screening is ineffective does not mean that healthcare professionals should abandon the idea of identifying and helping patients who have experienced IPV. In fact, these findings highlight the fact that screening alone does not necessarily lead to improvements in any meaningful outcomes for patients, and perhaps a more rigorous “active” intervention is warranted. Trials evaluating IPV identification paired with referral or counselling services, which were not included in this review, demonstrate a positive impact on the lives of patients who have experienced IPV [5, 6]. We recommend that IPV interventions go beyond identification alone, and are evaluated based on patient-important outcomes such as reduction in IPV frequency and/or severity, or IPV-related health outcomes that directly impact a patient's health and well-being. The American Academy of Orthopaedic Surgeons and other orthopaedic organizations have position statements that encourage orthopaedic surgeons to become familiar with IPV and their role in caring for abused women [1, 3]. Personnel in orthopaedic clinics can do five simple things to help the women whom they treat who may be experiencing IPV, even without establishing a formal screening and intervention program [1]. Be aware that IPV affects about one in six of the women whom you treat. If you feel comfortable asking your patients about IPV, here is a suggested method: “Because violence is so common in many women's lives, and because there is help available for women being abused, I now ask every patient about domestic violence.” Follow with three validated questions: (1) Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? (2) Do you feel safe in your current relationship? (3) Is there a partner from a previous relationship who is making you feel unsafe now? [3]. If a patient discloses IPV, be supportive and validate her disclosure; tell her that the abuse is not her fault. Become familiar with local resources, including hospital/clinic social services and community-based resources. For example, call the National Domestic Violence Hotline (1-800-799-SAFE) in the United States or visit sheltersafe.ca in Canada. If reporting is not mandatory in your jurisdiction and no children are at risk, always ensure that you have the patient's permission to contact outside services like police or shelters.

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