Draft Research Plan
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
May 26, 2016
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Intimate Partner Violence
a Includes reduction in the frequency or severity of IPV.
b Includes acute and chronic morbidity from physical trauma (e.g., fractures, dislocations, brain injury), sexual trauma (e.g., unwanted pregnancy, sexually transmitted infections), and mental trauma (e.g., depression, posttraumatic stress disorder); health care utilization attributed to abuse/neglect and associated physical and mental morbidity (e.g., rates of emergency room visits); adverse perinatal outcomes (e.g., miscarriage, low birth weight); social isolation; quality of life; and others.
This figure depicts the analytic framework that outlines the key questions addressed and the evidence covered in this research plan, including populations, screenings/interventions, and outcomes. On the left, the population of interest is specified as adults without obvious signs and symptoms of IPV. Moving from left to right, the figure illustrates the overarching question: Does screening for current, past, or increased risk for IPV reduce exposure to IPV, physical or mental morbidity, or mortality in asymptomatic adults and adolescents (key question 1)? The figure depicts the pathway from screening to reduction in IPV, reduction in physical or mental morbidity, and quality of life operating through exposure to IPV or risk of IPV (key question 2). Screening may result in harms (key question 3). The figure also illustrates the question: how well do interventions reduce exposure to IPV, physical or mental morbidity, or mortality among screen-detected adults and adolescents with current, past, or increased risk for IPV (key question 4)? Interventions may result in harms (key question 5).
Abuse of Elderly and Vulnerable Adults
a Includes reduction in the level of violence or abuse or leaving an unsafe situation.
b Includes acute and chronic morbidity from physical trauma (e.g., fractures, dislocations, brain injury), sexual trauma (e.g., unwanted pregnancy, sexually transmitted infections), and mental trauma (e.g., depression, posttraumatic stress disorder); health care utilization attributed to abuse/neglect and associated physical and mental morbidity (e.g., rates of emergency room visits); adverse perinatal outcomes (e.g., miscarriage, low birth weight); social isolation; quality of life; and others.
Abbreviations: IPV=intimate partner violence; KQ=key question.
This figure depicts the analytic framework that outlines the key questions addressed and the evidence covered in this research plan, including populations, screenings/interventions, and outcomes. On the left, the population of interest is specified as elderly and vulnerable adults without obvious signs or symptoms of abuse or neglect. Moving from left to right, the figure illustrates the overarching question: Does screening in health care settings for current, past, or increased risk for abuse and neglect in asymptomatic elderly and vulnerable adults reduce exposure to abuse and neglect, physical or mental morbidity, or mortality (key question 1)? The figure depicts the pathway from screening to reduction in abuse/neglect, reduction in physical or mental morbidity, and quality of life operating through exposure or risk of exposure to abuse/neglect (key question 2). Screening may result in harms (key question 3). The figure also illustrates the question: How well do interventions reduce exposure to abuse and neglect, physical or mental morbidity, or mortality among screen-detected elderly and vulnerable adults with current, past, or increased risk for abuse and neglect (key question 4)? Interventions may result in harms (key question 5).
Intimate Partner Violence
- Does screening for current, past, or increased risk for intimate partner violence (IPV) in asymptomatic adults and adolescents reduce exposure to IPV, physical or mental morbidity, or mortality?
- What is the accuracy of screening questionnaires or tools for identifying asymptomatic adults and adolescents with current, past, or increased risk for IPV?
- What are the harms of screening for IPV in asymptomatic adults and adolescents?
- How well do interventions reduce exposure to IPV, physical or mental morbidity, or mortality among screen-detected adults and adolescents with current, past, or increased risk for IPV?
- What are the harms of interventions to reduce exposure to IPV in asymptomatic adults and adolescents?
Abuse of Elderly and Vulnerable Adults
- Does screening in health care settings for current, past, or increased risk for abuse and neglect in asymptomatic elderly and vulnerable adults reduce exposure to abuse and neglect, physical or mental morbidity, or mortality?
- How effective are screening questionnaires or tools in identifying asymptomatic elderly and vulnerable adults with current, past, or increased risk for abuse and neglect?
- What are the harms of screening for abuse and neglect in elderly and vulnerable adults?
- How well do interventions reduce exposure to abuse and neglect, physical or mental morbidity, or mortality among screen-detected elderly and vulnerable adults with current, past, or increased risk for abuse and neglect?
- What are the harms of interventions to reduce exposure to abuse and neglect in elderly and vulnerable adults?
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
Intimate Partner Violence
- What factors limit the applicability of IPV screening and treatment studies conducted in emergency room settings to primary care settings?
Elderly and Vulnerable Adults
- What factors limit the applicability of elderly/vulnerable adult abuse and neglect screening and treatment studies conducted in emergency room settings to primary care settings?
The Proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions (KQs).
Intimate Partner Violence
| Include | Exclude | |
|---|---|---|
| Populations | Adolescentsa and adults (male and female) presenting for primary care services without signs or symptoms of IPV or abuseb | Persons undergoing diagnostic evaluations who have signs or symptoms of exposure to violence or abuse (e.g., those presenting with signs of physical abuse) |
| Screening | KQs 1–3: Screening tests designed to detect current or past IPV victimization or risk status for IPV victimization. These include self-administered, computer-enabled, or patient self-report instruments, as well as clinician-to-patient instruments. Instruments must be feasible for use for screening in U.S. primary care settings (i.e., brief, easy to interpret, acceptable to patients and clinicians). | KQs 1–3: Screening tests designed to identify perpetrators of IPV |
| Interventions | KQs 4, 5: Services that could be offered in or referred to by primary care; services may be implemented by nonclinicians, including the following services: counseling, home visitation, mentor support, referral to community services, and others | KQs 4, 5: Public awareness campaigns without specific interventions linked to screening; studies of other interventions that do not include a health service component (e.g., effectiveness of women's shelters, unless referred by a clinician) |
| Comparisons | KQs 1, 3: Screened vs. nonscreened groups
KQ 2: Eligible instrument must be compared with an acceptable reference standard (verified or self-reported abuse or longer validated instrument of abuse) KQs 4, 5: No treatment, usual care, attention control, or waitlist control |
KQs 4, 5: Head-to-head comparisons of two active interventions |
| Outcomes | KQs 1, 4: Reduced exposure to IPV as measured by a validated instrument (e.g., Community Composite Scale)self-report frequency of abuse (e.g., number of physical assaults), or discontinuation of an unsafe relationship; physical morbidity caused by IPV, including acute physical trauma (e.g., fractures, dislocations), chronic medical conditions (e.g., chronic pain, brain injury), and sexual trauma; mental health morbidity caused by IPV, including acute mental trauma (e.g., stress, nightmares) and chronic mental health conditions (e.g., posttraumatic stress disorder, depression); sexual trauma, unintended pregnancy, and sexually transmitted diseases; adverse perinatal outcomes (e.g., preterm birth, low birth weight, decreased mean gestational age); health care utilization attributed to physical or mental effects of IPV (e.g., rates of emergency room visits); quality of life and social isolation; and mortality
KQ 2: Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, diagnostic odds ratios, and relative risks for future abuse KQ 3: Psychosocial harms, false-positive or false-negative results, and any other potential effects of screening or identification (e.g., increased abuse) KQ 5: Any harms that result due to interventions, such as increased verbal abuse, emotional distress, and others |
All KQs: Screening or referral rates, attitudes about screening, plans or intentions related to screening, and other intermediate outcomes
KQ 2: Theory or survey development and validation without correlation to abuse outcomes, studies that focus only on particular risk factors, or assessment of provider or participant attitudes toward the instrument |
| Study Designs | All KQs: Randomized, controlled trials
KQ 2: Cross-sectional and cohort studies of diagnostic accuracy are also eligible KQs 3, 5: Cohort studies with a concurrent control group are also eligible |
All other study designs, including case series and case-control studies; systematic reviews;c and others |
| Quality | Studies rated good or fair quality | Studies rated poor quality |
| Clinical Setting | All KQs: Primary care clinics or other settings where primary care services are offered, such as student health centers, emergency rooms,d and others
KQs 4, 5: Settings referable from primary care are also eligible |
Nonclinically-based settings or nonapplicable settings (e.g., prisons) |
| Country Setting | Research conducted in the United States or in populations similar to U.S. populations with services and interventions applicable to U.S. practice (i.e., countries categorized as “very high” on the United Nations Human Development Index (as defined by the United Nations Development Programme) | Research not relevant to the United States (i.e., countries not categorized as “very high” on the Human Development Index) |
| Language | Full text published in English | Not English language |
a Studies enrolling adolescents at any age will be included as long as the focus is on abuse from an intimate partner and not a parent or other caregiver.
b Adults and adolescents with problems directly related to abuse (e.g., physical injuries) will have evaluations outside the scope of screening.
c Relevant systematic reviews will be identified in database searches and used for hand searches to ensure the databases have captured all relevant studies.
d In the evidence review, the EPC will stratify the results by study setting in order to assess whether results for IPV screening accuracy and intervention studies differ based on whether populations were enrolled from primary care or emergency room settings.
Abuse of Elderly and Vulnerable Adults
| Include | Exclude | |
|---|---|---|
| Populations | Elderly (age ≥60 years) and vulnerable adult (age ≥18 years) populations presenting for primary care services without signs or symptoms of abuse or neglect | Elderly (age ≥60 years) and vulnerable adult (age ≥18 years) populations presenting for primary care services without signs or symptoms of abuse or neglect |
| Screening | KQs 1–3: Screening tests designed to detect current or past abuse or neglect or risk of being abused. These include self-administered, computer-enabled, or patient self-report instruments, as well as clinician-to-patient screening methods; screening may involve input from caregivers. Instruments must be feasible for use in U.S. primary care settings (i.e., brief, easy to interpret, acceptable to patients and clinicians). | KQs 1–3: Screening to detect behavioral problems in elderly and vulnerable adults with specific conditions (e.g., Alzheimer’s dementia) |
| Interventions | KQs 4, 5: Services that could be offered in or referred to by primary care; services may be implemented by nonclinicians, including the following services: counseling, home visitation, referral to community services, and others | KQs 4, 5: Public awareness campaigns without specific interventions linked to screening; studies of other interventions that do not include a health service component (e.g., effectiveness of nursing facility policies and procedures to reduce violence) |
| Comparisons | KQs 1, 3: Screened vs. nonscreened groups
KQ 2: Eligible instruments must be compared with an acceptable reference standard (verified or self-reported abuse or longer validated instrument of abuse) KQs 4, 5: No treatment, usual care, attention control, or waitlist control |
KQs 4, 5: Head-to-head comparisons of two active interventions |
| Outcomes | KQs 1, 4: Reduced exposure to abuse or neglect (e.g., reduced episodes of physical violence); physical morbidity associated with abuse or neglect, including physical trauma (e.g., fractures, dislocations) and chronic conditions (e.g., brain injury, physical disability); mental morbidity associated with abuse or neglect (e.g., anxiety, nightmares) and chronic mental health conditions (e.g., posttraumatic stress disorder, chronic depression); sexual trauma, unintended pregnancy,a and sexually transmitted diseases; adverse perinatal outcomesa (e.g., preterm birth, low birth weight, decreased mean gestational age); health care utilization attributed to physical or mental effects of abuse (e.g., rates of emergency room visits); social isolation and quality of life; and mortality
KQ 2: Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, diagnostic odds ratios, and relative risks for future abuse KQ 3: Psychosocial harms, false-positive and false-negative results, and any other potential effects of screening or identification (e.g., increased abuse) KQ 5: Any harms that result due to interventions, such as increased verbal abuse, emotional distress, and others |
KQs 1, 4: Screening or referral rates, attitudes about screening, plans or intentions related to screening, and other intermediate outcomes
KQ 2: Theory or survey development and validation without correlation to abuse outcomes, studies that focus only on particular risk factors, or assessment of provider or participant attitudes toward the instrument |
| Study Designs | All KQs: Randomized, controlled trials
KQ 2: Cross-sectional and cohort studies of diagnostic accuracy are also eligible KQs 3, 5: Cohort studies with a concurrent control group are also eligible |
All other study designs, including case series, case-control studies, systematic reviews,b and others |
| Quality | Studies rated good or fair quality | Studies rated poor quality |
| Clinical Setting | Primary care clinics, emergency rooms,c or other settings where primary care services are offeredd | Nonclinically-based settings or nonapplicable settings (e.g., prisons), populations or services/interventions not applicable to U.S. practice |
| Country Setting | Research conducted in the United States or in populations similar to U.S. populations with services and interventions applicable to U.S. practice (i.e., countries categorized as “very high” on the United Nations Human Development Index (as defined by the United Nations Development Programme) | Research not relevant to the United States (i.e., countries not categorized as “very high” on the Human Development Index |
| Language | Full text published in English | Not English language |
a These outcomes apply to vulnerable adult women of childbearing age.
b Relevant systematic reviews will be identified in database searches and used in hand searches to ensure the databases have captured all relevant studies.
c In the evidence review, the EPC will stratify the results by study setting in order to assess whether results for elderly/vulnerable adult abuse screening accuracy or intervention studies differ based on whether populations were enrolled from primary care or emergency room settings.
d This includes community-dwelling, assisted living settings where primary care services are delivered, and where patients/residents are able to live independently and receive care similar to a traditional primary care setting.