Final Research Plan
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
August 25, 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.
The final Research Plan is used to guide a systematic review of the evidence by researchers at an Evidence-based Practice Center. The resulting Evidence Review will form the basis of the USPSTF Recommendation Statement on this topic.
The draft Research Plan was available for comment from May 26 until June 22, 2016 at 8:00 p.m., ET.
Intimate Partner Violence
a Includes reduction in the frequency or severity of IPV.
b Includes acute and chronic morbidity from physical abuse (e.g., fractures, dislocations, brain injury), sexual abuse (e.g., unwanted pregnancy, sexually transmitted infections), psychological abuse (e.g., depression, anxiety, posttraumatic stress disorder), and financial abuse (e.g., limiting access to money or other resources); health care utilization attributed to any form of 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; and quality of life.
This figure depicts the analytic framework that outlines the key questions that will be addressed in the evidence review. The population of interest is specified as adults and adolescents without recognized signs or symptoms of intimate partner violence (IPV). The figure illustrates the overarching question: Does screening for current, past, or increased risk for IPV in adults and adolescents reduce exposure to IPV, physical or mental morbidity, or mortality (key question 1)? The figure depicts the pathway from screening to reduction in IPV, physical or mental morbidity, and mortality, as well as improvement in quality of life (key question 2). Screening may result in harms (key question 3). The figure also illustrates the question: For screen-detected adults and adolescents with current, past, or increased risk for IPV, how well do interventions reduce exposure to IPV, physical or mental morbidity, or mortality (key question 4)? Interventions may result in harms (key question 5).
Elder Abuse and Abuse of 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 abuse (e.g., fractures, dislocations, brain injury), sexual abuse (e.g., unwanted pregnancy, sexually transmitted infections), psychological abuse (e.g., depression, anxiety, posttraumatic stress disorder), and financial abuse (e.g., misuse of assets by a caregiver); health care utilization attributed to any form of 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; and quality of life.
Abbreviations: IPV=intimate partner violence; KQ=key question.
This figure depicts the analytic framework that outlines the key questions that will be addressed in the evidence review. The population of interest is specified as older and vulnerable adults without recognized signs or symptoms of abuse or neglect. The figure illustrates the overarching question: Does screening in health care settings for current, past, or increased risk for abuse and neglect in older 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, physical or mental morbidity, and mortality, as well as improvement in quality of life (key question 2). Screening may result in harms (key question 3). The figure also illustrates the question: For screen-detected older and vulnerable adults with current, past, or increased risk for abuse and neglect, how well do interventions reduce exposure to abuse and neglect, physical or mental morbidity, or mortality (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 adults and adolescents reduce exposure to IPV, physical or mental morbidity, or mortality?
- What is the accuracy of screening questionnaires or tools for identifying adults and adolescents with current, past, or increased risk for IPV?
- What are the harms of screening for IPV in 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 for IPV in adults and adolescents?
Elder Abuse and Abuse of Vulnerable Adults
- Does screening in health care settings for current, past, or increased risk for abuse and neglect in older and vulnerable adults reduce exposure to abuse and neglect, physical or mental morbidity, or mortality?
- How effective are screening questionnaires or tools in identifying older and vulnerable adults with current, past, or increased risk for abuse and neglect?
- What are the harms of screening for abuse and neglect in older and vulnerable adults?
- How well do interventions reduce exposure to abuse and neglect, physical or mental morbidity, or mortality among screen-detected older and vulnerable adults with current, past, or increased risk for abuse and neglect?
- What are the harms of interventions for abuse and neglect in older 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 (e.g., differences in patient populations or characteristics of the clinical settings)?
Elder Abuse and Abuse of Vulnerable Adults
- What factors limit the applicability of older/vulnerable adult abuse and neglect screening and treatment studies conducted in emergency room settings to primary care settings (e.g., differences in patient populations or characteristics of the clinical settings)?
The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center (EPC) 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 |
|
Studies restricted to populations seeking care for IPV or for obvious signs or symptoms of abuse |
| Screening | KQs 1–3: Screening tests designed to detect current or past IPV victimization or risk status for IPV victimization, including self-administered, computer-enabled, or patient self-report instruments, as well as clinician-administered screening methods; 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, including counseling, case management, home visitation, mentor or peer support, safety planning, and referral to community services | 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 instruments must be compared with an acceptable reference standard (verified or self-reported abuse or validated screening instrument for 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 morbidity (e.g., stress, nightmares) and chronic mental health conditions (e.g., posttraumatic stress disorder, anxiety, depression); sexual trauma, unintended pregnancy, and sexually transmitted infections; 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, including labeling and stigma; false-positive and false-negative results; increased abuse or other forms of retaliation; and other reported harms of screening or identification KQ 5: Any harms that result from interventions, such as increased abuse or other forms of retaliation, and emotional distress |
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, case-control studies, and systematic reviewsc |
| Quality | Studies rated good or fair quality | Studies rated poor quality |
| Settings | All KQs: Primary care clinics or other settings where primary care services are offered, such as student health centers and emergency roomsd
KQs 4, 5: Settings referable from primary care are also eligible |
Nonclinically-based settings or nonapplicable settings (e.g., prisons) |
| Country | 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 | Languages other than English |
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 Results will be stratified by study setting 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.
Abbreviations: IPV=intimate partner violence; LGBTQ=lesbian, gay, bisexual, transgender, and questioning.
Elder Abuse and Abuse of Vulnerable Adults
| Include | Exclude | |
|---|---|---|
| Populations |
|
Studies restricted to populations seeking care for abuse or presenting with obvious signs or symptoms of abuse |
| Screening | KQs 1–3: Screening tests designed to detect current or past abuse or neglect or risk of being abused, including self-administered, computer-enabled, or patient self-report instruments, as well as clinician-administered screening methods; screening may involve input from caregivers, and 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 older 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, including counseling, case management, home visitation, and referral to community services (e.g., adult protective services) | 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 validated screening instrument for 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, anxiety, depression); sexual trauma, unintended pregnancy,b and sexually transmitted infections; adverse perinatal outcomesb (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, including labeling and stigma; false-positive and false-negative results; increased abuse or other forms of retaliation; and other reported harms of screening or identification KQ 5: Any harms that result from interventions, such as increased abuse or emotional distress |
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, and systematic reviewsc |
| Quality | Studies rated good or fair quality | Studies rated poor quality |
| Settings | Primary care clinics, emergency rooms,d or other settings where primary care services are offerede | Nonclinically-based or nonapplicable settings (e.g., prisons), populations or services/interventions not applicable to U.S. practice |
| Country | 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 | Languages other than English |
a "Vulnerable adult" is a person age 18 years or older whose ability to provide his or her own care or protection is impaired.
b Outcomes that are specific to pregnancy apply to vulnerable adult women of childbearing age.
c Relevant systematic reviews will be identified in database searches and used in hand searches to ensure the databases have captured all relevant studies.
d Results will be stratified by study setting to assess whether results for older/vulnerable adult abuse screening accuracy or intervention studies differ based on whether populations were enrolled from primary care or emergency room settings.
e 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.
Abbreviation: LGBTQ=lesbian, gay, bisexual, transgender, and questioning.
The draft Research Plan was posted on the USPSTF Web site for public comment from May 26 to June 22, 2016. Several comments requested that the USPSTF evaluate the evidence for the KQs by specific subpopulations. The USPSTF expanded the population inclusion criteria to search for evidence on important subgroups of interest, including by age, sex, race/ethnicity, pregnancy status, LGBTQ (lesbian, gay, bisexual, transgender, and questioning) identification, type of abuse (e.g., physical abuse, sexual abuse), history of IPV, or presence of comorbid conditions. Other comments asked for clarification on whether older and vulnerable adults would be included in the evidence review on screening for IPV. The USPSTF clarified that studies enrolling older adults that focused on screening for or treatment of IPV would be eligible. Some comments requested that the term "elderly" be replaced with "older adults" when referring to populations and individuals; the USPSTF revised the terminology accordingly. Other clarifications made based on comments included adding "retaliation" (from perpetrators of abuse) and "labeling or stigma" to the list of potential harms of screening, expanding the types of interventions included (e.g., case management), adding "anxiety" as an example of mental trauma, listing financial abuse and exploitation as a category of abuse for both reviews, and defining "vulnerable adults" in the research plan.