A Better Approach for Screening Women for Intimate Partner Violence in Primary Care

IPV, which includes “any physical or sexual violence, stalking, and/or psychological aggression by a current or former dating partner or spouse,”¹ is both prevalent and underdiagnosed in primary care. The U. S. Preventive Service Task Force recommends that primary care clinicians routinely screen all women of reproductive age for IPV, and refer those who screen positive to ongoing support services.² Unfortunately, due to internalized stigma and concerns about their confidentiality and safety, many women are reluctant to report IPV to their clinicians. Further preventing disclosure, the abuser may attend clinical visits with the patient and monitor personal electronic devices (such as a home computer or cell phone). In addition, many IPV screening tools currently used in healthcare settings generate documentation in the electronic health record (EHR) that can compromise patient privacy. 

To improve care for women experiencing IPV, it is important for primary care practices to securely screen patients and offer support services, rather than waiting until they show up in emergency rooms or urgent care centers with injuries. 

This AHRQ-funded study team led by Principal Investigators Leslie Lenert, M.D., M.S., and Alyssa Rheingold, Ph.D., of the Medical University of South Carolina, implemented and evaluated a population-based intervention for IPV screening during primary care visits. The intervention included the following features:³ 

• The medical assistant (MA) was notified by a non-interruptive alert in the EHR when a patient was due for their annual IPV screening. 
• The MA ensured the patient was alone in the exam room so they could complete a self-administered electronic IPV screening questionnaire. 
• The desktop computer in the exam room was converted into a kiosk-like mode to allow patients to self-administer the IPV screening questionnaire.
• For patients who screened positive, the clinician was offered guideline-based decision support for IP assessment, management, and referral. 
• Clinicians determined what follow-up care to recommend based on risk level, including immediate outreach to security and emergency department IPV support, a warm hand off for counseling services, and referrals to a national hotline. 
• The results of screening and resulting care were securely stored in an electronic flow sheet in the EHR, hidden from other visit records. 

The intervention used an innovative, highly private and confidential approach to screen for IPV and store the information within the EHR. The use of a population-based approach to IPV screening (i.e., screening all eligible patients rather than just those who present with a concern) in a primary care setting was a unique and important feature of this intervention. 

The study’s randomized stepped wedge trial found that: 

• The use of the non-interruptive alert increased the overall rate of screening for IPV from 45% to 65% (Relative Risk, 1.46 (95% CI, 1.44-1.49, P<0.001)). 
• The intervention’s screening process was more effective at identifying patients than nurse-led screening provided as usual care. Only 9 patients were identified as at risk for IPV using the nurse-led screening, while 130 were identified through the self-administered approach. 

Interestingly, only four patients who were referred by their clinician for tele-counseling accepted this referral. Dr. Lenert believes most patients need more time and support before they are ready to take steps to address their situation. 

This screening tool has the potential to improve the lives of countless women experiencing IPV by safely identifying them where they routinely receive primary care services and then connecting them with needed care and support. In addition, this same screening approach could be expanded to confidentially collect other sensitive information in primary care settings, including information about mental health, substance use, and social determinants of health. 

1. Leemis RW, Friar N, Khatiwada S, et al. The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Intimate Partner Violence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2022. The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Intimate Partner Violence (cdc.gov). Accessed September 3, 2024. 
2. US Preventive Services Task Force; Curry SJ, Krist AH, et al. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement. JAMA 2018 Oct 23;320(16):1678-1687. doi: 10.1001/jama.2018.14741. PMID: 30357305. 
3. Lenert L, Rheingold AA, Simpson KN, et al. Electronic Health Record-Based Screening for Intimate Partner Violence: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024 Aug 1;7(8):e2425070. doi: 10.1001/jamanetworkopen.2024.25070. PMID: 39088215; PMCID: PMC11294960.