How far does screening women for domestic (partner) - NIHR Health ...

DOI: 10.3310/hta13160 Health Technology Assessment 2009; Vol. 13: No. 16
© 2009 Queen’s Printer and Controller of HMSO. All rights reserved.
Chapter 10
Is screening for partner violence cost-effective?
(Question VII)
In this chapter we investigate whether screening
for partner violence in any health-care settings
is cost-effective. First, we conducted a systematic
review of the primary studies that reported the
cost-effectiveness of partner violence screening.
Second, a cost-effectiveness model was constructed
based on a pilot trial of a system-based intervention
to implement routine enquiry about partner
violence in a primary care setting.
Systematic review of
cost-consequence and
cost-effectiveness studies
The search for economic analyses of screening
interventions in health-care settings for partner
violence retrieved nine potentially eligible papers
detailing eight studies published between 1986 and
2005. All studies were sited in the USA. None of
these studies fulfilled our inclusion criteria.
Six studies did not evaluate two alternative
interventions; they simply measured costs of assault
and homicide within families, 200 hospital charges
associated with partner violence, 201 and costs of
correct and false detection of partner violence. 202
The other three papers described the costs
associated with resource utilisation by survivors of
partner violence compared with women who have
never experienced it. 203–205
Clark and colleagues 206 performed a cost–
benefit analysis on the implementation of the
Violence against Women Act (VAWA) of 1994,
suggesting that the benefit of the VAWA outweighs
implementation costs from a societal viewpoint
in the USA. However, the results of this analysis
cannot inform the question whether screening
programmes in health-care settings are costeffective.
Two articles from Domino and colleagues reported
the results from the Women, Co-occurring
Disorders, and Violence Study (WCDVS), a
multicentre, non-randomised trial comparing an
integrated counselling and advocacy service with
usual services as control. 207,208 The study recruited
women with a mental health or substance abuse
diagnosis and a co-occurring history of physical or
sexual abuse. Follow-up of the women took place
at 6 and 12 months. Screening for and detection
of partner violence was not part of the study
protocol, however, and the analyses therefore do
not address the research question for this review.
In spite of this, the study can serve as an indication
of the effectiveness and costs of a partner violence
intervention. For the population of 2026 women
in the study, the intervention of integrated
counselling and advocacy was likely to be costeffective
when compared with usual care.
The analysis was based on changes in four clinical
outcome measures: the Addiction Severity Index
drug and alcohol composite scores (ASI-D and
ASI-A), the Global Severity Index (GSI) and the
Post-traumatic Stress Disorder Symptom Scale
(PSS). The analysis at the 6-month follow-up 207
evaluated the cost from a Medicaid perspective,
which included service delivery costs, as well
as a societal perspective, which also comprised
additional costs to service such as housing schemes
and crime-related costs.
At the 12-month follow-up, 208 costs were evaluated
from a societal perspective, which included service
delivery plus participants’ costs for time and
transportation. Clinical outcomes were reported to
be in favour of the intervention, and incremental
cost-effectiveness ratios (ICERs) were presented
per unit improvement on each of the four clinical
outcome measures. Quality-adjusted life-years
(QALYs) were not calculated. ICERs ranged from
$123 to $12,227, and bootstrapped confidence
intervals included 0, which was interpreted as
uncertainty that incremental costs or savings
are achieved. These results have to be viewed in
the light of usual care containing a structured
counselling intervention already, which partly
explains similarities in treatment costs in both
arms. Generalisations to other populations and
countries would therefore strongly depend on
existing usual care provisions, although it is likely
that a similar intervention in an NHS context
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