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

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Review Question VII
would also be cost-effective if the clinical outcomes
were comparable. What Domino and colleagues
have not demonstrated, however, is that screening in
a health-care setting can be cost-effective.
Cost-effectiveness model of
PreDoVe: a pilot trial of a
primary care-based systemlevel
intervention to improve
identification and referral
of women experiencing
partner violence
The pilot study investigated a general practicebased
intervention in the UK and tested the
feasibility of this intervention in four general
practices (three acting as an intervention and
one as a control). The multifaceted, system-based
intervention aimed to change the behaviour of
clinicians towards women experiencing partner
violence, and was designed to increase routine
enquiry about partner violence and thereby
disclosure of current partner violence. Following
disclosure, clinicians were prompted to refer
women to an advocate based in a domestic violence
specialist agency or to a psychologist with specific
training related to partner violence. The systembased
intervention included initial educational
sessions for all clinicians within the practice, which
emphasised a pragmatic approach to enquiry and
referral and also gave an overview of the wider
community response. The referral component
of the intervention was supported by a direct
referral pathway to a domestic violence advocate
and a psychologist, both of whom were involved
in the initial training. In addition, prompts in
the electronic medical record were used to probe
for partner violence during routine consultations
based on a four-item screening tool termed HARK
(an acronym based on the dimensions of abuse,
i.e. Humiliation, Afraid, Rape and Kick) linked
to a range of coded diagnoses such as depression,
insomnia, sexually transmitted infections and
fatigue. 209 The HARK questions and a prompt
to refer women to the advocate or psychologist
were installed as a template onto the electronic
medical record in the practices. Although the
aim of the intervention was not a comprehensive
screening programme for all women, it aimed to
implement screening or routine enquiry for women
presenting with other problems. We maintain that
an economic analysis of this intervention is relevant
to the question of whether screening for domestic
violence could be cost-effective.
Model
A Markov model was developed to combine
the intervention costs and benefits. It was fitted
comparing the PreDoVe programme with usual
care and used the differences between the two
simulations to calculate the incremental net benefit.
The model evaluated the impact of increased
assessment and referral rates upon further violence
and quality of life over a 10-year period. Partner
violence affects several public services as women
experiencing such violence come into contact with,
for example, local authority housing departments
and social services. Women experiencing violence
who come into contact with the criminal justice
system are now routinely recorded. Taking a
societal perspective permitted a wide range of data
from sources to be incorporated into the model.
See Appendix 10.1 for summary of data sources for
the model.
The model defines six health states in which
women can find themselves (Figure 3). Following
assessment, women experiencing partner violence
can (1) remain unidentified, or are (2) identified
and subsequently referred and treated, or (3)
identified but decline referral to advocacy or
psychology services. Women who receive treatment
following disclosure during assessment can (4) drop
out without improvement, or (5) enter a state of
medium-term improvement where they can stay or
move to the no-abuse or identified/untreated state.
Women can also (6) die of non-related causes or
specifically from partner violence. The transition
probabilities for movement between these states
were taken from the literature or in discussion with
partner violence researchers. See Appendix 10.2
for details of transition probabilities. The average
length of time a woman remains in contact with
advocacy services is 6 months, and therefore the
model cycle length was set to 6 months with a
time horizon of 10 years. Following the approach
suggested by the National Institute for Health and
Clinical Excellence (NICE), we discounted both
costs and outcomes at 3.5% per annum. The reason
for this is that it is the approach most commonly
taken in UK cost-effectiveness analyses, facilitating
comparison of our results with other studies.
Costs associated with advocacy and/or psychological
interventions were collated for each woman in the