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

72
Review Question VII
transition probabilities were at worst equal. In
addition, the sensitivity analysis used an upper and
lower confidence interval for the impact of abuse
on health.
Combining net benefits and net costs in the model
resulted in an incremental cost-effectiveness
ratio (ICER) of £2450 per QALY. This result
would be considered cost-effective had a service
use perspective been applied under the implicit
willingness-to-pay threshold applied by NICE.
Including costs from a societal perspective will
result in lower costs per QALY. The estimated
cost-effectiveness was most sensitive to women
taking up an intervention and the success of these
interventions ‘downstream’ from disclosure to a
health-care professional (in PreDoVe this entailed
partner violence advocacy and a psychological
intervention), and to the likelihood that mediumterm
improvement will continue into living outside
of an abusive relationship. Most ICERs did not
increase above £5000 per QALY and only one
was greater than the £30,000 notional threshold
for cost-effectiveness in the UK. For details of the
sensitivity analysis results, see Appendix 10.5.
We have made a number of simplifying
assumptions in our model that could be
addressed with more research. We considered
the possibility that women may relapse into an
abusive relationship, but we did not capture the
fact that women with past histories of partner
violence have a greater likelihood of entering
into another abusive relationship. We also did not
differentiate between women in a relatively new
abusive relationship and those in longer-standing
relationships or long-term harassment after they
have left an abusive relationship. The latter group
may take longer to change their situation. Our
model draws upon the available evidence for the
effect of partner violence programmes but these
studies are based upon different populations and
this may affect the accuracy of our findings. For
instance, the main intervention effects were based
on data from the PreDoVe pilot trial, based in inner
city general practices with multiethnic, relatively
deprived populations in the UK. The population
targeted in PreDoVe were patients in primary care,
and the majority of referrals were women who
had not previously disclosed abuse. By contrast,
our estimate of effect of advocacy came from a
US study 126 focused on a refuge population who
had already self-identified and sought help, not
necessarily in the context of health care. There
is considerable uncertainty regarding both the
modelling of partner violence, and the costs and
quality of life for the women involved.
A limitation of the model for estimating the costeffectiveness
of screening is that the intervention
was aimed at implementing routine enquiry
of women presenting with a range of specific
conditions, rather than a comprehensive screening
programme within a health-care setting.
Discussion
In our review we were unable to identify any studies
that tested the cost-effectiveness of screening
women in health-care settings for partner violence.
We did find a study that calculated the costs and
service use for women with co-occurring mental
health and substance abuse disorders who were
survivors of partner violence and taking part in
an intervention programme. Overall costs were
the same for women within and without the
programme and clinical outcomes were improved,
which suggests that the intervention was costeffective.
Our cost-effectiveness model of a pilot
trial of a primary care intervention that resulted
in increased enquiry about partner violence by
clinicians supports the hypothesis that this type of
intervention could be cost-effective.