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Screening for interpersonal violence: Missed opportunities and potential harms

E.H. De Marchis, B. McCaw, E.W. Fleegler, A.J. Cohen, S.T. Lindau, A.G. Huebschmann, E.L. Tung, D.M. Hessler, L.M. Gottlieb
Am J Prev Med

Introduction: Screening for interpersonal violence is used in healthcare settings to identify patients experiencing violence. However, using unvalidated screening tools may misclassify patients’ experience with violence. The Center for Medicare & Medicaid Innovation adapted a previously validated intimate partner violence screening tool for use in assessing interpersonal violence and retained the tool's original scoring rubric, despite the new tool's broader scope. This study evaluates the scoring system for detecting safety concerns.

Methods: This was a cross-sectional survey of a convenience sample of adult patients and caregivers of pediatric patients at 7 primary care clinics and 4 emergency departments (2018–2019). Surveys included the adapted 4-item Hurt Insult Threat Scream tool. Questions are scored by frequency on a Likert scale (1=never; 5=frequently). Scores of 11–20 are considered positive for safety concerns. Two-sided Fisher's exact tests were used for descriptive analyses. Data analyses occurred in 2019–2020.

Results: Of 1,014 participants, 66 (6.5%) reported any frequency of physical violence. Of these, 54 (81.8%) did not reach the threshold score of 11. Of the 1,014 participants, 93 (9.2%) reported any frequency of physical violence or being threatened with harm; 76 of 93 participants (81.7%) scored <11.

Conclusions: Using the original scoring criteria for the adapted Hurt Insult Threat Scream, >80% of participants reporting physical violence did not screen positive for potential safety concerns. The scoring criteria did not reliably identify participants experiencing or at high risk for violence. To improve patient safety, the adapted Hurt Insult Threat Scream scoring rubric should be updated on the basis of stakeholder input and additional validation studies.

De Marchis E., McCaw B, Fleegler EW, et al. Screening for interpersonal violence: missed opportunities and potential harms. Am J Prev Med. 2021 Sep;61(3):439-444. doi: 10.1016/j.amepre.2021.02.010. Epub 2021 May 19. PMID: 34023161.

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Publication year
Resource type
Peer Reviewed Research
Social Needs/ SDH
Screening research
Social Determinant of Health
Study design
Other Study Design