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Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial
  1. Angela Devine1,
  2. Anne Spencer2,
  3. Sandra Eldridge1,
  4. Richard Norman3,
  5. Gene Feder4
  1. 1Centre for Primary Care and Public Health, Barts & The London School of Medicine, Queen Mary University of London, London, UK
  2. 2Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
  3. 3Centre for Health Economics Research and Evaluation, University of Technology Sydney, New South Wales, Australia
  4. 4Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
  1. Correspondence to Angela Devine; a.devine{at}


Objective The Identification and Referral to Improve Safety (IRIS) cluster randomised controlled trial tested the effectiveness of a training and support intervention to improve the response of primary care to women experiencing domestic violence (DV). The aim of this study is to estimate the cost-effectiveness of this intervention.

Design Markov model-based cost-effectiveness analysis.

Setting General practices in two urban areas in the UK.

Participants Simulated female individuals from the general UK population who were registered at general practices, aged 16 years and older.

Intervention General practices received staff training, prompts to ask women about DV embedded in the electronic medical record, a care pathway including referral to a specialist DV agency and continuing contact from that agency. The trial compared the rate of referrals of women with specialist DV agencies from 24 general practices that received the IRIS programme with 24 general practices not receiving the programme. The trial did not measure outcomes for women beyond the intermediate outcome of referral to specialist agencies. The Markov model extrapolated the trial results to estimate the long-term healthcare and societal costs and benefits using data from other trials and epidemiological studies.

Results The intervention would produce societal cost savings per woman registered in the general practice of UK£37 (95% CI £178 saved to a cost of £136) over 1 year. The incremental quality-adjusted life-year was estimated to be 0.0010 (95% CI −0.0157 to 0.0101) per woman. Probabilistic sensitivity analysis found 78% of model replications under a willingness to pay threshold of £20 000 per quality-adjusted life-year.

Conclusions The IRIS programme is likely to be cost-effective and possibly cost saving from a societal perspective. Better data on the trajectory of abuse and the effect of advocacy are needed for a more robust model.

Trial registration Current Controlled Trials, ISRCTN74012786.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • To cite: Devine A, Spencer A, Eldridge S, et al. Cost-effectiveness of identification and referral to improve safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial. BMJ Open 2012;2:e001008. doi:10.1136/bmjopen-2012-001008

  • Contributors All authors designed the analysis. AD constructed and ran the model, supervised by AS. GF contributed to specification of the transition probabilities and underlying data assumptions. SE and RN contributed to modifications of the model. AD wrote the first draft of the paper and all authors contributed to its revision.

  • Funding This work was supported by the Health Foundation grant number 2780/4601.

  • Competing interests None.

  • Ethics approval The Identification and Referral to Improve Safety (IRIS) programme had ethics approval from the South East Research Ethics Committee (REC Reference: 07/MRE01/65).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data set available from the principal investigator at gene.feder{at} Further details on the Markov model are available from the corresponding author.

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