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7 Findings and Recommendations for Addressing Identified Gaps in Preventive Services for Women The Committee on Preventive Services for Women reviewed a large body of evidence on conditions that are important to women’s health and well-being (see Chapters 1 and 4), including health conditions that may be specific to women, are more common or more serious in women, have distinct causes or manifestations in women, or have different outcomes or treatments in women (IOM, 2010). The committee also reviewed evidence on effective preventive measures used to address those diseases and condi- tions. The committee developed a list of potential preventive measures for the Secretary of the U.S. Department of Health and Human Services (HHS) to consider for coverage without cost sharing as it develops policies and programs as part of the requirements of the Patient Protection and Afford- able Care Act of 2010 (ACA). Finally, Chapter 6 outlined the committee’s suggested process for updating the review of preventive services for making decisions about coverage with no cost sharing by health plans governed by the ACA. Table 7-1 summarizes the committee’s recommendations for preventive services that could supplement currently recommended preventive services. CONCLUDING OBSERVATIONS FROM THE COMMITTEE The committee noted that a number of women’s health-related research needs identified throughout the study process have been addressed more comprehensively in other Institute of Medicine (IOM) reports. Most re- cently, the IOM reports Women’s Health Research: Progress, Pitfalls, and Promise, Weight Gain During Pregnancy: Reexamining the Guidelines, 163
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164 CLINICAL PREVENTIVE SERVICES FOR WOMEN TABLE 7-1 Summary of the Committee’s Recommendations on Preventive Services for Women Preventive USPSTF Service Grade Supporting Evidence Recommendations Recommendation 5.1 Screening for I The evidence provided to gestational support a recommendation The committee diabetes for screening for gestational recommends for diabetes is based on current consideration as a federal practice policy from preventive service for the U.S. Indian Health Service, women: screening for the U.S. Department of gestational diabetes in Veterans Affairs, as well as pregnant women between current practice and clinical 24 and 28 weeks of professional guidelines such gestation and at the first as those set forth by the prenatal visit for pregnant American Academy of Family women identified to be at Physicians and the American high risk for diabetes. Congress of Obstetricians and Gynecologists. Recommendation 5.2 Human I The evidence provided to papillomavirus support a recommendation The committee testing (HPV) to support testing for recommends for HPV is based on federal consideration as a practice policy from the U.S. preventive service for Department of Defense. Peer- women: the addition reviewed studies demonstrate of high-risk human that improved testing papillomavirus DNA technologies, particularly testing in addition to combined screening using both cytology testing in women conventional cytology and with normal cytology high-risk HPV DNA testing, results. Screening should may significantly improve the begin at 30 years of age rate of detection of cervical and should occur no more cancer precursors and facilitate frequently than every 3 the safe lengthening of the years. interval for screening. Recommendation 5.3 Counseling I The evidence provided to for sexually support a recommendation The committee transmitted related to STI counseling recommends for infections is based on federal goals consideration as a (STI) from the Centers for Disease preventive service for Control and Prevention and women: annual counseling Healthy People 2020, as on sexually transmitted well as recommendations infections for sexually from the American Medical active women. Association and the American College of Obstetricians and Gynecologists.
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165 FINDINGS AND RECOMMENDATIONS FOR ADDRESSING IDENTIFIED GAPS TABLE 7-1 Continued Preventive USPSTF Service Grade Supporting Evidence Recommendations Recommendation 5.4 Counseling C The evidence provided to and screening support a recommendation The committee for human for expanding screening for recommends for immuno- HIV is based on federal goals consideration as a deficiency from the Centers for Disease preventive service for virus (HIV) Control and Prevention, as women: counseling and well as clinical professional screening for human guidelines, such as those immunodeficiency virus from the American College infection on an annual of Physicians, the Infectious basis for sexually active Diseases Society of America, women. the American Medical Association, and the American College of Obstetricians and Gynecologists. Recommendation 5.5 Contraceptive Not The evidence provided to methods and Addressed support a recommendation The committee counseling related to unintended recommends for pregnancy is based on consideration as a systematic evidence reviews preventive service for and other peer-reviewed women: the full range studies, which indicate of Food and Drug that contraception and Administration-approved contraceptive counseling, contraceptive methods, are effective at reducing sterilization procedures, unintended pregnancies. and patient education and Current federal reimbursement counseling for women with policies provide coverage reproductive capacity. for contraception and contraceptive counseling and most private insurers also cover contraception in their health plans. Numerous health professional associations recommend family planning services as part of preventive care for women. Furthermore, a reduction in unintended pregnancies has been identified as a specific goal in Healthy People 2010 and Healthy People 2020. continued
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166 CLINICAL PREVENTIVE SERVICES FOR WOMEN TABLE 7-1 Continued Preventive USPSTF Service Grade Supporting Evidence Recommendations Recommendation 5.6 Breastfeeding B The evidence provided to support, support a recommendation The committee supplies, and regarding the inclusion of recommends for counseling breastfeeding services is based consideration as a on systematic evidence reviews, preventive service for federal and international goals women: comprehensive (such as the U.S. Surgeon lactation support and General, Health Resources counseling and costs of and Services [HRSA], Healthy renting breastfeeding People 2020, World Health equipment. A trained Organization and UNICEF), provider should provide and clinical professional counseling services to all guidelines such as those pregnant women and to set forth by the American those in the postpartum Academy of Family Physicians, period to ensure the the American Academy of successful initiation and Pediatrics, and the American duration of breastfeeding. College of Obstetricians and (The ACA ensures that Gynecologists. breastfeeding counseling is covered; however, the committee recognizes that interpretation of this varies.) Recommendation 5.7 Screening and I The evidence provided to counseling for support a recommendation The committee interpersonal related to increasing detection recommends for and domestic of and counseling for domestic consideration as a violence violence and abuse is based preventive service for on peer-review studies and women: screening federal and international and counseling for policies, in addition to clinical interpersonal and professional guidelines domestic violence. from organizations, such Screening and counseling as the American Medical involve elicitation of Association and the American information from women College of Obstetricians and and adolescents about Gynecologists. current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.
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167 FINDINGS AND RECOMMENDATIONS FOR ADDRESSING IDENTIFIED GAPS TABLE 7-1 Continued Preventive USPSTF Service Grade Supporting Evidence Recommendations Recommendation 5.8 Well-woman Not The evidence provided to visits Addressed support a recommendation The committee for including well-woman recommends for visits is based on federal and consideration as a state policies (such as included preventive service for in Medicaid, Medicare, women: at least one well- and the commonwealth woman preventive care visit of Massachusetts), clinical annually for adult women professional guidelines (such to obtain the recommended as those of the American preventive services, Medical Association and the including preconception American Academy of Family and prenatal care. The Practitioners), and private committee also recognizes health plan policies (such as that several visits may those of Kaiser Permanente). be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors. and Preterm Birth: Causes, Consequences, and Prevention identified re- search priorities (IOM, 2007, 2009b, 2010). Additionally, the conditions described in Appendix A serve as examples for where additional high- quality research is needed to understand and better address preventive services specific to women. The committee noted in its final deliberations that the United States Preventive Services Task Force (USPSTF) deserves much credit for identify- ing a nearly complete list of recommended preventive services for women. The USPSTF systematic evidence reviews were of great benefit during the committee’s initial and follow-up examinations of the evidence. Addition- ally, the Bright Futures report (AAP, 2008) and the guidelines of the Advi- sory Committee on Immunization Practices filled several gaps not reviewed by the USPSTF. Although the committee started with an expansive look at a large number of diseases and conditions, the final recommendations sum- marized in this chapter are few. Of note, during the course of the study process, the committee faced a number of difficult decisions. The committee decided that a strong case needed to be made regarding a disease or condition having a disproportion- ate effect on women. Although the committee upheld this standard, some of the recommendations made by the committee could also be considered for male populations.
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168 CLINICAL PREVENTIVE SERVICES FOR WOMEN Another factor that was difficult for the committee to fully ignore was the cost implications of the recommended services on the insurance market. Costs and cost-effectiveness are not easy to define or measure and differ depending upon priority perspectives—private insurer, government payer, patient, or society. The 2009 IOM study Initial National Priori- ties for Comparative Effectiveness Research examines priorities for con- sidering cost-effectiveness in developing policy decisions (IOM, 2009a). Although the cost-effectiveness of services and examination of what the impact of new preventive health care services will have on health insurers were specifically excluded from committee’s consideration, the committee notes that this sometimes made its task more difficult. In addition, the committee deliberated on a number of interventions for reducing the incidence of diseases and conditions that were deemed ef- fective but that were considered to be tertiary prevention, or interventions where a disease or condition had already been diagnosed. The committee determined that tertiary interventions involved treatment (and, potentially, prevention) decisions, which were outside of its scope. Finally, questions rose as to what is common sense practice for a physician to discuss with patients. Does encouraging wearing a seat belt fall into this category? Is it the physician’s responsibility to counsel patients with no clinical risk factors about healthful eating? To what extent should adolescents be afforded confidentiality? The gaps in gender analysis made this task even more difficult. The ACA offers much promise in promoting prevention as an effec- tive tool to improve health and well-being. When patients have health insurance coverage, a clear understanding of recommended services and screenings, and a usual source of care, it is the committee’s belief that positive health outcomes will ensue. The ACA provides hope in efforts to eliminate health disparities and improve the health and well-being of women, children, and men across the United States. REFERENCES AAP. 2008. Bright futures: Guidelines for health supervision of infants, children and adoles- cents, 3rd ed. (J. F. Hagan, J. S. Shaw, and P. M. Duncan, eds.). Elk Grove Village, IL: American Academy of Pediatrics. IOM (Institute of Medicine). 2007. Preterm birth: Causes, consequences, and prevention. Washington, DC: The National Academies Press. IOM. 2009a. Initial national priorities for comparative effectiveness research. Washington, DC: The National Academies Press. IOM. 2009b. Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: The National Academies Press. IOM. 2010. Women’s health research: Progress, pitfalls, and promise. Washington, DC: The National Academies Press.