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2
Preventive Services Defined by the ACA
The Patient Protection and Affordable Care Act of 2010 (ACA) de-
fined covered preventive health services for all patient populations to be
those with Grade A and B recommendations made by the United States
Preventive Services Task Force (USPSTF or the Task Force); for adoles-
cents, the Bright Futures recommendations from the American Academy of
Pediatrics (AAP) in cooperation with the U.S. Department of Health and
Human Services (HHS), and for all patient populations, recommendations
from the Advisory Committee on Immunization Practices (ACIP). The
USPSTF, AAP, and ACIP are national authorities on health with defined
processes for generating clinical recommendations. A summary of the
methods that these entities use to arrive at recommendations and the actual
recommendations follows.
UNITED STATES PREVENTIVE SERVICES TASK FORCE
The Task Force is an independent panel composed of nonfederal pri-
mary care clinicians, health behavior specialists, and methodologists. Its
mission is twofold: (1) assess the benefits and harms of preventive services
for people asymptomatic for the target condition on the basis of age, gen-
der, and risk factors for disease; and (2) make recommendations about
which preventive services should be incorporated into routine primary
care practice. The USPSTF is now entering its 27th year of existence, and
the medical community considers its methodologies and resulting recom-
mendations to be the “gold standard” for evidence-based clinical practice
in preventive services (USPSTF, 2008b).
29
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30 CLINICAL PREVENTIVE SERVICES FOR WOMEN
TABLE 2-1 USPSTF Grade Definitions
Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is Offer or provide this
high certainty that the net benefit is substantial. service.
B The USPSTF recommends the service. There is Offer or provide this
high certainty that the net benefit is moderate service.
or there is moderate degree of certainty that
the net benefit is moderate to substantial.
C The USPSTF recommends against routinely Offer or provide this
providing the service. There may be service only if other
considerations that support providing the considerations support the
service in an individual patient. There is at offering or providing the
least moderate certainty that the net benefit is service in an individual
small. patient.
D The USPSTF recommends against the service. Discourage the use of this
There is moderate or high certainty that the service.
service has no net benefit or that the harms
outweigh the benefits.
I Statement The USPSTF concludes that the current Read the clinical
evidence is insufficient to assess the balance considerations section of
of benefits and harms of the service. Evidence USPSTF Recommendation
is lacking, of poor quality, or conflicting; and Statement. If the service
the balance of benefits and harms cannot be is offered, patients should
determined. understand the uncertainty
about the balance of
benefits and harms.
SOURCE: USPSTF, 2008a.
The charge of the Task Force is limited in scope: “its recommendations
address primary or secondary preventive services targeting conditions that
represent a substantial burden in the United States and that are provided in
primary care settings or available through primary care referral” (USPSTF,
2008b). These recommendations are intended to inform primary care pro-
viders as they care for individual patients in primary care practice. They
are not intended to determine which preventive health care services health
insurers should be required to cover. The methodology used in developing
Task Force clinical recommendations does not take into consideration many
nonclinical issues related to health care coverage (USPSTF, 2011). USPSTF
uses a grade system, which is described in Table 2-1.
USPSTF Methodology
Task Force recommendations and their accompanying evidence reports
are produced through the collaborative efforts of the USPSTF, the Agency
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31
PREVENTIVE SERVICES DEFINED BY THE ACA
for Healthcare Research and Quality (AHRQ), Evidence-based Practice
Centers (EPCs), and partner organizations. AHRQ provides methodologi-
cal, technical, scientific, and administrative support to the Task Force. EPCs
aid the USPSTF by developing technical reports, evidence summaries and
reports, and systematic reviews that target new topics under consideration
by the Task Force or that update ones addressed previously. The USPSTF
uses systematic evidence reviews produced primarily by the Oregon EPC
(under contract by AHRQ) and occasionally uses reviews and other analy-
ses conducted by other groups, depending on the topic under consideration.
Partner organizations consist of federal partners (examples include the
Centers for Disease Control and Prevention [CDC], the U.S. Department
of Defense, Centers for Medicare and Medicaid Services, and the Food
and Drug Administration [FDA]) and organizations representing primary
care professionals (examples include the American Academy of Family
Physicians [AAFP], the American College of Obstetricians and Gynecolo-
gists [ACOG], the American Medical Association [AMA], and AAP). They
contribute expertise to the evaluation process and comment on preliminary
drafts of Task Force recommendation statements and the accompanying
evidence reports. A step-by-step overview of the process of recommenda-
tion development, from topic selection to recommendation dissemination,
follows. The average amount of time required to complete this process is
21 months (USPSTF, 2011).
1. Topic Selection—USPSTF
EPCs, Task Force members, organizations, and individuals can nomi-
nate topics through a publicly accessible website, as well as through
solicitations to partner organizations and the Federal Register. On the
basis of these submissions, the Task Force Topic Prioritization Work Group
periodically updates a prioritized list of topics to be addressed either for the
first time or for updating during the year.
2. Work Plan Development—AHRQ, EPCs, USPSTF
Prioritized topics are appointed to “topic teams,” consisting of USPSTF
“leads,” AHRQ staff (including a Medical Officer), and EPC members. The
topic team develops preliminary work plans from the work assignment
that AHRQ has issued to the team. The work plan includes the analytic
framework, key questions, the literature search strategy, and a timeline for
recommendation dissemination.
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32 CLINICAL PREVENTIVE SERVICES FOR WOMEN
3. External Work Plan Peer Review—Outside Experts
Work plans for new topics are sent to a limited number of outside ex-
perts in appropriate fields for their comments and review.
4. Approval of Work Plan—USPSTF
The topic team presents work plans for new topics to the entire Task
Force. The Task Force then evaluates and requests any revisions to the work
plan that it deems necessary. The work plan is then edited by the EPC in
accordance with the Task Force’s requests and is finalized.
5. Draft Evidence Report—EPC
The EPC next conducts a systematic evidence review addressing the
key questions posed by the Task Force in the work plan, and generates a
draft evidence report.
6. Peer-Review of Draft Evidence Report—USPSTF,
Content Area Experts, Federal Partners
Draft evidence reports are sent to Task Force leads, content area ex-
perts, federal partners, and other partner organizations for review and
comment.
7. Development of Draft Recommendation Statement—USPSTF, AHRQ
Concomitant with the draft evidence report review process, Task Force
leads collaborate with the AHRQ Medical Officer to discuss and draft a
preliminary recommendation statement.
8. Vote on Draft Recommendation Statement—USPSTF
The Task Force is presented with the peer-reviewed evidence report
findings by the EPC and the preliminary recommendation statement by the
Task Force leads at one of three annual meetings that include the USPSTF,
AHRQ, the EPC, and representatives from the partner organizations. The
entire Task Force, including the leads, discusses the evidence and debates
the language of the recommendation statement until a consensus is reached
and the statement passes a vote. The revised recommendation statement is
then sent to Task Force leads for completion and editing prior to external
review.
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33
PREVENTIVE SERVICES DEFINED BY THE ACA
9. Final Evidence Report—EPC
The EPC revises the evidence report in response to comments from the
federal partners, content area experts, and Task Force leads. The EPC then
sends a summary of the comments and how the comments were addressed
to AHRQ. AHRQ staff then review, approve, and finalize the revised
evidence report. The EPC then prepares the finalized evidence report for
submission to a peer-reviewed journal for publication. The final technical
report is also made available on the AHRQ website.
10. Review of Draft Recommendation Statement—Federal and
Primary Care Professional Organization Partners and the Public
The newly revised and approved recommendation statement is sent to
relevant federal and primary care professional organization partners for
review and comment. The statement is also posted on the AHRQ website
for one month for public comment.
11. Approval of Final Recommendation Statement—USPSTF
Task Force leads edit the recommendation statement on the basis of the
comments received from the federal and primary care professional organi-
zation partners and the public after discussion with the AHRQ Medical
Officer.
12. Release of Recommendation Statement and
Evidence Report—Peer-Reviewed Journals
Recommendation statements and the accompanying EPC evidence
report-derived manuscript are often published simultaneously in the pro-
fessional journals Annals of Internal Medicine (adult topics) or Pediatrics
(child/adolescent topics) and must go through the respective journal’s peer-
review process before publication. They are occasionally published in other
journals (USPSTF, 2008b).
Preventive services relevant to women that have a grade of A or B from
the USPSTF are listed in Table 2-2.
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34 CLINICAL PREVENTIVE SERVICES FOR WOMEN
TABLE 2-2 USPSTF Preventive Services Relevant to Women That Have a
Grade of A or B
Topic Description Grade
Alcohol misuse counseling The USPSTF recommends screening and B
behavioral counseling interventions
to reduce alcohol misuse by adults,
including pregnant women, in primary
care settings.
Anemia screening: pregnant The USPSTF recommends routine B
women screening for iron deficiency anemia in
asymptomatic pregnant women.
Aspirin to prevent The USPSTF recommends the use of A
cardiovascular disease aspirin for women age 55 to 79
(CVD): women years when the potential benefit
of a reduction in ischemic strokes
outweighs the potential harm of
an increase in gastrointestinal
hemorrhage.
Bacteriuria screening: The USPSTF recommends screening for A
pregnant women asymptomatic bacteriuria with urine
culture for pregnant women at 12
to 16 weeks’ gestation or at the first
prenatal visit, if later.
Blood pressure screening The USPSTF recommends screening for A
high blood pressure in adults aged 18
and older.
BRCA screening, counseling The USPSTF recommends that women B
about whose family history is associated
with an increased risk for deleterious
mutations in BRCA1 or BRCA2 genes
be referred for genetic counseling and
evaluation for BRCA testing.
Breast cancer preventive The USPSTF recommends that clinicians B
medication discuss chemoprevention with women
at high risk for breast cancer and
at low risk for adverse effects of
chemoprevention. Clinicians should
inform patients of the potential benefits
and harms of chemoprevention.
Breast cancer screeninga The USPSTF recommends screening B
mammography for women, with or
without clinical breast examination,
every 1–2 years for women aged 40
and older.
Breastfeeding counseling The USPSTF recommends interventions B
during pregnancy and after birth to
promote and support breastfeeding.
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PREVENTIVE SERVICES DEFINED BY THE ACA
TABLE 2-2 Continued
Topic Description Grade
Cervical cancer screening The USPSTF strongly recommends A
screening for cervical cancer in women
who have been sexually active and
have a cervix.
Chlamydial infection The USPSTF recommends screening for A
screening: non-pregnant chlamydial infection for all sexually
women active non-pregnant young women
aged 24 and younger and for older
non-pregnant women who are at
increased risk.
Chlamydial infection The USPSTF recommends screening for B
screening: pregnant women chlamydial infection for all pregnant
women aged 24 and younger and for
older pregnant women who are at
increased risk.
Cholesterol abnormalities The USPSTF strongly recommends A
screening: women 45 and screening women aged 45 and older
older for lipid disorders if they are at
increased risk for coronary heart
disease.
Cholesterol abnormalities The USPSTF recommends screening B
screening: women younger women aged 20 to 45 for lipid
than 45 disorders if they are at increased risk
for coronary heart disease.
Colorectal cancer screening The USPSTF recommends screening for A
colorectal cancer using fecal occult
blood testing, sigmoidoscopy, or
colonoscopy, in adults, beginning at
age 50 years and continuing until age
75 years. The risks and benefits of
these screening methods vary.
Depression screening: The USPSTF recommends screening of B
adolescents adolescents (12–18 years of age)
for major depressive disorder when
systems are in place to ensure accurate
diagnosis, psychotherapy (cognitive-
behavioral or interpersonal), and
follow-up.
Depression screening: adults The USPSTF recommends screening adults B
for depression when staff-assisted
depression care supports are in place
to assure accurate diagnosis, effective
treatment, and follow-up.
Diabetes screening The USPSTF recommends screening for B
type 2 diabetes in asymptomatic adults
with sustained blood pressure (either
treated or untreated) greater than
135/80 mm Hg.
continued
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36 CLINICAL PREVENTIVE SERVICES FOR WOMEN
TABLE 2-2 Continued
Topic Description Grade
Folic acid supplementation The USPSTF recommends that all women A
planning or capable of pregnancy take
a daily supplement containing 0.4 to
0.8 mg (400 to 800 µg) of folic acid.
Gonorrhea screening: The USPSTF recommends that clinicians B
women screen all sexually active women,
including those who are pregnant,
for gonorrhea infection if they are
at increased risk for infection (that
is, if they are young or have other
individual or population risk factors).
Healthy diet counseling The USPSTF recommends intensive B
behavioral dietary counseling for
adult patients with hyperlipidemia
and other known risk factors for
cardiovascular and diet-related chronic
disease. Intensive counseling can be
delivered by primary care clinicians or
by referral to other specialists, such as
nutritionists or dietitians.
Hepatitis B screening: The USPSTF strongly recommends A
pregnant women screening for hepatitis B virus infection
in pregnant women at their first
prenatal visit.
Human immunodeficiency The USPSTF strongly recommends A
virus (HIV) screening that clinicians screen for HIV all
adolescents and adults at increased risk
for HIV infection.
Obesity screening and The USPSTF recommends that clinicians B
counseling: adults screen all adult patients for obesity
and offer intensive counseling and
behavioral interventions to promote
sustained weight loss for obese adults.
Osteoporosis screening: The USPSTF recommends screening for B
women osteoporosis in women aged 65 years
or older and in younger women whose
fracture risk is equal to or greater than
that of a 65-year-old white woman
who has no additional risk factors.
Rh incompatibility screening: The USPSTF strongly recommends Rh (D) A
first pregnancy visit blood typing and antibody testing for
all pregnant women during their first
visit for pregnancy-related care.
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PREVENTIVE SERVICES DEFINED BY THE ACA
TABLE 2-2 Continued
Topic Description Grade
Rh incompatibility screening: The USPSTF recommends repeated Rh (D) B
24–28 weeks gestation antibody testing for all unsensitized Rh
(D)-negative women at 24–28 weeks’
gestation, unless the biological father is
known to be Rh (D)-negative.
Sexually transmitted The USPSTF recommends high-intensity B
infections (STIs) counseling behavioral counseling to prevent STIs
for all sexually active adolescents and
for adults at increased risk for STIs.
Tobacco use counseling and The USPSTF recommends that clinicians A
interventions: non-pregnant ask all adults about tobacco use and
adults provide tobacco cessation interventions
for those who use tobacco products.
Tobacco use counseling: The USPSTF recommends that clinicians A
pregnant women ask all pregnant women about
tobacco use and provide augmented,
pregnancy-tailored counseling to those
who smoke.
Syphilis screening: non- The USPSTF strongly recommends that A
pregnant persons clinicians screen persons at increased
risk for syphilis infection.
Syphilis screening: pregnant The USPSTF recommends that clinicians A
women screen all pregnant women for syphilis
infection.
aHHS, in implementing ACA under the standard that it sets out in revised Section 2713(a)(5)
of the Public Health Service Act, uses the 2002 recommendation on breast cancer screening
of the USPSTF.
SOURCE: USPSTF, 2010b.
BRIGHT FUTURES—AMERICAN ACADEMY OF PEDIATRICS
The HHS Health Resources and Services Administration’s Maternal
and Child Health Bureau established the Bright Futures project in 1990
with the mission to “promote and improve the health, education, and well-
being of infants, children, adolescents, families, and communities” (AAP,
2008). It is a “set of principles, strategies, and tools that are theory based
and system oriented that can be used to improve the health and well-being
of all children through culturally appropriate interventions that address the
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38 CLINICAL PREVENTIVE SERVICES FOR WOMEN
current and emerging health promotion needs at the family, clinical prac-
tice, community, health system, and policy levels” (AAP, 2008). The most
recent report, published in 2008, was developed through the collaborative
efforts of four multidisciplinary panels consisting of experts in health dur-
ing infancy, early childhood, middle childhood, and adolescence and was
then reviewed by more than 1,000 educators, public health and health care
professionals, child health advocates, and parents.
Bright Futures Methodology
The Bright Futures Steering Committee used three approaches to de-
velop its guidance and recommendations and described these approaches
as follows:
1. “Multidisciplinary Expert Panels were convened to write recom-
mendations for Bright Futures visit priorities, the physical exami-
nation, anticipatory guidance, immunizations, and universal and
selective screening topics for each age and stage of development.
In carrying out this task, the Expert Panels were charged with ex-
amining the evidence for each recommendation, and evidence was
an important consideration in the guidance they provided. How-
ever, lack of evidence was sometimes problematic for the physical
examination (the elements of which can be considered screening
interventions) and for counseling interventions. For these compo-
nents, the Expert Panels relied on an indirect approach buttressed
by their expertise and clinical experience” (AAP, 2008).
2. A Bright Futures Evidence Panel, composed of consultants who are
experts in finding and evaluating evidence from clinical studies,
was convened to examine studies and systematic evidence reviews
and to develop a method of informing readers about the strength
of the evidence.
The Evidence Panel conducted literature searches for key ques-
tions using the MEDLINE® database of the National Library
of Medicine. Key themes were searched in the Medical Subject
Headings (MeSH) database to determine the most appropri -
ate search terms. Searches were limited to clinical trials, meta-
analyses, and randomized controlled trials. Other limits included
English language and designations for age, when appropriate.
Standardized terms were used for counseling (i.e., counseling,
primary prevention, health promotion, health education, and
patient education) and for screening (i.e., mass screening and
risk assessment). The Evidence Panel also used the systematic
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39
PREVENTIVE SERVICES DEFINED BY THE ACA
evidence reviews performed for the USPSTF and the Cochrane
Collaboration [the publisher of Cochrane Reviews of primary
research in human health care and health policy]. This approach
was by no means exhaustive, but it did provide an assessment of
the most relevant literature. (AAP, 2008)
3. “Throughout the Guidelines development process, the Project Ad-
visory Committee and Expert Panels consulted with individuals
and organizations with expertise and experience in a wide range of
topic areas. The entire Guidelines document also underwent public
review twice in 2004 and once in 2006. More than 1,000 reviewers,
representing national organizations concerned with infant, child,
and adolescent health and welfare, provided nearly 3,500 com-
ments. The contributions of these reviewers provided an opportu-
nity to refine the guidelines and strengthen the scientific base for the
guidance provided” (AAP, 2008).
Bright Futures describes its guidelines as “evidence informed rather
than fully evidence driven” (AAP, 2008) and takes a broader view of
prevention that is less focused on specific conditions and more on general
health guidance (e.g., aggregating services into health supervision visits and
extensive anticipatory guidance). Like the USPSTF, Bright Futures does not
directly comment on insurance coverage, but unlike the USPSTF, Bright
Futures does not have categories regarding services comparable to “C” or
“I” grades that do not definitively recommend for or against a particular
service. Bright Futures intends to leave no gaps in its recommendations,
supplementing the evidence where needed with experience and expert opin-
ion so that clinical guidance is always provided. Figures 2-1, 2-2, and 2-3
present the Bright Futures recommendations for adolescents and outline the
preventive services that are covered for adolescent women in the ACA. In
addition to the information in the tables shown in Figures 2-1 to 2-3, Bright
Futures also provides extensive anticipatory guidance on a range of health
matters in the context of discussing health issues with adolescents. These
measures do not provide action steps and are not suitable for summary in
a structured format.
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40 CLINICAL PREVENTIVE SERVICES FOR WOMEN
Physical Examination
A complete physical examination is included as ■ Breast
part of every health supervision visit. Female
• Assess sexual maturity rating
When performing a physical examination, the health
Male
care professional’s attention is directed to the following
• Observe for gynecomastia
components of the exam that are important for 11- to
■ Genitalia
14-year-olds:
Female
■ Measure: • Perform visual inspection for sexual maturity
• Blood pressure rating and observation for signs of STIs (eg,
■ Measure and plot: warts, vesicles, vaginal discharge)
• Height • Perform pelvic exam, if clinically warranted,
• Weight based on sexual activity (eg, for Pap smear
■ Calculate and plot: within 3 years of onset of sexual activity) and/or
• BMI specific problems (eg, pubertal aberrancy,
■ Skin abnormal bleeding, abdominal or pelvic pain)
Male
• Inspect for acne, acanthosis nigricans, atypical
nevi, tattoos, piercings, and signs of abuse or • Perform visual inspection for sexual maturity
self-inflicted injury rating and observations for signs of STIs (ie,
■ Spine warts, vesicles)
• Examine back • Examine testicles for hydrocele, hernias,
varicocele, or masses
Screening
UNIVERSAL SCREENING ACTION
Snellen test
Vision (once in early adolescence)
SELECTIVE SCREENING RISK ASSESSMENT* ACTION IF RA +
Vision at other ages + on risk screening questions Snellen test
Hearing + on risk screening questions Audiometry
Anemia + on risk screening questions Hemoglobin or hematocrit
Tuberculosis + on risk screening questions Tuberculin skin test
+ on risk screening questions and not Lipid screen
Dyslipidemia
previously screened with normal results
STIs Sexually active Screen for chlamydia and gonorrhea;
use tests appropriate to the patient
population and clinical setting
Sexually active and + on risk questions Syphilis blood test
HIV†
Sexually active without contraception, Urine hCG
Pregnancy
late menses, or amenorrhea
Sexually active, within 3 years of Pap smear, conventional slide
Cervical dysplasia
onset of sexual activity or liquid-based
Alcohol or drug use + on risk screening questions Administer alcohol and drug
screening tool
*See Rationale and Evidence chapter for the criteria on which risk screening questions are based.
The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of
†
publication, the AAP and other groups had not yet commented on the CDC recommendation, nor recommended screening criteria or
techniques. The health care professional’s attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in
communities where the HIV rate is <0.1%. The management of positives and false positives must be considered before testing.
FIGURE 2-1 Adolescence 11–14 year visits.
ABBREVIATIONS: AAP = American Academy of Pediatrics; BMI = body mass in-
Figure 2-1.eps
dex; CDC = Centers for Disease Control and Prevention; hCG = human chorionic
gonadotropin; HIV = human immunodeficiency virus; RA = risk assessment; STI =
sexually transmitted infection.
SOURCE: AAP, 2008. Used with permission of the American Academy of Pediat-
rics, Bright Futures—Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition, American Academy of Pediatrics, 2008.
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41
PREVENTIVE SERVICES DEFINED BY THE ACA
Physical Examination
A complete physical examination is included as ■ Breast
part of every health supervision visit. Female
• Assess sexual maturity rating
When performing a physical examination, the health
Male
care professional’s attention is directed to the following
• Observe for gynecomastia
components of the exam that are important for 15- to
■ Genitalia
17-year-olds:
Female
■ Measure: • Perform visual inspection for sexual maturity
• Blood pressure rating and observation for signs of STIs (eg,
■ Measure and plot: warts, vesicles, vaginal discharge)
• Height • Perform pelvic exam, if clinically warranted,
• Weight based on sexual activity (eg, for Pap smear
■ Calculate and plot: within 3 years of onset of sexual activity) and/or
• BMI specific problems (eg, pubertal aberrancy,
■ Skin abnormal bleeding, abdominal or pelvic pain)
Male
• Inspect for acne, acanthosis nigricans, atypical
nevi, tattoos, piercings, and signs of abuse or • Perform visual inspection for sexual maturity
self-inflicted injury rating and observations for signs of STIs (ie,
■ Spine warts, vesicles)
• Examine back • Examine testicles for hydrocele, hernias,
varicocele, or masses
Screening
UNIVERSAL SCREENING ACTION
Vision (once in middle adolescence) Snellen test
SELECTIVE SCREENING RISK ASSESSMENT* ACTION IF RA +
Vision at other ages + on risk screening questions Snellen test
Hearing + on risk screening questions Audiometry
Anemia + on risk screening questions Hemoglobin or hematocrit
Tuberculosis + on risk screening questions Tuberculin skin test
+ on risk screening questions and not Lipid screen
Dyslipidemia
previously screened with normal results
STIs Sexually active Screen for chlamydia and gonorrhea;
use tests appropriate to the patient
population and clinical setting
Sexually active and + on risk questions Syphilis blood test
HIV†
Sexually active without contraception, Urine hCG
Pregnancy
late menses, or amenorrhea
Sexually active, within 3 years of Pap smear, conventional slide
Cervical dysplasia
onset of sexual activity or liquid-based
Alcohol or drug use + on risk screening questions Administer alcohol and drug
screening tool
*See Rationale and Evidence chapter for the criteria on which risk screening questions are based.
The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of
†
publication, the AAP and other groups had not yet commented on the CDC recommendation, nor recommended screening criteria or
techniques. The health care professional’s attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in
communities where the HIV rate is <0.1%. The management of positives and false positives must be considered before testing.
Figure 2-2.eps
FIGURE 2-2 Adolescence 15–17 year visits.
ABBREVIATIONS: AAP = American Academy of Pediatrics; BMI = body mass in-
dex; CDC = Centers for Disease Control and Prevention; hCG = human chorionic
gonadotropin; HIV = human immunodeficiency virus; RA = risk assessment; STI =
sexually transmitted infection.
SOURCE: AAP, 2008. Used with permission of the American Academy of Pediat-
rics, Bright Futures—Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition, American Academy of Pediatrics, 2008.
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42 CLINICAL PREVENTIVE SERVICES FOR WOMEN
Physical Examination
A complete physical examination is included as ■ Breast
part of every health supervision visit. Female
• Clinical Breast Examination is considered
When performing a physical examination, the health
routine after age 20.
care professional’s attention is directed to the following
■ Genitalia
components of the exam that are important for 18- to
Female
21-year-olds:
• Inspect for signs of STIs (eg, warts, vesicles,
■ Measure: vaginal discharge)
• Blood pressure • Perform pelvic exam by age 21 or if clinically
■ Measure and plot: warranted, based on sexual activity (eg, for Pap
• Height smear within 3 years of onset of sexual activity)
• Weight and/or specific problems (eg, pubertal aber-
■ Calculate and plot: rancy, abnormal bleeding, abdominal or pelvic
• BMI pain)
■ Skin Male
• Inspect for acne, acanthosis nigricans, atypical • Perform visual inspection for sexual maturity
nevi, tattoos, piercings, and signs of abuse or rating and observations for signs of STIs (ie,
self-inflicted injury warts, vesicles)
• Examine testicles for hydrocele, hernias,
varicocele, or masses
Screening
UNIVERSAL SCREENING ACTION
Snellen test
Vision (once in late adolescence)
A fasting lipoprotein profile (total cholesterol, LDL choesterol, high density
Dyslipidemia (once in late
adolescence) lipoprotein (HCL), cholesterol, and triglyceride). If the testing opportunity is
non-fasting, only total cholesterol and HDL cholesterol will be usable.
SELECTIVE SCREENING RISK ASSESSMENT* ACTION IF RA +
Vision at other ages + on risk screening questions Snellen test
Hearing + on risk screening questions Audiometry
Anemia + on risk screening questions Hemoglobin or hematocrit
Tuberculosis + on risk screening questions Tuberculin skin test
If not age 20, + on risk screening Lipid screen
Dyslipidemia
questions and not previously
screeened with normal resaults
STIs Sexually active Screen for chlamydia and gonorrhea;
use tests appropriate to the patient
population and clinical setting
Sexually active and + on risk questions Syphilis blood test
HIV†
Sexually active without contraception, Urine hCG
Pregnancy
late or absent menses, or heavy or
irregular bleeding
Sexually active, within 3 years of Pap smear, conventional slide
Cervical dysplasia
onset of sexual activity or liquid-based
Alcohol or drug use + on risk screening questions Administer alcohol and drug
screening tool
*See Rationale and Evidence chapter for the criteria on which risk screening questions are based.
The CDC has recently recommended universal voluntary HIV screening for all sexually active people, beginning at age 13. At the time of
†
publication, the AAP and other groups had not yet commented on the CDC recommendation, nor recommended screening criteria or
techniques. The health care professional’s attention is drawn to the voluntary nature of screening and that the CDC allows an opt out in
communities where the HIV rate is <0.1%. The management of positives and false positives must be considered before testing.
Figure 2-3.eps
FIGURE 2-3 Adolescence 18–21 year visits.
ABBREVIATIONS: AAP = American Academy of Pediatrics; BMI = body mass in-
dex; CDC = Centers for Disease Control and Prevention; hCG = human chorionic
gonadotropin; HDL = high-density lipoprotein; HIV = human immunodeficiency
virus; LDL = low-density lipoprotein; RA = risk assessment; STI = sexually trans-
mitted infection.
SOURCE: AAP, 2008. Used with permission of the American Academy of Pediat-
rics, Bright Futures—Guidelines for Health Supervision of Infants, Children, and
Adolescents, Third Edition, American Academy of Pediatrics, 2008.
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43
PREVENTIVE SERVICES DEFINED BY THE ACA
ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES
ACIP is the sole federal government entity that provides written rec-
ommendations for delivering vaccines to children and adults in the general
population. It provides guidance and recommendations to HHS and the CDC
on matters regarding the approval, administration, and safety of vaccines.
Its goal is to reduce the prevalence of vaccine-preventable diseases in the
United States and bolster the safe use of vaccines and other related biological
products. ACIP is comprised of 15 voting immunization-related experts and
34 other representatives from liaison organizations and federal agencies that
oversee national immunizations programs (CDC, 2011a).
ACIP Methodology
The ACIP General Recommendations Work Group (GRWG) revises the
General Recommendations on Immunization every 3 to 5 years. Relevant
topics are those identified by ACIP to be topics that relate to all vaccines,
including timing and spacing of doses, vaccine administration procedures,
and vaccine storage and handling. New topics are often added when ACIP
decides that previous ACIP statements on general issues, such as combina-
tion vaccines, adolescent vaccination, and adult vaccination, should be
revised and combined with the General Recommendations on Immuniza-
tion (CDC, 2011b).
The recommendations in the 2011 GRWG report are based not only
on available scientific evidence but also on expertise that comes directly
from a diverse group of health care providers and public health officials.
GRWG includes “professionals from academic medicine (pediatrics, family
practice, and pharmacy); international (Canada), federal, and state public
health professionals; and a member of the nongovernmental Immunization
Action Coalition” (CDC, 2011b).
ACIP committee work groups comprising an ACIP member chair, a
CDC subject-matter expert, and at least two ACIP members meet during
the year to perform analyses of vaccine-related data and generate potential
policy recommendations to be presented to the committee. These analyses
include review of the available scientific literature on the immunizing agent,
morbidity and mortality from the disease in the U.S. population, recom-
mendation statements issued by other professional organizations, results of
clinical trials with the immunizing agent, cost-effectiveness projections, and
the feasibility of incorporating the vaccine into preexisting U.S. immuniza-
tion programs. Draft recommendations are then subjected to further review
by the FDA, CDC, ACIP members, external expert consultants, and other
relevant federal agencies. Work group findings and potential recommen-
dations are presented to ACIP at one of three annual open meetings and
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44 CLINICAL PREVENTIVE SERVICES FOR WOMEN
are deliberated upon by the committee. Public comments are heard at the
meetings and taken into consideration during the deliberations. A majority
vote is then conducted to pass a recommendation that includes guidance re-
garding the route of administration and dosing intervals, contraindications
and precautions, and target groups for immunization. Recommendations
are published on the ACIP website and in Morbidity and Mortality Weekly
Report (Smith et al., 2009).
ACIP functions in a unique position because its recommendations are
relevant to the general population and to some quite specific subpopula-
tions, but its recommendations focus on efficacy and safety for intended
populations. Some of its recommendations are not intended for general clin-
ical use (e.g., recommendations for international travelers), are not intended
for the entire population (e.g., recommendations for high-risk groups such
as health care workers), or require specific guidance in footnotes for special
circumstances (e.g., allergies and immunosuppression).
Table 2-3 lists the FDA-Licensed Combination Vaccines, and Table 2-4
lists ACIP-recommended vaccines that are covered without cost sharing as
part of the ACA.
TABLE 2-3 FDA-Licensed Combination Vaccines
Trade Name
Vaccine (Year Licensed) Age Range Routinely Recommended Ages
≥18 years
HepA-HepB Twinrix (2001) Three doses on a schedule of 0, 1, and
6 months
MMRV ProQuad (2005) 12 months– Two doses, the first at 12–15 months,
12 years the second at 4–6 years
ABBREVIATIONS: HepA = hepatitis A; HepB = hepatitis B; MMRV = measles, mumps,
rubella, and varicella.
SOURCES: AAP, 2009; CDC, 2011.
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PREVENTIVE SERVICES DEFINED BY THE ACA
TABLE 2-4 Recommended and Minimum Ages and Intervals Between
Vaccine Doses
Recommended Minimum Recommended Minimum
Vaccine and Dose Age for This Age for This Interval to Interval to
Number Dose Dose Next Dose Next Dose
LAIV (intranasal)a 2–49 years 2 years 1 month 4 weeks
MCV4-1b 11–12 years 2 years 5 years 8 weeks
MCV4-2 16 years 11 years
(+8 weeks)
HPV-1c 11–12 years 9 years 2 months 4 weeks
HPV-2 11–12 years 9 years 4 months 12 weeks
(+2 months) (+4 weeks)
HPV-3d 11–12 years 9 years
(+6 months) (+24 weeks)
Td 11–12 years 7 years 10 years 5 years
Tdap 11–12 years 7 years
NOTE: Combination vaccines are available. Use of licensed combination vaccines is generally
preferred to separate injections of their equivalent component vaccines. When combination
vaccines, the minimum age for administration is the oldest age for any of the individual
components; the minimum interval between doses is equal to the greatest interval of any of
the individual components. Information on traveler vaccines, including typhoid, Japanese
encephalitis, and yellow fever, is available at http://www.cdc.gov/travel. Information on other
vaccines that are licensed in the United States but not distributed, including anthrax and
smallpox, is available at http://www.bt.cdc.gov.
ABBREVIATIONS: LAIV = live, attenuated influenza vaccine; MCV4 = quadrivalent meningo-
coccal conjugate vaccine; HPV-1 to HPV-3 = human papillomavirus doses 1 to 3, respectively;
Td = adult tetanus and diphtheria toxoids; Tdap = tetanus and reduced diphtheria toxoids and
acellular pertussis vaccine (for adolescents and adults).
a One dose of influenza vaccine per season is recommended for most persons. Children aged
< 9 years who are receiving influenza vaccine for the first time or who received only one dose
the previous season (if it was their first vaccination season) should receive two doses this
season.
b Revaccination with meningococcal vaccine is recommended for previously vaccinated persons
who remain at high risk for meningococcal disease (CDC, 2009).
c Bivalent HPV vaccine is approved for females aged 10–25 years. Quadrivalent HPV vaccine
is approved for males and females aged 9–26 years.
d The minimum age for HPV-3 is based on the baseline minimum age for the first dose (i.e.,
108 months) and the minimum interval of 24 weeks between the first and third doses. Dose 3
need not be repeated if it is administered at least 16 weeks after the first dose.
SOURCES: AAP, 2009; CDC, 2011b.
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46 CLINICAL PREVENTIVE SERVICES FOR WOMEN
REFERENCES
AAP (American Academy of Pediatrics). 2008. Bright Futures: Guidelines for health super-
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