Clinical Preventive Services for Women: Closing the Gaps (2011)

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Committee Methodology

This chapter outlines the methodology that the Institute of Medicine Committee on Preventive Services for Women used to identify preventive services necessary for women’s health and well-being that are not included in the United States Preventive Services Task Force (USPSTF) Grade A and B recommendations, Bright Futures’ recommendations, or the Advisory Committee on Immunization Practices (ACIP) guidelines and to identify specific services that could supplement the current list of preventive services recommended for women under the Patient Protection and Affordable Care Act of 2010 (ACA). The committee’s first step in this process was to review and reach an understanding of the guidelines of these analytic bodies. The second step was to assemble and assess additional evidence, including reviews of the literature, federal health priority goals and objectives, federal reimbursement policies, and professional clinical guidelines. The committee also considered comments submitted by the public. Finally, the committee recommended preventive services that the Secretary of the U.S. Department of Health and Human Services (HHS) should consider in developing a comprehensive package of preventive services for women to be included under the ACA.¹

REVIEW OF USPSTF RECOMMENDATIONS

The USPSTF process was developed to provide guidance to primary care providers. The committee’s approach to identifying gaps in existing

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¹ One committee member’s dissenting comments regarding much of the study process are included in Appendix D.

services accounts for contextual issues beyond traditional research evidence used by the USPSTF. The committee looked at women’s preventive service needs more broadly to account for women’s health and well-being.

The committee found that the USPSTF Grade A and B recommendations required close examination. The specificity of several recommendations is not clear in some cases, including such details as the periodicity of screenings or how the service is to be delivered. For example, the Grade B recommendation for screening for depression could be interpreted to be universal screening, under the assumption that the primary care provider offices offering the service have adequate staff in place to support the correct delivery of the service, or the USPSTF’s recommendation could be interpreted narrowly to include screening only in those practices that have a certified depression screening quality assurance program in place. Thus, after a review of the supporting evidence that led to their recommendations, the committee decided that it was important to note its interpretation of the Grade A and B recommendations in those cases in which specific aspects of the recommendation were found to be ambiguous (see Table 5-1). The committee also compared the USPSTF guidelines with the guidelines of other professional organizations to identify potential gaps.

The USPSTF Grade C and I statements (Table 4-1) also required further analysis by the committee because in neither case had the USPSTF intended its conclusions to limit or preclude consideration for coverage. The USPSTF informally refers to Grade C recommendations as close calls in which the balance of potential benefits and harms does not strongly favor the clinician recommending the preventive service to all patients, although it may be appropriate in some cases. The USPSTF makes the point that either choosing or not choosing the service with a Grade C recommendation would be within the standard of care and assumes that the service would be covered if clinically appropriate (USPSTF, 2008). The USPSTF also considers decision making to be a shared activity of the patient and the provider based on the individual circumstances of the patient.

The Grade I statement is a conclusion that the evidence is “insufficient to conclude whether the service is effective or not because evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined” (USPSTF, 2008). The I statement simply means that important outcomes have not yet been adequately evaluated by current research. The committee notes that from a coverage perspective, the evidence supporting many clinical interventions in common use, whether in prevention or in general medical practice, is insufficient or unclear, and that coverage decisions may be made or have been made on the basis of other factors. For example, although knowledge of the evidence for the benefits and harms of services and screenings informs a primary care provider’s

TABLE 4-1 USPSTF Grade C Recommendations and I Statements

SOURCE: USPSTF, 2011.

decision for each patient, in many instances, research either is inconclusive or has not been conducted.

The Institute of Medicine (IOM) report on women’s health research identified many areas in which research is needed (IOM, 2010). For example, the report indicated a lack of large-scale studies identifying effective gender- and age-specific interventions involving modification of lifestyle and other behaviors that affect health, such as alcohol abuse and obesity. Furthermore, determining the evidence for the value of certain services is challenging, because it is difficult to prove the effectiveness of an intervention across the life span. For example, prevention interventions that should be conducted early in the life span (e.g., skin cancer prevention) require decades to demonstrate effectiveness.

Each of the Grade C and I recommendation statements and the evidence supporting them were collected and reviewed. The committee’s evaluation included reviewing relevant supporting USPSTF publications, other peer-reviewed research and clinical articles, and clinician fact sheets. The committee did not reassess the Grade D recommendations, given the evidence base driving the USPSTF to recommend against providing these services. Additional literature searches were conducted to identify randomized control trials that were conducted after the USPSTF recommendation was released for each of the Grade C and I recommendations. Furthermore, the committee compared the Grade C and I guidelines with guidelines from other professional groups.

REVIEW OF BRIGHT FUTURES RECOMMENDATIONS

The committee reviewed all Bright Futures guidelines and compared them with the USPSTF guidelines for adolescents. The committee noted that the methodology that Bright Futures uses to develop recommendations is considered “evidence informed” and includes expert opinion. Bright

Futures also uses a more comprehensive focus on health promotion and disease prevention, on the basis of its criteria for the burden of the condition (AAP, 2008).

For the committee, the principal challenge in identifying preventive services to supplement the guidance from Bright Futures was to disaggregate the health supervision visits recommended by Bright Futures and some of its anticipatory guidance into conditions and preventive measures fitting the committee’s overall approach. The committee considered the sample questions and advice suggested in the anticipatory guidance section of the Bright Futures report to be preventive services to be covered under the ACA. According to the guidelines, these preventive services should be addressed in an annual visit of sufficient length to cover age- and sex-appropriate topics in the health domain. Thus, the topics of physical growth and development, social and academic competence, emotional well-being, risk reduction, and violence and injury prevention, as well as the sample questions and suggested guidance for both the parents and the adolescent, are expected to be addressed at each and every annual visit. The task of addressing each and every one of the suggested topics during a yearly visit seemed daunting to the committee. However, the committee assumes that primary care providers will identify priorities from this section on the basis of the unique circumstances of each patient.

REVIEW OF ACIP RECOMMENDATIONS

The committee reviewed ACIP General Recommendations on Immunization, which include all Food and Drug Administration-approved immunizations recommended for the general population of adolescent and adult women (CDC, 2011; Smith et al., 2009). In addition, to assess potential supplemental immunizations, the committee reviewed the immunizations recommended for high-risk groups and for individuals in special circumstances to determine whether some substantial subpopulation of women, clearly defined, might warrant further attention. Although literature searches were conducted to identify areas where supplemental immunization recommendations might be warranted, the committee identified little evidence to indicate clear deficiencies in existing ACIP recommendations.

FURTHER COMMITTEE CONSIDERATIONS

The committee reviewed both oral and written public comments submitted throughout the course of the study. Some of these comments were from experts, individuals expressing personal experiences with preventable conditions, and members of the U.S. Congress. All of these comments contained recommendations for the committee’s consideration. Additionally,

several nongovernmental organizations submitted research studies, public statements, and recommended guidelines for preventive services for women. The committee reviewed all of this information.

The committee also invited researchers and leaders of organizations to deliver presentations in areas where the committee believed that it could benefit from their expertise. These included, for example, presentations on mental health, oral health, occupational health, and the perspectives of employers and health insurers. The committee invited speakers who requested the opportunity in addition to inviting individuals with expertise in potential gap areas or individuals identified as having a perspective that the committee should consider. Furthermore, the committee reviewed HHS documents relating to prevention priorities and reimbursement policies. It also reviewed the existing coverage practices of national, state, and private health plans (these are detailed in Chapter 3). In some cases, committee members also identified current practice in clinical care by using sources such as the British Medical Journal Best Evidence and UpToDate (BMJ Clinical Evidence, 2011; UpToDate Inc., 2011). Finally, the committee also used the 2011 IOM report Leading Health Indicators for Healthy People 2020 as a tool to perform horizon scanning or examine priority goals and/ or persistent trends relating to women’s health and well-being to identify potential gaps (IOM, 2011).

Committee Analysis

The product of these reviews was an array of areas in which supplemental preventive measures might be warranted. Some of these areas were identified on the basis of traditional indicators such as morbidity and mortality, whereas others were more generally identified to be supportive of a woman’s well-being. Adhering to the definitions described in Chapter 1, the committee focused on conditions unique to women or that affect women in some specific or disproportionate way. In general, the committee used criteria adapted from the USPSTF that consider frequency, severity, morbidity, mortality, and quality of life to bring consistency to the analyses.

For each potential supplemental preventive measure considered, an extensive comparison with the guidelines of professional organizations (e.g., American Academy of Family Physicians, American College of Physicians, American College of Obstetricians and Gynecologists, American Cancer Society, American Medical Association) was conducted to understand these guidelines development processes and the evidence that the organizations use to reach their conclusions. Many of these guidelines are posted in the Agency for Healthcare Research and Quality’s National Guidelines Clearinghouse. The committee also performed targeted literature searches.

Identifying Potential Supplemental Preventive Measures

The committee then attempted to identify preventive measures that were aimed at filling the gaps that it had identified. In most cases, the committee found that measures had already been proposed by the other organizations mentioned above. The committee also eliminated preventive measures that, even at this early stage in the analysis, were clearly not developed, tested, or known well enough to have a measurable impact. The resulting product of this step was a series of areas with gaps, with the accompanying preventive measure or measures that could be considered by the Secretary for HHS for inclusion in guiding policy and program development relating to the ACA.

Identifying Gap Areas and Measures with Adequate Evidence

The core of the committee’s task was to assemble the evidence that would allow it to recommend consideration of a preventive service. The committee found that systematic reviews of clinical effectiveness were not available to address all the potential gaps and that a standard methodology addressing coverage of preventive services does not exist. These two issues are discussed below.

Reviews of Clinical Effectiveness

Assessment of the efficacy and effectiveness of preventive measures to provide clinical guidance was one of the topics of clinical focus that, more than 30 years ago, launched the change in the approach to health care delivery that is now called evidence-based medicine. The USPSTF and its Canadian sister organization, the Canadian Taskforce on Preventive Health Care, were active at the beginning of this movement, with a major focus being on developing the methodology. Since the 1980s, the standards for judging the effectiveness of preventive measures have matured, and the bar for determining the effectiveness of preventive measures has been set very high. Furthermore, for a number of reasons, including ethical constraints, the evidence bar is usually set higher for preventive services than for the services offered in many other areas of conventional medical care. It is generally assumed that a preventive service intended for the general population should have proven benefits and minimal harms, with the benefits clearly outweighing the harms. As noted below, the committee had neither the time and resources nor a charge to conduct its own systematic reviews, which, using the USPSTF as an example, often take 12 to 18 months for a single topic.

Methodologies with a Coverage Decision as the Goal

The USPSTF, Bright Futures, and ACIP focus on the provision of guidance to clinicians and patients, not on insurance coverage. Decision making about covering a preventive service may consider a host of other issues, such as established practice; patient and clinician preferences; availability; ethical, legal, and social issues; and availability of alternatives. Further complicating matters, special population groups, such as minority populations, recent immigrants, lesbians, prisoners, and those employed in high-risk environments, may have different health needs or benefit from different preventive services. In addition, high-risk groups, population subsets, and special populations are unevenly identified and are addressed at varying degrees in current guidelines. Finally, because cost was explicitly excluded as a factor that the committee could use in forming recommendations, the committee process could not evaluate preventive services on the basis of cost.

Against this background, the committee selected a hybrid approach that collected relevant evidence for each measure, and it determined that the question of a methodology to fully address insurance coverage was beyond its scope. Four categories of evidence—posed in the form of questions—were developed to systematically query support for each potential preventive measure. The committee neither formally ranked or assigned weights to the categories, nor did it stipulate that evidence in any one category would automatically result in a recommendation for a measure or service to be considered. Instead, the queries and categories were used to consider the range of evidence and to ensure consistency in the committee’s analysis and deliberations. Many of the recommendations are supported by more than one category of evidence.

Category I. Are high-quality systematic evidence reviews available indicating that the service is effective in women?

Category II. Are quality peer-reviewed studies available demonstrating effectiveness of the service in women?

Category III. Has the measure been identified as a federal priority to address in women’s preventive services?

Category IV. Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure?

RECOMMENDATIONS ON PREVENTIVE SERVICES TO BE CONSIDERED IN DEVELOPMENT OF COMPREHENSIVE GUIDELINES

Subcommittees queried the available evidence applicable to potential preventive measures and assigned the evidence to one or more of the categories listed above. Each subcommittee then brought its analysis of the range of evidence before the full committee for deliberation. The committee combined the burden of the condition and its potential impact on health and well-being with the array of available evidence and support noted above to come to a consensus over whether to recommend that a specific preventive measure be considered by the Secretary. As is true in most analytical processes in decision making, evidence and expert judgment are inextricably linked; thus, the expert judgments of the committee members also played a role in decision making.

In general, preventive measures recommended by the committee met the following criteria:

• The condition to be prevented affects a broad population;
• The condition to be prevented has a large potential impact on health and well-being; and
• The quality and strength of the evidence is supportive.

Ultimately, the decision to develop a recommendation for a preventive measure or service was made after a thoughtful review and debate of each of the subcommittee’s reports. Recommendations were made when the evidence was found compelling based on the committee’s interpretation of the strength of the evidence. In Chapters 5, the committee describes the evidence that factored into its decision making for each supplemental preventive measure recommendation.

In some instances, a subcommittee’s analysis resulted in the development of a clarifying statement (added to Table 5-1) on the committee’s interpretation of current USPSTF guidelines. In other cases, the subcommittee’s analysis suggested a service that could be considered part of a well-woman visit (Table 5-6). These are addressed in Appendix A of this report.

REFERENCES

AAP (American Academy of Pediatrics). 2008. Bright Futures: Guidelines for health supervision of infants, children and adolescents, 3rd ed. (J. F. Hagan, J. S. Shaw, and P. M. Duncan, eds.). Elk Grove Village, IL: American Academy of Pediatrics.

BMJ Clinical Evidence. 2011. Clinical evidence. London, United Kingdom: BMJ Publishing Group.

CDC (Centers for Disease Control and Prevention). 2011. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports: Morbidity and Mortality Weekly Report 60(2):1–64.

IOM (Institute of Medicine). 2010. Women’s health research: Progress, pitfalls, and promise. Washington, DC: The National Academies Press.

IOM. 2011. Leading health indicators for Healthy People 2020. Washington, DC: The National Academies Press.

Smith, J. C., D. E. Snider, and L. K. Pickering. 2009. Immunization policy development in the United States: The role of the Advisory Committee on Immunization Practices. Annals of Internal Medicine 150(1):W45–W49.

UpToDate Inc. 2011. UpToDate. Waltham, MA: UpToDate Inc.

USPSTF (United States Preventive Services Task Force). 2008. Grade definitions. Rockville, MD: United States Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm (accessed May 31, 2011).

USPSTF. 2011. A-Z topic guide. Rockville, MD: United States Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstopics.htm (accessed May 31, 2011).