Clinical
Preventive
Services
for Women


Closing the Gaps

Committee on Preventive Services for Women

Board on Population Health and Public Health Practice


INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES







THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Clinical Preventive Services for Women Closing the Gaps Committee on Preventive Services for Women Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract HHSP23337013T between the National Academy of Sciences and the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21538-1 International Standard Book Number-10: 0-309-21538-2 Additional copies of this report are available from the National Academies Press, 500 Fifth Street NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover credit: The cover painting is reprinted with permission from the artist, Alberto Schunk. Suggested citation: IOM (Institute of Medicine). 2011. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PREVENTIVE SERVICES FOR WOMEN Linda Rosenstock (Chair), Dean, School of Public Health, University of California, Los Angeles Alfred O. Berg, Professor, Department of Family Medicine, University of Washington School of Medicine, Seattle Claire D. Brindis, Professor of Pediatrics and Health Policy, Department of Pediatrics and Department of Obstetrics, Gynecology and Reproductive Health Services, and Director, Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco Angela Diaz, Jean C. and James W. Crystal Professor of Adolescent Health, Department of Pediatrics and Community Preventative Medicine, Mount Sinai Medical Center, New York, New York Francisco Garcia, Distinguished Outreach Professor of Public Health, Obstetrics and Gynecology; Director, University of Arizona Center of Excellence in Women’s Health; and Codirector, Cancer Disparities Institute, University of Arizona, Tucson Kimberly Gregory, Vice Chair, Women’s Healthcare Quality and Performance Improvement, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California Paula A. Johnson, Executive Director, Connors Center for Women’s Health and Gender Biology, and Chief, Division of Women’s Health, Brigham and Women’s Hospital, Boston, Massachusetts Anthony Lo Sasso, Professor and Senior Research Scientist, Division of Health Policy and Administration, University of Illinois at Chicago School of Public Health Jeanette H. Magnus, Cecile Usdin Professor in Women’s Health and Chair, Department of Community Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana Heidi D. Nelson, Research Professor of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health and Science University, and Medical Director for Cancer Prevention and Screening, Providence Cancer Center, Providence Health & Services, Portland, Oregon Roberta B. Ness, Dean and M. David Low Chair in Public Health, School of Public Health, University of Texas, Houston Magda G. Peck, Professor of Public Health and Pediatrics and Associate Dean for Community Engagement and Public Health Practice, College of Public Health, University of Nebraska Medical Centers, Omaha, Nebraska v

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E. Albert Reece, Vice President for Medical Affairs, University of Maryland, and John Z. and Akiko K. Bowers Distinguished Professor and Dean, University of Maryland School of Medicine, Baltimore Alina Salganicoff, Vice President and Director, Women’s Health Policy, Henry J. Kaiser Family Foundation, Menlo Park, California Sally W. Vernon, Division Director, Health Promotion and Behavioral Sciences, Blair Justice, Ph.D. Professorship in Mind-Body Medicine and Public Health, and Professor of Epidemiology and Behavioral Sciences, University of Texas School of Public Health, Houston Carol S. Weisman, Distinguished Professor of Public Health Sciences and Obstetrics and Gynecology and Associate Dean for Faculty Affairs, Pennsylvania State University College of Medicine, Hershey Study Staff Karen Helsing, Study Director Jesse Flynn, Associate Program Officer Suzanne Landi, Research Assistant Chelsea Frakes, Senior Program Assistant Rebekah E. Gee, Institute of Medicine Anniversary Fellow Amy Pryzbocki, Financial Associate Rose Marie Martinez, Senior Director, Board on Population Health and Public Health Practice vi

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Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of this report: Eli Y. Adashi, Professor of Medical Science, The Warren Alpert Medical School, Brown University Wylie Burke, Professor and Chair, Department of Bioethics and Humanities, School of Medicine, University of Washington Ned Calonge, President and Chief Executive Officer, The Colorado Trust Carol A. Ford, Chief, Craig Dalsimer Division of Adolescent Medicine and Orton Jackson Endowed Chair in Adolescent Medicine, the Children’s Hospital of Philadelphia Paula M. Lantz, S.J. Axelrod Collegiate Professor of Health Management and Policy and Chair, Department of Health Management and Policy, School of Public Health, University of Michigan JoAnn E. Manson, Chief, Division of Preventive Medicine, Brigham and Women’s Hospital and Elizabeth F. Brigham Professor of Medicine and Women’s Health, Harvard Medical School vii

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viii REVIEWERS Gary E. Raskob, Dean and Professor of Epidemiology and Medicine, College of Public Health, University of Oklahoma Health Sciences Center Rita Redberg, Director, Women’s Cardiovascular Services Medical Center, University of California, San Francisco Sara Rosenbaum, Hirsh Professor and Chair, Department of Health Policy, School of Public Health and Health Services, The George Washington University Medical Center Donna Strobino, Professor and Vice Chair of Education, Bloomberg School of Public Health, Johns Hopkins University Nancy Fugate Woods, Dean Emeritus, School of Nursing, University of Washington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Nancy E. Adler, Profes- sor of Medical Psychology, Departments of Psychiatry and Pediatrics, and Director, Center for Health and Community, University of California, San Francisco and Susan J. Curry, Dean, College of Public Health, University of Iowa. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of the report rests entirely with the author committee and the institution.

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Preface As chair of the Committee on Preventive Services for Women, I want to personally thank my fellow committee members for their willingness to serve, for their hard work, and for contributing their remarkable expertise to this study. I have been honored to contribute to this effort. Each of us works in different domains relating to preventive health services, and although the short time frame provided to perform this study presented a challenge, my esteemed colleagues who comprised the committee worked as a team with great dedication and spirit to achieve consensus. It was a pleasure to work with each and every one of them. The diverse committee involves an impressive array of researchers and practitioners, including two members who served on the United States Pre- ventive Services Task Force (USPSTF) and one who leads USPSTF systematic evidence reviews. Although we could not conduct a USPSTF-style system- atic review for any single preventable health condition or determinant of well-being, nor were we expected to do so, I believe that our end product is a study that has important, evidence-based recommendations that provide a road map to improved preventive services for women. Throughout the process we repeatedly asked ourselves whether the disease or condition that we were addressing was of significance to women and especially whether it was more common or more serious in women than in men or whether women experienced different outcomes or benefited from different interven- tions than men. I believe that the preventive services that we recommend for consideration in this report readily satisfy these questions. The Patient Protection and Affordable Care Act of 2010 has afforded ix

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x PREFACE us an historic occasion. For the first time, prevention plays a central role within the scope of new health insurance plans in the United States. Also, an ongoing focus on women’s preventive services is expected to be included in these efforts. Given the history of inadequate attention to women’s health research and preventive services noted by many (including previous Institute of Medicine [IOM] committees), I am truly optimistic that gains in women’s health and well-being will ensue. With the multiple roles that women play in society, to invest in the health and well-being of women is to invest in progress for all. I regret that we were unable to resolve to his satisfaction the issues raised by one committee member, Anthony Lo Sasso. In his statement of dissent, he identifies his main concerns, which are with the constraints of the study’s charge and subsequent process. His statement, along with the committee’s response, can be found in Appendix D of the report. I thank the IOM staff, especially our senior project officer, Karen Helsing, and also Jesse Flynn, Suzanne Landi, Chelsea Frakes, and IOM Anniversary Fellow Rebekah Gee. All went above and beyond to support the committee throughout the process. We also are indebted to Rose Marie Martinez, senior director of the Board on Population Health and Public Health Practice, for her presence throughout and her invaluable guidance and support. I am grateful as well to those who presented and attended our committee’s open sessions and those who submitted comments and informed our work with their research and opinion pieces. Without their dedicated work this report would not have been possible. Linda Rosenstock, Chair Committee on Preventive Services for Women

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Contents SUMMARY 1 1 INTRODUCTION 15 Specifics of the Legislation, 15 Role of Prevention in Addressing Health and Well-Being, 16 Why Women?, 18 Preventive Services for Women, 20 Committee on Preventive Services for Women, 20 Committee Process, 22 References, 26 2 PREVENTIVE SERVICES DEFINED BY THE ACA 29 United States Preventive Services Task Force, 29 Bright Futures—American Academy of Pediatrics, 37 Advisory Committee on Immunization Practices, 43 References, 46 3 EXISTING COVERAGE PRACTICES OF NATIONAL, STATE, AND PRIVATE HEALTH PLANS 47 Rules Governing Coverage Requirements Before and After the ACA, 48 Discussion, 64 References, 64 xi

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xii CONTENTS 4 COMMITTEE METHODOLOGY 67 Review of USPSTF Recommendations, 67 Review of Bright Futures Recommendations, 72 Review of ACIP Recommendations, 73 Further Committee Considerations, 73 Recommendations on Preventive Services to Be Considered in Development of Comprehensive Guidelines, 77 References, 77 5 RECOMMENDATIONS 79 Diabetes and Gestational Diabetes, 79 Cervical Cancer, 88 Sexually Transmitted Infections, 94 Human Immunodeficiency Virus Infection, 98 Preventing Unintended Pregnancy and Promoting Healthy Birth Spacing, 102 Breastfeeding, 110 Interpersonal and Domestic Violence, 117 Well-Woman Preventive Visits, 123 References, 135 6 PROCESS FOR REGULARLY UPDATING THE RECOMMENDATIONS 157 Guiding Principles and Recommendations, 158 A Preventive Services Coverage Commission, 158 Role of Evidence-Based Review Bodies, 159 Discussion, 160 References, 162 7 FINDINGS AND RECOMMENDATIONS FOR ADDRESSING IDENTIFIED GAPS IN PREVENTIVE SERVICES FOR WOMEN 163 Concluding Observations from the Committee, 163 References, 168 APPENDIXES A CLARIFICATIONS 171 Cardiovascular Disease, 171 Bone/Skeletal Disease, 178 Breast Cancer, 182

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xiii CONTENTS Mental Health, 188 Tobacco Use, 193 Diet/Physical Activity, 198 References, 202 B AGENDAS OF PUBLIC MEETINGS HELD BY THE COMMITTEE ON PREVENTIVE SERVICES FOR WOMEN 217 C COMMITTEE BIOGRAPHIES 223 D DISSENT AND RESPONSE 231