Clinical Preventive Services for Women Closing the Gaps (2011) / Chapter Skim
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5 Recommendations
5 Recommendations
Pages 79-156
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From page 79... ...
The rationale for including these two statements is presented in Appendix A DIABETES AND GESTATIONAL DIABETES Diabetes mellitus (DM)
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Blood pressure The USPSTF recommends screening A Annual screening. screening for high blood pressure in adults aged 18 and older.
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Syphilis The USPSTF recommends that A Screening at first screening: clinicians screen all pregnant prenatal visit, and as pregnant women women for syphilis infection. indicated if at high risk.
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is diabetes that arises or is diagnosed in pregnancy, typically during the second and third trimesters of pregnancy. It accounts for about 135,000 diabetic patients annually in the United States and occurs in approximately 2 to 10 percent of pregnant women (NIDDK, 2011)
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. Cases of GDM increase with maternal age and occur 7 to 10 times more often among pregnant women age 24 and older than among women younger than 24 years old (Reece, 2010)
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. Besides obesity, other risk factors for developing type 2 diabetes include impaired glucose tolerance or impaired fasting glucose, insulin resistance, ethnic background, high blood pressure, a history of gestational diabetes, a sedentary lifestyle, family history, polycystic ovary syndrome, and older age (ADA, 2011a)
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From page 85... ...
The USPSTF recommends screening for type 2 diabetes only in asymptomatic adults with a sustained blood pressure of greater than 135/80 mm Hg and found insufficient evidence to support screening in asymptomatic adults with lower blood pressure levels. Bright Futures does not specifically address screening for diabetes.
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However, some bodies have considered it important to screen pregnant women for GDM because these women are at increased risk for having infants with excessive birth weight and require operative delivery or infants with increased neonatal morbidity.
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Since the conclusion of the DPP study, additional data analyses continue to provide important insights into the value of lifestyle changes in helping people prevent type 2 diabetes and its complications. One analysis found that DPP participants with specific genetic profiles had a significantly increased risk of developing diabetes and selective responses to specific interventions (Florez et al., 2007)
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From page 88... ...
The evidence provided to support a recommendation for gestational diabetes is based on current federal practice policy from IHS and the VA as well as current practice and clinical professional guidelines such as those set forth by AAFP and ACOG. Recommendation 5.1: The committee recommends for consideration as a preventive service for women: screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.
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From page 89... ...
, the fact that these deaths are almost entirely preventable through primary prevention, screening and early detection, treatment of precancerous lesions, and effective therapies for invasive disease, makes cervical cancer a high-impact public health priority. Because sexually acquired persistent high-risk HPV infection is the primary causal factor associated with the development of cervical cancer, regular screening of all adult women with a history of sexual activity has been the mainstay of prevention efforts (USPSTF, 2003a)
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From page 90... ...
by 10 percent so that 93 percent of women are screened. Existing Guidelines and Recommendations USPSTF Recommendations The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.
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Effective Interventions On the basis of the summary of observational data, it can be concluded that the use of cytology for cervical cancer screening has contributed significantly to the reduction in the incidence of and rate of mortality from invasive cervical cancer. This has been accomplished on the basis of the substantial uptake of screening for cervical cancer.
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Changing Screening Paradigms A number of European trials have examined the usefulness of primary screening using high-risk HPV DNA testing compared with that of cervical cytology for the detection of cervical cancer and its precursors. A large randomized controlled trial conducted within the Italian national screening program compared the performance of the HC2 assay to that of conventional cytology among 35,471 women 35 years of age or older (Ronco et al., 2007)
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is that currently there is an absence of coverage for co-testing with cytology and high-risk HPV DNA testing among women 30 years of age and older as a strategy to increase screening intervals to every three years. Cervical cancer is
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Peer-reviewed studies demonstrate that improved testing technologies, particularly combined screening using both conventional cytology and high-risk HPV DNA screening, may significantly improve the rate of detection of cervical cancer precursors and facilitate the safe lengthening of the interval for screening. Recommendation 5.2: The committee recommends for consideration as a preventive service for women: the addition of high-risk HPV DNA testing to cytology testing in women with normal cytology results.
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. Existing Guidelines and Recommendations The USPSTF recommends screening and counseling for STIs on the basis of the following risk factors listed in Table 5-2.
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If the practice's population has a high rate of STIs, all sexually active patients in non-monogamous relationships may be considered to be at increased risk" (Calonge et al., 2008)
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. Bright Futures recommends that sexually active adolescents receive annual screenings for gonorrhea and chlamydia.
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Recommendation 5.3: The committee recommends for consideration as a preventive service for women: annual counseling on sexually trans mitted infections for sexually active women. HUMAN IMMUNODEFICIENCY VIRUS INFECTION HIV was addressed above in the section on STIs, as HIV infection frequently coexists with other STIs and the risk factors for HIV infection and STIs are much the same.
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From page 99... ...
. Although women share with men the complication of the progression of HIV infection to AIDS, they also experience gender-specific comorbidities, such as recurrent vaginal yeast infections, severe pelvic inflammatory disease, and increased risk of precancerous changes in the cervix (NIAID, 2008)
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From page 100... ...
Screening of adults and adolescent women who are not pregnant or who are not considered to be at increased risk for HIV infection is a USPSTF Grade C recommendation, implying that screening should not be routinely done but, rather, should be done on an individualized case-specific basis. Bright Futures recommends that all sexually active and at risk adolescents aged 11 to 21 years be screened for HIV infection annually (AAP, 2008)
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, only 10 percent were subsequently screened for HIV infection, despite the evidence that these are known risk factors for HIV infection (Rust et al., 2003)
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Recommendation 5.4: The committee recommends for consideration as a preventive service for women: counseling and screening for HIV infection on an annual basis for sexually active women. PREVENTING UNINTENDED PREGNANCY AND PROMOTING HEALTHY BIRTH SPACING Unintended pregnancy is defined as a pregnancy that is either unwanted or mistimed at the time of conception (Finer and Henshaw, 2006)
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Although certain subgroups of women are at greater risk for unintended pregnancy than others (e.g., women aged 18 to 24 years, unmarried women, women with low incomes, women who are not high school graduates, and women who are members of a racial or ethnic minority group) , all sexually active women with reproductive capacity are at risk for unintended pregnancy.
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From page 104... ...
Bright Futures recommends that information about contraception be offered to all sexually active adolescents and those who plan to become sexually active (AAP, 2008)
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For women with certain medical conditions or risk factors, some contraceptive methods may be contraindicated. These can be assessed clinically so that an appropriate method can be selected for the individual (CDC, 2010; Dragoman et al., 2010)
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106 CLINICAL PREVENTIVE SERVICES FOR WOMEN TABLE 5-3 Percentage of U.S. Women Experiencing an Unintended Pregnancy During First Year of Typical Use and First Year of Perfect Use, by Contraceptive Method % Experiencing Unintended Pregnancy in First Year of Typical Usea Perfect Useb Method None 85 85 Spermicides (foams, creams, gels, vaginal suppositories, and 29 18 vaginal film)
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From page 107... ...
who do not want a future baby (Upson et al., 2010) , and that counseling of adult women in primary care settings is associated with greater contraceptive use and the use of more effective methods (Lee et al., 2011; Weisman et al., 2002)
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From page 108... ...
. A federal court ruling issued in 2000 by the Equal Employment Opportunity Commission found an employer's failure to cover prescription contraceptive drugs and devices in a health plan that covers other drugs, devices, and preventive care to be discrimination against women in violation of Title VII of the Civil Rights Act (EEOC, 2000)
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From page 109... ...
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 (HHS, 2000, 2011a)
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families complied, $10.5 billion would be saved and 741 deaths would be prevented each year. In the United States, the majority of pregnant women plan to breastfeed (DiGirolamo et al., 2005)
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(2002) identified confidence to be a modifiable variable that may be "amenable to supportive interventions," rather than nonmodifiable demographic risk factors that are associated with feeding choices.
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. The CDC survey of Maternity Practices in Infant Nutrition and Care biannually assesses breastfeeding-related maternity practices in hospitals and birth centers across the United States.
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and between providers and mothers may also make mothers less likely to comply with recommended postpartum health care visits than they were during the prenatal period (Stark and Lannon, 2009)
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. Existing Guidelines and Recommendations USPSTF Recommendations The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.
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3. Inform all pregnant women about the benefits and management of breastfeeding.
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The primary gap in preventive services not already addressed by the provisions set forth in the ACA (reviewed in this section) is that comprehensive prenatal and postnatal lactation support, counseling, and supplies are not currently included.
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(The ACA ensures that breastfeeding counsel ing is covered; however, the committee recognizes that interpretation of this varies.) INTERPERSONAL AND DOMESTIC VIOLENCE Interpersonal and domestic violence, including intimate partner violence and childhood abuse, is a pattern of coercive behaviors that may include progressive social isolation, deprivation, intimidation, psychological abuse, childhood physical abuse, childhood sexual abuse, sexual assault, and repeated battering and injury.
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. Women experiencing intimate partner violence have medical care costs 60 percent higher than women not experiencing abuse (Ulrich et al., 2003)
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From page 119... ...
. Asking women and adolescent girls about their interpersonal and domestic violence experiences could identify abuse not otherwise detected, help prevent future abuse, lessen disability, and improve future functioning and success in life (Battaglia et al., 2003; Coker et al., 2009; Martin et al., 2008; National Center for Injury Prevention, 2003; Svavarsdottir and Orlygsdottir, 2009)
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. The Canadian Task Force on Preventive Health Care also found insufficient evidence to recommend for or against screening women for intimate partner violence (Wathen and MacMillan, 2003)
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From page 121... ...
Some states also require physicians to report cases of adult intimate partner violence to legal authorities, and most states require reporting of injuries resulting from firearms, knives, or other weapons. Effective Interventions Although numerous community-based programs to safeguard victims of interpersonal and domestic violence exist, including counseling, hotlines, shelters, and advocacy groups, they are usually not directly associated with health care delivery systems.
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From page 122... ...
This study also collected information on the potential harms of screening and reported no harms. A randomized trial of counseling that included intimate partner violence as well as other health risks during pregnancy and postpartum reported less violence and better infant outcomes among women receiving counseling compared to those who did not (Kiely et al., 2010)
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From page 123... ...
Primary care office visits that are dedicated to preventive care may facilitate increased access to health care services that are shown to identify chronic disease risk factors, promote well-being, and/or decrease the likelihood or delay the onset of a targeted disease or condition. Box 5-2 contains examples of terms that are commonly used to label the prevention-oriented clinical encounter; this report BOX 5-2 Common Terms Used for Well Visits Preventive pediatric health care visit (AAP/Bright Futures)
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. Because many preventive services for women are for reproductive health (e.g., screening for cervical cancer and sexually transmitted infections and contraception services)
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Existing Guidelines and Recommendations Adolescence Clinical preventive services guidelines for adolescents issued by governmental agencies and nonprofit medical organizations (e.g., HRSA, the Maternal and Child Health Bureau, AAP, AMA, and AAFP) have long
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Chlamydial The USPSTF recommends screening for chlamydial A infection screening: infection for all sexually active nonpregnant young women non-pregnant aged 24 and younger and for older nonpregnant women women who are at increased risk. Chlamydial The USPSTF recommends screening for chlamydial B infection screening: infection for all pregnant women aged 24 and younger and pregnant women for older pregnant women who are at increased risk.
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From page 127... ...
of folic acid. Gonorrhea The USPSTF recommends that clinicians screen all B screening: women 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)
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From page 128... ...
The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. Rh incompatibility The USPSTF strongly recommends Rh (D)
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. Bright Futures recommends preventive pediatric health care visits for children annually from ages 3 through age 21 years, including initial/interval medical histories, measurements, sensory screening, developmental/behavioral assessments, physical examination, age-appropriate procedures, oral health, and anticipatory guidance.
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Adulthood For adults, the USPSTF clinical preventive services recommendations do not address how, when, where, or by whom prevention services are to be provided. For adolescents and adults, ACIP recommends age-specific timing of a full array of immunizations but does not explicitly mention their preferred provision in the context of the well-care office visit.
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From page 131... ...
. These guidelines include health maintenance visits that were recommended annually for people age 18 to 21 years; every one to three years, depending on risk factors, from ages 22 to 49 years; and then annually for all adults 50 years of age and older.
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. Prenatal Care for the Provision of Preventive Services Another type of well-woman preventive care visit is the routine prenatal care visit for pregnant women.
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recommends less frequent visits, and some studies have supported the safety and efficacy of visits at a reduced frequency for multiparous and low-risk women. Regardless of the periodicity, pregnant women are likely to make more well-woman preventive care visits than nonpregnant women.
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. Recommendation 5.8: The committee recommends for consideration as a preventive service for women: at least one well-woman preventive care visit annually for adult women to obtain the recommended preven tive services, including preconception and prenatal care.
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2009. Family and intimate partner violence.
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2007. Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings: Version 1.
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2002. Parental screening for intimate partner violence by pediatricians and family physicians.
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2002. Health consequences of intimate partner violence.
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2011a. Cervical cancer screening rates.
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2000. Physical health consequences of physical and psychological intimate partner violence.
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2003. Efficiency of the Hybrid Capture 2 HPV DNA test in cervical cancer screening -- a study by the French Society of Clinical Cytology.
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2004. Detecting ongoing intimate partner violence in the emergency department using a simple 4-question screen: The OVAT.
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1999. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
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2001. Intimate partner violence screening and inter vention: Data from eleven Pennsylvania and California community hospital emergency departments.
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1997. The hidden epidemic: Confronting sexually transmitted diseases.
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2011. Cervical cancer risk for women undergoing concurrent testing for human papillomavirus and cervical cytology: A population-based study in routine clinical practice.
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2010. An integrated intervention to reduce intimate partner violence in pregnancy a randomized controlled trial.
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2009. Screening for intimate partner violence in health care settings: A randomized trial.
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2003. Costs of intimate partner violence against women in the United States.
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2004. Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S.
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2009. Intimate partner violence screening tools: A systematic review.
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2009. Comparison of liquid-based cytology with conventional cytology for detection of cervical cancer precursors: A randomized controlled trial.
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From page 153... ...
2007. Screening for intimate partner violence within a health care setting: A systematic review of the literature.
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2004a. Screening for family and intimate partner violence.
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2003. Development of a screen for ongoing intimate partner violence.
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2010. Preventing intimate partner and sexual violence against women: Taking action and generating evidence.
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