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