Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 163
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 condi-
tions. 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 Afford-
able 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 re-
cently, the IOM reports Women’s Health Research: Progress, Pitfalls, and
Promise, Weight Gain During Pregnancy: Reexamining the Guidelines,
163
OCR for page 164
164 CLINICAL PREVENTIVE SERVICES FOR WOMEN
TABLE 7-1 Summary of the Committee’s Recommendations on
Preventive Services for Women
Preventive USPSTF
Service Grade Supporting Evidence Recommendations
Recommendation 5.1
Screening for I The evidence provided to
gestational support a recommendation The committee
diabetes for screening for gestational recommends for
diabetes is based on current consideration as a
federal practice policy from preventive service for
the U.S. Indian Health Service, women: screening for
the U.S. Department of gestational diabetes in
Veterans Affairs, as well as pregnant women between
current practice and clinical 24 and 28 weeks of
professional guidelines such gestation and at the first
as those set forth by the prenatal visit for pregnant
American Academy of Family women identified to be at
Physicians and the American high risk for diabetes.
Congress of Obstetricians and
Gynecologists.
Recommendation 5.2
Human I The evidence provided to
papillomavirus support a recommendation The committee
testing (HPV) to support testing for recommends for
HPV is based on federal consideration as a
practice policy from the U.S. preventive service for
Department of Defense. Peer- women: the addition
reviewed studies demonstrate of high-risk human
that improved testing papillomavirus DNA
technologies, particularly testing in addition to
combined screening using both cytology testing in women
conventional cytology and with normal cytology
high-risk HPV DNA testing, results. Screening should
may significantly improve the begin at 30 years of age
rate of detection of cervical and should occur no more
cancer precursors and facilitate frequently than every 3
the safe lengthening of the years.
interval for screening.
Recommendation 5.3
Counseling I The evidence provided to
for sexually support a recommendation The committee
transmitted related to STI counseling recommends for
infections is based on federal goals consideration as a
(STI) from the Centers for Disease preventive service for
Control and Prevention and women: annual counseling
Healthy People 2020, as on sexually transmitted
well as recommendations infections for sexually
from the American Medical active women.
Association and the American
College of Obstetricians and
Gynecologists.
OCR for page 165
165
FINDINGS AND RECOMMENDATIONS FOR ADDRESSING IDENTIFIED GAPS
TABLE 7-1 Continued
Preventive USPSTF
Service Grade Supporting Evidence Recommendations
Recommendation 5.4
Counseling C The evidence provided to
and screening support a recommendation The committee
for human for expanding screening for recommends for
immuno- HIV is based on federal goals consideration as a
deficiency from the Centers for Disease preventive service for
virus (HIV) Control and Prevention, as women: counseling and
well as clinical professional screening for human
guidelines, such as those immunodeficiency virus
from the American College infection on an annual
of Physicians, the Infectious basis for sexually active
Diseases Society of America, women.
the American Medical
Association, and the American
College of Obstetricians and
Gynecologists.
Recommendation 5.5
Contraceptive Not The evidence provided to
methods and Addressed support a recommendation The committee
counseling related to unintended recommends for
pregnancy is based on consideration as a
systematic evidence reviews preventive service for
and other peer-reviewed women: the full range
studies, which indicate of Food and Drug
that contraception and Administration-approved
contraceptive counseling, contraceptive methods,
are effective at reducing sterilization procedures,
unintended pregnancies. and patient education and
Current federal reimbursement counseling for women with
policies provide coverage reproductive capacity.
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.
continued
OCR for page 166
166 CLINICAL PREVENTIVE SERVICES FOR WOMEN
TABLE 7-1 Continued
Preventive USPSTF
Service Grade Supporting Evidence Recommendations
Recommendation 5.6
Breastfeeding B The evidence provided to
support, support a recommendation The committee
supplies, and regarding the inclusion of recommends for
counseling breastfeeding services is based consideration as a
on systematic evidence reviews, preventive service for
federal and international goals women: comprehensive
(such as the U.S. Surgeon lactation support and
General, Health Resources counseling and costs of
and Services [HRSA], Healthy renting breastfeeding
People 2020, World Health equipment. A trained
Organization and UNICEF), provider should provide
and clinical professional counseling services to all
guidelines such as those pregnant women and to
set forth by the American those in the postpartum
Academy of Family Physicians, period to ensure the
the American Academy of successful initiation and
Pediatrics, and the American duration of breastfeeding.
College of Obstetricians and (The ACA ensures that
Gynecologists. breastfeeding counseling
is covered; however, the
committee recognizes
that interpretation of this
varies.)
Recommendation 5.7
Screening and I The evidence provided to
counseling for support a recommendation The committee
interpersonal related to increasing detection recommends for
and domestic of and counseling for domestic consideration as a
violence violence and abuse is based preventive service for
on peer-review studies and women: screening
federal and international and counseling for
policies, in addition to clinical interpersonal and
professional guidelines domestic violence.
from organizations, such Screening and counseling
as the American Medical involve elicitation of
Association and the American information from women
College of Obstetricians and and adolescents about
Gynecologists. 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.
OCR for page 167
167
FINDINGS AND RECOMMENDATIONS FOR ADDRESSING IDENTIFIED GAPS
TABLE 7-1 Continued
Preventive USPSTF
Service Grade Supporting Evidence Recommendations
Recommendation 5.8
Well-woman Not The evidence provided to
visits Addressed support a recommendation The committee
for including well-woman recommends for
visits is based on federal and consideration as a
state policies (such as included preventive service for
in Medicaid, Medicare, women: at least one well-
and the commonwealth woman preventive care visit
of Massachusetts), clinical annually for adult women
professional guidelines (such to obtain the recommended
as those of the American preventive services,
Medical Association and the including preconception
American Academy of Family and prenatal care. The
Practitioners), and private committee also recognizes
health plan policies (such as that several visits may
those of Kaiser Permanente). be needed to obtain all
necessary recommended
preventive services,
depending on a woman’s
health status, health needs,
and other risk factors.
and Preterm Birth: Causes, Consequences, and Prevention identified re-
search 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 identify-
ing 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. Addition-
ally, the Bright Futures report (AAP, 2008) and the guidelines of the Advi-
sory 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 sum-
marized 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 disproportion-
ate effect on women. Although the committee upheld this standard, some
of the recommendations made by the committee could also be considered
for male populations.
OCR for page 168
168 CLINICAL PREVENTIVE SERVICES FOR WOMEN
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 Priori-
ties for Comparative Effectiveness Research examines priorities for con-
sidering 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 ef-
fective 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 effec-
tive 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.
REFERENCES
AAP. 2008. Bright futures: Guidelines for health supervision of infants, children and adoles-
cents, 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.
