Clinical Preventive Services for Women Closing the Gaps

REPORT BRIEF JULY 2011

For more information visit www.iom.edu/preventiveserviceswomen

As a centerpiece of the Patient Protection and Affordable Care Act (ACA) of 2010, the focus on preventive services is a profound shift from a reactive system that primarily responds to acute problems and urgent needs to one that helps foster optimal health and well-being. Women stand to benefit from this shift given their longer life expectancies, reproductive and gender- specific conditions, and historically greater burden of chronic disease and disability. And, for the same reasons, they will benefit economically since the ACA removes cost-sharing requirements for specified preventive services— eliminating out-of-pocket costs that often put screenings, counseling and Women stand to benefit from this procedures supporting health out of reach for moderate- and lower-income shift given their longer life expec- women. tancies, reproductive and gender- Given the magnitude of change, the U.S. Department of Health and Human specific conditions, and historically Services (HHS) charged the Institute of Medicine (IOM) with reviewing what greater burden of chronic disease preventive services are important to women’s health and well-being and then and disability. recommending which of these should be considered in the development of comprehensive guidelines. The IOM convened a committee of experts to identify critical gaps in the preventive services already identified in the ACA, which are based on recommendations developed by three independent bodies: the United States Preventive Services Task Force, the American Academy of Pediatrics’ Bright Futures recommendations for adolescents, and the Cen- ters for Disease Control and Prevention’s Advisory Committee on Immuniza- tion Practices. The committee defined preventive health services as measures— including medications, procedures, devices, tests, education, and counseling—shown to improve well-being and/or decrease the likelihood or delay the onset of a targeted disease or condition. To guide ventive services and screenings that support its deliberations in determining gaps in preventive women’s overall health. services not included in existing guidelines, the For sexually active women, the committee committee developed four overarching questions: found that current recommendations of screen- • Are high-quality systematic evidence ing for cervical cancer, counseling for sexually reviews available which indicate that the transmitted infections, and HIV counseling and service is effective in women? screening are too limited in scope and should be expanded. It also made several recommendations • Are quality peer-reviewed studies avail- that support women’s reproductive health. These able that demonstrate effectiveness of the include a fuller range of contraceptive education, service in women? counseling, methods, and services so that women • Has the measure been identified as a federal can better avoid unwanted pregnancies and space priority to address in women’s preventive their pregnancies to promote optimal birth out- services? comes. Additional recommendations address • Are there existing federal, state, or interna- needs of pregnant women, including screening tional practices, professional guidelines, or for gestational diabetes and lactation counseling federal reimbursement policies that sup- and equipment to help women who choose to port the use of the measure? breastfeed to do so successfully. The committee recommended including at Preventive measures recommended by the least one well-woman preventive care visit annu- IOM committee for preventive coverage consid- ally for women to receive comprehensive services. eration met the following criteria: Depending on a woman’s health status, health • The condition to be prevented affects a needs, and risk factors, multiple visits might be broad population; recommended to provide the full range of preventive services. • The condition to be prevented has a large Finally, the committee recommended that potential impact on health and well-being; all women and adolescent girls be screened and and counseled for interpersonal and domestic violence • The quality and strength of the evidence is in a culturally sensitive and supportive manner. supportive. An estimated five million women are physically, The committee took seriously its task of focus- sexually, or emotionally abused by their partners ing on women’s unique health needs. Throughout each year in the United States. Screening for risk the study process, the committee repeatedly ques- of abuse is central to women’s safety, as well as to tioned whether the disease or condition was sig- addressing current health concerns and prevent- nificant to women and, especially, whether it was ing future health problems. more common or more serious in women than in men or whether women experienced different outcomes or benefited from different interven- Keeping Preventive Care Up-to-Date tions than men. The committee made several recommendations that will enable HHS to periodically update the review of preventive services covered under the Protecting Women’s Health ACA. The committee recommends developing The committee found sufficient evidence to the structures within HHS that involve account- endorse eight recommendations for specific pre- ability and processes to ensure that preventive

2 The committee defined preventive health services as measures—including medications, procedures, devices, tests, education, and counseling—shown to improve well-being and/or decrease the likelihood or delay the onset of a targeted disease or condition.

Recommendations for Preventive Health Care Services for Women that Should be Considered by the U.S. Department of Health and Human Services

Recommendation 5.1: Screening for gestational Recommendation 5.6: Comprehensive lactation diabetes in pregnant women between 24 and 28 weeks support and counseling and costs of renting breast- of gestation and at the first prenatal visit for pregnant feeding equipment. A trained provider should provide women identified to be at high risk for diabetes. counseling services to all pregnant women and to those in the postpartum period to ensure the successful initia- tion and duration of breastfeeding. (The ACA ensures that breastfeeding counseling is covered; however, the committee recognizes that interpretation of this varies.)

Recommendation 5.2: The addition of high-risk human Recommendation 5.7: Screening and counseling for papillomavirus DNA testing in addition to cytology test- interpersonal and domestic violence. Screening and ing in women with normal cytology results. Screening counseling involve elicitation of information from should begin at 30 years of age and should occur no women and adolescents about current and past vio- more frequently than every 3 years. lence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.

Recommendation 5.3: Annual counseling on sexually Recommendation 5.8: At least one well-woman pre- transmitted infections for sexually active women. ventive 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.

Recommendation 5.4: Counseling and screening for human immunodeficiency virus infection on an annual basis for sexually active women.

Recommendation 5.5: The full range of Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity.

3 Committee on Preventive Services for Women services meeting the requisite criteria will be considered in the future, as science emerges. Further, Linda Rosenstock (Chair) Heidi D. Nelson Dean, School of Public Health, Research Professor of Medical HHS should establish an independent commission University of California, Los Informatics and Clinical Epide- Angeles miology and Medicine, Oregon to support the process. Alfred O. Berg Health and Science University, Professor, Department of and Medical Director for Can- The committee noted that the public health Family Medicine, University of cer Prevention and Screening, system and community-based preventive services Washington School of Medi- Providence Cancer Center, cine, Seattle Providence Health & Services, Portland are important to achieving the aims of preventive Claire D. Brindis Professor of Pediatrics and Roberta B. Ness health services. Community-based health services Health Policy, Department of Dean and M. David Low Chair Pediatrics and Department of in Public Health, School of Pub- can play significant roles in providing preventive Obstetrics, Gynecology and lic Health, University of Texas, Reproductive Health Services, Houston care to many different populations. The commit- and Director, Philip R. Lee Insti- Magda G. Peck tute for Health Policy Studies, Professor of Public Health and tee encourages HHS to consider widening the School of Medicine, University Pediatrics and Associate Dean of California, San Francisco for Community Engagement proposed commission’s scope of authority so that Angela Diaz and Public Health Practice, public health efforts work in coordination with Jean C. and James W. Crystal College of Public Health, Professor of Adolescent Health, University of Nebraska Medical the new and existing bodies that are charged with Department of Pediatrics Centers, Omaha and Community Preventative E. Albert Reece overseeing other elements of the ACA. Medicine, Mount Sinai Medical Vice President for Medical Center, New York Affairs, University of Maryland, Francisco Garcia and John Z. and Akiko K. Bow- Distinguished Outreach Pro- ers Distinguished Professor and fessor of Public Health, and Dean, University of Maryland Obstetrics and Gynecology; School of Medicine, Baltimore Conclusion Director, University of Arizona Alina Salganicoff Center of Excellence in Wom- Vice President and Director, Positioning preventive care as the foundation of en’s Health; and Codirector of Women’s Health Policy, Henry the Cancer Disparities Institute, J. Kaiser Family Foundation, the U.S. healthcare system is critical to ensuring University of Arizona, Tucson Menlo Park, California Kimberly Gregory Sally W. Vernon Americans’ health and well-being. Although the Vice Chair of Women’s Health- Division Director, Health ACA addresses preventive services for both men care Quality and Performance Promotion and Behavioral Improvement, and Department Sciences, Blair Justice, Ph.D. and women of all ages, women particularly stand of Obstetrics and Gynecology, Professorship in Mind-Body Cedars-Sinai Medical Center, Medicine and Public Health, to benefit from additional preventive health ser- Los Angeles and Professor of Epidemiol- Paula A. Johnson ogy and Behavioral Sciences, vices. The inclusion of evidence-based screenings, Executive Director, Connors University of Texas School of Center for Women’s Health Public Health, Houston counseling, and procedures that address women’s and Gender Biology, and Chief, Carol S. Weisman Division of Women’s Health, Distinguished Professor of greater need for services over the course of a life- Brigham and Women’s Hospi- Public Health Sciences and tal, Boston Obstetrics and Gynecology and time may have a profound impact for individuals Anthony Lo Sasso Associate Dean for Faculty and the nation as a whole. f Professor and Senior Research Affairs, Pennsylvania State Scientist, Division of Health College of Medicine, Hershey 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

Study Staff

Karen Helsing Amy Pryzbocki Study Director Financial Associate Jesse Flynn Rose Marie Martinez Associate Program Officer Director, Board on Popula- Suzanne Landi tion Health and Public Health Research Assistant Practice Chelsea Frakes 500 Fifth Street, NW Senior Program Assistant Washington, DC 20001 Rebekah E. Gee Institute of Medicine TEL 202.334.2352 Anniversary Fellow FAX 202.334.1412

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The Department of Health and Human Services The Institute of Medicine serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policy makers, health professionals, the private sector, and the public. Copyright 2011 by the National Academy of Sciences. All rights reserved.