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Women's Preventive Services Initiative's Well-Woman Chart

A Summary of Preventive Health Recommendations for Women

Phipps, Maureen G. MD, MPH; Son, Sarah MPH; Zahn, Christopher MD; O'Reilly, Nancy MHS; Cantor, Amy MD, MPH; Frost, Jennifer MD; Gregory, Kimberly D. MD, MPH; Jones, Michelle MSc; Kendig, Susan M. JD, WHNP-BC; Nelson, Heidi D. MD, MPH; Pappas, Miranda MA; Qaseem, Amir MD, PhD, MHA; Ramos, Diana MD, MPH; Salganicoff, Alina PhD; Taylor, Gabrelle MPH; Conry, Jeanne MD, PhD; ; for the Women's Preventive Services Initiative

doi: 10.1097/AOG.0000000000003368
Contents: Preventive Health: Current Commentary
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The Well-Woman Chart summarizes current recommendations for preventive health services for women from adolescence and continuing across the lifespan. It was developed by the Women's Preventive Services Initiative, a national collaborative of women's health professional organizations and patient representatives. The Well-Woman Chart includes current clinical guidelines from the U.S. Preventive Services Task Force, Bright Futures from the American Academy of Pediatrics, and the Women's Preventive Services Initiative that are covered with no cost-sharing for public and most private insurance plans under the prevention service mandate of the Affordable Care Act. The structure of the Well-Woman Chart is based on age intervals and pregnancy status categories that align with existing recommendations. The target audience for the Well-Woman Chart is all clinicians providing preventive health care for women, particularly in primary care settings, and patients affected by the recommendations. The preventive services recommendations apply to females 13 years of age and older and pregnant females of any age. The Well-Woman Chart provides clinical guidance for screening, counseling, and other recommended preventive services for women during health care visits based on age, pregnancy status, and risk factors.

“Recommendations for Well-Woman Care” is a well-woman chart that includes evidence-based clinical prevention service recommendations issued by the American Academy of Pediatrics' Bright Futures, the United States Preventive Services Task Force, and the Women's Preventive Services Initiative.

Women & Infants Hospital of Rhode Island and the Warren Alpert Medical School of Brown University, Providence, Rhode Island; the American College of Obstetricians and Gynecologists, Washington DC; the Oregon Health & Science University, Portland, Oregon; the American Academy of Family Physicians, Leewood, Kansas; Cedars-Sinai Medical Center, Los Angeles, California; the National Association of Nurse Practitioners in Women's Health, Washington, DC; the Kaiser Family Foundation, Menlo Park, California; the California Department of Public Health, Sacramento, California, and the American College of Physicians, Philadelphia, Pennsylvania.

Corresponding author: Sarah Son, MPH, American College of Obstetricians and Gynecologists, Washington, DC; email: sson@acog.org.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UHOMC29940, Bright Futures for Women's Health: Standard Practice Guidelines for Well Women Care.

Each author has confirmed compliance with the journal's requirements for authorship.

Financial Disclosure All financial and intellectual disclosures of interest were declared and potential conflicts were discussed and managed following the conflict of interest process of the American College of Obstetricians and Gynecologists (ACOG). Sarah Son, Christopher Zahn, Nancy O'Reilly, Michelle Jones, and Gabrelle Taylor are employees of ACOG. During her work on WPSI, Maureen G. Phipps was employed by Brown University in Providence, Rhode Island. Dr. Phipps is ACOG's incoming CEO and will be an employee of ACOG as of September 9, 2019. Jeanne Conry consults for the nonprofit Forum Institute on Maternal Child Health. The other authors did not report any potential conflicts of interest.

*For a list of members of the Women's Preventive Services Initiative, see Appendix 1, available online at http://links.lww.com/AOG/B472.

Advisory Panel or Multidisciplinary Steering Committee participation in the Women's Preventive Services Initiative (WPSI) or authorship of this document does not constitute organizational or individual endorsement of the recommendations or conclusions. Information or content and conclusions in this article are those of the WPSI and should not be construed as the official position or policy of, or should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

Peer reviews are available at http://links.lww.com/AOG/B473.

Clinical preventive services are generally underused in the United States.1 Although reasons for underuse include many factors, clinicians' lack of awareness of existing recommendations, the complexity or inconsistency of recommendations issued by different guideline groups, and inadequate time and resources to deliver recommended services are often cited.1,2 Patients may lack information about services appropriate for them based on their age, risk factors, and history. As well, they may be unaware of insurance coverage. In addition, clinicians and patients often need to prioritize acute issues over preventive care during usually brief and infrequent clinical encounters.

Despite these barriers to preventive care, health care systems and clinicians are responsible for providing comprehensive preventive health services to their patients.3,4 Preventive health care plays a central role in improving the health and quality of life of women through delivery of services including screening and prevention of diseases, family planning and pregnancy, nutrition and exercise, immunizations, infectious disease exposure and management, psychological well-being, and behavioral health.5,6

Although preventive services can be implemented during the course of various types of clinical encounters, preventive health care visits provide an opportunity to specifically deliver preventive care. These visits have been associated with subsequent use of increased preventive care and cancer screening7 and may serve as entry points to additional prevention care, as well as opportunities to reach marginalized individuals who would not otherwise seek regular health care.8 However, this opportunity is often not realized in practice, despite coverage of at least one preventive visit per year and appropriate preventive services with no cost-sharing for public and most private plans under the prevention service mandate of the Patient Protection and Affordable Care Act of 2010 (ACA)9,10 and other provisions,11,12 reducing one of the barriers women face when seeking health care.13–16

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PURPOSE

The purpose of the Well-Woman Chart (https://www.womenspreventivehealth.org/wellwomanchart/) is to improve the delivery of preventive health services for women in clinical settings. The Well-Woman Chart summarizes currently covered preventive services recommendations in one source and is intended to provide a comprehensive and practical method to guide busy practices, similar to the Bright Futures/American Academy of Pediatrics Periodicity Schedule for children and adolescents.17

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TARGET AUDIENCE AND TARGET PATIENT POPULATION

The target audience for the Well-Woman Chart is all clinicians providing preventive health care for women, particularly in primary care settings, and patients affected by the recommendations. The preventive services recommendations apply to females 13 years of age and older and pregnant females of any age.

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METHODS

The Well-Woman Chart was developed by the Women's Preventive Services Initiative, a national collaborative of 21 health professional organizations and patient representatives that develops, reviews, updates, and disseminates evidence-based clinical recommendations for women's preventive health care services in the United States.10,18–20 Supported by the Health Resources and Services Administration and led by the American College of Obstetricians and Gynecologists, the Women's Preventive Services Initiative builds on prior recommendations for women's prevention services developed by the Institute of Medicine (now known as the National Academy of Medicine) in 2011.21 An advisory panel oversees the initiative and includes representatives from the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American College of Physicians, and the National Association of Nurse Practitioners in Women's Health; three experts in women's preventive health care and evidence review. The Women's Preventive Services Initiative partners with the Pacific Northwest Evidence-based Practice Center at the Oregon Health and Science University to conduct evidence-based updates and systematic reviews for each topic using established methods.22,23

The intention of the collaborative effort of the Women's Preventive Services Initiative, with its broad membership of specialty societies providing women's health care, is to share consistent guidelines across specialties to enhance the coordination of providers in optimizing the health and well-being of women. The Women's Preventive Services Initiative addresses conditions that may be specific to women, are more common or serious in women, or have different outcomes or treatments in women. In addition, the Women's Preventive Services Initiative recommendations focus on gaps in existing clinical guidelines provided by the U.S. Preventive Services Task Force and Bright Futures/American Academy of Pediatrics and address health conditions and needs that have not been previously considered by these groups, such as contraception. The Women's Preventive Services Initiative recommendations are then reviewed by the Health Resources and Services Administration for insurance coverage under the ACA.10,18,19 The Women's Preventive Services Initiative bases recommendations on evidence of both benefits and harms of an intervention or service and does not consider cost, similar to the U.S. Preventive Services Task Force. The Women's Preventive Services Initiative evaluates preventive services that often lack definitive research in important areas. Many times, effectiveness of preventive services is not addressed by scientific literature for women in general or for population subgroups, such as adolescents, pregnant women, or elderly women. The Women's Preventive Services Initiative considers disparities that persist in the use of preventive services among underserved communities, such as racial and ethnic minorities, low-income women, and those with low health literacy.24 When direct evidence is lacking, such as measures of efficacy from randomized controlled trials, the Women's Preventive Services Initiative evaluates indirect evidence, such as compelling epidemiologic data, and uses the synthesis of this information to inform recommendations.

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WELL-WOMAN CHART

The Well-Woman Chart summarizes clinical prevention recommendations currently covered under the ACA as of January 1, 201910 (https://www.womenspreventivehealth.org/wellwomanchart/; Fig. 1). The Chart will be reviewed annually and updated as needed. Recommendations include U.S. Preventive Services Task Force A and B recommendations,20,25 Women's Preventive Services Initiative recommendations accepted for coverage by the Health Resources and Services Administration,10 and the Bright Futures health initiative, a nationally recognized pediatric periodicity schedule that recommends preventive health care visits annually for children and adolescents aged 3 through 21 years.17 Recommendations for immunizations are not included in the Well-Woman Chart but are provided in separate tables from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.26 The Pacific Northwest Evidence-based Practice Center reviewed all recommendations, and members of the Advisory Panel and Multidisciplinary Steering Committee reviewed, refined, and approved the Well-Woman Chart and supporting materials. As with all clinical recommendations, the Well-Woman Chart serves as a guide and does not replace clinical judgment for individual patients.

Fig. 1.

Fig. 1.

When recommendations vary across groups, the Well-Woman Chart includes the most comprehensive recommendation. For example, the U.S. Preventive Services Task Force recommends screening only women of reproductive age for domestic violence, whereas the Well-Woman Chart includes the more expansive recommendation for screening women of all ages, as recommended by the Women's Preventive Services Initiative. Terminology in the chart is consistent with the language used by the group that issued the recommendation. Each preventive service is supported by a corresponding narrative that includes a brief rationale for the specific service, the recommendation language from the originating guideline group, clinical practice and risk assessment considerations, and references to the full-text recommendation (see the Clinical Summary Tables, available online at https://www.womenspreventivehealth.org/wp-content/uploads/Final-Clinical-Summary-Tables-for-website.pdf).

The Well-Woman Chart is separated into age intervals (13–17, 18–21, 22–39, 40–49, 50–64, 65–75, and older than 75 years) and pregnancy conditions (not pregnant, pregnant, postpartum) that most closely align with existing recommendations. A closed circle indicates the preventive service should be considered for all women in the corresponding age group as appropriate, and an open circle indicates it should be used selectively. Footnotes describe characteristics of patients requiring selective services according to the original recommendation. Preventive services are categorized by general health, infectious diseases, and cancer, and services within categories are listed in alphabetical order. Some topics are divided into two or more services to indicate separate actions. For example, one condition may require two different clinical services (eg, human immunodeficiency virus [HIV] risk assessment and HIV testing), or one service may be dependent on another (eg, lipid testing and statin use). Some services occur in more than one section, when separate recommendations have been issued for different groups or situations (eg, universal screening for syphilis in pregnant women and selective screening in high-risk women who are not pregnant), or the service is essential to more than one section of the chart (eg, breastfeeding services during pregnancy and postpartum).

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DISCUSSION

An investment in the health of women is an investment in the health of this and future generations. Preventive care plays a central role in improving the lives of women and is the foundation of well-woman care. The goal of preventive health care is to identify and reduce risk factors for disease, detect diseases or conditions early when they can be treated more effectively, and promote healthy behaviors that can result in better health outcomes.2 Preventive health care visits provide an important opportunity to deliver preventive care as well as improve the patient–provider relationship and serve as an entry point to additional health care.7,8,27 Women may seek guidance for preventive services from a variety of clinicians, including family physicians, internists, obstetrician–gynecologists, physician assistants, nurse practitioners, and certified nurse–midwives. To make meaningful changes in the way providers think about and conduct patient care, the entire medical community must deliberately seek out evidence-based information to improve women's health. Women's health providers will have to work together to set shared goals and establish collaborative relationships. The Well-Woman Chart was developed to improve the delivery of preventive services to women across these settings and throughout their lives to optimize benefits of preventive care.

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REFERENCES

1. Office of Disease Prevention and Health Promotion. Clinical preventive services. Available at: https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Clinical-Preventive-Services. Retrieved July 11, 2019.
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3. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900-1999. MMWR Morb Mortal Wkly Rep 1999;48:241–3.
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