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
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
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.
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.
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.
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).
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.
2. Maciosek MV, Coffield AB, Flottemesch TJ, Edwards NM, Solberg LI. Greater use of preventive services in U.S. health care could save lives at little or no cost. Health Aff (Millwood) 2010;29:1656–60.
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.
4. LaVeist TA, Rolley NC, Diala C. Prevalence and patterns of discrimination among U.S. health care consumers. Int J Health Serv 2003;33:331–44.
6. National Prevention Council. National prevention strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.
7. Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007;146:289–300.
8. Duerksen A, Dubey V, Iglar K. Annual adult health checkup: update on the preventive care checklist Form. Can Fam Physician 2012;58:43–7.
12. Government Accountability Office. Medicaid preventive services: concerted efforts needed to ensure beneficiaries receive services. Available at: http://www.gao.gov/products/GAO-09-578
. Retrieved February 1, 2019. Government Accountability Office.
13. U.S. Department of Health & Human Services. The Affordable Care Act is improving access to preventive services for millions of Americans. Washington, DC:U.S. Department of Health and Human Services; 2015.
14. Glied S, Jackson A. The future of the Affordable Care Act and insurance coverage. Am J Public Health 2017;107:538–40.
15. Kirby JB, Davidoff AJ, Basu J. The ACA's zero cost-sharing mandate and trends in out-of-pocket expenditures on well-child and screening mammography visits. Med Care 2016;54:1056–62.
16. U.S. Department of Health and Human Services. HHS activities to improve women's health as required by the Affordable Care Act. Washington, DC: U.S. Department of Health and Human Services; 2015.
17. Hagan JF, Shaw JS, Duncan PM, editors. Bright futures: guidelines for health supervision of infants, children, and adolescents. 3rd ed. Itasca (IL): American Academy of Pediatrics; 2007.
19. Women's Preventive Services Initiative. Recommendations for preventive services for women: final report to the U.S. Department of Health and Human Services, Health Resources & Services Administration. Washington, DC: American College of Obstetricians and Gynecologists; 2016.
21. Institute of Medicine. Clinical preventive services for women: closing the gaps. Washington, DC: National Academies Press; 2011.
22. Agency for Healthcare Research and Quality. Methods guide for effectiveness and comparative effectiveness reviews. Rockville (MD): AHRQ; 2014.
24. National Commission on Prevention Priorities. Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: National Commission on Prevention Priorities; 2007.
27. Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med 2005;165:1347–52.