Clinical Preventive Services for Women Closing the Gaps (2011) / Chapter Skim
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Appendix A: Clarifications
Appendix A: Clarifications
Pages 171-216
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From page 171... ...
guidelines. The committee conducted a full review of the following conditions and risk factors, including those relating to cardiovascular disease, osteoporosis, breast cancer, mental health, tobacco use, and diet and physical activity.
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From page 172... ...
Risk Factors for CVD Most modifiable risk factors for the primary prevention of CVD, such as hypertension, hyperlipidemia, diabetes mellitus, smoking, obesity, metabolic syndrome, and physical inactivity, are similar in women and men; but the prevalence and impact of certain risk factors may differ by sex. Risk factors in which there are sex differences in prevalence and impact or in
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From page 173... ...
No sex-specific interventions for increasing HDL levels currently exist. Metabolic Syndrome: Metabolic syndrome is a constellation of risk factors that are associated with the development of CVD and type 2 diabetes mellitus.
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From page 174... ...
An accurate measurement of the waist circumference must be obtained to make a diagnosis of metabolic syndrome. Pregnancy-Related Risk Factors: Pregnancy-related risk factors such as preeclampsia, gestational hypertension, and gestational diabetes mellitus are specific to women and are risk factors for the development of CVD and CVD events in women as they age.
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From page 175... ...
High-Sensitivity C-Reactive Protein: High-sensitivity C-reactive protein is a nonspecific biomarker of increased risk for CVD. The role of the highsensitivity C-reactive protein levels in the assessment of risk and in defining preventive strategies remains unclear.
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From page 176... ...
. The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.
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From page 177... ...
Metabolic syndrome is a significant risk factor for CVD in women, and the major focus is on preventing or treating the underlying modifiable risk factors, such as central obesity, hypertension, increased LDL and triglyceride levels, and diabetes mellitus. Lifestyle modification, including weight loss, physical activity, and a healthy diet, decreases all of the metabolic risk factors (Grundy et al., 2005)
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From page 178... ...
there is no comprehensive mechanism in place to collect pregnancy complication histories to better predict the risk level of a woman for developing cardiovascular disease in the future. The committee found insufficient evidence to support a new recommendation; instead, evidence supported by professional clinical guidelines led to committee support for the reasonableness of including screening for metabolic syndrome in women and obtaining a history of pregnancy complications within the context of the well-woman preventive visit.
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From page 179... ...
Risk factors that cannot be modified include age, menopause, low body mass index, and a family history of osteoporosis and fractures. Modifiable risk factors include immobility, falls, tobacco use, and excessive alcohol intake (three or more drinks daily)
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From page 180... ...
Existing Guidelines and Recommendations USPSTF Recommendations The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. Grade B recommendation (USPSTF, 2011c)
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From page 181... ...
Drugs for prevention are intended for individuals who have no previous fractures and whose bone density levels are not in the osteoporotic range (i.e., T-score ≥–2.5)
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From page 182... ...
These interventions include functional assessment and improvement, safety evaluations, vision examinations, and nutritional analyses, among others. Identified Gap The primary gap in preventive services not already addressed by the provisions set forth in the ACA (reviewed in this section)
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From page 183... ...
Identifying women with risk factors most strongly associated with breast cancer can lead to the use of additional screening measures to improve early breast cancer detection and reduce the burden of disease for these women. Clinically significant BRCA mutations are associated with an approximately 60 percent lifetime risk of breast cancer and a 15–40 percent lifetime risk of ovarian cancer.
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From page 184... ...
Some of these abnormal lesions can increase the breast cancer risk 4 to 10 times above average, depending on the type of lesion (Arpino et al., 2005)
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From page 185... ...
Genetic counseling to determine cancer risk status for women without breast cancer is a new concept in practice. No study has yet determined how genetic counseling modifies cancer screening behaviors or if doing so improves early detection and mortality.
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From page 186... ...
. The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemo prevention.
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From page 187... ...
. The Society of Breast Imaging and the American College of Radiology recently published guidelines on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer, recommending for women at high risk earlier screening and additional technologies that vary depending on the risk factor (Lee et al., 2010)
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From page 188... ...
Identified Gap The primary gap in preventive services not already addressed by the provisions set forth in the ACA (reviewed in this section) is the lack of enhanced breast cancer screening services for high-risk women who may require earlier and/or more frequent examinations and imaging, as well as additional imaging technologies beyond mammography.
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From page 189... ...
. Data from psychological autopsy studies have revealed that diagnoses of clinical mental disorders were found in nearly all suicide victims.
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From page 190... ...
. Existing Guidelines and Recommendations USPSTF Recommendations The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
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From page 191... ...
Department of Veterans Affairs (VA) Clinical Practice Guideline for the Management of Major Depressive Disorder states that women receiving care through the VA be screened for depression at first contact with health care services in the antenatal and postnatal periods, separate from its guidelines on screening for depression in the general patient population (VA, 2009)
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From page 192... ...
Identified Gap The primary gap in preventive services not already addressed by the provisions set forth in the ACA (reviewed in this section) is that the current
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From page 193... ...
, and the U.S. Surgeon General, as well as clinical professional guidelines and federal practice guidelines support the reasonableness of including screening for suicide ideation and postpartum depression in women who are pregnant and/or who have recently given birth during the context of a well-woman visit.
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From page 194... ...
. Cigarette smoking also increases the risk for infertility, and smoking during pregnancy may result in negative reproductive and developmental effects, including premature birth, stillbirth, low birth weight, intrauterine growth retardation, and sudden infant death syndrome (Ashford et al., 2010; Behm et al., 2011; IOM, 2011; Khader et al., 2011; Ye et al., 2010)
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made 10 recommendations regarding effective interventions delivered in health care settings. The updated guidelines were sponsored by eight federal government and private nonprofit organizations, including the Adolescent Health Research Program, the Centers for Disease Control and Prevention (CDC)
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From page 196... ...
. In a systematic review conducted by the National Commission on Prevention Priorities for the Partnership for Prevention, screening for tobacco use and brief intervention counseling with an offer of pharmacotherapy ranked third of 25 clinical preventive services in terms of the most beneficial services to offer patients (Maciosek et al., 2009, 2010)
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From page 197... ...
is that while tobacco cessation aids and counseling are recommended, the potential need for multiple interventions defined by the Public Health Service Guidelines, which include pharmacotherapy, in helping women to quit smoking are not addressed. The committee found insufficient evidence to develop a new recommendation; instead, the evidence supported by high-quality systematic reviews, supportive systematic reviews, federal agendas from the CDC, NCI, NHLBI, and NIDA, as well as clinical professional guidelines, led to a clarifying statement, which was added to the USPSTF recommendation.
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From page 198... ...
The target populations for diet and physical activity counseling are adult women 18 years of age and older, pregnant women of any age, and adolescent females. Prevalence/Burden Physical inactivity is associated with increased risk of all-cause mortality, coronary heart disease, high blood pressure, stroke, type 2 diabetes, metabolic syndrome, colon cancer, breast cancer, osteoporotic fractures, falls, and depression.
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From page 199... ...
. Healthy diet and physical activity during pregnancy have health benefits for the woman and her child (Physical Activity Guidelines Advisory Committee, 2008)
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From page 200... ...
. The earlier systematic reviews found insufficient evidence to recommend for or against behavioral counseling in primary care settings to promote either physical activity or healthy dietary behaviors in adults without preexisting cardiovascular disease or its risk factors (2003; Berg et al., 2002)
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From page 201... ...
The outcomes measured in these trials included morbidity and mortality related to cardiovascular disease, risk factors for cardiovascular disease, and self-reported dietary and physical activity behaviors. High-intensity counseling about a healthy diet with or without counseling about physical activity resulted in positive changes in body mass index (adiposity)
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From page 202... ...
are the lack of interventions in primary care practice that address healthy diet and physical activity. The committee found insufficient evidence to develop a new recommendation; instead, the evidence supported by high-quality systematic evidence reviews and clinical practice guidelines, as well as the draft recommendation statement from the USPSTF (indicating that medium- to high-intensity interventions for diet and physical activity led to small benefits toward prevention of cardiovascular disease)
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From page 203... ...
2003. Evaluation of breast cancer risk assessment packages in the family history evalua tion and screening programme.
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H Woolf, and United States Preventive Services Task Force.
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1996. Behavioral Risk Factor Surveillance System Survey data.
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2010. Interim final rules for group health plans and health insurance issuers relating to coverage of preventive services under the patient protection and affordable care act.
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Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality.
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2010. Breast cancer risk by breast density, menopause, and postmenopausal hormone therapy use.
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2010. Breast cancer screening with imaging: Recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer.
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2009. Prioritizing clinical preventive services: A review and framework with implications for community preventive services.
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Preventive Services Task Force recommendation. Evidence Synthesis No.
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A Russell, and American Cancer Society Breast Cancer Advisory Group.
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Eyre, S Sener, American Cancer Society High-Risk Work Group, American Cancer Society Screening Older Women Work Group, American Cancer Society Mammography Work Group, American Cancer Society Physical Examination Work Group, American Cancer Society New Technologies Work Group, and American Cancer Society Breast Cancer Advisory Group.
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From page 214... ...
Rockville, MD: United States Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm (accessed June 1, 2011)
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2001. Nutrition and physi cal activity interventions to reduce cardiovascular disease risk in health care settings: A quantitative review with a focus on women.
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