Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Well-Woman Task Force A collaborative initiative hosted by the American College of Obstetricians & Gynecologists Final Report April 18, 2014 Well-Woman Task Force Jeanne Conry, MD, PhD, FACOG ACOG President 2013-2014 Kaiser Permanente Roseville, CA Haywood Brown, MD, FACOG, Chair Duke Univ Medical Center Durham, NC Sandra Adamson Fryhofer, MD, MACP, FRCP American College of Physicians Victoria Green, MD, MHSA, JD, MBA, FACOG National Medical Association Sue Kendig, JD, MSN, WHNP-BC, FAANP National Association of Nurse Practitioners in Women’s Health Elizabeth M. Alderman, MD, FAAP American Academy of Pediatrics Chiara Benedetto, Professor European Board & College of Obstetrics and Gynaecology Molly Brewer, DVM, MD, MS Society of Gynecologic Oncology Octavia Cannon, DO, FACOOG American College of Osteopathic Obstetricians & Gynecologists Merry-K Moos, BSN, MPH, FAAN Preconception Health and Health Care Clinical Work Group Mimi Pomerleau, DNP, MSN, RNC-OB Association of Women’s Health, Obstetric and Neonatal Nurses George Saade, MD, FACOG Society for Maternal-Fetal Medicine Robert M. Wah, MD, FACOG American College of Obstetricians & Gynecologists David Chelmow, MD Society for Academic Specialists in General Obstetrics and Gynecology Judy Waxman National Women’s Law Center Vanessa Cullins, MD, MPH, MBA Planned Parenthood Federation for America Ruth E. Zielinski, PhD, CNM American College of Nurse-Midwives Diana D’Amelio, PA-C American Academy of Physician Assistants R. Louise Floyd, DSN, RN National Center on Birth Defects and Developmental Disabilities Karen Davenport National Women’s Law Center Mark DeFrancesco, MD, MBA, FACOG American College of Obstetricians & Gynecologists Linda Dominguez, RN-C, NP Association of Reproductive Health Professionals Patricia L. Fontaine, MD, MS, FAAFP American Academy of Family Physicians Nancy Lee, MD Office on Women’s Health Janet L. McCauley, MD, FACOG Committee on Health Economics & Coding, American College of Obstetricians and Gynecologists Timothy C. McFarren, MD, MS, FACOG Committee on Practice Management, American College of Obstetricians & Gynecologists American College of Obstetricians & Gynecologists Staff Gerald F. Joseph Jr, MD, Vice President of Practice Activities Nancy O’Reilly, MHS Caitlin Phelps, MA Lyndona Charles Table of Contents Introduction……………………………………………………………………………….. 1 Topics ……………………………………………………………………………………... 11 Abdominal Exam 11 Alcohol Misuse 14 Anemia 21 Bacteriuria 22 Blood Pressure Screening 24 Breast Cancer, Chemoprevention 26 Self Breast Exam 28 Breastfeeding 32 Cervical Cancer Screening and Prevention 34 Clinical Breast Examination 44 Colorectal Screening 50 Contraception, STIs, & Reproductive Health 57 Dyslipidemia/Cardiovascular Disease 66 Depression 70 Diabetes 76 Diabetes Postpartum 78 Diet, Fitness, Nutrition 79 Domestic and Intimate Partner Violence 81 Drug Use 84 Genetic Screening 88 Hearing 93 Hepatitis B Screening 94 Hepatitis C Screening 96 Hypothyroidism 99 Immunizations 104 Injury Prevention 105 Kidney Disease 108 Mammography 110 Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment 113 Metabolic Syndrome 118 Neural Tube Defects 120 Obesity 121 Oral Cavity Exam 124 Oral Hygiene 125 Osteoporosis 128 Ovarian Cancer 130 Pelvic Examination 133 Pelvic Floor Disorders 138 Piercing and Tattooing 140 Preconception, Interconception Care 141 Sexual Health 148 Skin Cancer 150 Sleep Disorders 154 Tobacco Use 155 Visual Acuity/Glaucoma 160 Glossary…………………………………………………………………………………… 163 Well-Woman Task Force Components of the Well-Woman Visit Background The well-woman visit promotes health through disease prevention and preventive health care over the course of a woman’s lifetime. As outlined by the Institute of Medicine 1, the Patient Protection and Affordable Care Act (ACA) of 2010 ushered in a paradigm shift from a reactive health care system that responds to acute and urgent needs to one that fosters optimal health and well-being. Under the ACA, well-woman care is a covered benefit (with no copayment required) and may be provided by an assortment of providers, including family physicians, internists, nurse midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants. The selection of a provider for well-woman care will be determined as much by a woman’s needs and preferences as by her access or health plan availability. The focus on well-woman health care is a particularly timely topic given the ACA’s strong wellwoman health care provisions. The law covers a range of preventive services, from cancer screening to contraceptive care. It does not, however, address definitional and practice issues across providers and health plans, nor does it adequately look at preventive services across a woman’s life span from a holistic perspective. Purpose 1 IOM (Institute of Medicine). 2011. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press. 1 The American Congress of Obstetricians and Gynecologists (ACOG) convened the Well-Woman Task Force to develop a consensus about the basic elements that make up the well-woman visit and can be used by any provider who cares for adolescent girls or women. Organizations were invited to participate in this collaborative effort to ensure that women receive consistent, highquality health care to the full extent intended by the ACA. Composed of leading professional associations representing women’s health clinicians, the Well-Woman Task Force aimed to focus on delineating the well-woman visit throughout the life span, across all providers and health plans. The Well-Woman Task Force believes that its joint voice will be powerful, reflecting the collective wisdom of all of the professional associations represented and, ultimately, the needs of women throughout the United States. The task force recognized that many recommendations from medical societies and government agencies already exist and provide guidelines about the basic elements of women’s health. Such recommendations are based on evidence and expert opinion but are not consistent across organizations or health plans. The task force also acknowledged that a variety of providers will deliver care, and they must be skilled in the elements of well-woman care to meet the minimum requirements of well-woman visits. The task force sought to provide a forum in which to reach consensus on well-woman care and to develop and submit recommendations to the U.S. Department of Health and Human Services (HHS) and others as the ACA is fully implemented. Components of the Well-Woman Visit identifies needs across a woman’s life span—from adolescence through the reproductive years and into maturity. It describes age-specific elements of care with a goal of improving health outcomes. (Other terms for such primary care approaches 2 to overall health evaluations are “adolescent health visit,” “health risk assessment,” and “health maintenance.”) Methodology To ensure a broad range of perspectives, ACOG reached out to the following organizations to participate in the Well-Woman Task Force: • American Academy of Family Physicians • American Academy of Pediatrics • American Academy of Physician Assistants • American College of Nurse-Midwives • American College of Osteopathic Obstetricians & Gynecologists • American College of Physicians • Association of Reproductive Health Professionals • Association of Women’s Health, Obstetric and Neonatal Nurses • National Association of Nurse Practitioners in Women’s Health • National Medical Association • Planned Parenthood Federation of America • Society for Maternal–Fetal Medicine • Society of Academic Specialists in General Obstetrics and Gynecology • Society of Gynecologic Oncology 3 This collaborative effort proceeded in three phases: compilation of existing guidelines, review of existing guidelines, and development of joint recommendations. Compilation of Existing Guidelines As a preliminary step, ACOG compiled existing guidelines from HHS, the Institute of Medicine, the U.S. Preventive Services Task Force, and each of the participating organizations, as well as from other authoritative organizations not represented. Then, ACOG provided all participants with a summary of the guidelines organized according to the level of agreement. The topics to be reviewed were sorted into five agreement categories: • Single source (eg, abdominal exam) • No agreement (eg, breast cancer/mammography screening) • Limited agreement (eg, pelvic examination) • General agreement (eg, hypertension, osteoporosis) • Sound agreement (eg, screening for sexually transmitted infections) Participants were asked to verify the guidelines from their own organizations and supplement as necessary before the first meeting of the task force. For example, ACOG submitted the methodology for the development of its Practice Bulletins that described the process for evaluating evidence and crafting recommendations. To ensure that the recommendations addressed key issues of concern, task force members provided their organizations’ top three priorities for well-woman care. For example, ACOG identified reproductive health management, obesity prevention, and smoking cessation as its top three priorities. 4 Task Force Review The task force reviewed all recommendations. The foundation for the final recommendations relied on evidenced-based guidelines, evidence-informed guidelines, uniform expert opinion, or some combination of these. • Evidenced-based recommendations were derived primarily from guidelines of the U.S. Public Health Services Task Force, the Institute of Medicine, and the Centers for Disease Control and Prevention. • Evidenced-informed recommendations were derived from guidelines published by medical societies and professional organizations. • Uniform expert agreement recommendations were derived from deliberations of the task force intended to resolve conflicting guidelines or to supplement evidence-based and evidence informed guidelines. In many areas, there were conflicting recommendations across organizations. In most instances, differences were small. In such cases, task force members negotiated a consensus, typically based on the strength of the evidence, the ease of implementation of the recommendation, or current prevailing practice. The strength of each recommendation in Components of the Well-Woman Visit is identified. Recommendations were considered “strong” if they rely primarily on evidence-based or evidence-informed guidelines or “qualified” if they rely primarily on expert consensus. 5 Special Considerations In developing recommendations for the components of the well-woman visit, task force members balanced many considerations. The recommendations focus on what should be done to optimize health for women at average risk. The task force did not examine data supporting the concept of an annual visit in general but rather accepted that the annual visit is an essential part of preventive health care for women. In determining the appropriate components, the task force took into account a number of limitations and special considerations. Age Ranges Preventive guidelines are often presented in general categories based on age and reproductive potential. For the purpose of this report, the task force sought to categorize the recommendations in Components of the Well-Woman Visit as follows: • Adolescents (13–18 years) • Reproductive-aged women (19–45 years) • Mature adults (46–64 years) • Women over age 64 years It is important to note that many organizations use different age ranges and categories, and many evidence-based recommendations for screening or preventive care do not use the categories above at all. When evidence supported specific ages for screening or prevention strategies, the task force included these ages, even if they were inconsistent with the initial age categories identified for the purpose of this report or conflicted with a category of a given organization. 6 State and Local Laws and Regulations For a number of topics, local laws and regulations apply to screening or to conditions uncovered during screening. While the most significant relate to intimate partner violence, child abuse, and sexually transmitted infections (including human immunodeficiency virus [HIV]), they can also apply in unexpected areas, such as reporting of breast density on mammography. The task force did not take these requirements into account because they vary from region to region. Providers should be aware of regulations and laws that apply to their patients and include them in counseling when they may affect the patient’s decisions regarding screening or provision of information. The task force felt strongly that appropriate consideration be given to the impact of regulations and laws on well-woman care when they are drafted. Insurance Coverage The task force understood that not every patient will have insurance coverage for all of the care included in the recommendations, and some patients may not have coverage for any. The recommendations were developed to include elements that optimize health of a well woman. Providers may have to modify the elements based on the individual patient’s resources. The task force recommends that insurers cover all components described in the recommendations. Costs and Cost-Effectiveness of Preventive Care The Task Force did not consider cost or cost-effectiveness. Many recommendations were developed using formal guidelines published by major medical and professional societies that explicitly did not include cost as a factor in guideline development. Moreover, many of the 7 recommendations involve low-cost screening methods based on a patient’s history or physical exam. Where laboratory tests are recommended, these recommendations stem from consensus across multiple organizations, some of which do consider cost-effectiveness. They generally were already recommended by major societies, including the U.S. Preventative Services Task Force or Institute of Medicine. Evidence Base The task force considered several levels of evidence. When available, the task force relied on high-quality evidence. In general, screening that involves laboratory testing and imaging was only included if it was supported by high-quality evidence previously reviewed and accepted by other organizations. Approaches that involve low-cost screening methods (eg, history or physical exam) were included when the task force felt that detecting the outcome was clearly important (eg, identifying domestic violence), even if high-quality evidence was not available. When highquality evidence was not available but the task force felt a recommendation should be included, the recommendation was phrased to be permissive as opposed to prescriptive. Timeliness The recommendations are an amalgam of guidelines from major medical and professional societies and government organizations, all of which are updated systematically but at irregular intervals. Similarly, we realize that some subjects were not addressed, so their review will take place in updates. Given the number of recommendations, it is expected that some of the recommendations made at the initial task force meetings will rapidly become out of date. Components of the Well-Woman Visit is intended to be a living document. Regular update of 8 components is planned, as is the ability to remove recommendations no longer relevant and add new ones as necessary. Availability of Referral Services Abnormal screening results must be appropriately managed. Management can be by the provider or referral, depending on local resources and the individual provider’s expertise and training. The task force advocates that patients should not be denied recommended screening because of any limitation of local resources. Rather, providers should have plans for referral, even if it means the patient will have to travel outside her community. Providers are encouraged to develop initial management skills that are within the scope of their specialty and practice to meet local patient needs. Patients should be counseled about limitations in local resources at the time of testing. Delivery of Care While Components of the Well-Woman Visit envisions at least one annual well-woman visit, there is no requirement that all the recommended components be performed at the same visit or by the same provider. Care models such as patient-centered medical homes will allow delivery in more flexible formats. In developing the recommendations, the task force focused on delineating the services that should be provided and the overall frequency at which they should be provided, rather than the specifics of how and when they should be provided. Finalizing and Disseminating Joint Recommendations At the end of the process, the task force finalized its recommendations. Components of the WellWoman Visit will be submitted to HHS, participating organizations, and all agencies tasked with 9 implementation and enforcement of the ACA. This information will also assist the National Women’s Law Center as they advocate for women and wellness care. Incorporating Recommendations Into Practice The charge of the Well-Woman Task Force was to provide guidance to women and clinicians with age-appropriate recommendations for a well woman visit. Well-woman care comprises history, physical examination, counseling, and screening intended to maintain physical, mental, and social wellness and general health throughout a woman’s lifetime. The foundation for the final Task Force recommendation for each topic was derived using evidence-based, evidenceinformed, uniformed expert opinion, or some combination. Clinicians and patients must be informed and educated to ensure that a well-woman visit meets the standards of care for each recommendation, as well as the indications and rationale for that recommendation for prevention, wellness, and general health. 10 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Abdominal Exam Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation Adolescents (13-21) Evidence-Based Standard physical exam taught in medical school and advanced practice programs includes abdominal exam as part of a routine periodic exam. The elements can include four-quadrant/nineregion abdominal inspection, auscultation, percussion, and palpation. The inspection can reveal distension, both operative and traumatic scars, striae, pubic hair distribution, jaundice, and distended veins. Auscultation can reveal bowel sounds and fetal heart. Percussion can reveal ascites. Palpation can assess An abdominal exam is an appropriate component of the well-adolescent visit. (Qualified) 11 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid superficial or deep tenderness, guarding, rebound, and rigidity. ACOG: Abdominal exam is recommended as part of wellwoman physical exam regardless of age. (Committee Opinion 534, http://www.acog.org/Res ources_And_Publications/Co mmittee_Opinions/Committe e_on_Gynecologic_Practice/W ell-Woman_Visit; Guidelines for Women’s Health, http://www.acog.org/Resourc es_And_Publications/Guidelin es_for_Womens_Health_Care /Patient_Care) AAP Bright Futures: Annual well-child assessment and physical exam is recommended. At this visit, an age-appropriate physical exam is essential. The older child (11-21 years) will be undressed and suitably draped. (Recommendations for Preventive Pediatric Health Care, http://brightfutures.aap.org/p dfs/AAP_Bright_Futures_Perio dicity_Sched_101107.pdf) 12 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (22 and older) See also Alcohol Misuse; Diet, Fitness, and Nutrition; Drug Use; Hepatitis C Screening; Skin Cancer Evidence-Based Evidence-Informed Standard physical exam taught in medical school and advanced practice programs includes abdominal exam as part of a routine periodic exam. An abdominal exam can assess a woman’s risk of exposure to hepatitis C; drug and alcohol use/abuse; dietary, hereditary, or lifestyle risks for gastrointestinal disorders; and cancers of the skin and internal organs. Uniform Expert Agreement Final WWTF Recommendation An abdominal exam is an appropriate component of the well-woman visit. (Qualified) ACOG: Abdominal exam is recommended as part of wellwoman physical exam regardless of age. (Committee Opinion 534, http://www.acog.org/Res ources_And_Publications/Co mmittee_Opinions/Committe e_on_Gynecologic_Practice/W ell-Woman_Visit; Guidelines 13 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid for Women’s Health, http://www.acog.org/ Resources_And_Publications/ Guidelines_for_Womens_Heal th_Care/Patient_Care) 14 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Alcohol Misuse Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adolescents (13-18) See also Preconception/Interconception Care Evidence-Based Evidence-Informed USPSTF: There is inconclusive evidence that counseling is effective in adolescents. (Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, grade B recommendation; U.S. Preventive Services Task Force. Screening and Behavioral Counseling Intervention in Primary Care to Reduce Alcohol Misuse: Recommendations Statement. AHRQ Publication No. 12-05171-EF3. http://www.uspreventiveservice staskforce.org/uspstf12/alcmisuse/ alcmisusefinalrs.htm) AAP Bright Futures: Recommends annual evaluation and counseling for alcohol use in adolescents. (Performing Preventive Services: A Bright Futures Handbook) Annual screening of adolescents for alcohol use by questionnaire or history or both but not by testing is recommended. Provide or refer patient to counseling about alcohol use. (Strong) AAP: Strongly advises against the use of alcohol, tobacco, and other illicit drugs by youth. (AAP Policy Statement: Alcohol use by Youth and Adolescents: A Pediatric Concern, Pediatrics Vol. 125 No. 5 May 1, 2010 15 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid pp. 1078 -1087; Alcohol Use by Youth and Adolescents: A Pediatric Concern. ) ACOG: Recommends annual screening for alcohol use in teens. (GAHC, p. 104) ACOG: Recommends screening by questionnaire/history (not testing) at least yearly. (CO #496) PCHHC: All women of childbearing age should be screened for alcohol use, and brief interventions should be provided in primary care settings, which should include advice regarding the potential for adverse health outcomes. Women who show signs of alcohol dependence should be educated about the risks of alcohol consumption; for women who are interested in modifying their alcohol use patterns, efforts should be made to identify programs that would assist them in achieving cessation and longterm abstinence. (The Clinical 16 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Content of Preconception Care [B I-a]) PCHHC: Assess at least annually for alcohol use patterns and risky drinking behaviors and provide appropriate counseling; all women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established. (The Clinical Content of Preconception Care [A III]) AAFP: The evidence is inconclusive that counseling is effective in adolescents. Recommends screening and behavioral counseling interventions to reduce alcohol misuse, in primary care settings. (AAFP, Alcohol Misuse) CDC: Binge drinking increases the risk for unintended pregnancy, delayed pregnancy recognition, STIs, and adverse pregnancy outcomes including fetal alcohol spectrum disorder. Assess patterns of risky drinking at least annually and counsel the teenager on the harm to self and, should she become pregnant, to her embryo/fetus. 17 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid (http://www.cdc.gov/Feature s/VitalSigns/bingedrinkingfe male/index.html) NIAAA: Recommends alcohol screening and brief intervention for youth. (http://pubs.niaaa.nih.gov/p ublications/Practitioner/Yout hGuide/YouthGuide.pdf) Adults (19 and older) See also Preconception/Interconception Care Evidence-Based Evidence-Informed USPSTF: Recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. (Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse; grade B recommendation) AAFP: Recommends screening and behavioral counseling interventions to reduce alcohol misuse, in primary care settings. (AAFP, Alcohol Misuse) ACOG: Recommends screening by questionnaire/history (not testing) at least yearly. (CO #496) Uniform Expert Agreement Final WWTF Recommendation Annual screening of adults for alcohol misuse by questionnaire or history or both but not by testing is recommended. Provide or refer persons engaged in risky or hazardous drinking to brief behavioral counseling interventions to reduce alcohol misuse. (Strong) PCHHC: All women of childbearing age should be 18 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid screened for alcohol use, and brief interventions should be provided in primary care settings, which should include advice regarding the potential for adverse health outcomes. Women who show signs of alcohol dependence should be educated about the risks of alcohol consumption; for women who are interested in modifying their alcohol use patterns, efforts should be made to identify programs that would assist them in achieving cessation and longterm abstinence. (The Clinical Content of Preconception Care [B I-a]) PCHHC: Assess at least annually for alcohol use patterns and risky drinking behaviors and provide appropriate counseling; all women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established. (The Clinical Content of Preconception Care [A III]) 19 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid AAP Bright Futures: Recommends annual evaluation and counseling for alcohol use in adolescents (through age 21). (Performing Preventive Services: A Bright Futures Handbook) 20 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Anemia Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents and Adults (all ages) Evidence-Based Evidence-Informed USPSTF: Evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children ages 6 to 12 months. Grade: I Statement. (USPSTF, Screening for Iron Deficiency Anemia, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsiron.htm) There is no recommendation for routine screening for anemia in asymptomatic girls or women. Uniform Expert Agreement Final WWTF Recommendation Routine screening for anemia is not recommended. (Qualified) 21 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Bacteriuria Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13–18) Evidence-Based Evidence-Informed Uniform Expert Agreement USPSTF: Recommends against screening for asymptomatic bacteriuria in AAFP: Recommends There is evidence of men and nonpregnant women. against screening harm resulting from for asymptomatic treatment of (Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. bacteriuria in men asymptomatic U.S. Preventive Services Task bacteriuria in Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm; and nonpregnant women. (AAFP nonpregnant grade D recommendation) women. There is no Bacteriuria, evidence of benefit Asymptomatic) to screening older, asymptomatic nonpregnant women. Recommend following USPSTF guidelines. Final WWTF Recommendation Screening for bacteriuria in asymptomatic, nonpregnant women is not recommended. (Strong) 22 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (19–64) Evidence-Based Evidence-Informed USPSTF: Recommends against screening for asymptomatic bacteriuria in men and nonpregnant women. (Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsba ct.htm; grade D recommendation) AAFP: Recommends against screening for asymptomatic bacteriuria in men and nonpregnant women. (AAFP Bacteriuria, Asymptomatic) Uniform Expert Agreement There is evidence of harm resulting from treatment of asymptomatic bacteriuria in nonpregnant women. Final WWTF Recommendation Screening for bacteriuria in asymptomatic, nonpregnant women is not recommended. (Strong) Adults (65+) Evidence-Based EvidenceInformed USPSTF: Recommends against screening for asymptomatic bacteriuria in ACOG: Perform men and nonpregnant women. urinalysis. (Annual (Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. U.S. Preventive Services Task Women's Health Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm; Care) grade D recommendation) Uniform Expert Agreement There is evidence of harm resulting from treatment of asymptomatic bacteriuria in nonpregnant women. Recommend following USPSTF guidelines. Final WWTF Recommendation Screening for bacteriuria in asymptomatic women is not recommended. (Strong) 23 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Blood Pressure Screening Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents and Adults (all ages) See also Cardiovascular Disease Evidence-Based Evidence-Informed USPSTF: Screen for high blood pressure in adults age 18 years or older. Current evidence is insufficient to assess the balance of benefits and harms of screening for hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood. (Screening for high blood pressure: U.S. Preventive Services Task Force AAFP: There is insufficient evidence to recommend for or against screening children and adolescents for high blood pressure to reduce risk of CVD. (http://www.aafp.org/dam/AAFP/documents/patient_care/ clinical_recommendations/October2012SCPS.pdf) Uniform Expert Agreement Final WWTF Recommendation Routine blood pressure screening is recommended. (Strong) AAP Bright Futures: Recommends routine blood pressure measurement for adolescents. (http://brightfutures.aap.org/pdfs/preventive%20services%20pdfs/ physical%20examination.pdf) 24 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid reaffirmation recommendation statement. Ann Intern Med. 2007 Dec 4;147(11):783-6; Moyer VA; U.S. Preventive Services Task Force. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2013 Nov;132(5):907-14. doi: 10.1542/peds.20132864. Epub 2013 Oct 7.) 25 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Breast Cancer, Chemoprevention Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidencebased or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation Adults (All ages) Evidence-Based (source) 26 USPSTF: Recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. (B recommendation 2013; http://www.uspreventiveservicesta skforce.org/uspstf13/breastcanme ds/breastcanmedsrs.htm) ACOG: Counsel women aged 35 Recommend following USPSTF years and older at high risk. guidelines. (http://www.acog.org/About_A COG/ACOG_Departments/Annu al_Womens_Health_Care/Asses sments_and_Recommendations ) For women who are at increased risk for breast cancer, it is recommended that clinicians engage in shared, informed decision-making about medications to reduce their risk. (Strong) AAFP: Recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe riskreducing medications such as tamoxifen or raloxifene. (2013, http://www.aafp.org/pati ent-care/clinicalrecommendations/all/bre ast-cancer.html) It is recommended that women who are at increased risk for breast cancer and at low risk for adverse medication effects be offered risk-reducing medications, such as tamoxifen or raloxifene. (Strong) 27 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Self Breast Exam Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (All ages) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 28 USPSTF: Recommends against teaching breast self-examination. (http://www.uspreventiveservicest askforce.org/uspstf09/breastcancer /brcanrs.htm; grade D recommendation; Evidence review at http://www.uspreventiveservicesta skforce.org/uspstf09/breastcancer/ brcanes.pdf) AAP Bright Futures: Does not recommend breast selfexamination. (https://brightfutures.aap.org/ pdfs/Guidelines_PDF/13Rationale_and_Evidence.pdf ) ACOG: Because other screening methods can have false-negative results, and because breast cancer can occur in unscreened women, breast self-examination and breast self-awareness have a role in breast cancer screening. Physicians should consider teaching breast selfexamination to high-risk patients. Recommend educating women about breast self-awareness. (2003, http://www.guideline.gov/ content.aspx?id=34275; Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82) Physicians should educate women about breast self-awareness, encouraging them to understand the normal appearance and feel of their breasts and to report any changes in their breasts to their health care providers. Breast self-awareness can include breast self-examination. (Qualified) NCCN: Breast awareness is encouraged. (2013, http://www.nccn.org/def ault.aspx) ACS: Starting at age 20, women should be counseled on the benefits 29 and limitations of breast self-examination. (2013, http://www.cancer.org/acs /groups/cid/documents/we bcontent/003165-pdf.pdf) Cochrane Collaborative: The review of data from two large population-based studies involving 388,535 women compared breast selfexamination with no intervention did not find a beneficial effect of screening in terms of improvement in breast cancer mortality. The trials showed that women who were randomized to breast self-examination were almost twice as likely to undergo a biopsy of the breast. The authors suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. (http://summaries.cochrane.or g/CD003373/regular-selfexamination-or-clinicalexamination-for-earlydetection-of-breastcancer.#sthash.UIO2ZUcf.dpuf) 30 31 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Breastfeeding Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation All Women of Reproductive Capacity Evidence-Based Evidence-Informed IOM: Recommends women’s preventive services include comprehensive lactation support and counseling and costs of renting breastfeeding equipment. A trained provider should provide counseling services to all pregnant women and to those in the postpartum period to ensure the successful initiation and duration of breastfeeding. (Clinical Preventive Services for Women: Closing the Gaps) ACNM: Provide timely and ongoing counseling and support for breastfeeding. Maternity/newborn facilities must follow lactation-friendly policies. (Breastfeeding) AAFP: Recommends interventions during pregnancy and after birth to promote and support breastfeeding.(Breastfeeding) Promotion of breastfeeding and counseling is recommended for all pregnant and postpartum women to ensure successful initiation and duration of breastfeeding. Provide interventions such as comprehensive lactation support and counseling and information on the costs of renting breastfeeding equipment to promote and support breastfeeding. (Strong) USPSTF: Recommends interventions during pregnancy and after birth to promote and support breastfeeding. (Grade B 32 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid recommendation; http://www.usp reventiveservicestaskforce.org/us pstf/uspsbrfd.htm) 33 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Cervical Cancer Screening and Prevention Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: Screening is not recommended for cervical cancer in women younger than age 21 years. The recommendation does not apply to women who have received a diagnosis of a highgrade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV-positive). (http://www.uspreventiveservices taskforce.org/uspstf11/cervcancer /cervcancerrs.pdf) ACOG: Screening is not Healthy women under 21 years recommended for old should not be screened. adolescents. (http://www.acog.org/Resour ces_And_Publications/Practice _Bulletins/Committee_on_Pra ctice_Bulletins_-_Gynecology/Screening_for_C ervical_Cancer) Adolescents (13-20) ACS/ASCCP/ACSP: Cervical cancer screening should begin at age 21. Screening for cervical cancer is not recommended for women under 21. (Strong) AAFP: Screening is not recommended for adolescents. (http://www.aafp.org/patientcare/clinicalrecommendations/all/cervical -cancer.html) 34 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Women under 21 should not be screened regardless of the age of sexual initiation or other risk factors. (http://journals.lww.com/jlgtd/Pu blishingImages/ASCCP%20Guidelin es.pdf#zoom=80) ACIP: Women ages 10-26 should receive bivalent or quadrivalent human papillomavirus (HPV) vaccine. (http://www.cdc.gov/vaccines/hc p/acip-recs/vaccspecific/hpv.html) CDC: For those who are HIVpositive, a Pap test should be obtained twice during the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter. (http://www.cdc.gov/mmwr/pdf/r r/rr5804.pdf) AAFP, ACP, ACOG, ACNM: ACIP adult and childhood vaccines schedules endorsed. (ACOG CO #467; ACOG, AAFP, ACNM, ACP: http://www.aafp.org/content/ dam/AAFP/documents/patien t_care/immunizations/hpvrecommendation-letter.pdf) AWHONN: HPV vaccine is recommended. (http://www.awhonn.org/awh onn/binary.content.do;jsessio nid=18DC4DFDA7A95EA82E7A FB308008EF63?name=Resour ces/Documents/pdf/5_HPV.pd f) ACOG: Annual cytology screening starting at age 21 years is reasonable for this group. (http://www.acog.org/Resour ces_And_Publications/Practice _Bulletins/Committee_on_Pra ctice_Bulletins_-_Gynecology/Screening_for_C Adolescents should receive HPV vaccine prior to the initiation of sexual activity. HPV vaccine is recommended for adolescents, preferably before the initiation of sexual activity, and according to the ACIP schedule. (Strong) There are conflicting guidelines for HIVinfected girls and women under 21. Compliance with either of the guidelines is acceptable. (Qualified) 35 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid ervical_Cancer) Adults (21-29 with cervix and without history of DES exposure, immunocompromise, or prior high-grade lesion) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 36 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends cytology every 3 years. Recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology. The recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV-positive). (http://www.uspreventiveservicest askforce.org/uspstf11/cervcancer/ cervcancerrs.pdf) ACS/ASCCP/ASCP: Recommend cytology alone every 3 years. HPV testing should not be used for screening in this age group. (http://journals.lww.com/jlgtd/Pub lishingImages/ASCCP%20Guideline s.pdf#zoom=80) ACIP: For adolescents and women ages 10-26, bivalent or quadrivalent HPV vaccine is recommended. (Bridges CB, CoyneBeasley T; Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC. Advisory committee on immunization practices ACOG, AAFP: For women ages 21-29, cytology alone every 3 years is recommended. (ACOG: http://www.acog.org/Resour ces_And_Publications/Practic e_Bulletins/Committee_on_P ractice_Bulletins_-_Gynecology/Screening_for_ Cervical_Cancer; AAFP: http://www.aafp.org/patient -care/clinicalrecommendations/all/cervica l-cancer.html) AAFP, ACP, ACOG, ACNM: ACIP adult and childhood vaccine schedules endorsed. (http://www.aafp.org/conte nt/dam/AAFP/documents/pa tient_care/immunizations/hp v-recommendationletter.pdf) ACOG, ACS, and USPSTF guidelines are all similar and appropriate for this age group. Screening for cervical cancer is recommended with cytology alone every 3 years in women with a cervix who have not had DES exposure or prior high-grade lesion or cancer and who are not immunocompromised. (Strong) Screening with HPV testing is not recommended. (Strong) HPV vaccine is recommended for women aged 26 and under according to the ACIP schedule. (Strong) 37 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid recommended immunization schedule for adults aged 19 years or older - United States, 2014. MMWR Morb Mortal Wkly Rep. 2014 Feb 7;63(5):110-2; AkinsanyaBeysolow I; Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC. Advisory committee on immunization practices recommended immunization schedules for persons aged 0 through 18 years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2014 Feb 7;63(5):108-9.) Adults (30-65 with cervix and without history of DES exposure, immunocompromise, or prior high-grade lesion) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 38 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid IOM: Recommends the addition of high-risk HPV DNA testing in addition to cytology testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every 3 years. (http://www.iom.edu/Reports/201 1/Clinical-Preventive-Services-forWomen-Closing-theGaps/Recommendations.aspx) USPSTF: Recommends cytology every 3 years. For women who want to lengthen the screening interval, combine cytology and HPV testing every 5 years. The recommendation does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV-positive). (http://www.uspreventiveservicest askforce.org/uspstf11/cervcancer/ cervcancerrs.pdf) ACOG: Cytology alone every 3 years is acceptable. Cotesting (HPV test plus cytology) is preferable. (http://www.acog.org/Resou rces_And_Publications/Practi ce_Bulletins/Committee_on_ Practice_Bulletins_-_Gynecology/Screening_for_ Cervical_Cancer) Despite conflicting opinions among the major sources of recommendations, cotesting is an acceptable strategy that allows lengthening of screening intervals. Screening for cervical cancer with a combination of cytology and HPV testing (cotesting) is recommended every 5 years in women with a cervix who have not had DES exposure or a prior high-grade lesion or cancer and who are not immunocompromised. Screening with cytology alone every 3 years is acceptable. (Strong) AAFP: Cytology alone every 3 years is recommended. For women who want to lengthen the screening interval, cotesting every 5 years is recommended. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/cervica l-cancer.html) ACS/ASCCP/ASCP: HPV and cytology "cotesting" every 5 years is the preferred approach. Cytology 39 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid alone every 3 years is acceptable. Screening by HPV testing alone is not recommended for most clinical settings. (http://journals.lww.com/jlgtd/Pub lishingImages/ASCCP%20Guideline s.pdf#zoom=80) Adults (over 65 with cervix and without history of DES exposure, immunocompromise, or prior high-grade lesion) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 40 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. The recommendation does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV-positive). (http://www.uspreventiveservicest askforce.org/uspstf11/cervcancer/ cervcancerrs.pdf) ACS/ASCCP/ASCP: Screening is not recommended following adequate negative prior screening. Women with a history of CIN 2 or a more severe diagnosis should continue routine screening for at least 20 years. (http://journals.lww.com/jlgtd/Pub lishingImages/ASCCP%20Guideline s.pdf#zoom=80) ACOG: Discontinue screening in women older than 65 years with evidence of adequate negative prior screening and no history of CIN 2 or greater. (http://www.acog.org/Resou rces_And_Publications/Practi ce_Bulletins/Committee_on_ Practice_Bulletins_-_Gynecology/Screening_for_ Cervical_Cancer) Screening for cervical cancer is not recommended for women over 65 who have had adequate prior screening with negative results. (Strong) Routine screening for at least 20 years is recommended for women with a history of CIN 2 or a more severe diagnosis. (Strong) AAFP: Do not screen women 65 and over who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/cervica l-cancer.html) Adults (21 and over without cervix) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 41 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Screening for cervical cancer is not recommended in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia grade 2 or 3) or cervical cancer. The recommendation does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV-positive). (http://www.uspreventiveservicest askforce.org/uspstf11/cervcancer/ cervcancerrs.pdf) ACOG: Do not screen women after total hysterectomy who have no history of CIN 2 or higher. (http://www.acog.org/Resou rces_And_Publications/Practi ce_Bulletins/Committee_on_ Practice_Bulletins_-_Gynecology/Screening_for_ Cervical_Cancer) Screening for cervical cancer is not recommended for women who have had a hysterectomy provided they have no history of CIN 2 or more severe diagnosis in the past 20 years or cervical cancer ever. (Strong) AAFP: Do not screen women who have had hysterectomy with removal of cervix and who do not have a history of high-grade precancerous lesion (CIN 2 or 3) or cervical cancer. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/cervica l-cancer.html) ACS/ASCCP/ASCP: After hysterectomy, screening is not recommended. The recommendation applies to women without a cervix and without a history of CIN 2 or a more severe diagnosis in the past 20 years or cervical cancer ever. ( http://journals.lww.com/jlgtd/Publ ishingImages/ASCCP%20Guidelines 42 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid .pdf#zoom=80) 43 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Clinical Breast Examination Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adults (All Women) Evidence-Based Evidence-Informed 44 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. (2009, http://www.uspreventiveser vicestaskforce.org/uspstf09/breast cancer/brcanrs.htm; Evidence review at http://www.uspreventiveservicesta skforce.org/uspstf09/breastcancer/ brcanes.pdf) ACOG: CBE should be performed every 1 to 3 years for women ages 20–39 years and annually for women ages 40 years and older. (2011, http://www.guideline. gov/content.aspx?id=34275; recommendations are based primarily on consensus and expert opinion [Level C]) ACOG: CBE should be performed annually for women 40 or older. Although the value of screening CBE for women with low prevalence of breast cancer (i.e., women ages 20–39) is not clear, CBE for these women is recommended every 1-3 years (Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82. http://www.acog.org/~/medi a/Practice%20Bulletins/Com mittee%20on%20Practice%2 0Bulletins%20-%20Gynecology/pb122.pdf?d mc=1&ts=20140312T091822 4010) CBE should be offered to asymptomatic women without breast cancer risk factors in the context of a shared decisionmaking approach that takes into account a woman's personal preferences and the balance of benefit to harm. CBE should be performed annually for women aged 40 years and older. For women aged 20-39 years, CBEs are recommended every 1-3 years. Clinical breast exam (CBE) may be offered to women in the context of a shared decisionmaking approach that recognizes the uncertainty of additional benefits and harms of CBE beyond screening mammography. (Qualified) CBE may be offered to women ages 19–39 every 1 to 3 years. (Qualified) CBE may be offered to women ages 40 and older annually. (Qualified) Routine CBE is not recommended for adolescents (ages 13–18). (Qualified) 45 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid AAFP: Current evidence is insufficient to assess the benefits and harms of CBE for women aged 40 years and older. (2009; http://www.aafp.org/patient -care/clinicalrecommendations/all/breastcancer.html) ACS: Recommends CBE about every 3 years for women in their 20s and 30s and every year for women 40 and over. (http://www.cancer.org/heal thy/findcancerearly/cancersc reeningguidelines/americancancer-society-guidelines-forthe-early-detection-ofcancer) Susan G Komen: CBE can be helpful in finding tumors in women under age 40 for whom mammography is not indicated. In women 40 and older, CBE and mammography may find more cancers than mammography alone (i.e., when used together fewer breast cancers are missed). CBE is not a substitute for mammography in women 46 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid over 40. (Oestreicher N, Lehman CD, Seger DJ, Buist DS, White E. The incremental contribution of clinical breast examination to invasive cancer detection in a mammography screening program. AJR Am J Roentgenol. 184(2):428-32, 2005; Chiarelli AM, Majpruz V, Brown P, Thriault M, Shumak R, Mai V. The contribution of clinical breast examination to the accuracy of breast screening. J Natl Cancer Inst. 101(18):1236-43, 2009. Cited at http://ww5.komen.org/Br eastCancer/ClinicalBreastExa m.html ) CTFPHC: Recommends not routinely performing clinical breast exa minations alone or in conjunction with mammography to screen for breast cancer. (Weak recommendation; low-quality evidence; Canadian Task Force on Preventive Health Care, Tonelli M, Gorber SC, Joffres M, Dickinson J, Singh H, Lewin G, Birtwhistle R. 47 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Recommendations on screening for breast cancer in average-risk women aged 4074 years. CMAJ. 2011 Nov 22;183(17):1991-2001.) WHO: The only breast cancer screening method that has proved to be effective is mammography screening. Research is underway to evaluate CBE as a low-cost approach to breast cancer screening that can work in less affluent countries. (http://www.who.int/cancer/ detection/breastcancer/en/) Cochrane Collaborative: The only large population-based trial of clinical breast examination combined with breast self-examination that was identified was discontinued because of poor compliance with follow up. (http://summaries.cochrane. org/CD003373/regular-selfexamination-or-clinicalexamination-for-earlydetection-of-breastcancer.#sthash.UIO2ZUcf.dpu f 48 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid KPCMI: Recommends CBE be offered to asymptomatic women without breast cancer risk factors, in the context of a shared decisionmaking approach that takes into account a woman's personal preferences and the balance of benefit to harm. (http://www.guideline.gov/s yntheses/synthesis.aspx?id=3 9251) 49 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Colorectal Screening Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adults (45–75) Evidence-Based Evidence-Informed ACP: Individualized assessment for risk of colorectal cancer is recommended. (http://annals.org/article.asp x?articleid=1090701) USPSTF: Screening for colorectal cancer should begin at age 50 and continue to age 75. (http://www.uspreventiveservicest askforce.org/uspstf/uspscolo.htm) ACP: All adults at average risk for colorectal cancer should be screened. (http://annals.org/article.asp x?articleid=1090701) Individualized assessment of risk, including family history and individualized counseling, is recommended. (Strong) Screening for all adults at average risk should begin at age 50, except for African Americans, for whom screening should begin at age 45. Screening for colorectal cancer is recommended beginning at age 50. For African American women, screening should begin at age 45. (Strong) ACG: Screening should start at age 50. For African Americans, begin screening age 45. (http://gi.org/guideline/color 50 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid ectal-cancer-screening/) ACOG: Screening should start at age 50. For African Americans, begin screening at age 45. (http://www.acog.org/About _ACOG/ACOG_Departments/ Annual_Womens_Health_Car e/Assessments_and_Recom mendations) USPSTF: The following methods of screening are recommended: -Fecal occult blood testing -Sigmoidoscopy -Colonoscopy There is insufficient evidence to assess the benefits or harms of computed tomographic colonography and fecal DNA testing as screening modalities. (http://www.uspreventiveservicest askforce.org/uspstf/uspscolo.htm) AAFP: The following methods of screening are recommended: -Fecal occult blood testing -Sigmoidoscopy -Colonoscopy There is insufficient evidence to assess the benefits or harms of computed tomographic colonography and fecal DNA testing as screening modalities. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/colore ctal-cancer.html) Screening is recommended by one of the following methods: -Colonoscopy every 10 years -FOBT or FIT annually -Flexible sigmoidoscopy every 5 years -Double contrast barium enema every 5 years -Computed tomography colonography every 5 years -Stool DNA (no interval determined) Screening should not be performed using inoffice FOBT or FIT with sample collected during digital rectal exam. (Strong) ACP: The following methods of screening are recommended: 51 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid –Stool-based test -Flexible sigmoidoscopy -Optical colonoscopy (http://annals.org/article.asp x?articleid=1090701) ACOG: The following approach is recommended: Colonoscopy every 10 years OR alternative methods: - Fecal occult blood testing or fecal immunochemical test annually -Flexible sigmoidoscopy every 5 years -Double contrast barium enema every 5 years -Computed tomography colonography every 5 years -Stool DNA (no interval determined) Do not use in-office FOBT or FIT with sample collected during digital rectal exam. (http://www.acog.org/About _ACOG/ACOG_Departments/ Annual_Womens_Health_Car e/Assessments_and_Recom mendations) ACG: Screening by colonoscopy is recommended. If 52 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid colonoscopy is not available or affordable: -Flexible sigmoidoscopy every 5-10 years -Computed tomography colonography every 5 years -Cancer detection test (fecal immunochemical test for blood) (http://gi.org/guideline/color ectal-cancer-screening/) Adults (76 and older) Evidence-Based USPSTF: Routine screening is not recommended for those ages 76 to 85. There may be considerations to support screening in individual patients. Screening is not recommended in adults older than 85 years. (http://www.uspreventiveservicest askforce.org/uspstf/uspscolo.htm) Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation ACP: Individualized assessment for risk of colorectal cancer is recommended. (http://annals.org/article.asp x?articleid=1090701) Individualized assessment of risk, including family history and individualized counseling, is recommended. (Strong) ACP: Do not screen over age 75 or with a life expectancy of less than 10 years. (http://annals.org/article.asp x?articleid=1090701) Routine screening is not recommended for women ages 75-85, but individual considerations may support screening in some patients following informed, shared decision-making. (Strong) AAFP: There may be considerations that support colorectal cancer screening Screening is not recommended for women over age 85. (Strong) 53 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid in an individual patient. Do not screen patients over age 85. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/colore ctal-cancer.html) Women at Increased Risk Evidence Based Evidence-Informed Uniform Expert Opinion ACP: Screen via optical colonoscopy starting at age 40 or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer. (http://annals.org/article.asp x?articleid=1090701) Final WWTF Recommendation Screening for colorectal cancer with optical colonoscopy is recommended for women at increased risk, beginning at age 40 (or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer). (Strong) AAFP: Do not use aspirin or NSAIDs to prevent colorectal cancer in individuals at risk for colorectal cancer. (http://www.aafp.org/patientcare/clinicalrecommendations/all/colorectal -cancer.html) Prophylactic treatment is not recommended for women at increased risk of colorectal cancer. (Strong) 54 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid AAFP: Genetic testing for Lynch syndrome is recommended for patients with newly diagnosed colorectal cancer to reduce morbidity and mortality to relatives. Those with Lynch syndrome should be offered earlier and more frequent screening, and their firstdegree relatives should be offered genetic testing. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/colore ctal-cancer.html) ACG: Patients who are hereditary nonpolyposis colorectal cancer (Lynch syndrome) carriers may be offered genetic counseling and should undergo colonoscopy every 2 years beginning at age 20-25 years until age 40 years, then annually thereafter. Patients with familial adenomatous polyposis (FAP) should undergo adenomatous polyposis coli (APC) mutation testing and, if negative, MYH mutation testing. Patients with FAP or Women with newly diagnosed colorectal cancer should be offered genetic testing for Lynch syndrome to reduce morbidity and mortality to relatives. (Strong) Women who are HNPCC carriers may be offered genetic counseling and should undergo colonoscopy every 2 years beginning at age 20-25 until age 40, then annually thereafter. (Strong) For women with FAP, APC mutation testing is recommended; if negative, MYH mutation testing is recommended. For women with FAP or at risk of FAP based on family history, annual flexible sigmoidoscopy or colonoscopy is recommended until such time when colectomy is deemed appropriate by the patient and her physician. (Strong) 55 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid at risk of FAP based on family history should undergo annual flexible sigmoidoscopy or colonoscopy until such time when colectomy is deemed the best treatment by the patient and provider. (http://gi.org/guideline/color ectal-cancer-screening/ 56 Topic: Contraception, STIs, & Reproductive Health Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Alcohol Misuse, Preconception/Interconception Care, Sexual Health Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation IOM, CDC: Recommends that women with reproductive capacity have access to the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling. (IOM: Clinical Preventive Services for Women: Closing the Gaps; CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2013 – Adapted from the world Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd Edition. ACOG: Recommends preventing unwanted and unintended pregnancy by postponing sexual involvement or using contraceptive options, including emergency contraception. (Emergency Contraception. Practice Bulletin No. 112. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:1100– 9. http://www.acog.org/About_A COG/ACOG_Departments/Annual _Womens_Health_Care) ACOG: Recommends first reproductive care visit at ages 1315, prior to sexual activity (usually does not include a pelvic exam.) (ACOG Committee Opinion. Number 335, May 2006: The initial reproductive health visit. Obstet Gynecol 2006;107:12159.) Adolescents of reproductive capacity should be counseled regarding contraceptive methods (including postponing sexual activity); ensured access to basic contraceptive services, either within their office setting or by referral to appropriate services; and offered appropriate follow-up to ensure compliance and monitor for adverse effects and complications. (Strong) AAP Bright Futures: Integrate Hoover et al: Adolescent visit provides an opportunity to establish a relationship. Content of visit can include screening, education, and guidance on sexual development, menses, HPV 57 MMWR Recommendations and Reports. Vol. 62, No. 5:1-60.) sexuality education into the longitudinal relationship developed through care experiences with the preadolescent child, the adolescent, and the family. (http://brightfutures.aap.org/pdfs /Guidelines_PDF/11_8_Sexuality. pdf) CDC: Routine screening for N. gonorrhoeae in all sexually active women at risk for infection is recommended annually. Women aged <25 years are at highest risk for gonorrhea infection. Routine screening for C. trachomatis of all sexually active females aged ≤25 years is recommended annually. (Sexually transmitted diseases treatment guidelines, 2010. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2010 Dec 17;59(RR12):1-110. Erratum in: MMWR Recomm Rep. 2011 Jan 14;60(1):18.) ACOG: Recommends chlamydia and gonorrhea testing (if sexually active). (Urine-based STI screening is an efficient method without a speculum examination.) (http://www.acog.org/About_AC OG/ACOG_Departments/Annual_ Womens_Health_Care/Assessme nts_and_Recommendations) vaccine, preventing pregnancy, STDs, and other issues on sexual health. (Hoover, KW, et al. Utilization of Health Services in Physician Offices and Outpatient Clinics by Adolescents and Young Women in the U.S. Journal of Adolescent Health 46; 2010:324330. [A CDC report]) Annual chlamydia and gonorrhea testing is recommended for those who are sexually active. (Strong) USPSTF: Recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for 58 infection (that is, if they are young or have other individual or population risk factors). Women and men under the age of 25— including sexually active adolescents—are at highest risk for genital gonorrhea infection. (Grade B recommendation; http://www.uspreventiveservices taskforce.org/uspstf05/gonorrhea /gonrs.htm) USPSTF: Recommends screening for chlamydial infection for all sexually active, nonpregnant young women aged 24 and younger and for older nonpregnant women who are at increased risk ( http://www.uspreventiveservices taskforce.org/uspstf07/chlamydia /chlamydiars; grade A recommendation). USPSTF: Recommends highintensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs. (http://www.uspreventiveservices taskforce.org/uspstf08/sti/stirs.pd f; grade B recommendation) 59 CDC: Prevent unwanted/unintended pregnancy by assessing the woman’s need for contraceptive methods and those that are available for her. (CDC (2010). Medical Eligibility Criteria for Contraceptive Use. MMWR;59(RR04):1–85; (CDC. (2009) Contraceptive use among postpartum women – 12 states and New York City, MMWR, 58, 821-826.; CDC. (2011). Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2010) Adults (All ages) See also Alcohol Misuse, Preconception Care, Sexual Health Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation IOM, CDC: Recommends that women with reproductive capacity have access to the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling. (IOM: Clinical Preventive Services for Women: Closing the Gaps; CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2013 – Adapted from the world Health ACOG: Prevent unwanted/unintended pregnancy by assessing the woman’s need for contraceptive methods and those that are available for her. (http://www.acog.org/Resources_ And_Publications/Guidelines for Women’s Health Care) Time to counsel, educate, and solve problems regarding contraceptive needs and management should be part of any given visit. Alternatively, arrangements should be made for a separate visit for contraception follow-up. Adult women of reproductive capacity should be evaluated at least annually regarding contraceptive method use and satisfaction. Women with reproductive capacity should have access to the full range of FDAapproved contraceptive methods, sterilization procedures, and patient education and counseling appropriate to their childbearing intentions. (Strong) 60 Organization Selected Practice Recommendations for Contraceptive Use, 2nd Edition. MMWR Recommendations and Reports. Vol. 62, No. 5:1-60.) CDC: Prevent unwanted/unintended pregnancy by assessing the woman’s need for contraceptive methods and those that are available for her. (CDC (2010). Medical Eligibility Criteria for Contraceptive Use. MMWR;59(RR04):1–85; (CDC. (2009) Contraceptive use among postpartum women – 12 states and New York City, MMWR, 58, 821-826.; CDC. (2011). Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR, 60(26, 878-883; CDC/OPA ( In press. Due to be published in MMWR Feb. 2014; Recommendations for Quality Family Planning Services) CDC: Safety, efficacy, availability, and acceptability should be considered by women, men, or couples when choosing the most appropriate contraceptive 61 method. Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, where applicable, may be an important contributor to the successful use of contraceptive methods. Assessment as to the safety of a given contraceptive method for a person with a particular characteristic or medical condition should be included in counseling. (CDC (2010). Medical Eligibility Criteria for Contraceptive Use. MMWR;59(RR04):1–85.) CDC: In choosing a method of contraception, the risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), also must be considered. Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STIs. Consistent and correct use of the male latex condom reduces the risk for STIs. When a male condom cannot be Women who use contraceptive methods other than condoms should be counseled about the use of condoms and the risk for STIs. (Strong) 62 used properly for infection prevention, a female condom should be considered. (CDC STD Treatment Guidelines (2006), MMWR, (55-R11), 1-94. (http://www.cdc.gov/std/treatme nt; CDC, (2009.Contraceptive use among postpartum women – 12 states and New York City, MMWR, 58, 821-826; CDC, 2011. Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR, 60(26, 878-883; CDC/OPA ( In press. Due to be published in MMWR Feb. 2014). Recommendations for Quality Family Planning Services). CDC: Unintended pregnancy and short interpregnancy birth spacing contribute to poor maternal and newborn outcomes. Initiation of contraception during the postpartum period is important to prevent unintended pregnancy and short birth intervals, which can lead to negative health outcomes for mother and infant. Venous thromboembolism risk should be Evidence-based guidance should be used in contraceptive counseling and prescribing during the immediate postpartum period. (Qualified) 63 assessed when recommending and prescribing contraception during the immediate postpartum period. (CDC, 2009. Contraceptive use among postpartum women – 12 states and New York City, MMWR, 58, 821-826.; CDC. (2011). Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR, 60(26, 878-883; CDC/OPA ( In press. Due to be published in MMWR Feb. 2014). Recommendations for Quality Family Planning Services) USPSTF: Recommends highintensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs. (http://www.uspreventiveservices taskforce.org/uspstf08/sti/stirs.pd f) CDC: Health care providers should routinely and regularly obtain sexual histories from their patients and address management of risk reduction for STIs. (Sexually transmitted diseases treatment guidelines, A sexual history and risk assessment for STD exposure should be incorporated into each well-woman visit. Screening should be instituted according to the CDC STD Treatment Guidelines. (Qualified) 64 2010; Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2010 Dec 17;59(RR12):1-110. Erratum in: MMWR Recomm Rep. 2011 Jan 14;60(1):18; http://www.cdc.gov/ StD/treatment/2010/default.htm) USPSTF: Recommends screening for chlamydial infection for all sexually active, nonpregnant young women aged 24 and younger and for older nonpregnant women who are at increased risk ( http://www.uspreventiveservices taskforce.org/uspstf07/chlamydia /chlamydiars; grade A recommendation; USPSTF. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendations statement. Ann Intern Med 2007; 147:128-34.) 65 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Dyslipidemia/Cardiovascular Disease* Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (18–44) See also Blood Pressure Screening; Genetic Screening (Other than BRCA); Diet, Fitness, and Nutrition; Obesity; Preconception Care; Tobacco Use Evidence-Based USPSTF: Recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (Grade D Recommendation, Ann Intern Med. 2007 Dec 18;147(12):854-9. Screening for carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf07 Evidence-Informed Uniform Final WWTF Expert Recommendation Agreement AAP: Recommends dyslipidemia screening once Dyslipidemia between ages 18 and 21 years. screening is (http://www.aap.org/en-us/professionalrecommended onc resources/practicebetween ages 18 and 21 years. support/Periodicity/Periodicity%20Schedule_FINAL.pdf) (Qualified) Screening for asymptomatic carotid artery stenosis in the general adult population is not recommended. (Strong) 66 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid /cas/casrs.pdf) USPSTF: Recommends against screening with resting or exercise electrocardiography for the prediction of coronary heart disease events in asymptomatic adults at low risk for CHD events. (Grade D Recommendation, Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Moyer VA; U.S. Preventive Services Task Force. Ann Intern Med. 2012 Oct 2;157(7):512-8. http://www.uspreventiveservicestaskforce.org/uspstf11 /coronarydis/chdfinalrs.pdf) USPSTF: Recommends against routine screening for abdominal aortic aneurysm in women. (Grade D Recommendation, http://www.uspreventiveservicestaskforce.org/ uspstf05/aaascr/aaars.pdf) USPSTF: Recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease. (Grade D Recommendation, Ann Intern Med. 2014 Feb 25. doi: 10.7326/M14-0198. [Epub ahead of print] Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of Cardiovascular Disease and Cancer: U.S. Preventive Services Task Force Recommendation Statement. Moyer VA. http://www.uspreventiveservicestaskforce.org/uspstf14 /vitasupp/vitasuppfinalrs.pdf) Screening with resting or exercise electrocardiograph for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events is not recommended (Strong) Routine screening for abdominal aortic aneurysm in women is not recommended. (Strong) The use of betacarotene supplements, eithe alone or in combination, for the prevention of cancer or cardiovascular disease is not recommended. (Strong) 67 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid *Note: The USPSTF make no recommendations to screen adolescents for hypertension or dyslipidemia. It finds insufficient evidence to make a recommendation. Adults (20-54) See also Blood Pressure Screening; Diet, Fitness, and Nutrition; Obesity; Preconception Care; Tobacco Use Evidence-Based USPSTF: Recommends screening women ages 20–45 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B Recommendation, http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm) EvidenceInformed USPSTF: Recommends against the use of aspirin for stroke prevention in women younger than age 55 years. (Grade D Recommendation, Ann Intern Med. 2009 Mar 17;150(6):396-404. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.pdf) Uniform Expert Agreement Final WWTF Recommendation Screening for lipid disorders in women ages 20–45 who are at increased risk for coronary heart disease is recommended. (Strong) The use of aspirin for stroke prevention in women younger than age 55 years is not recommended. (Strong) Adults (45 and older) See also Blood Pressure Screening; Diet, Fitness, and Nutrition; Obesity; Tobacco Use Evidence-Based EvidenceInformed Uniform Final WWTF Recommendation Expert Agreement 68 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (Grade A Recommendation, http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm) USPSTF: Recommends the use of aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic stroke outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Grade A Recommendation, Ann Intern Med. 2009 Mar 17;150(6):396-404. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. US Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.pdf) Screening for lipid disorders in women ages 45 years and older who are at increased risk for coronary heart disease is recommended. (Strong) The use of aspirin is recommended for women ages 55 to 79 years when the potential benefit of a reduction in ischemic stroke outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Strong) 69 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Depression Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment; Preconception/Interconception Care Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: Recommends screening adolescents (12–18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal), and follow-up. (Screening and Treatment for Major Depressive Disorder in Children and Adolescents [Grade B]) AAP: Primary care clinicians should assess for depression in adolescents at high risk and those presenting with emotional problems. (Performing Preventive Services: A Bright Futures Handbook) Patients should not be denied recommended screening because of any limitation of local resources. Rather, providers should have plans for referral, even if it means the patient will have to travel outside her community. Providers are encouraged to develop initial management skills that are within the scope of their specialty and practice to meet local patient needs. Patients should be counseled about limitations in local resources at the time of testing. Annual screening of adolescents for depressive disorders, using a validated tool, is recommended. (Qualified) AMA: Screen adolescents who may be at risk as a result of family problems, drug or alcohol use, or other indicators of risk. (Guidelines for Adolescent Preventive Services (GAPS): Screening postpartum adolescents for depression, using a validated tool, is recommended. (Qualified) 70 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Recommendations Monograph. American Medical Association. Chicago: American Medical Assoc; 1997; cited in USPSTF 2002 recommendations for screening for depression, http://annals.org/ article.aspx?articleid=715291# r13-12; also cited in 2009 update of USPSTF recommendations but the AMA source is not provided.) AAP: Ask questions about depression in routine historytaking throughout adolescence. Patients with depression risk factors should be identified and systematically monitored over time for the development of a depressive disorder. (Guidelines for Adolescent Depression in Primary Care I.) AAFP: Screen for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal), and follow-up. (AAFP, Depression) 71 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid AWHONN: Health care facilities that serve pregnant women, new mothers and newborns should have routine screening protocols and educational mechanisms for staff training and education related to postpartum mood and anxiety disorders. (The Role of the Nurse in Postpartum Mood and Anxiety Disorders) ACOG: Recommends asking annually about emotions and behaviors that indicate recurrent or severe depression and thoughts of killing or harming themselves. (GAHC p. 37) ACOG: Recommends screening in practices that have systems in place to ensure accurate diagnosis, treatment, and follow up. (GWHC 2014, Chapter 3Z) ACNM: Recommends universal screening, treatment and/or referral for depression as part of routine primary 72 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid health care. Recommends increasing the number of postpartum visits for all women. (ACNM Position Statement: Depression in Women) Adults (19 and older) See also Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment; Preconception/Interconception Care; Sleep Disorders Evidence-Based Evidence-Informed Uniform Expert Agreement USPSTF: Recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. (Screening for Depression in Adults [Grade C]) AWHONN: Health care facilities that serve pregnant women, new mothers and newborns should have routine screening protocols and educational mechanisms for staff training and client education related to postpartum mood and anxiety disorders. (The Role of the Nurse in Postpartum Mood and Anxiety Disorders) Patients should not be denied recommended screening because of any limitation of local resources. Rather, providers should have plans for referral, even if it means the patient will have to travel outside her community. Providers are encouraged to develop initial management skills that are within the scope of their specialty and practice to meet local patient needs. Patients should be counseled about limitations in local resources at the time of testing. USPSTF: Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (eg, panic disorder or generalized anxiety), substance abuse, or chronic pain. Recommends AAFP: Do not screen when staff-assisted depression care supports are not in place. (AAFP, Depression) Final WWTF Recommendation Annual screening for depression, using a validated tool, is recommended. (Qualified) Screening postpartum women for depression, using a validated tool, is recommended. (Qualified) 73 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (Screening for Depression in Adults [Grade B]) AAFP: Screen when staffassisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (AAFP, Depression) ACOG: Evaluate and counsel women for suicide and depressive symptoms. (Annual Women's Health Care) ACOG: Recommends screening in practices that have systems in place to ensure accurate diagnosis, treatment, and follow up. (GWHC 2014, Chapter 3Z) ACNM: Recommends universal screening, treatment and/or referral for depression as part of routine primary health care. Recommends increasing the number of postpartum visits for all women. (ACNM Position Statement: Depression in Women) PCHHC: Providers should screen and be vigilant for depression and anxiety 74 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid disorders among women of reproductive age because treating or controlling these conditions before pregnancy may help prevent negative pregnancy and family outcomes. Women of reproductive age with depressive and anxiety disorders who are planning a pregnancy or who could become pregnant should be informed about the potential risks of an untreated illness during pregnancy and about the risks and benefits of various treatments during pregnancy. (The Clinical Content of Preconception Care [B III]) 75 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Diabetes Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Cardiovascular Disease; Diabetes Postpartum; Diet, Fitness, and Nutrition; Obesity Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation There is no recommendation for routine screening in asymptomatic adolescents. Routine screening for diabetes in adolescents is not recommended except for those who are obese (ie, BMI of 30 or higher). (Qualified) Adults (Women of Reproductive Age; Perimenopause/Menopause]) See also Cardiovascular Disease; Diabetes Postpartum; Diet, Fitness, and Nutrition; Obesity Evidence-Based Evidence-Informed Uniform Final WWTF Expert Recommendation Agreement 76 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Screen for diabetes in adults with blood pressure over 130/85 mm Hg. (Ann Intern Med. 2008 Jun 3;148(11):846-54. Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/ uspstf08/type2/type2rs.pdf) AAFP: Screen asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.. (http://www.aafp.org/dam/AAFP/documents/patient_care/ clinical_recommendations/October2012SCPS.pdf) ACOG: Begin screening every 3 years beginning at age 45, more frequently if risk factors are present. (http://www.acog.org/About_ACOG/ACOG_Departments/ Annual_Womens_Health_Care/Assessments_and_Recommendations) Currently there is no expert consensus. Screening for diabetes is recommended every 3 years beginning age 45 or earlier for those with risk factors for diabetes. (Strong) American Diabetes Association: Begin screening every 3 years beginning at age 45, more frequently if risk factors are present. (Executive summary: Standards of medical care in diabetes--2013. Diabetes Care. 2013 Jan;36 Suppl 1:S4-10. doi: 10.2337/dc13-S004. http://care.diabetesjournals.org/content/36/Supplement_1/S4.full) AACE: Begin screening at age 30. (http://outpatient.aace.com/prediabetes/screening-and-monitoringprediabetes) 77 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Diabetes Postpartum Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone All Women of Reproductive Capacity See also Diabetes Evidence-Based Evidence-Informed ACOG: Recommends screening 6–12 weeks postpartum, then every 3 years. (Gestational diabetes mellitus. Practice Bulletin No. 137. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 122:406–16.) American Diabetes Association: Recommends screening 6–12 weeks postpartum, then every 3 years. (Executive summary: Standards of medical care in diabetes--2013. Diabetes Care. 2013 Jan;36 Suppl 1:S4-10. doi: 10.2337/dc13-S004. http://care.diabetesjournals.org/content/36/Supplement_1/S4.full) Uniform Expert Agreement Final WWTF Recommendation Laboratory screening for diabetes is recommended at 6–12 weeks postpartum. For patients with a history of gestational diabetes, follow-up screening at least every 3 years is recommended. (Strong) 78 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Diet, Fitness, Nutrition Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents and Adults (All ages) See also Cardiovascular Disease, Obesity, Preconception/Interconception Care Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. All adult patients should be screened for obesity and offered intensive counseling and behavioral interventions. (http://www.uspreventiveservices taskforce.org/3rduspstf/diet/dietr r.pdf, Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. U.S. Preventive Services Task Force et al. Am Fam Physician. (2003) ACOG: Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and dietrelated chronic disease. All adult patients should be screened for obesity and offered intensive counseling and behavioral interventions. Also recommends evaluation and counseling on physical activity. (http://www.acog.org/About_ ACOG/ACOG_Departments/ Annual_Womens_Health_Car All agree that diet, nutrition, exercise are keys to good health and improved health and can prevent illness. However, the science on how this is best accomplished is debatable. Routine weight assessment using BMI calculation is recommended. For women with risk factors for dietrelated chronic disease, BMI <19, or BMI >25, assessment of diet, nutritional status, and physical activity, followed by intensive counseling and behavioral interventions, is recommended. (Qualified) 79 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid e/Assessments_and_Recomm endations) American Dietetic Association: Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and dietrelated chronic disease. All adult patients should be screened for obesity and offered intensive counseling and behavioral interventions. Also recommends evaluation and counseling on physical activity. (Maillet JO, Young EA. Nutrition education for healthcare professionals: Position of the ADA. J Am Diet Assoc 1998;98:343-346.) AAP Bright Futures: Recommends assessing BMI annually. (http://www.aap.org/enus/professionalresources/practicesupport/Periodicity/Periodicit y%20Schedule_FINAL.pdf) 80 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Domestic and Intimate Partner Violence Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment (0-18 years). (Primary Care Interventions to Prevent Child Maltreatment [I statement]) AAP: Consider screening adolescents if they say they have a new intimate partner, when signs or symptoms raise concerns, or during any prenatal visits. (Performing Preventive Services: A Bright Futures Handbook.) USPSTF: Recommends that clinicians screen women of childbearing age for intimate partner violence such as domestic violence and provide or refer women who screen positive to intervention services. (Screening for Intimate Partner Violence and ACOG: Screen periodically in all women (eg, annual visit, new patient, and postpartum visit) and in women at risk (signs of depression, substance abuse, mental health problems, requests for repeat pregnancy tests when AAP: Screen for intimate partner violence and sexual coercion at least annually and with each new partner (if a patient has multiple repeat visits for pregnancy testing, STI testing, etc, consider these as clinical indictors to assess more frequently). (Performing Preventive Services: A Bright Futures Handbook.) Adolescents (13-18) See also Preconception Care Screening is recommended at least annually for intimate partner violence, such as domestic violence or reproductive or sexual coercion. Provide or refer women who screen positive to intervention services. (Strong) ACOG/FWV: Signs or symptoms of abuse or neglect should prompt risk assessment. Evidence of neglect or abuse must be reported to law 81 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Abuse of Elderly and Vulnerable Adults [Grade B]) woman does not wish to be pregnant, new or recurrent STDs or requesting STD test, expressing fear when negotiating condom use). (CO 518) enforcement agencies as required by state or federal laws and regulations. (Futures Without Violence) Evidence-Based Evidence-Informed Uniform Expert Agreement IOM: Screening and counseling involve elicitation of information from women and adolescents about 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. (Clinical Preventive Services for Women: Closing the Gaps) ACOG: Screen periodically in all women (eg, annual visit, new patient, and postpartum visit) and in women at risk (signs of depression, substance abuse, mental health problems, requests for repeat pregnancy tests when woman does not wish to be pregnant, new or recurrent STDs or requesting STD test, AAP: Screen for intimate partner violence and sexual coercion at least annually and with each new partner (if a patient has multiple repeat visits for pregnancy testing, STI testing, etc, consider these as clinical indictors to assess more frequently). (Performing Preventive Services: A Bright Futures Handbook.) IOM: Screening and counseling involve elicitation of information from women and adolescents about 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. (Clinical Preventive Services for Women: Closing the Gaps) Adults (All ages) See also Preconception Care Final WWTF Recommendation Screening is recommended at least annually for intimate partner violence, such as domestic violence or reproductive or sexual coercion. Provide or refer women who screen positive to intervention services. (Recommended) 82 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends that clinicians screen women of childbearing age for intimate partner violence such as domestic violence, and provide or refer women who screen positive to intervention services. (Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults; grade B) USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect. (Screening for Intimate Partner Violence and Abuse in Elderly and Vulnerable Adults; grade I) expressing fear when negotiating condom use). (CO 518 ) AAFP: Screen women of childbearing age for intimate partner violence and provide or refer women who screen positive to intervention services; this applies to women who do not have signs or symptoms of abuse. (Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults; grade B) ACOG/FWV: Signs or symptoms of abuse or neglect should prompt risk assessment. Evidence of neglect or abuse must be reported to law enforcement agencies as required by state or federal laws and regulations. (Futures Without Violence) AAFP: There is insufficient evidences to asses the benefits and harms of screening elderly and vulnerable adults for abuse and neglect. (Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults; grade I) 83 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Drug Use Evidence Based Evidence Informed Uniform Expert Agreement Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Additional guidelines from medical societies used for developing consensus recommendations. WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Preconception Care Evidence-Based USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. (Screening for Illicit Drug Use (I statement) ACOG: Recommends annual screening by questionnaire/history (not testing) for illicit drugs, prescription and nonprescription medications, and performanceenhancing drugs. (ACOG Guidelines for Adolescent Health Care) ACOG: Evaluate and counsel on substance use other than alcohol and tobacco. (GAHC p. 104) Final WWTF Recommendation AHRQ: Screen by history for substance use at every health maintenance exam or initial pregnancy visit (repeat as indicated), using a validated screening tool (improves accuracy of detecting substance abuse or dependence). (Screening, diagnosis and referral for substance use disorders. Grade D) At least annual screening for substance abuse by history (not lab testing) is recommended. Provide or refer patients to counseling as needed. (Strong) NCQA: HEDIS discusses engagement in treatment and 84 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid AAP: Evaluation and counseling/screening are part of an age-appropriate comprehensive history. Recommends annual screening for alcohol, tobacco, and substance abuse. Strongly advise against the use of alcohol, tobacco, and other illicit drugs by youth. (Performing Preventive Services: A Bright Futures Handbook) referral for smoking cessation/alcohol and marijuana dependence. (Summary Table Of Measures, Product Lines And Changes) PCHHC: A careful history should be obtained to identify use of illegal substances as part of the preconception risk assessment. Men and women should be counseled about the risks of using illicit drugs before and during pregnancy and offered information on programs that support abstinence and rehabilitation. Contraception services should be offered, and pregnancy should be delayed until individuals are drug-free. (The Clinical Content of Preconception Care [C III]) AAFP: Current evidence is insufficient to assess the balance of benefits and harms of 85 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid screening adolescents, adults, and pregnant women for illicit drug use. (Illicit Drug Use (Grade I) NAHIC: Recommends annual screening and counseling for substance abuse. (Summary of Recommended Guidelines for Clinical Preventive Services) Adults (All ages) See also Preconception Care Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. (Screening for Illicit Drug Use (I statement) ACOG: Evaluate and counsel on substance use other than alcohol and tobacco. (Annual Women's Health Care) AHRQ: Screen by history for substance use at every health maintenance exam or initial pregnancy visit (repeat as indicated), using a validated screening tool (improves accuracy of detecting substance abuse or dependence). (Screening, diagnosis and referral for substance use disorders, Grade D.) At least annual screening for substance abuse by history (not lab testing) is recommended. Provide or refer patients to counseling as needed. (Strong) PCHHC: A careful history should be obtained to identify use of illegal substances as part of the preconception risk assessment. Men and women should be counseled about the risks of using illicit drugs before and during pregnancy and offered information on programs that support abstinence and rehabilitation. Contraception services should NCQA: HEDIS discusses engagement in treatment and referral for smoking cessation/alcohol and marijuana dependence. (Summary Table Of 86 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid be offered, and pregnancy should be delayed until individuals are drug-free. (The Clinical Content of Preconception Care (C III) Measures, Product Lines And Changes) AAFP: Current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. (Illicit Drug Use (Grade I) NAHIC: Recommends annual screening and counseling for substance abuse. (Summary of Recommended Guidelines for Clinical Preventive Services) 87 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Genetic Screening Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) EvidenceBased (source) Evidence-Informed (source) ACOG: If medical or psychosocial benefits of a genetic test will not accrue until adulthood, as in the case of carrier status or adult-onset diseases, genetic testing generally should be deferred. (Hereditary breast and ovarian cancer syndrome. ACOG Practice Bulletin No. 103. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:957–66. http://www.acog.org/Resources_And_Pu blications/Practice_Bulletins/Committee_ on_Practice_Bulletins_-_Gynecology/Hereditary_Breast_and_Ov arian_Cancer_Syndrome) Uniform Expert Agreement Final WWTF Recommendation For adolescents, if medical or psychosocial benefits of a genetic test will not accrue until adulthood (eg, for carrier status or adult-onset diseases), testing generally should be deferred until adulthood or until the adolescent has developed mature decision-making capacities. (Qualified) AAP/ACMGG: Genetic testing for adultonset conditions generally should be 88 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid deferred until adulthood or until an adolescent interested in testing has developed mature decision-making capacities. It is inappropriate to test for late-onset disorders when genetic information has not been shown to reduce morbidity and mortality through interventions initiated in childhood. Routine carrier testing in minors is not supported when such testing does not provide health benefits in childhood. (Ethical and Policy Issues in Genetic Testing and Screening of Children http://pediatrics.aappublications.org/con tent/131/3/620.full.html) Adults (All ages) See also Dyslipidemia/Cardiovascular Disease, Ovarian Cancer Evidence-Based (source) Evidence-Informed BRCA Screening ACOG: Recommends that all women receive a family history evaluation as a screening tool for inherited risk. Family history information should be reviewed and updated regularly, especially when there are significant changes to family history. Where appropriate, further evaluation should be considered for positive USPSTF: Recommends that women who have family members with breast, ovarian, tubal, or peritoneal cancers be screened with one of several screening tools designed to identify increased risk for potentially harmful mutations in BRCA1 or BRCA2 genes. Women with positive screening results should receive genetic counseling and, if indicated, BRCA testing. (2013, http://www.uspreventiveservicestaskforce.org/uspstf Uniform Expert Agreement Final WWTF Recommendation Genetic screening for BRCA1 or BRCA2 is recommended for women whose personal or family history is associated with an increased risk for potentially harmful mutations in BRCA1 or BRCA2 genes. Women with positive screening 89 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid /uspsbrgen.htm; grade B recommendation) responses, with referral to genetic testing and counseling as needed. (Family history as a risk assessment tool. Committee Opinion No. 478. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:747–50.) results should receive genetic counseling and, if indicated after counseling, BRCA testing. (Strong) AAFP: Recommends referral for genetic counseling and evaluation for BRCA testing for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2. (http://www.aafp.org/patientcare/clinicalrecommendations/all/breastcancer.html) ACOG: Genetic risk assessment is recommended for women with greater than an approximate 2025% chance of having an inherited predisposition to breast cancer and ovarian cancer. Genetic risk assessment may be helpful for women with greater than an approximate 5-10% chance of having an inherited predisposition to breast and ovarian cancer. (Hereditary breast and ovarian cancer 90 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid syndrome. ACOG Practice Bulletin No. 103. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:957–66. http://www.acog.org/Resources_ And_Publications/Practice_Bullet ins/Committee_on_Practice_Bull etins_-_Gynecology/Hereditary_Breast_ and_Ovarian_Cancer_Syndrome) USPSTF: Recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2). (2013, http://www.uspreventiveservicestaskforce.org/uspstf/uspsb rgen.htm; grade D recommendation) AAFP: Recommends against routine referral for genetic counseling for BRCA testing for women whose family history is not associated with increased risk for deleterious mutation in BRCA1 or BRCA2. (http://www.aafp.org/patientcare/clinicalrecommendations/all/breastcancer.html) Genetic Screening for Cardiovascular Disease AAFP: Recommends against genomics profile to assess risk for CVD. (http://www.aafp.org/patientcare/clinicalrecommendations/all/cvd.html) EGAPP: There is insufficient evidence to recommend testing for the 9p21 genetic variant or 57 Routine genetic counseling or BRCA testing is not recommended for women who do not have a personal or family history associated with an increased risk for potentially harmful mutations in BRCA1 or BRCA2 genes. (Strong) Recommend against genomics profile to asses risk for CVD, as current evidence finds the net health benefit to be negligible. Testing for genetic variants to assess for risk of cardiovascular disease in the general population is not recommended. (Strong) 91 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid other variants in 28 genes to assess risk for cardiovascular disease (CVD) in the general population, specifically heart disease and stroke. The magnitude of net health benefit from use of any of these tests alone or in combination is negligible. Clinical use is discouraged unless further evidence supports improved clinical outcomes. Based on the available evidence, the overall certainty of net health benefit is deemed “low.” (Recommendations from the Evaluation of Genomic Applications in Practice and Prevention Working Group: Genomic profiling to assess cardiovascular risk to improve cardiovascular health Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group* Genetics IN Medicine • Volume 12, Number 12, December 2010) 92 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Hearing Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (All ages) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation USPSTF: There is insufficient evidence to assess the benefits or harms of screening for hearing loss in asymptomatic adults 50 and older (who show no signs or symptoms of hearing loss). (http://www.uspreventiveservicest askforce.org/uspstf11/adulthearin g/adulthearrs.htm) AAFP: There is insufficient Hearing screening in adults who Hearing screening in adults who show no show no signs or symptoms of signs or symptoms of hearing loss is not evidence to assess the benefits or harms of screening hearing loss is not recommended. recommended. (Strong) for hearing loss in asymptomatic adults 50 and older (who show no signs or symptoms of hearing loss). http://www.aafp.org/patientcare/clinicalrecommendations/all/hearing) h l 93 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Hepatitis B Screening Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adolescents and Adults (All ages) See also Immunization Evidence-Based (source) USPSTF: Recommends against routinely screening the general asymptomatic population for chronic hepatitis B virus infection. (2004, http://www.uspreventiveservicest askforce.org/uspstf/uspshepb.htm ; grade D recommendation) Evidence-Informed (source) Routine screening of the general population for chronic hepatitis B infection is not recommended. (Strong) 94 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends ACOG: Recommends routine screening pregnant women for prenatal screening of all hepatitis B infection at their pregnant women by hepatitis B first prenatal visit. (2009, surface antigen (HBsAg) testing. http://www.uspreventiveservic (2007, Practice Bulletin no. 86, estaskforce.org/uspstf/uspshep reaffirmed 2012, bpg.htm; grade A http://www.guideline.gov/cont recommendation) ent.aspx?id=12627; level A recommendation) Screening pregnant women for hepatitis B infection is recommended at the first prenatal visit. (Strong) 95 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Hepatitis C Screening Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents and Adults (All ages) Evidence-Based (source) USPSTF: Recommends screening for hepatitis C virus infection in persons at high risk for infection. Recommends offering one- time screening for HCV infection to adults born between 1945 and 1965. (2013, http://www.uspreventiveservicest askforce.org/uspstf12/hepc/hepcfi nalrs.htm; grade B recommendation) Evidence-Informed (source) AAFP: Recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. Recommends offering one-time screening for HCV infection to adults born between 1945 and 1965. (2013, http://www.aafp.org/patien t-care/clinicalrecommendations/all/hepat itis.html) Uniform Expert Agreement Final WWTF Recommendation Screening for hepatitis C virus is recommended for women at high risk for infection. (Strong) One-time screening for HCV infection should be offered to women born between 1945 and 1965. (Strong) ACOG: Recommends onetime testing for persons born from 1945 through 1965 and unaware of 96 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid their infection status. (http://www.acog.org/Ab out_ACOG/ACOG_Depart ments/Annual_Womens_ Health_Care/Assessment s_and_Recommendation s) CDC: Adults born during 1945 through 1965 should be tested once for hepatitis C virus (HCV) infection without prior ascertainment of HCV risk factors. Recommends routine testing of asymptomatic persons at high risk for HCV infection (see risk factors in: Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease; MMWR 1998;47(RR-19)). (Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965 (MMWR 2012;61(RR04);118; http://www.cdc.gov/hep atitis/HCV/GuidelinesC.htm) PCHHC: Recommends 97 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid screening for high-risk women. Women who are positive for hepatitis C and desire pregnancy should be counseled regarding the uncertain infectivity, the link between viral load and neonatal transmission, the importance of avoiding hepatotoxic drugs, and the risk of chronic liver disease. (Floyd RL, Johnson KA, Owens JR, Verbiest S, Moore CA, Boyle C. A national action plan for promoting preconception health and health care in the United States (2012-2014). J Womens Health (Larchmt). 2013 Oct;22(10):797-802.) 98 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Hypothyroidism Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone USPSTF: There is fair evidence that the thyroid-stimulating hormone (TSH) test can detect subclinical thyroid disease in people without symptoms of thyroid dysfunction but poor evidence that treatment improves clinically important outcomes in adults with screendetected thyroid disease. The evidence is insufficient to recommend for or against routine screening for thyroid disease in adults. (http://www.uspreventiveservicesta skforce.org/uspstf/uspsthyr.htm) AAFP: The evidence is insufficient to recommend for or against routine screening for thyroid disease in adults. Ultrasound screening for thyroid cancer in asymptomatic patients is not recommended. (http://www.aafp.org/patien t-care/clinicalrecommendations/all/thyroid .html) There is insufficient evidence for routine screening for hypothyroidism in asymptomatic low-risk women, as available evidence does not show that diagnosis and treatment improves outcome. Routine screening is not recommended for asymptomatic women at low risk. (Strong) ACOG: In women 19 and older, examine thyroid. Thyroid-stimulating hormone (TSH) screening is recommended for women ages 19–49 at high risk (ie, strong family history of thyroid disease, autoimmune disease). TSH screening is 99 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid recommended every 5 years beginning at age 50. (http://www.acog.org/About _ACOG/ACOG_Departments/ Annual_Womens_Health_Car e/Assessments_and_Recom mendations) AACE/ATA: Screening for hypothyroidism should be considered in patients over the age of 60. “Aggressive case finding” (rather than universal screening) should be considered in those at increased risk for hypothyroidism. (http://thyroidguidelines.net /hypothyroidism; Endocr Pract. 2012 NovDec;18(6):988-1028. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Garber JR1, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA; American Association of Clinical Endocrinologists and 100 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid American Thyroid Association Taskforce on Hypothyroidism in Adults.) AACE/ATA: Universal screening is not recommended for patients who are pregnant or are planning pregnancy, including those undergoing assisted reproduction. “Aggressive case finding” (rather than universal screening) should be considered for patients who are planning pregnancy. (http://thyroidguidelines.net /hypothyroidism) AACE/ATA: “Aggressive case finding” (rather than universal screening) should be considered in those at increased risk for hypothyroidism. Screening is suggested for those with the following: -Autoimmune disease, such as type 1 diabetes -Pernicious anemia -A first-degree relative with autoimmune thyroid disease -A history of neck radiation to While there is evidence to suggest that subclinical hypothyroidism in early pregnancy may be associated with impaired intellectual and psychomotor development, a randomized control trial did not demonstrate improvement with levothyroxine supplementation. (Lazarus JH, Bestwick JP, Channon S et al. Antenatal thyroid screening and childhood cognitive function. NEJM 2012;366:493-501) Universal screening is not recommended for patients who are pregnant or are planning pregnancy, including those undergoing assisted reproduction. (Qualified) Screening for hypothyroidism is recommended in symptomatic and highrisk patients. (Strong). 101 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid the thyroid gland, including radioactive iodine therapy for hyperthyroidism and external beam radiotherapy for head and neck malignancies -A prior history of thyroid surgery or dysfunction -An abnormal thyroid examination -Psychiatric disorders -Taking amiodarone or lithium -Additional diagnoses: Adrenal insufficiency Alopecia Anemia, unspecified deficiency Cardiac dysrhythmia, unspecified Changes in skin texture Congestive heart failure Constipation Dementia Diabetes mellitus, type 1 Dysmenorrhea Hypercholesterolemia Hypertension Mixed hyperlipidemia Malaise and fatigue Myopathy, unspecified Prolonged QT interval Vitiligo Weight gain (http://www.thyroidguidelin 102 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid es.net/sites/thyroidguideline s.net/files/file/thy.2012.0205 .pdf) 103 Well-Woman Task Force 2013–2014 Individual Recommendation Evidence Grid Topic: Immunizations Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents and Adults (All Ages) See also Cervical Cancer, Hepatitis B, Preconception/Interconception Care Evidence-Based ACIP: Recommends routine vaccines for children, adolescents, and adults according to its published immunization schedule. (Birth-18 Years & "Catch-up" Immunization Schedules, http://www.cdc.gov/vaccines/schedules/hcp/childadolescent.html; Recommended Adult Immunization Schedule, by Vaccine and Age Group, http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html) Evidence-Informed Uniform Expert Agreement Recommend following ACIP guidelines for all immunizations. Final WWTF Recommendation Immunization is recommended according to the schedule and protocols outlined by the ACIP. (Strong) 104 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Injury Prevention Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Alcohol Misuse, Domestic and Intimate Partner Violence, Drug Use, Tobacco Use Evidence-Based Evidence-Informed USPSTF: There is insufficient evidence to assess the incremental benefit, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting in improving rates of proper use of motor vehicle occupant restraints (child safety seats, booster seats, and lap-andshoulder belts). (http://www.uspreventiveservices taskforce.org/uspstf07/mvoi/mvoi rs.pdf; Ann Intern Med. 2007 Aug 7;147(3):187-93; Counseling AAP: Integrate counseling about preventing unintentional injury into every well-child visit. Adolescent counseling should be part of a broader discussion of healthy lifestyle choices, especially the avoidance of alcohol, tobacco, or other drug use. (http://pediatrics.aappublications.org/content/119/1/20 2.full?sid=ac96961f-52bf-4f1d-9da1-1744e9a2e0f9#sec5) Uniform Expert Agreement Recommend incorporating AAP guideline. Final WWTF Recommendation Discussion of injury prevention is recommended as part of every wellchild visit. Adolescent counseling should be part of a broader discussion of healthy lifestyle choices, especially the avoidance of alcohol, tobacco, or other drug use. (Strong) 105 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid about proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving: U.S. Preventive Services Task Force recommendation statement.) Adults (65 and older) See also Domestic and Intimate Partner Violence Evidence-Based USPSTF: Recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. There is insufficient evidence for or against vision correction, medication discontinuation, protein supplementation, education or counseling, and home hazard modification. (Grade B Recommendation; Ann Intern Med. 2012 Aug 7;157(3):197-204. Prevention of falls in communitydwelling older adults: U.S. Preventive Services Task Force recommendation statement, http://www.uspreventiveservicestaskforce.org/uspstf 11/fallsprevention/fallsprevrs.pdf) USPSTF: Recommends against automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation Recommend following the USPSTF approach and individualizing assessment. Automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older is not Clinicians should recommend exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Strong) 106 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (Grade C Recommendation, Ann Intern Med. 2012 Aug 7;157(3):197-204. Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Moyer VA1; U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf 11/fallsprevention/fallsprevrs.pdf) recommended because the likelihood of benefit is small. Individual factors such as history and circumstances of prior falls and comorbidities should be considered In determining whether this service is appropriate in individual cases (Qualified) 107 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Kidney Disease Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (All ages) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 108 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: There is ACP: Recommends against screening for chronic kidney disease insufficient evidence in asymptomatic adults without risk factors. to assess the balance (http://www.sciencedaily.com/releases/2013/10/13102121170 of benefits and 8.htm) harms of routine screening for chronic ASN: Strongly recommends screening even in the absence of kidney disease in risk factors. asymptomatic adults. (http://www.nephrologynews.com/articles/109817-asn(http://www.uspreve disagrees-with-new-guidelines-says-adults-should-bentiveservicestaskforc screened-for-kidney-disease) e.org/uspstf12/kidne y/ckdfinalrs.htm) NKF: Recommends screening for at-risk individuals 18 years or older (risks include diabetes, hypertension, family history of kidney disease). (https://www.kidney.org/professionals/kdoqi/guidel ines_ckd/p4_class_g3.htm) Recommend against screening for chronic kidney disease in asymptomatic adults without risk factors, based on lack of evidence to assess the balance of benefits and harms. Routine screening for chronic kidney disease in asymptomatic adults is not recommended. (Qualified) The major risk factors include diabetes, hypertension, and cardiovascular disease. The current evidence is insufficient to evaluate the benefits and harms of screening in asymptomatic adults with risk factors. 109 Topic: Mammography Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (All Ages) These mammography guidelines are not intended to apply to women at increased risk of breast cancer, symptomatic women undergoing diagnostic mammography, or women with a history of breast cancer receiving follow-up mammograms. Evidence-Based Evidence-Informed Age < 50 years ACOG: Women aged 40 years and older should have annual mammograms. (http://www.guideline.gov/content.aspx?id=34275) USPSTF: The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (Grade C recommendation; ACP: Breast cancer risk is not evenly distributed in women between the ages of 40 and 49. Thus, the benefits of screening mammography are not uniformly applicable in women in this age group. For women ages 40 to 49, individualized assessment of risk for breast cancer to guide decisions about mammography screening is recommended. Base screening on benefits and harms, women's preference, and risk. (Qaseem A, Snow V, Sherif K et al, Clinical Efficacy Assessment Subcommittee of the American College of Physicians; Screening Mammography Uniform Expert Agreement The WWTF agrees with the USPSTF that “Mammography screening reduces breast cancer mortality for women aged 39-69 years: data are insufficient for older women. Falsepositive mammography and results and additional imaging are common.” (Nelson HD, Tyne K, Final WWTF Recommendation For women aged 40 and older, the decision to start or terminate regular screening mammography should be individualized and should take into account patient context, including an assessment of breast cancer risk, comorbidities, and the patient's values regarding specific 110 Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-37; W237–42.) Ages 50–74 years USPSTF: Recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation; Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-37; W237–42.) for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine. 2007 Apr;146(7):511-515.) AAFP: Mammography before age 50 should be individualized and take into account patient context, including risks, values, and harms. (http://www.aafp.org/patient-care/clinicalrecommendations/all/breast-cancer.html) AWHONN: Supports access for women to screening mammography and other health care services based on an assessment for breast cancer risk. (AWHONN Position statement on breast cancer screening. JOGNN 2010, 39:608-610.) CTFPHC: Current evidence regarding the effectiveness of screening mammography does not suggest the inclusion of the manoeuvre or its exclusion from the periodic health examination of women aged 40-49 years at average risk of breast cancer (grade C recommendation). Upon reaching the age of 40, Canadian women should be informed of the potential benefits and risks of screening mammography and assisted in deciding at what age they wish to initiate the manoeuvre (every 12–18 months). (Ringash J, with the Canadian Task Force on Preventive Health Care. Preventive health care 2001 update: screening mammography among women aged 40-49 years at average risk of breast cancer. CMAJ 2001 ; 164(4): 469) AWHONN: “Risk assessment for breast cancer includes Naik A, et al. Screening for breast cancer: an update for the US preventive services task force. Ann Intern Med 2009;151:727-737. Page 727). Biennial screening achieves most, but not all, of the benefit of annual screening with less harm. “Decisions about the best strategy depend on program and individual objectives and the weight placed on benefits, harms and resource considerations.” (Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. benefits and harms of screening. (Strong) Routine screening mammography should occur by age 50. (Strong) The frequency of routine screening should take into account patient context and should be either annual or biennial. (Qualified) 111 Age > 75 years USPSTF: There is insufficient evidence to assess the additional benefits and harms of screening mammography in women 75 years or older. (Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-37; W237–42.) age; hormonal factors such as early age of menarche, late age of menopause, late age of first pregnancy, nulliparity, and use of hormonal therapies; familial factors including family history of breast cancer and genetic test results for BRCA mutations; and personal factors such as personal history of breast cancer, findings from earlier breast biopsies, and past exposure to chest irradiation. Other associated risk factors include postmenopausal obesity, lack of exercise, and alcohol use.” (AWHONN Position statement on breast cancer screening. JOGNN 2010, 39:608-610. Page 608. From American Cancer Society Breast Cancer Facts and Figures 2009-2010. Atlanta, GA 2009) 2009;151:738-747) ACS: Screening decisions in older women should be individualized by considering the potential benefits and risks of mammography in the context of current health status and estimated life expectancy. As long as a woman is in reasonably good health and would be a candidate for treatment, she should continue to be screened with mammography. (Smith RA, Saslow D, Andrews K, et al. American Cancer Society Guidelines for breast cancer screening: Update 2003 Ca J Clin 2003; 54: 141-169) AAFP: There is insufficient evidence about the benefits and harms of mammography for women over 75. (http://www.aafp.org/patient-care/clinicalrecommendations/all/breast-cancer.html) 112 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Depression, Domestic and Intimate Partner Violence, Preconception/Interconception Care Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation AAP: Recommends annual screening for depression, suicide, and mental health. Surveillance at yearly health supervision visits: continuous monitoring of a child's developmental and behavioral status. May include historytaking and use of structured parent questionnaires. (Performing Preventive Services: A Bright Futures Handbook.) During annual preventive care visits, all adolescents should be screened for any mental health disorder by asking questions (such as those found in Bright Futures, Third Edition) that address depressive symptoms; interpersonal/family relationships; sexual orientation and gender identity; personal goal development; behavioral/learning disorders; emotional, physical, and sexual abuse by family or partner; school experience; peer relationships; acquaintance rape Annual screening of all adolescents for mental health disorders is recommended. (Strong). ACOG: Assess and provide health guidance on 113 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid psychosocial development annually. (GAHC p. 30-31) ACOG: Recommends psychosocial evaluation for suicide: depressive symptoms; interpersonal/family relationships; sexual orientation and gender identity; personal goal development; behavioral/ learning disorders; emotional, physical, and sexual abuse by family or partner; school experience; peer relationships; acquaintance rape prevention, bullying. (Annual Women's Health Care) ACOG: Ask annually about emotions and behaviors that indicate recurrent or severe depression and thoughts of killing or harming themselves. (ACOG, GAHC p. 37) prevention; and bullying. Annual assessment for emotions and behaviors that indicate recurrent or severe depression and thoughts of killing or harming themselves is recommended. (Strong). Adults (19-64) See also Depression, Domestic and Intimate Partner Violence, Preconception/Interconception Care, Sleep Disorders 114 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Evidence-Based Evidence-Informed ACOG: Evaluate psychosocial aspects of health: interpersonal/family relationships, intimate partner violence, work satisfaction, lifestyle/stress, sleep disorders (all women); acquaintance rape prevention (19-39); advance directives (women 40 and older); neglect/abuse; depression. (Annual Women's Health Care) USPSTF: The evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population. (USPSTF, Screening for Suicide Risk (Grade I) AAFP: There is insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in general population. (AAFP, Suicide (Grade I) Uniform Expert Agreement Final WWTF Recommendation Evaluation of psychosocial aspects of health (interpersonal/family relationships, intimate partner violence, work satisfaction, lifestyle/stress, sleep disorders [all women]; acquaintance rape prevention [ages 19-39 years]; advance directives [women 40 years and older]; neglect/abuse; depression) is recommended as part of routine health assessment. (Strong) Routine screening for suicide risk in asymptomatic general populations is not recommended. (Strong) ACOG: Evaluate and counsel women for suicide and depressive symptoms. (ACOG, Annual Women's Health Care) 115 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (65 and older) See also Depression, Domestic and Intimate Partner Violence, Sleep Disorders Evidence-Based Evidence-Informed USPSTF, AHRQ: The evidence is insufficient to recommend for or against routine screening for dementia in older adults. (USPSTF: Screening for Dementia; AHRQ: Screening for Dementia Systematic Evidence Review Number 20) NICE: Primary healthcare staff should consider referring people who show signs of mild cognitive impairment (MCI) for assessment by memory assessment services to aid early identification of dementia, because more than 50% of people with MCI later develop dementia. Mild cognitive impairment is a syndrome defined as cognitive decline greater than expected for an individual’s age and education level, which does not interfere notably with activities of daily living. It is not a diagnosis of dementia of any type, although it may lead to dementia in some cases. (Supporting People With Dementia And Their Careers In Health And Social Care) Uniform Expert Agreement Final WWTF Recommendation Routine screening of asymptomatic adults ages 65 and older for dementia is not recommended. (Strong) Screening adults ages 65 and older for mild cognitive impairment is recommended. Refer those with signs of mild cognitive impairment for memory assessment services to aid in early identification of dementia. (Strong) ACOG: Evaluate psychosocial aspects of health: interpersonal/family relationships, intimate partner violence, Evaluation of psychosocial aspects of health (interpersonal/family relationships, intimate partner 116 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid lifestyle/stress, sleep disorders; advance directive; neglect/abuse, depression, and family relationships. (Annual Women's Health Care) violence, work satisfaction, lifestyle/stress, sleep disorders [all women]; advance directives [women 40 years and older]; neglect/abuse; depression) is recommended as part of routine health assessment. (Strong) 117 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Metabolic Syndrome Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Cardiovascular Disease, Diabetes, Obesity Evidence-Based Evidence-Informed USPSTF: Screen children aged 6 years and older for obesity and offer or refer to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B recommendation; Pediatrics. 2010 Feb;125(2):361-7. doi: 10.1542/peds.2009-2037. Epub 2010 Jan 18. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. US Preventive Services Task Force, Barton M. http://www.uspreventiveservicestas kforce.org/uspstf10/childobes/chobe AAP: Assess BMI and screen for dyslipidemia. Screening for dyslipidemia is recommended once in late adolescence for all patients regardless of risk factors. (http://brightfutures.aap.org/pdfs/Other 3/D.Adol.MST.Adolescence.pdf) Uniform Expert Agreement Screen patients with elevated BMI for dyslipidemia and hyperglycemia. Final WWTF Recommendation Screening for dyslipidemia is recommended once in late adolescence for all patients regardless of risk factors . (Strong) Screening for dyslipidemia and hyperglycemia is recommended for patients with elevated BMI. Provide or refer patients to counseling about appropriate lifestyle modifications and/or medical treatment. (Strong) 118 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid srs.pdf) Adults (19-65) See also Cardiovascular Disease, Diabetes, Obesity Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation CDC: Diagnosis of metabolic syndrome requires at least three of the following traits: 1) Abdominal obesity: waistline >40” for men, >35” for women 2) Triglycerides >150 or on medications to treat 3) HDL cholesterol <40 in men, <50 in women or on medications to treat 4) Blood pressure >130/85 or on medications to treat 5) Fasting glucose >100 or on medications to treat (http://www.cdc.gov/nchs/data/nhsr/nhsr013.pdf) AHA, USPSTF, NIH, ADA: Identify appropriate lifestyle modifications and medications. Screen patients via physical exam and blood work, then help patient identify appropriate lifestyle modifications and/or medical treatment. Screening is recommended for patients with elevated BMI for dyslipidemia and hyperglycemia. Provide or refer patients to counseling about appropriate lifestyle modifications and/or medical treatment. (Strong) 119 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Neural Tube Defects Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone All Women of Reproductive Capacity Evidence-Based Evidence-Informed USPSTF, CDC: Recommend that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid. (USPSTF: Grade A Recommendation; Ann Intern Med. 2009 May 5;150(9):626-31. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. http://www.uspreventiveservicesta skforce.org/uspstf09/folicacid/folicacidrs. pdf; CDC: http://www.cdc.gov/ncbddd/orders/pdfs/ 09_202063-a_nash_neural-tube-bd-guidefinal508.pdf) AAP, AAFP, HMHB, MoD: All women planning or capable of pregnancy should take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid. Increase to 4 mg in patients with prior NTD baby, a history of NTD herself, or taking anticonvulsant medications. (AAP: http://pediatrics.aappublications.org/content/104/ 2/325.full; AAFP: http://www.aafp.org/patientcare/clinical-recommendations/all/neural-tubedefects.html; HMHB: http://www.hmhb.org/press_release/mothersday-call-to-action/; MoD: http://www.marchofdimes.com/baby/neural-tubedefects.aspx#) Uniform Expert Agreement Adopt the evidenceinformed guideline and recommend increased levels for patients at high risk. Final WWTF Recommendation Counsel all women planning or capable of pregnancy to take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid. The recommended dose should be increased to 4 mg per day in those taking anticonvulsant medications or who have a personal history of NTD or who have delivered a baby affected by NTD in an earlier pregnancy. (Strong) 120 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Obesity Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) See also Cardiovascular Disease; Diet, Fitness, and Nutrition; Preconception Care Evidence-Based Evidence-Informed USPSTF: Recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (Grade B recommendation; Pediatrics. 2010 Feb;125(2):361-7. doi: 10.1542/peds.2009-2037. Epub 2010 Jan 18. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. US Preventive Services Task Force, Barton M. http://www.uspreventiveservicestaskforce.org/uspstf10/ childobes/chobesrs.pdf) ACOG: Screen annually for obesity/overweight with BMI for age percentile, ask about body image, eating patterns, activity levels, and sedentary behavior. (GAHC p. 148) Uniform Expert Agreement The USPSTF approach is reasonable. At the very least, BMI should be calculated and some counseling should take place recommending local solutions. Final WWTF Recommendation Routine weight assessment using BMI calculation is recommended. Results should be explained to the patient. For those with BMI greater than 30, provide or refer patients to intensive multicomponent behavioral interventions. (Strong) AAP: For overweight and obese adolescents, choose interventions according to the patient’s age, BMI, weight goals, and health risks. AAP interventions are categorized as 121 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid prevention counseling; Stage 1, Prevention Plus; Stage 2, Structured Weight Management; Stage 3, Comprehensive Multidisciplinary Intervention; and Stage 4, Tertiary Care Intervention. (Recommendations for Prevention of Childhood Obesity; Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity, see Table 8) Adults (All ages) See also Cardiovascular Disease; Diet, Fitness, and Nutrition; Preconception Care Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 122 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (Ann Intern Med. 2012 Sep 4;157(5):373-8. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Moyer VA; U.S. Preventive Services Task Force. Screening for and Management of Obesity in Adults; grade B) AAFP: Refer patients with BMI of 30 or higher to intensive, multicomponent behavioral interventions. (Obesity; grade B) The USPSTF approach is reasonable. At the very least, BMI ACOG: Determine BMI and evaluate and counsel on physical activity, should be calculated dietary/nutrition assessment, and obesity as cardiovascular risk and some counseling factor. should take place (http://www.acog.org/About_ACOG/ACOG_Departments/ Annual_Womens_Health_Care/Assessments_and_Recommendations) recommending local solutions. PCHHC: Calculate BMI at least annually. All women with BMI of 26 or more should be counseled about the risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. These women should be offered specific behavioral strategies to decrease caloric intake and increase physical activity and be encouraged to consider enrolling in structured weight loss programs. (The Clinical Content of Preconception Care; A III) Routine weight assessment using BMI calculation is recommended. Results should be explained to the patient. For those with BMI greater than 30, provide or refer patients to intensive multicomponent behavioral interventions. (Strong) 123 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Oral Cavity Exam Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (All ages) See also Oral Hygiene, Tobacco Use Evidence-Based Evidence-Informed Uniform Expert Agreement USPSTF: There is insufficient evidence to make a recommendation on oral cancer screening. (2013, http://www.uspreventiveservicestask force.org/uspstf13/oralcan/oralcanfin alrec.htm) ACS: Physicians should There is insufficient evidence to recommend a distinct oral examine the mouth and throat during routine cancer- cavity exam. related check-ups. (http://www.cancer.org/acs/ groups/cid/documents/webc ontent/003128-pdf.pdf) Final WWTF Recommendation Examination of the mouth and throat may be performed as part of an assessment of overall health and oral hygiene. (Qualified) American Dental Association: Clinicians should “remain alert” for signs of malignancy when performing routine visual and tactile examination of dental patients. (2013, http://jada.ada.org/content/ 141/5/509.full.pdf+html) 124 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Oral Hygiene Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13–18) See also Oral Cavity Exam, Tobacco Use 125 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Evidence-Based USPSTF: Recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. (Grade B Recommendation; http://ww w.uspreventiveservicestaskfo rce.org/uspstf/uspsdnch.htm) USPSTF: The evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease. (Grade I Statement; http://www.uspr eventiveservicestaskforce.org /uspstf/uspsdnch.htm) Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation Caries risk assessment is not Fluoride AAFP: For children 6 months to 16 years, fluoride supplementation is recommended to prevent dental caries supported by the literature, supplementation in areas with inadequate fluoride in the water supply. should be and no reliable risk (http://www.aafp.org/patient-care/clinicalrecommended for assessment tool exists. recommendations/all/dental-caries.html) adolescents up to age “Oral health risk 16 who live in areas assessment” could ACOG: Counsel on fluoride supplementation and dental with inadequate conceivably include fluoride in water hygiene. asking about smoking supplies. (Strong) (http://www.acog.org/About_ACOG/ACOG_Departmen (oral cancer risk). ts/Annual_Womens_Health_Care/Assessments_and_R ecommendations) AAP: Recommends oral health risk assessment. Dietary counseling for optimal oral health should be an intrinsic component of general health counseling. Administration of all fluoride modalities should be based on individual's caries risk. Supervised use of fluoride toothpaste is recommended for all children with teeth. The application of fluoride varnish by the medical practitioner is appropriate for patients with significant risk of dental caries who are unable to establish a dental home. (Preventive Oral Health Intervention for Pediatricians, http://pediatrics.aappublications.org/conte nt/122/6/1387.full.html) Adults (All ages) See also Oral Cavity Exam, Tobacco Use 126 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Evidence-Based (source) Evidence-Informed ACOG: Counsel on hygiene, including dental hygiene. (http://www.acog.org/About_ACOG/ACOG_Departments /Annual_Womens_Health_Care/Assessments_and_Reco mmendations) Uniform Expert Agreement Final WWTF Recommendation Caries risk assessment is not Oral health risk supported by the literature, assessment and dietary counseling for optimal and no reliable risk assessment tool exists. Oral oral health may be health risk assessment and performed as part of an assessment of overall dietary counseling for optimal oral health may be health and oral hygiene. (Qualified) recommended as part of general health counseling. “Oral health risk assessment” could conceivably include asking about smoking (oral cancer risk). 127 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Osteoporosis Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation 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. (B Recommendation; Screening for Osteoporosis: Recommendation Statement. AHRQ Publication No. 10-05145EF-2, January 2011. http://www.uspreventivese rvicestaskforce.org/uspstf10/oste oporosis/osteors.htm) AAFP: 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. (http://www.aafp.org/patientcare/clinicalrecommendations/all/osteopo rosis.html) Adults (65 and older) Screening for osteoporosis in women aged 65 years or older is recommended. (Strong) ACOG: Bone density screening for women should begin at age 65 years. Dual-energy Xray absorptiometry screening can be used selectively for 128 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid women younger than 65 years if they are postmenopausal and have other significant risk factors for osteoporosis or fracture. (Osteoporosis. Practice Bulletin No. 129. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:718–34. http://www.acog.org/Resourc es_And_Publications/Practice _Bulletins/Committee_on_Pra ctice_Bulletins_-_Gynecology/Osteoporosis ) ACP: Follow USPSTF guidelines. (http://www.acponline.org/cli nical_information/guidelines/ guidelines/) 129 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Ovarian Cancer Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (Women of Reproductive Age; Perimenopause/Menopause) See also Genetic Screening Evidence-Based Evidence-Informed Women at Low Risk AAFP: The USPSTF recommends against routine screening for ovarian cancer. (http://www.aafp.org/afp/20 05/0215/p759.html) USPSTF: Screening for ovarian cancer is not recommended in women without known genetic mutations that increase the risk of ovarian cancer. There is at least moderate certainty that the harms of screening for ovarian cancer outweigh the benefits. (http://www.uspreventiveservicest askforce.org/uspstf/uspsovar.htm) Uniform Expert Agreement Final WWTF Recommendation Screening for ovarian cancer is not recommended for women at low risk. (Strong) ACOG: Because of the low prevalence of epithelial ovarian cancer, reported to be approximately one case per 2,500 women per year, it has been estimated that a test with even 100% sensitivity and 99% specificity would have a positive predictive value of only 4.8%, which means 20 of 21 130 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Women at High Risk women undergoing surgery would not have primary ovarian cancer. There is currently no effective strategy for ovarian cancer screening. (http://www.acog.org/Resou rces_And_Publications/Com mittee_Opinions/Committee _on_Gynecologic_Practice/T he_Role_of_the_Obstetrician _Gynecologist_in_the_Early_ Detection_of_Epithelial_Ovar ian_Cancer) ACOG: Women with BRCA1 or BRCA2 mutations should be offered risk-reducing salpingo-oophorectomy by age 40 years or after the conclusion of childbearing. It is reasonable to offer women with HNPCC risk-reducing hysterectomy and bilateral salpingo-oophorectomy between ages 35 and 40 if childbearing is no longer desired. (http://www.acog.org/Resou rces_And_Publications/Practi ce_Bulletins/Committee_on_ Practice_Bulletins_-_Gynecology/Hereditary_Bre ast_and_Ovarian_Cancer_Sy ndrome) Women with BRCA1 or BRCA2 mutations or HNPCC should be offered risk-reducing surgery (Strong). Women with hereditary ovarian cancer syndromes who choose not to have riskreducing surgery may be offered surveillance with a combination of transvaginal ultrasonography and CA-125. (Qualified) 131 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid NCCN: For those patients who elect not to have riskreducing salpingooophorectomy, consider concurrent transvaginal ultrasound (preferably day 110 of menstrual cycle in premenopausal women) plus CA-125 testing (preferably after day 5 of menstrual cycle in premenopausal women). Note: There are data that show that annual transvaginal ultrasound and CA-125 are not effective strategies for screening for ovarian cancer in high-risk women. There are limited data regarding the effectiveness of a 6-month screening interval. Thus, until such data are available it is reasonable to consider this approach in high-risk women, especially in the context of a clinical research setting. (NCCN Guidelines Version 4.2013 Hereditary breast and/or ovarian cancer syndrome) 132 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Pelvic Examination Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adolescents (13-20) Evidence-Based Evidence-Informed 133 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid ACOG: Recommends pelvic examinations be performed only when indicated by the medical history for patients younger than 21 years. An “externalonly” genital examination can provide the health care provider with the opportunity to evaluate the patient for normal external genital anatomy; issues of personal hygiene; and abnormalities of the vulva, introitus, and perineum that might require further investigation. (http://www.acog.org/Resource s_And_Publications/Committee _Opinions/Committee_on_Gyne cologic_Practice/WellWoman_Visit) Internal and speculum examinations should be reserved for symptomatic patients or those with specific indications (eg, IUD placement) and need not be part of the well visit in this age group. (Qualified) An external examination is an appropriate component of the well visit in this age group at some point in the adolescent’s development. (Qualified) AAP: Examination of the external genitalia should be included as part of the annual comprehensive physical examination of children and adolescents of all ages. Routinely explaining and including this examination normalizes the experience rather than setting it apart as something that is only performed as an exception. Most adolescents do not need 134 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid an internal examination involving a speculum or bimanual examination. More extensive examination, which may include internal or speculum examination, is appropriate in the primary care setting for patients with persistent vaginal discharge, dysuria or urinary tract symptoms in a sexually active female, dysmenorrhea unresponsive to NSAIDs, amenorrhea, abnormal vaginal bleeding, lower abdominal pain, suspected/reported rape or sexual abuse, or pregnancy. It is also appropriate as part of contraceptive counseling about use of an intrauterine device or diaphragm and in conjunction with a Pap test. (http://pediatrics.aappublication s.org/content/126/3/583.full) Adults (21 and older) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation ACOG: Recommends pelvic examination be performed on an annual basis in all patients aged 21 years and older. The decision whether to perform a Speculum and/or bimanual exam is recommended for symptomatic patients and asymptomatic patients with specific indications (eg, IUD placement and cervical cancer screening). External examinations 135 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her health care provider. may be performed annually in healthy patients. Inclusion of speculum and/or bimanual exam in other well women should be a shared decision between patient and provider. (Qualified) The decision to receive an internal examination can be left to the patient if she is asymptomatic and has undergone a total hysterectomy and bilateral salpingo– oophorectomy for benign indications and has no history of vulvar intraepithelial neoplasia, cervical intraepithelial neoplasia 2 or 3, or cancer; is not HIVinfected; is not immunocompromised; and was not exposed to diethylstilbestrol in utero. Annual examination of the external genitalia should continue. Also, it is reasonable to stop performing pelvic examinations when a woman’s age or other health issues reach a point where the woman would not choose to intervene on conditions detected during the routine examination, particularly if she is discontinuing her other routine health care maintenance 136 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid assessments. (http://www.acog.org/Resource s_And_Publications/Committee _Opinions/Committee_on_Gyne cologic_Practice/WellWoman_Visit) 137 Well Woman Task Force 2013-2014 Model: Recommendation Evidence Grid Topic: Pelvic Floor Disorders Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (50 and older) Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation CDC: Health care providers should routinely ask patients 65 and older about urinary incontinence. (http://www.cdc.gov /mmwr/preview/mm wrhtml/00039261.ht m) WHO: All women age 50 and older should be screened for urinary incontinence. (2008, AgeFriendly Primary Health Care Centres Toolkit, WHO Press: Geneva, Switzerland) Branch et al: Health care providers should routinely ask patients 65 and older about urinary incontinence. (Knowledge, Attitudes, and Practices of Physicians Regarding Urinary Incontinence in Persons Aged greater than or equal to 65 Years -Massachusetts and Oklahoma, 1993. MMWR 1995;44(40):753–754) For women 50 and older, screening for urinary and fecal incontinence is recommended. (Qualified) ACOG: Functional assessment of the elderly woman includes evaluation of bowel and bladder function. (Guidelines for Women's Health) ACOG: For all adults 18 years and older, screening history of urinary and fecal incontinence is Urinary and fecal incontinence has profound effects on quality of life and is associated with depression and anxiety, work impairment, social isolation, and sexual dysfunction. 138 Well Woman Task Force 2013-2014 Model: Recommendation Evidence Grid recommended. (CO 483, Primary and preventative care: periodic assessments) AMA/CCP/NCQA: Recommend assessment of presence or absence of urinary incontinence in women age 65 or older. (PQRS 2013 measures list, AMA-CCPNCQA) 139 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Piercing and Tattooing Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13-18) Evidence-Based Evidence-Informed ACOG: Recommends annual evaluation and counseling. Educate adolescents about concerns (infections, scars, allergies, permanence of body art) associated with piercing and tattooing. (ACOG Guidelines for Adolescent Health Care, GAHC p. 31) Uniform Expert Agreement Final WWTF Recommendation Annual evaluation and counseling adolescents about concerns associated with piercing and tattooing is recommended. (Strong) AAPD: Provide anticipatory guidance/counseling on intraoral/oral piercing beginning at age 12 years or older annually. (Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling and oral treatment for infants, children, and adolescents. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2009; Guideline on adolescent oral health care. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2010) 140 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Preconception/Interconception Care Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Uniform Expert Agreement Additional guidelines from medical societies used for developing consensus recommendations. WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone All Women of Reproductive Capacity See also Alcohol Misuse; Depression; Diabetes; Diabetes Postpartum; Mental Health and Psychosocial Issues/Suicide/Behavioral Assessment; Reproductive Health; Sexual Health; Tobacco Use Evidence-Based Evidence-Informed IOM: Provide evidence-based tests, procedures, and screening for nonpregnant women to optimize reproductive outcomes and prevent or optimize treatments for chronic conditions as well as topics for counseling and guidance for preconception health. (Clinical Preventive Services for Women; Closing the Gaps. 2011. Washington, DC: The National Academy of Sciences, p. 129; http://www.iom.edu/Report s/2011/Clinical-Preventive- ACOG, AAP, PCCHC: Counsel patients about preventing unwanted and unintended pregnancy by postponing sexual involvement or using contraceptive options, including emergency contraception. (ACOG/AAP: Guidelines for Perinatal Care. 7th ed. , 2012; pp. 95-105; PCHHC Initiative: Preconception Health and Health Care: The Clinical Content of Preconception Uniform Expert Agreement Final WWTF Recommendation Risk assessment, education, and health promotion counseling, based on the individual woman’s desire for pregnancy, are recommended for all women to prevent unintended pregnancy, reduce risks, and improve pregnancy outcomes. (Strong) 141 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid services-for-Women-Closing-theGaps.aspx) IOM, CDC: Ensure access to the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity. (IOM: Clinical Preventive Services for Women; Closing the Gaps. 2011. Washington, DC: The National Academy of Sciences, p. 102– 110; http://www.iom.edu/Reports /2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx; CDC: MMWR. U.S. Selected Practice Recommendations for Contraceptive Use, 2013.; http://www.cdc.gov/repro ductivehealth/UnintendedPregna ncy/USSPR.htm) IOM: Obtain a history of pregnancy complications, including preeclampsia, gestational hypertension, and gestational diabetes mellitus, from all women who have had at least one pregnancy. (Clinical Preventive Services for Women; Care. Obstet Gynecol. 2008 ;199(6 Suppl 2)S257S395; http://www.beforeandb eyond.org/uploads/Clinical%2 0content%20of%20preconcep tion%20care%20overview.pdf) AHA: Health care professionals who meet women for the first time later in their lives (ie, after their reproductive years) should take a careful and detailed history of pregnancy complications with focused For women with risks identified in pregnancy that have implications for subsequent pregnancies, as well as chronic disease development (e.g., PIH, GDM) or management (e.g., clotting disorders, hepatitis), postpartum screening and development of a plan for continuing care are recommended. (Strong) 142 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Closing the Gaps. 2011. Washington, DC: The National Academy of Sciences; p. 128; http://www.iom.edu/Reports /2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx) questions about a history of gestational diabetes mellitus, preeclampsia, preterm birth, or birth of an infant who was small for gestational age. (J Am Coll Cardiol. 2011 Mar 22;57(12):1404-23. doi: 10.1016/j.jacc.2011.02.005. CDC: Safety, efficacy, availability, Effectiveness-based guidelines and acceptability should be for the prevention of considered by women, men, or cardiovascular disease in couples when choosing the most women--2011 update: a appropriate contraceptive guideline from the American method. Voluntary informed Heart Association. Mosca L1, choice of contraceptive methods Benjamin EJ, Berra K, is an essential guiding principle, Bezanson JL, Dolor RJ, Lloydand contraceptive counseling, Jones DM, Newby LK, Piña IL, where applicable, may be an Roger VL, Shaw LJ, Zhao D, important contributor to the Beckie TM, Bushnell C, successful use of contraceptive D'Armiento J, Kris-Etherton methods. Assessment of the PM, Fang J, Ganiats TG, safety of a given contraceptive Gomes AS, Gracia CR, Haan method for a person with a particular characteristic or medical CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore condition should be included in A, Nussmeier NA, Ofili E, counseling. (2010. Medical Oparil S, Ouyang P, Pinn VW, Eligibility Criteria for Sherif K, Smith SC Jr, Sopko G, Contraceptive Use. Chandra-Strobos N, Urbina MMWR;59(RR04):1– 85; http://www.cdc.gov/mmwr/p EM, Vaccarino V, Wenger NK; American Heart Association.) df/rr/rr59e0528.pdf) AHA/ASA: Because of the increased risk of future 143 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid hypertension and stroke one to 30 years after delivery in women with a history of preeclampsia (Level of Evidence B), it is reasonable to (1) consider evaluating all women starting 6 months to 1 year post partum, as well as those who are past childbearing age, for a history of preeclampsia/eclampsia and document their history of preeclampsia/eclampsia as a risk factor, and (2) evaluate and treat for cardiovascular risk factors including hypertension, obesity, smoking, and dyslipidemia (Class IIa; Level of Evidence C). (Stroke. 2014 Feb 6. [Epub ahead of print] Guidelines for the Prevention of Stroke in Women: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, Howard VJ, Lichtman JH, Lisabeth LD, Piña IL, Reeves MJ, Rexrode KM, Saposnik G, Singh V, Towfighi A, Vaccarino V, Walters MR; on behalf of 144 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research.) IOM, USPSTF: Clinicians should ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products (IOM: Clinical Preventive Services for Women; Closing the Gaps. 2011. p. 128, Washington, DC: The National Academy of Sciences; http://www.iom.edu/Re ports/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx; USPSTF: Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women; http://www.uspreventiv eservicestaskforce.org/uspstf/usp stbac2.htm; grade A recommendation) For women with lifestyle behaviors (e.g., use of tobacco, alcohol, or Illicit drugs) or mental health issues (e.g., antepartum/postpartum depression) identified during pregnancy that increase health risks, postpartum screening, follow-up, and development of a plan for continuing care are recommended. (Strong). IOM, USPSTF: Screening and behavioral counseling interventions are recommended to reduce alcohol misuse by adults, including nonpregnant and 145 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid pregnant women, in primary care settings. (IOM: Clinical Preventive Services for Women; Closing the Gaps. 2011. p. 126, Washington, DC: The National Academy of Sciences; http://www.iom.edu/Reports/201 1/Clinical-Preventive-services-forWomen-Closing-the-Gaps.aspx; USPSTF: Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, http://www.uspreventiveservices taskforce.org/uspstf/uspsdrin.htm ; grade B recommendation) PCHHC Initiative, USDHHS: Assess at least annually for alcohol use patterns and risky drinking behaviors and provide appropriate counseling. All women should be advised of the risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established. (PCHHC: The Clinical Content of Preconception Care (A III); USDHHS: 2005 Advisory on Alcohol and Pregnancy; http://www.cdc.gov/n cbddd/fasd/documents/sgadvisory.pdf) 146 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid PCHHC, USDHHS: Assess for tobacco use at each encounter with healthcare system. Women who smoke should be counseled, using the 5 A’s, to limit exposure. (PCHHC; The Clinical Content of Preconception Care (A II-2); USDHHS/PHS: Treating Tobacco Use and Dependence. Clinical Practice Guideline (Evidence level A for screening, B and C for interventions; Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.) IOM: Screen for suicide ideation and postpartum depression in women who are pregnant or who have recently given birth. (Clinical Preventive Services for Women; Closing the Gaps. 2011; p. 188193, Washington, DC: The National Academy of Sciences; http://www.iom.edu/Re ports/2011/Clinical-Preventiveservices-for-Women-Closing-theGaps.aspx) 147 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Sexual Health Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adolescents (13–18) See also Reproductive Health Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation Satcher: Open and respectful dialogue by health care providers is recommended; while adolescents desire this, providers are reluctant to discuss sexual health more broadly with adolescents (rather than simply avoidance of unplanned pregnancy and STIs). (Satcher, 2013; http://www.publichealthreports.org/issueopen.cfm?articleID=29 46) Providers should offer the opportunity for respectful and open dialogue about sexual health and sexuality that includes sexual orientation, gender identity, and sexual dysfunction at every comprehensive health visit. (Qualified) Douglas & Fenton: A more holistic approach with adolescents to sexual health that includes issues of desire and relationships may increase healthy sexual behavior. (Douglas, Fenton, 2013; http://www.publichealthreports.org/issueopen.cfm?articleI D=2933) Nystrom, Duke, & Victor: Sexuality is a normal and healthy part of adolescent development. (Public Health Reports, 2013 (Suppl 1), vol 28 148 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid http://www.publichealthreports.org/issueopen.cfm?articleID=29 43) Hoover et al: Obstetrician-gynecologists and family practitioners should be targeted for interventions to improve the quality and availability of reproductive health services. (Hoover, KW, Tao G, Berman S, Kent, CK. Utilization of Health Services in Physician’s Offices in Outpatient Clinics by Adolescents and Young Women in the U.S.: Implications for Improving Access to Reproductive Health Services. Journal of Adolescent Health 46. 2010:324-330.) Adults (All ages) See also Reproductive Health Evidence-Based Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation WHO: Sexual health is a state of physical, mental, and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. (http://www.who.int/topics/sexual_health/e n/) Ford et al: Patient interactions addressing sexual health should occur and evolve over the life course, depending on the target age and personal circumstances, such as relationship status, sexual orientation, gender identity, and pregnancy intent. (Ford et al., 2013, http://www.publichealthreports.org/issueopen. cfm?articleID=2944) Address sexual health/sexuality as part of every comprehensive health assessment (annually). Sexually active women can be screened for sexual health issues with one or two questions, such as “Are you satisfied with your sex life?” or “Do you have any questions or concerns about sex?” (Qualified) ACOG: Obtain a sexual history if women present with a potential sexual problem. (Practice Bulletin 119 (2011) Female Sexual Dysfunction) Farrell & Belza: Patients, regardless of age want to discusses sexual health issues with their providers. (Are older patients comfortable discussing sexual health with nurses? Nursing Research 61(1) 51-57) 149 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Skin Cancer Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Informed AAFP: Counsel children, adolescents and young adults (10-24) who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (Skin Cancer [Grade B]) Uniform Expert Agreement Final WWTF Recommendation Counseling adolescents about minimizing their exposure to ultraviolet radiation is recommended to reduce risk for skin cancer. (Strong) Adolescents (Ages 13-18) Evidence-Based USPSTF: Recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (Behavioral Counseling to Prevent Skin Cancer [Grade B]) AAP: Incorporate advice about UVR exposure into healthsupervision practices for all children, especially for children at high risk of developing skin cancer: children with light skin, those with nevi and/or freckling, and those with a family history of melanoma. Aim to incorporate 150 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid UVR exposure advice into at least one health-maintenance visit per year, beginning in infancy. Because melanoma occurs in teenagers and is a common cancer among young adults, it seems prudent to recommend that clinicians caring for these groups include a skin examination as part of a complete physical examination. (Ultraviolet Radiation: A Hazard to Children and Adolescents.) ACOG: Counsel about skin exposure to ultraviolet rays. (http://www.acog.org/About_ ACOG/ACOG_Departments/A nnual_Womens_Health_Care/ Assessments_and_Recommen dations) ACOG: Encourage regular use of sunscreen and avoidance of artificial tanning. (GAHC p. 29) Adolescents should be encouraged to use sunscreen regularly and avoid artificial tanning. (Strong) 151 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (19 and older) Evidence-Based USPSTF: Recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (Behavioral Counseling to Prevent Skin Cancer (Grade B) Evidence-Informed AAFP: Counsel children, adolescents and young adults (10-24) who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (Skin Cancer [Grade B]) USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of screening for skin cancer by primary care clinicians or by patient skin selfexamination. (Screening for Skin Cancer (Grade I) AAFP: There is insufficient evidence to assess benefits and harms of using whole-body skin examination by primary care clinician or patient skin selfexamination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult population. (Skin Cancer [Grade I]) Uniform Expert Agreement Final WWTF Recommendation Counseling young adults aged 19-24 years about minimizing their exposure to ultraviolet radiation is recommended to reduce risk for skin cancer. (Strong) Routine whole-body skin examination or patient skin self-examination for detection of skin cancers is not recommended. (Strong) 152 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than 24 years about minimizing risks to prevent skin cancer. (Behavioral Counseling to Prevent Skin Cancer [Grade I]) AAFP: There is insufficient evidence to assess benefits and harms of counseling adults older than 24 years. (Skin Cancer [Grade I]) Adults should be encouraged to use sunscreen regularly and avoid artificial tanning. (Strong) ACOG: Encourage regular use of sunscreen and avoidance of artificial tanning. (GAHC p. 29) 153 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Sleep Disorders Evidence-Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence-Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Adults (65 years and older) See also Depression EvidenceBased Evidence-Informed Uniform Expert Agreement ACOG: Recommends assessing for sleep disorders as part of an assessment for depression in those 65 and over and “psychosocial issues” for those of other ages. http://www.acog.org/About_ACOG/ACOG_Departments/ Annual_Womens_Health_Care/Assessments_and_Recommendations The 2006 IOM report “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem” focuses on research needs. (Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Washington (DC): National Academies Press (US); 2006.) Final WWTF Recommendation Assessment for sleep disorders is recommended as part of depression screening or evaluation of other psychosocial issues. (Qualified) 154 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Tobacco Use Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Uniform Expert Agreement Final WWTF Recommendation Adolescents (13-18) See also Oral Cavity Exam, Oral Hygiene Evidence-Based Evidence-Informed USPSTF: Recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in schoolaged children and adolescents. (Counseling to Prevent Tobacco Use and Tobacco Caused Disease in Children and Adolescents (Grade I) Grade: B Recommendation.) AAFP: Strongly recommends counseling to smoking parents with children in the house regarding the harmful effects of smoking on children's health. (Second Hand Smoke) AAP: Screen annually for tobacco use and tobacco smoke exposure, encourage tobacco use cessation, and provide tobacco use cessation strategies and resources at most visits. (Performing Preventive Providing annual education or brief counseling to prevent initiation of tobacco use is recommended. (Strong) Screening annually for tobacco use and tobacco smoke exposure is recommended. For those who use tobacco products, encourage tobacco use cessation and provide cessation strategies. (Strong) Provide effective interventions for treating tobacco use and dependence among adolescents. (Strong) 155 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Services: A Bright Futures Handbook) AAFP: Effectiveness of physician's advice and counseling in this area is uncertain; avoidance of tobacco products by children and adolescents is desirable. (Tobacco Use [Grade I]) ACOG: Ask about use of tobacco products. (GAHC p. 34) AAP: Counseling should be developmentally appropriate and relevant across various age groups. (Technical Report-Tobacco as a Substance of Abuse PEDIATRICS Vol. 124 No. 5 November 1, 2009, Tobacco as a Substance of Abuse) ACOG: Recommends annual screening for tobacco use and evaluation and counseling at unspecified periodicity. (Annual Women's Health Care) PCHHC: Assess for tobacco 156 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid use at each encounter with health care system; women who smoke should be counseled, using the 5 As, to limit exposure. (The Clinical Content of Preconception Care [A II-2]) PCHHC: All women of childbearing age should be screened for tobacco use. Brief interventions should be provided to all tobacco users and should include brief counseling that describes the benefits of not smoking before, during, and after pregnancy; discussion of medication; and referral for more intensive services (individual, group, or telephone counseling) if the woman is willing to use these services. For pregnant women, augmented counseling interventions should be used. (The Clinical Content of Preconception Care [A I-a]) 157 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (19 and older) See also Oral Cavity Exam, Oral Hygiene Evidence-Based Evidence-Informed USPSTF: Screen annually for tobacco use and provide tobacco cessation education and treatment. (Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women [Grade A]) AAFP: Strongly recommends counseling to smoking parents with children in the house regarding the harmful effects of smoking on children's health. (Second Hand Smoke) USPSTF: Evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low-dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests. (Lung Cancer Screening (Grade I) Systematic Review to Update USPSTF Recs: http://annals.org/article.aspx?articleid=1721248) AAFP: Screen for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Tobacco Use [Grade A]) Uniform Expert Agreement Final WWTF Recommendation Screening all women annually for tobacco use is recommended. For those who use tobacco products, provide tobacco cessation education and treatment. (Strong) Routine screening for lung cancer in asymptomatic women is not recommended. (Strong) ACOG: Recommends annual screening for tobacco use, evaluation and counseling at unspecified periodicity. (Annual Women's Health Care) PCHHC: Assess for 158 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid tobacco use at each encounter with health care system; women who smoke should be counseled, using the 5 As, to limit exposure. (The Clinical Content of Preconception Care [A II2]) PCHHC: All women of childbearing age should be screened for tobacco use. Brief interventions should be provided to all tobacco users and should include brief counseling that describes the benefits of not smoking before, during, and after pregnancy; discussion of medication; and referral for more intensive services (individual, group, or telephone counseling) if the woman is willing to use these services. For pregnant women, augmented counseling interventions should be used (The Clinical Content of Preconception Care [A Ia]) 159 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Topic: Visual Acuity/Glaucoma Evidence Based Foundation for WWTF recommendations. Primarily USPSTF, IOM, and CDC guidelines. Evidence Informed Additional guidelines from medical societies used for developing consensus recommendations. Uniform Expert Agreement WWTF expert consensus: Describes resolution of conflicting guidelines or outlines expert opinion that does not have a strong evidence foundation. Final WWTF Recommendation and Strength of Recommendation “Strong” = Based on evidence-based or evidence-informed guidelines “Qualified” = Based on expert opinion alone Evidence-Informed Uniform Expert Agreement Final WWTF Recommendation AAP: Screen one time per year for years 3-6, 8, 10, 12, 15, 18, at other health supervision visits based on risk assessment or any concern on the part of the families or the child. (Performing Preventive Services: A Bright Futures Handbook) Visual acuity screening should be performed once a year at ages 15 and 18, if a screen was performed at age 12. If no screen at age 12, then screen when seen at age 13 or 14, then 15 and 18. Any abnormality or suspicion of abnormality should be referred to an optometrist or ophthalmologist. Screening for visual acuity is recommended twice: once in early adolescence (less than 15 years) and once in late adolescence (15– 18 years). Refer patients with any abnormality or suspicion of abnormality to an optometrist or ophthalmologist. (Qualified) Adolescents (13-18) Evidence-Based 160 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid Adults (All ages) Evidence-Based Evidence-Informed USPSTF: There is insufficient evidence to recommend for or against screening adults for glaucoma. (Screening for Glaucoma) AAFP: There is insufficient evidence to recommend for or against screening for adults for glaucoma. http://www.aafp.org/patientcare/clinicalrecommendations/all/glauco ma.html Uniform Expert Agreement Final WWTF Recommendation Routine screening by primary care providers for glaucoma is not recommended. (Qualified) Adults (65 years and older) Evidence-Based Evidence-Informed USPSTF: Current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults (age 65+). (Screening for Impaired Visual Acuity in Older Adults) ACOG: Recommends evaluation and counseling. (Annual Women's Health Care) Uniform Expert Agreement Final WWTF Recommendation Routine screening by primary care providers for visual acuity in adults ages 65 years and older is not recommended. (Qualified) AAFP: There is insufficient evidence to assess benefit/harms of screening for visual acuity for the improvement of outcomes in older adults. http://www.aafp.org/dam/AA FP/documents/patient_care/cl 161 Well-Woman Task Force 2013-2014 Individual Recommendation Evidence Grid inical_recommendations/cpsrecommendations.pdf 162 Glossary This glossary defines terms related to screening or well woman care that may not be familiar across all specialties. It does not include terms generally understood by clinicians. It also describes standard thresholds or values for some commonly used clinical measurements. Aggressive case finding: As an alternative to universal screening or population screening, testing on the basis of a broad range of variably defined risk factors. Behavioral counseling: Targeted intervention aimed at changing patient behavior to improve health, typically involving a clinician with expertise in the area of focus. Intensity of behavioral counseling may be assessed on the basis of factors such as the number and length of counseling sessions, the magnitude and intensity of educational materials provided, and the use of supplemental interventions such as support group sessions or classes 1. For example, the Expert Committee on preventing childhood obesity described a detailed, stepwise approach to behavioral counseling of increasing intensity. Birth interval, birth spacing 2: The time between the birth date of one child and the birth date of the next child. Body mass index 3: Weight-to-height ratio defined as mass in kilograms divided by height in meters squared. For adults, BMI is categorized as follows: • Underweight: Less than 18.5 • Normal: 18.5-24.9 • Overweight: 25–29.9 • Obese: 30 or higher Additionally, there are 3 classes of obesity: class II, 35-39.9; and class III, “40 and over.” The interpretation of BMI is both age- and sex-specific for children and teens. Breast self-awareness 4: A woman’s understanding of the normal appearance and feel of her own breasts. Breast self-examination 5: A woman’s systematic and regular examination of her own breasts. CA-125 testing 6: A tumor marker that may be elevated in the blood of patients with some types of cancer, particularly ovarian. Testing for CA-125 is primarily used to monitor patients during and after ovarian cancer treatment. It may also be helpful in screening women at particularly 1 From http://www.uspreventiveservicestaskforce.org/3rduspstf/diet/dietrr.htm From http://health.utah.gov/mihp/pregnancy/preged/afterpreg/Pregnancy_Spacing.htm 3 From: http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html 4 From https://www.acog.org/About_ACOG/News_Room/News_Releases/2011/Annual_Mammograms _Now_Recommended_for_Women_Beginning_at_Age_40 5 From https://www.acog.org/About_ACOG/News_Room/News_Releases/2011/Annual_Mammograms _Now_Recommended_for_Women_Beginning_at_Age_40 6 http://www.nlm.nih.gov/medlineplus/ency/article/007217.htm 2 163 Glossary high risk for ovarian cancer, but is limited by false negatives and false positives, particularly in women at average risk. Catch-up immunization: Vaccines given to ensure that an individual who has missed a vaccination(s) is on par with the schedule of vaccinations for his or her peers, as opposed to booster vaccines 7, which are given to ensure that earlier doses remain effective. Cervical lesions 8: Cervical intraepithelial neoplasia (CIN) is characterized as either CIN1 (mild dysplasia), CIN2 (moderate to marked dysplasia), or CIN3 (severe dysplasia to carcinoma in situ). CIN1 generally reflects transient viral infection with little risk of progression to cancer, while CIN2 and CIN3 are high-grade lesions with risk of cancer. This nomenclature was recently revised at the Lower Anogenital Squamous Terminology (LAST) conference as LSIL (low grade) and HSIL (high grade). Chemoprevention 9: The use of medication to prevent disease or slow the progress of disease. Cotesting: Screening for cervical cancer and its precursors with a combination of cytology (Pap test) and high-risk human papillomavirus (HPV) testing. Diethylstilbestrol (DES) 10: Drug once prescribed during pregnancy to prevent miscarriages or premature deliveries. In utero exposure to DES poses several health risks, such as uterine and cervical anomalies and certain cancers in women. Dyslipidemia: Cholesterol levels out of the normal range. Desirable cholesterol levels 11 are as follows: • Total cholesterol: Less than 200 mg/dL • Low-density lipoprotein (LDL): Less than 100 mg/dL • High-density lipoprotein (HDL): 60 mg/dL or higher • Triglycerides: Less than 150 mg/dL Emergency contraception 12: The use of certain methods to prevent pregnancy after a woman has had sex. Also referred to as postcoital contraception. Evidence of immunity: Varies by disease and vaccine, but typically includes such factors as documentation of administration of vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or diagnosis or verification of history of disease by a health care provider. 7 http://wordnetweb.princeton.edu/perl/webwn?s=booster%20shot http://www.nlm.nih.gov/medlineplus/ency/article/001491.htm 9 http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancertopics/prevention-and-screening/chemoprevention/index.html 10 http://www.cdc.gov/des/index.html 11 http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm 12 http://www.acog.org/~/media/For%20Patients/faq114.pdf?dmc=1&ts=20140324T1522108735 8 164 Glossary Familial adenomatous polyposis (FAP) 13: An inherited disorder characterized by cancer of the large intestine (colon) and rectum. Functional assessment 14: Evaluation of an individual’s ability to function in the arena of everyday life. Functional assessment in an elderly woman, for example, includes evaluation of cognitive and affective mental functions, vision, hearing, motor function, gait and balance, bowel and bladder function, activities of daily living, and environmental risks and support systems. Gender identity 15: According to the American Psychological Association, a person’s basic sense of self as male, female, or transgender. Gestational diabetes 16: Glucose intolerance first occurring during pregnancy and resolving after delivery. Hyperglycemia 17: High blood sugar; in most people, more than 140 mg/dl (before meals). Interconception care 18: Interventions between pregnancies to identify and modify risk to a woman’s health or pregnancy outcomes. Intimate partner violence 19 (also called domestic violence): A pattern of assaultive behavior and coercive behavior that may include physical injury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion. Lactation support: Interventions and counseling designed to increase initiation and continuation of breastfeeding. Lynch syndrome/Hereditary nonpolyposis colorectal cancer 20: An inherited disorder that increases the risk of many types of cancer, particularly cancers of the colon (large intestine) and rectum. Patients are also at increased risk of endometrial, ovarian, and breast cancers. Metabolic syndrome 21: A group of risk factors that raises the risk for heart disease and other health problems, such as diabetes and stroke. Metabolic syndrome is defined by the presence of 13 http://ghr.nlm.nih.gov/condition/familial-adenomatous-polyposis ACOG Guidelines for Women’s Health Care, 2nd ed., 2002, p. 178 (please verify against current edition) 15 http://www.apa.org/pi/lgbt/resources/guidelines.aspx?item=2 16 http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?productid=1296&pageaction=displayproduct 17 http://www.cdc.gov/diabetes/pubs/tcyd/ktrack.htm 14 18 http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/healthfollowingpregnan cy.pdf 19 http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf 20 http://ghr.nlm.nih.gov/condition/lynch-syndrome 21 http://www.nhlbi.nih.gov/health/health-topics/topics/ms/ 165 Glossary at least three of the following risk factors: large waistline, high triglyceride level, low HDL cholesterol level, high blood pressure, and high fasting blood sugar level. Preconception care 22: Interventions before a pregnancy to identify and modify risk to a woman’s health or pregnancy outcomes. Postpartum 23: A period of time after the delivery of a newborn during which certain events may occur. This may be as short as 6 weeks. Postpartum depression 24: Intense feelings of sadness, anxiety, or despair after giving birth that prevent a woman from being able to do her daily tasks. Postpartum depression can occur up to 1 year after having a baby, but it most commonly starts about 1–3 weeks after childbirth. By contrast, postpartum blues may occur about 2-3 days after childbirth and manifest as feelings of depression, anxiety, anger, or other emotions, but the feelings resolve within 1-2 weeks with no treatment. Reproductive coercion 25: Behavior intended to maintain power and control in a relationship by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent. Specifically, reproductive coercion is behavior that interferes with contraception use and pregnancy. The most common forms of reproductive coercion include sabotage of contraceptive methods, pregnancy coercion, and pregnancy pressure. Screening 26: Tests, examinations, or other procedures used to find evidence of otherwise unrecognized disease or defects. Screening test are usually not definitive. Positive screening tests usually require further diagnostic testing to confirm the abnormality. Sexual coercion 27: A range of behavior that a partner may use related to sexual decision-making to pressure or coerce a person to have sex without using physical force. This behavior includes repeatedly pressuring a partner to have sex, threatening to end a relationship if the person does not have sex, forcing sex without a condom or not allowing other prophylaxis use, intentionally exposing a partner to a sexually transmitted infection (STI), including human immunodeficiency virus (HIV), or threatening retaliation if notified of a positive STI test result. 22 http://www.hrsa.gov/advisorycommittees/mchbadvisory/InfantMortality/healthfollowingpregnan cy.pdf 23 http://www.aafp.org/afp/2005/1215/p2491.html 24 https://www.acog.org/~/media/For%20Patients/faq091.pdf?dmc=1&ts=20140324T1627086079 25 http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health _Care_for_Underserved_Women/Reproductive_and_Sexual_Coercion 26 http://www.who.int/cancer/detection/variouscancer/en/ 27 http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health _Care_for_Underserved_Women/Reproductive_and_Sexual_Coercion#1 166 Glossary Sexual health 28: A state of physical, mental, and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. Sexual orientation 29: Refers to the sex of those to whom one is sexually and romantically attracted. Sexually active: To be engaged physically in sexual activity, including but not exclusively including manual, oral, vaginal, or anal contact. Shared decision-making 30: A process in which patients and their clinicians discuss options and decide the best course of action on the basis of the available evidence and the patient’s preferences and values. Suicide ideation 31: Thinking about, considering, or planning for suicide. Abbreviations AACE: American Association of Clinical Endocrinologists AAFP: American Academy of Family Physicians AAP: American Academy of Pediatrics AAPD: American Academy of Pediatric Dentistry ACG: American College of Gastroenterology ACIP: Advisory Committee on Immunization Practices ACNM: American College of Nurse-Midwives ACOG: American Congress of Obstetricians and Gynecologists ACP: American College of Physicians ACS: American Cancer Society ACSP: American Society for Clinical Pathology ADA: American Dental Association ADA: American Diabetes Association ADA: American Dietetic Association AHA: American Heart Association AHRQ: Agency for Healthcare Research and Quality AMA: American Medical Association APC: Adenomatous polyposis coli (gene) ASCCP: American Society for Colposcopy and Cervical Pathology ASN: American Society of Nephrology http://www.who.int/topics/sexual_health/en/ http://www.apa.org/pi/lgbt/resources/guidelines.aspx?item=2 30 http://www.innovations.ahrq.gov/content.aspx?id=3868 31 http://www.cdc.gov/violenceprevention/suicide/definitions.html 28 29 167 Glossary ATA: American Thyroid Association AWHONN: Association of Women’s Health, Obstetric and Neonatal Nurses BMI: Body mass index BRCA: Breast cancer (genes) BSE: Breast self-examination CBE: Clinical breast examination CCP: CDC: Centers for Disease Control and Prevention. CHD: Coronary heart disease CIN: Cervical intraepithelial neoplasia CSF: Cerebrospinal fluid CTFPHC: Canadian Task Force on Preventive Health Care CVD: Cardiovascular disease DES: Diethylstilbestrol DTaP: Diphtheria, tetanus, and pertussis (vaccine) EGAPP: Evaluation of Genomic Applications FAP: Familial adenomatous polyposis FDA: U.S. Food and Drug Administration FOBT: Fecal occult blood test FWV: Futures Without Violence GDM: Gestational diabetes mellitus HEDIS: Healthcare Effectiveness Data and Information Set HIV: Human immunodeficiency virus HCV: Hepatitis C virus HDL: High-density lipoprotein HMHB: National Healthy Mothers Healthy Babies Coalition HNPCC: Hereditary nonpolyposis colorectal cancer HPV: Human papillomavirus IOM: Institute of Medicine IPV: Intimate partner violence IUD: Intrauterine device KPCMI: Kaiser Permanente Care Management Institute LDL: Low-density lipoprotein MoD: March of Dimes MYH: NAHIC: National Adolescent and Young Adult Health Information Center NCCN: National Comprehensive Care Network NCQA: National Committee for Quality Assurance NIH: National Institutes of Health NKF: National Kidney Foundation NSAIDs: Nonsteroidal anti-inflammatory drugs NTD: Neural tube defect PCHHC: Preconception Health and Health Care Steering Committee PIH: Pregnancy-induced hypertension SASGOG: Society for Academic Specialists in General Obstetrics and Gynecology STD: Sexually transmitted disease in Practice and Pre 168 Glossary STI: Sexually transmitted infection Tdap: Tetanus, diphtheria, and pertussis (vaccine) TSH: Thyroid-stimulating hormone USDHHS: U.S. Department of Health and Human Services USPSTF: U.S. Preventive Services Task Force UVR: Ultraviolet ray WHO: World Health Organization 169