The well-woman visit comes of age: What it offers, how we got here

In the fall of 2015, the task force’s findings were published in an article entitled “Components of the well-woman visit” in the journal Obstetrics & Gynecology.² Those findings outline a core set of well-woman care practices across a woman’s lifespan, from adolescence through the reproductive years and into maturity, and they are usable by any provider who cares for adolescent girls or women.

ACOG has summarized its well-woman recommendations, by age, on its website,³ at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.

3. Do all women have a copay for the well-woman visit?
Because research has revealed that any type of copay or deductible for preventive care significantly lessens the likelihood that patients will seek out such care, the ACA sought to make basic preventive care available without cost sharing.⁴

The US Department of Health and Human Services notes that: “The Affordable Care Act requires most health plans to cover recommended preventive services without cost sharing. In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the law.”⁴

Grandfathered plans (those created or sold before March 23, 2010) are exempt from this requirement, as are Medicare, TRICARE, and traditional Medicaid plans.

4. What does well-woman care mean from one doctor to another?
Under the ACA, well-woman care can be provided by a “wide range of providers, including family physicians, internists, nurse–midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants,” depending on the age of the patient, her particular needs and preferences, and access to health services.²

The ACOG Well-Woman Task Force “focused on delineating the well-woman visit throughout the lifespan, across all providers and health plans.”²

In determining the components of well-woman care, ACOG’s task force compiled existing guidelines from many sources, including the Department of Health and Human Services, the IOM, the US Preventive Services Task Force, and each member organization.

Members categorized guidelines as:

• single source (eg, abdominal examination)
• no agreement (breast cancer/mammography screening)
• limited agreement (pelvic examination)
• general agreement (hypertension, osteoporosis)
• sound agreement (screening for sexually transmitted infections)

The task force also agreed that final recommendations would rely on evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement. Recommendations were considered “strong” if they relied primarily on evidence-based or evidence-informed guidelines and “qualified” if they relied primarily on expert consensus.

Guidelines were further separated into age bands:

• adolescents (13–18 years)
• reproductive-aged women (19–45 years)
• mature women (46–64 years)
• women older than 64 years.

The task force recommended that, during the well-woman visit, health care professionals educate patients about:

• healthy eating habits and maintenance of healthy weight
• exercise and physical activity
• seat belt use
• risk factors for certain types of cancer
• heart health
• breast health
• bone health
• safer sex practices and prevention of sexually transmitted infections
• healthy interpersonal relationships
• prevention and management of chronic disease
• resources for the patient (online, written, community, patient groups)
• medication use
• fall prevention.

Health care providers also should counsel patients regarding:

• recommended preventive screenings and immunizations
• any concerns about mood, such as prolonged periods of sadness, a failure to enjoy what they usually find pleasant, or anxiety or irritability that seems out of proportion to events
• what to expect in terms of effects on mood and anxiety at reproductive life transitions, including menarche, pregnancy, the postpartum period, and perimenopause
• body image issues
• what to expect in terms of the menstrual cycle during perimenopause and menopause
• reproductive health or fertility concerns
• reproductive life planning (contraception appropriate for life stage, reproductive plans, and risk factors, including risk factors for breast and ovarian cancer and cardiovascular disease)
• pregnancy planning, including attaining and maintaining a healthy weight and managing any chronic conditions before or during pregnancy
• what to expect during menopause, including signs and symptoms and options for addressing symptoms (midlife and older women)
• symptoms of cardiovascular disease
• urinary incontinence.

The task force acknowledged that not all of these recommendations can be carried out at a single well-woman visit or by a single provider.

See, again, ACOG’s specific well-woman recommendations, by age range, at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.³

How to winnow a long list of recommendations to determine the most pressing issues for a specific patient
In an editorial accompanying the ACOG Well-Woman Task Force report, entitled “Re-envisioning the annual well-woman visit: the task forward,” George F. Sawaya, MD, of the University of California, San Francisco, devised a plan to determine the most pressing well-woman needs for a specific patient.¹ He chose as an example a 41-year-old sexually active woman who does not smoke.

While Dr. Sawaya praised the Well-Woman Task Force recommendations for their “comprehensive scope,” he also noted that the sheer number of recommendations might be “overwhelming and difficult to navigate.”¹ One tool for winnowing the recommendations comes from the Agency for Healthcare Research and Quality, which offers an Electronic Preventive Services Selector (http://epss.ahrq.gov/PDA/index.jsp), available both online and as a smartphone app. Once the clinician plugs in the patient’s age and a few risk factors, the tool generates a list of recommended preventive services. This list of services has been evaluated by the US Preventive Services Task Force, with each recommendation graded “A” through “D,” based on benefits versus harms.

Back to that 41-year-old sexually active woman: Using the Electronic Preventive Services Selector, a list of as many as 20 grade A and B recommendations would be generated. However, only 3 of them would be grade A (screening for cervical cancer, HIV, and high blood pressure). An additional 2 grade B recommendations might apply to an average-risk patient such as this: screening for alcohol misuse and depression. All 5 services fall within the Well-Woman Task Force’s recommendations. They also have “good face validity with clinicians as being important, so it seems reasonable that these be prioritized above the others, at least at the first visit,” Dr. Sawaya says.¹

Clinicians can use a similar strategy for patients of various ages and risk factors.

Reference
1. Sawaya GF. Re-envisioning the annual well-woman visit: the task forward [editorial]. Obstet Gynecol. 2015;126(4):695–696.