Guidelines for primary and preventive services are issued by a number of medical bodies including the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the U.S. Preventive Services Task Force (USPSTF), and the American Medical Association (1,10–14). The guidelines from various organizations differ somewhat in their specific details, and a national guideline clearinghouse for evidence-based clinical practice guidelines, sponsored by the Agency for Healthcare Research and Quality (AHRQ), is available to provide comparisons between guidelines for a given medical condition or intervention (15).
In 2006 in the United States, there were approximately 660 million visits by women to ambulatory medical care providers (16). In the past, approximately eighteen percent of the visits were made to gynecologists (17). Less than a third of ambulatory visits were made by individuals between the ages of 15 and 44 years, and this percentage is declining with an aging population (16).
Normal pregnancy and gynecologic examination were among the most common reasons for care.
When asked to characterize the nature of an office or clinic visit, obstetricians-gynecologists may or may not identify themselves as primary care providers, depending on a number of variables (18). Those variables may include the patient’s age, pregnancy status, whether it is a new versus a return visit, the diagnosis, insurance or referral status, and even geographic practice region. Primary and preventive services clearly within the realm of obstetricians and gynecologists include cervical cytology testing, pelvic examination and breast examination, and family planning services including contraception. When compared with other physicians, obstetricians-gynecologists are more likely than other physicians to perform cervical cytology testing, pelvic examination, and breast examination.
Approaches to Preventive Care
In health care, the focus is shifting from disease to prevention. Efforts are under way to promote effective screening measures that can have a beneficial effect on public and individual health. Following is a brief description of programs developed by American College of Obstetricians and Gynecologists (ACOG), the USPSTF, and the American Medical Association to provide guidelines for preventive care.
The initial evaluation of a patient involves a complete history, physical examination, routine and indicated laboratory studies, evaluation and counseling, appropriate immunizations, and relevant interventions. Risk factors should be identified and arrangements should be made for continuing care or referral, as needed. The ACOG recommendations for periodic evaluation, screening, and counseling by age groups, and the leading causes of death and morbidity within different age groups are shown in Tables 8.1 through 8.4 (10). These tables include recommendations for patients who have high-risk factors that require targeted screening or treatment; patients should be made aware of any high-risk conditions that require more specific screening or treatment (Table 8.5). Recommendations for immunizations, indicated according to age group, are available from the U.S. Centers for Disease Control and Prevention (CDC). The CDC recommends HIV screening for pregnant women, adults, and adolescent patients in all health care settings after the patient is notified that testing will be performed, unless the patient declines (opt-out screening) (19). Subsequent care should follow a specific schedule, yearly or as appropriate, based on the patient’s needs and age.
Table 8.1 Periodic Assessment Ages 13–18 Years
Health status: medical, menstrual, surgical, family High-risk behaviors
Use of complementary and alternative medicine —Contraceptive options, including emergency contraception
Tobacco, alcohol, other drug use Sexually transmitted diseases
Height Exercise: discussion of program
Pelvic examination (when indicated by the Suicide: depressive symptoms medical history)
Hygiene (including dental), ﬂuoride supplementation*
Table 8.1 (Continued )
Skin exposure to ultraviolet rays Leading Causes of Death¶
Tobacco, alcohol, other drug use 1. Accidents (unintentional injuries)
Immunizations 2. Malignant neoplasms