Women typically visit an ob/gyn practice, family practice, or internal medicine practice for routine, annual well-woman visits (WWVs). The focus of this visit may vary within these different settings.1 This can result in missing important components in the history, physical examination, and screening tests that constitute a comprehensive preventive health assessment along with appropriate health promotion education and counseling.

Guidelines and recommendations for preventive healthcare are available that can be incorporated into the annual WWV wherever it occurs. The Women’s Preventive Services Initiative (WPSI), made up of an advisory panel that included the American Academy of Physicians, American College of Obstetricians and Gynecologists (ACOG), American College of Physicians, and National Association of Nurse Practitioners in Women’s Health, developed the ‘Recommendations for Well-Woman Care—A Well-Woman Chart.”  This outlines preventive services recommended by WPSI, US Preventive Services Task Force (USPSTF), and Bright Futures based on age, health status, and risk factors.2 Preventive service guidelines are also available from the American Cancer Society, National Osteoporosis Foundation, and the American Diabetes Association, among others.

The Centers for Disease Control Advisory Committee on Immunization Practices (ACIP) provides regularly updated immunization recommendations.3 Recommendations regarding hereditary breast and ovarian cancer risk assessment and genetic testing are available from sources including the National Comprehensive Cancer Network, ACOG, and USPSTF.4–6

We are also beginning to understand that particular problems during pregnancy such as gestational diabetes, hypertension, pre-eclampsia, and preterm labor may place a woman at future risk for heart disease.7 Although guidelines for preventive measures regarding all of these potential risks associated with pregnancy history have not been established, healthcare providers (HCPs) can consider this information in regard to a woman’s other risk factors to develop a plan of care. 

An organized review of current preventive healthcare given in a clinical practice that provides annual WWVs, with adaptation of health histories, physical examination, and screening tests to include all preventive healthcare recommendations, can facilitate comprehensive WWVs that promote the health of women.

Purpose

The purpose of the quality improvement (QI) project Closing the Gap was to design and implement an updated WWV health history in the electronic health record (EHR) and to define expected physical examination and screening test components based on current nationally recognized recommendations within one family practice setting. The goal was to change and sustain the behaviors of the HCPs in the setting to incorporate a more comprehensive preventive health approach in the annual WWV.8 

Methods

The university’s Institutional Review Board determined the project to be in the quality improvement category, thus not requiring approval for human subjects research. The setting for the project was one family practice office. Two physicians and one nurse practitioner in this office agreed to participate.

The project director (PD) revised the current WWV health history used in the family practice office based on nationally recognized preventive care recommendations and current evidence regarding pregnancy history and future health risks. Prompts were added in sections on family history, medical history, and pregnancy history. For family history, age of diagnosis (eg, At what age did the family member have a heart attack?) and a query about any family members who had genetic testing and the results were added. For medical history, a query about any genetic testing and results was added, and for pregnancy history, a query about pregnancy complications, specifically gestational diabetes, pre-eclampsia, and preterm labor, was added. 

A checklist for auditing charts was developed to monitor the effectiveness of the revised health history in improving the annual WWV. The checklist had 10 criteria including: demographics, update of medical history to include issues during previous pregnancies, update of family medical history, update of systems review, physical examination with all body systems addressed, screening tests ordered based on national guidelines, update of immunizations, plan of care, client goals/concerns, and a health improvement process based on thorough preventive wellness care.

Prior to implementation of the revised health history, the PD conducted a preintervention audit of 1 week’s charts of patients seen for annual WWVs to provide a baseline. The PD met with the HCPs and staff to review the revised health history, discuss the rationale for changes, provide information from the preintervention audit, and discuss expectations for the annual WWV. The PD explained the use of the checklist for chart audits and how the charts would be graded. The total points that could be reached when all criteria were met was 100. The revised health history was placed in the EHR.

At the beginning of each clinic day during the 12-week project, a staff person assigned a number to the charts of women who had appointments for annual WWVs. At the end of each week, the PD reviewed these charts using the checklist and assigning points. The points were averaged to provide a grade for that week’s group of charts. Individual provider scores were not tabulated. At the beginning of each week, an office e-mail was sent to all HCPs and staff with a report on the previous week’s grade to promote ongoing interest in the project.

Outcomes

A total of 174 annual WWVs were conducted during the 12-week project period. The age range of the women seen was 13 to 82 years. The grade achieved for the preintervention baseline chart audit was 54%. The grade achieved on week 1 was 78%, increasing to 98% on week 12. An additional “unscheduled” chart audit 2 weeks later received a grade of 95%.

Limitations

One limitation was the short time interval for the project. Improvement in chart audit scores was seen immediately in the first week, however, and continued to be maintained or further improved throughout the 12-week project period and 2 weeks later. A second limitation was the small number of providers participating in the project.

Implications for women’s health

The Closing the Gap QI project demonstrated that comprehensive annual WWVs are possible in the family practice setting. The steps taken to improve this preventive health visit can be implemented in any setting in which women are seen for annual WWVs.

As healthcare systems and models of care continue to evolve, it is crucial that women have access to evidence-based, client-centered, comprehensive preventive health services wherever they go for their routine wellness care. Ongoing initiatives are needed to explore the best strategies to promote health when risk factors are identified. That is, it is necessary to go beyond identifying risks to provide education, counseling, treatment, referrals, and timely follow-up. A next step in the practice where the project was implemented is to develop and implement best practices regarding the management of identified risks. This truly reflects an ongoing commitment to continuous quality improvement for women’s healthcare and health outcomes. =

Barbara A. Persons is a retired US Air Force Colonel and current faculty in the master’s degree nursing program at Northern Kentucky University in Highland Heights. She is a women’s health nurse practitioner at Integrative Medicine in Cincinnati, Ohio, and northern Kentucky specializing in preventive cardiac health for women plus bioidentical hormone therapy and wellness. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

  1. Rayburn WF. Are fewer nonpregnant women seeing ObGyns? OBG Manag. 2017:29(12):51-52.
  2. WPSI. Women’s Preventive Services Initiative. Recommendations for well-woman care–a well-woman chart. Women’s Healthcare. 2018;6(4):44-47.

3. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Updated March 21, 2019. https://www.cdc.gov/vaccines/acip/.

4. Lantz PM, Evans WD, Mead H, Alvarez C, Stewart L. Knowledge of and attitudes toward evidence-based guidelines for and against clinical preventive services: results from a national survey. Milbank Q. 2016:94(1):51-76.

5. American Society of Breast Surgeons. ASBrS releases position statement on screening mammography (news release). May 3, 2019. https://www.breastsurgeons.org/news/?id=23.

6. Drake D. Your heart is a lady part. Women’s Health Wisdom (NPWH blog).  www.https://thenpwhblog.wordpress.com/2018/02.

7. Brown HL, Warner JJ, Gianos E, et al. Promoting risk identification and reduction of cardiovascular disease in women through collaboration with obstetricians and gynecologists: a presidential advisory from the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. 2018:137(24):e843-e852.

8. Duhigg C. The power of habit: why we do what we do in life and business. Bookmarks. 2012:52. https://search.ebscohost.com/login.aspx?direct=true&db=edsglr&AN=edsgcl.324763465&site=eds-live.

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