tm preconception care: policy, challenges, opportunities hani k. atrash md, mph associate director...
TRANSCRIPT
TM
Preconception Care: Policy, Challenges, Opportunities
Hani K. Atrash MD, MPH
Associate Director for Program Development
National Center on Birth defects and Developmental Disabilities
Centers for Disease Control and Prevention
http://www.cdc.gov/ncbddd
TM
TM
We Have A Problem
Preconception care is not being delivered
• Providers don’t provide it• Insurers don’t pay for it• Consumers don’t ask for it
TM
Why Should We Care?
Because it is the right thing to do
Because we have moral, ethical and LEGAL obligations to do
“The Right Thing”
TM
Why Don’t We?
Do we have the Science, Policy, Tools, Programs?
What are the barriers and challenges:• Knowledge, Attitudes, Practices of:
Consumers Providers Insurers
• Practical Guidelines and Tools for implementation:
Who does it, who gets it, how much, what is it, why do it, how to do it, where to do it, when to do it, etc?
TM
Do We Have The Science?
Yes, but may not be enough for today’s climate:
• Strong evidence for some components• Some evidence for others• Non-existent for others
TM
Do We Have The Science?
Today’s climate:
Scientific evidence
+ Business Case
TM
Do We Have The Policy?
We have recommendations from professional organizations
We have no national policy
•No “legal obligations”•No accountability
TM
Current “Policy”
There is consensus that preconception care should be provided to all women
TM
Current “Policy”
HP Objectives 5.10 and 14.12
Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling.
TM
Current “Policy”
ACOG/AAP All health encounters during a
woman’s reproductive years, particularly those that are a part of preconceptional care should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes.
TM
“Current Policy”
U.S. Public Health Service Expert Panel
Preconception care is a critical component of prenatal care
TM
Are We Asking For Too Much????ACOG/AAP PCC Components: Maternal assessment
• Family planning and pregnancy spacing
• Family history• Genetic history (maternal
and paternal)• Medical, surgical,
pulmonary and neurologic history
• Current medications (prescription and OTC)
• Substance use, including alcohol, tobacco and illicit drugs
• Nutrition
• Domestic abuse and violence
• Environmental and occupational exposures
• Immunity and immunization status
• Risk factors for STDs• Obstetric history• Gynecologic history• General physical exam• Assessment of
Socioeconomic, educational, and cultural context
TM
Are We Asking For Too Much???? ACOG/AAP PCC Components: Vaccinations
Vaccinations should be offered to women found to be at risk for or susceptible to:
• Rubella• Varicella• Hepatitis B
TM
Are We Asking For Too Much???? ACOG/AAP PCC Components: Screening Tests
Screening for HIV should be strongly recommended
A number of tests can be performed for specific indications:
• Screening for STDs• Testing for specific diseases based on medical or
reproductive history• Mantoux skin test for TB• Screening for genetic disorders based on racial/ethnic
background• Screening for other genetic disorders based on family
history
TM
Are We Asking For Too Much???? ACOG/AAP PCC Components: Screening Tests
Screening for genetic disorders based on racial/ethnic background:
• Β-Thalassemia (Mediterraneans, SE Asia, AA/B)• α-Thalassemia (AA/B and Asians)• Tay Sachs disease (Ashkhenazi Jews, French Canadians,
Cajuns)• Gaucher’s, Canavan, and Nieman-Pick Disease (Ashkenazi
Jews)• Cystic Fibrosis (Caucasians and Ashkenazi Jews)
Screening for other genetic disorders based on family history: CF, Fragile X, mental retardation, Duchene muscular dystrophy.
TM
Are We Asking For Too Much???? ACOG/AAP PCC Components: Counseling
Patients should be counseled regarding the benefits of the following activities:
• Exercising• Reducing weight before pregnancy, if overweight• Increasing weight before pregnancy, if underweight• Avoiding food additives• Preventing HIV infection• Determining the time of conception by an accurate menstrual
history• Abstaining from tobacco, alcohol, and illicit drug use before
and during pregnancy• Consuming Folic Acid• Maintaining good control of any pre-existing medical
conditions
TM
Do We Have Tools And Programs?
Yes, no, maybe! but:• Mostly individual efforts• Not standard or homogenous• No impact evaluation• No clear / practical guidelines• No tools
NO WE DO NOT HAVE PROGRAMS!!!
TM
Common Excuses: Challenges, Barriers
Unplanned pregnancies Better definition of components Timing Target population Training and education:
• Providers• Policy makers• Consumers
Policy development and implementation
$$$ Reimbursement $$$
TM
Before We Proceed, Simple Questions
What is it? Who should provide it? Who should get it? Where do we provide it? When do we provide it? Who pays for it?
TM
What Is It?
What are the components of PCC that work?
Do we have scientific basis for All the recommended components of PCC?
Is the benefit of the sum equal to or greater than the benefit of each component?
Is it cost-effective?
TM
Who Should Provide It?
Or, Who should provide what? Obstetricians/Gynecologists Other physicians Nurses Social workers Health educators The media Schools Others
TM
Who Should Get It?
Women/Couples planning pregnancies? All women at risk of getting pregnant? Women with poor prior pregnancy
outcome? All women of reproductive age? Young women at schools before they are
sexually active? Men and women Others?
TM
Where Do We Provide It?
Ob/Gyn clinics Clinics where “at risk of
pregnancy” women get services? Every health care provision
setting? Schools and community settings? Other?
TM
When Do We Provide It?
Between pregnancies? Few months before
pregnancy? A year before pregnancy? At every encounter with the
health care system?
TM
Who Pays For It?
And what do they pay for?
• Should it be part of the “pregnancy package”?
• Do we expect them to pay every time for all recommended services?
• Should they pay for selected services at selected times?
TM
What To Do?The CDC PCC Initiative
Try to answer the simple, practical questions Make the scientific case; Solidify the scientific
evidence Make the business case Develop consensus Develop recommendations and national policy Develop the knowledge and skills of providers Educate consumers Develop guidelines and tools for implementation Implement recommendations
TM
Making the Scientific and Business Cases, Assessing PCC Components
Qualitative assessment of the strength of evidence supporting the guidelines recommending care
Quantitative estimation of women (or couples) who potentially could benefit from improved access
TM
Making the Scientific CaseQualitative Assessment of Components
Evidence is strong that: • Interventions are effective • Interventions must be begun before
conception
There are clinical practice guidelines to inform health care delivery
There are surveillance systems to measure risk factor prevalence
TM
Making the Scientific CaseQualitative Assessment, Selected Components
Universal:• Folic Acid
Supplements• Rubella Sero-
Negativity• HIV/AIDS• Maternal PKU• Diet (Obesity)
Targeted:• Oral
Anticoagulant use
• Anti-Epileptic Drugs (AEDs)
• Accutane Use• Smoking • Alcohol Misuse• Diabetes• Hypothyroidism
TM
Making the Business CaseQuantitative Assessment of Components
Table 4: Estimation of the Potential to Lower Risk among Planned Pregnancies (PLRPP)
Risk Factor Prevalence Component of
Preconception Care
Among Women [18-44 yrs]
Among Women [18-44 yrs]
having Births
PLRPP- (Number of Pregnancies
per Component)
Targeted percent of PLRPP per Component
(To Be Estimated From Best Evidence)
Folic Acid Supplements
721/1000 (40.2 million)
Gallup Poll 2001
2,837,908 (Modeled)
1,999,267
Rubella Sero-Negativity
276,082 (7.1%)
Surveillance
196,287
Diabetes (Preconceptional)
38/1000 (2.1 million) BRFSS 2001
113,132 (Modeled)
66,442
Hypothyroidism 412/1000 (2,3 M) NAMC
2001-2002
160,199 (Modeled)
90,987
HIV/AIDS CDC HIV/AIDS
Maternal PKU 0.09/1000 (5,000)
Modeled
349 (Modeled)
250
Also Maternal PKU, oral anticoagulant use, Anti-epileptic drugs, accutane use, smoking, alcohol, obesity
TM
Making The Business CaseTarget Population: 2000 Statistics
2,069,995 Intended Births
1,988,819 Unintended Births
77,519 Very Preterm 57,967 Very Low Birthweight467,201 Preterm307,030 Low Birthweight857,475 Induced abortions
80,759,000 Women 15-44 years
TM
Activities to Date
Literature Review: Qualitative and Quantitative assessments
CDC PCC Workgroup, internal discussions
Partnerships and discussions with national partners: MOD, ACOG, AAP, CityMatCH, MCHEP, CSTE, NACCHO, ASTHO, others
Discussions at conferences
TM
Next Steps Assessment of Ob/Gyn’s Knowledge, Attitudes and
Practices:• Identify knowledge gaps• Develop training materials
Assessment of Health Plans practices Exploring best practices:
• Telephone support• Chronic care model• Self assessment tools
Workshop to develop a Workplan and Recommendations Implementation
TM