The WISEWOMAN Program provides free screenings and counseling for women about their risk for heart disease and stroke. WISEWOMAN aims to improve the delivery of heart disease and stroke prevention services by focusing on CVD risk factors, specifically improving blood pressure control. Women are then supported as they participate in evidence-based lifestyle programs, Health Coaching and/or are referred to community resources. WISEWOMAN Clinical Screening Services are funded through the provider’s annual contract amendment.

WISEWOMAN Screening Requirements

ll WISEWOMAN providers must conduct a baseline screening, in accordance with national clinical guidance, for all women enrolling in WISEWOMAN and rescreen WISEWOMAN participants 12-18 months* after their previous WISEWOMAN screening. WISEWOMAN participants should have their demographics and enrollment paperwork obtained prior to a screening by completing the SMHW/WISEWOMAN Participant Agreement Form (white) and the SMHW/WISEWOMAN Patient History Form (green).

*Note: Although a rescreening visit should occur 12-18 months after the previous WISEWOMAN screening visit, an 11-month cutoff has been established to allow flexibility for women who return just before the one-year mark*

Baseline Screening and Rescreening Components

For WISEWOMAN screenings to be considered valid, they must include:

• Demographics—date of birth, race and ethnicity
• Previous cardiovascular disease risk—high cholesterol, hypertension, diabetes, stroke/TIA, heart attack, coronary artery disease, heart failure, vascular disease/peripheral artery disease, congenital heart disease and defects
• Use of medications to lower cholesterol, blood pressure, blood sugar and/or daily aspirin for heart attack and stroke prevention
• Diet—consumption of fruits, vegetables, fish, whole grains, beverages with added sugar and salt/sodium intake
• Physical activity
• Alcohol consumption
• Overall wellness/mental health status
• Tobacco use/smoking status
• Height, weight and BMI
• Two complete blood pressure (BP) measurements [2 systolic blood pressures (SBP) and 2 diastolic blood pressures (DBP)] with an average of the readings
• Laboratory values—total cholesterol, HDL, LDL, triglycerides and a fasting glucose or hemoglobin A1C

WISEWOMAN Clinical Measurements

The clinical screening component of the WISEWOMAN Program is used to assess the presence and evaluate a participant’s cardiovascular risk, provide participant-centered Risk Reduction Counseling and determine appropriate next steps.

Body Mass Index (BMI)

Body Mass Index (BMI) is an indicator of the amount of body fat, for most people, and is used as a screening tool to identify if an adult is at a healthy weight. BMI is a numerical value of a person’s height in relation to their weight. Individuals with a BMI that is considered overweight (≥25kg/m²) are at a higher risk of cardiovascular disease, hypertension and type 2 diabetes.

To Calculate a Participant’s BMI:

• Obtain the participant’s weight in pounds (lbs) and height in inches (in)
• Calculate BMI using a standard BMI chart or table
  • Find the appropriate height in the left-hand column labeled “height”
  • Move across to a given weight to the number at the top of the column that correlates to the BMI for that height and weight

Waist-To-Hip Ratio

In women, waist–to-hip ratio can be a stronger independent risk factor than BMI (Lapidus et al., 1984). The World Health Organization (WHO) Expert Consultation on Obesity recognizes the importance of abdominal fat mass/abdominal obesity, which can vary considerably within range of total body fat and BMI (WHO, 2000a).

Guidelines on waist and hip measurements:

• Make both measurements with a stretch‐resistant tape that is wrapped snugly around the subject, but not to the point that the tape is constricting
• Keep the tape level and parallel to the floor at the point of measurement
• Ensure that the subject is standing upright during the measurement, with arms relaxed at the side, feet evenly spread apart and body weight evenly distributed
• Measure waist circumference at the end of several consecutive natural breaths, at a level parallel to the floor, midpoint between the top of the iliac crest and the lower margin of the last palpable rib in the mid axillary line
• Measure the hip circumference at a level parallel to the floor, at the largest circumference of the buttocks

*Note: Waist and hip measurements to calculate waist-to-hip ratio are NOT required for WISEWOMAN screenings, but are strongly suggested to help support the understanding of CVD risk factors of individual participants and the overall WISEWOMAN population*

Blood Pressure Guidelines

The Missouri WISEWOMAN Program follows the blood pressure guidelines of the American Heart Association (AHA) and American College of Cardiologists (ACC).

Two complete BP measurements are required for wisewoman services and should be taken using the following steps/techniques to ensure accuracy:

Step 1: Properly prepare the patient

• Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 minutes
• The patient should avoid caffeine, exercise and smoking for at least 30 minutes before measurement
• Ensure patient has emptied her bladder
• Neither the patient nor the observer should talk during the rest period or during the measurement
• Remove all clothing covering the location of cuff placement
• Measurements made while the patient is sitting or lying on an examining table do not fulfill these criteria

Step 2: Use proper technique for BP measurements

• Use a BP measurement device that has been validated and ensure that the device is calibrated periodically
• Support the patient’s arm (e.g., resting on a desk)
• Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the midpoint of the sternum)
• Use the correct cuff size, such that the bladder encircles 80% of the arm and note if a larger- or smaller-than-normal cuff size is used
• Either the stethoscope diaphragm or bell may be used for auscultatory readings

Step 3: Take the measurements needed for diagnosis and treatment of hypertension

• At the first visit, record BP in both arms and use the arm that gives the higher reading for subsequent readings
• Separate repeated measurements by 1–2 minutes
• For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate SBP—inflate the cuff 20–30 mm Hg above this level for an auscultatory determination of the BP level
• For auscultatory readings, deflate the cuff pressure 2 mm Hg per second, and listen for Korotkoff sounds

Step 4: Properly document accurate BP readings

• Record SBP and DBP—if using the auscultatory technique, record SBP and DBP as onset of the first Korotkoff sound and disappearance of all Korotkoff sounds, respectively, using the nearest even number
• Note the time of most recent BP medication taken before measurements, if applicable

Step 5: Average the readings using ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP

Step 6: Provide BP readings to patient both verbally and in writing

Reference: Whelton, Paul K., et al. “Correction to: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure In Adults: A Report of the American College OF CARDIOLOGY/AMERICAN Heart Association Task Force on Clinical Practice Guidelines.” Hypertension, vol. 71, no. 6, June 2018, doi:10.1161/hyp.0000000000000076.

Laboratory Values

• WISEWOMAN labs must be completed 30 days before or after a screening visit
• Lab values must be reviewed verbally and in writing with WISEWOMAN participants with proper documentation by providers
• A complete lipid panel (total cholesterol, HDL, LDL, triglycerides) and a fasting glucose or A1C are required for WISEWOMAN screening
• A participant may have one Comprehensive Metabolic Panel (CMP) or Basic Metabolic Panel (BMP) per year, if medically necessary, and the provider should document the reasoning for the lab draw, as well as any abnormal values found on the CMP or BMP
• If a CMP or BMP is drawn, the provider will not be reimbursed for a glucose, also, as you can obtain the value from the CMP or BMP
• Fasting laboratory tests are preferred over non-fasting, in accordance with national clinical guidelines
• When fasting laboratory tests are not feasible, providers may use non-fasting laboratory tests to maximize screening opportunities

Fasting Lab Guidelines

• Women should fast for 9-12 hours prior to a fasting lab draw
• If a woman has a history of high cholesterol and/or is on lipid-lowering therapy, a fasting lab value is required
• In participants with pre-existing diabetes or for those who are non-fasting, A1C should be performed for glucose testing
• If the participant presents in a non-fasting state, only the values for total cholesterol and HDL will be useable and a follow-up fasting lipid profile is needed

Follow-Up/Repeat Lab Guidelines

• WISEWOMAN will reimburse for a repeat fasting lab within 30 days of the WISEWOMAN Screening if a woman’s non-fasting labs are abnormal, she has a history of high cholesterol and/or she is on lipid-lowering therapy
• If a participant has an abnormal WISEWOMAN Screening, they may have repeat labs drawn 3-6 months following their screening office visit
• If a woman is participating in Health Coaching, an ideal time to repeat labs is during her face-to-face Follow-Up Rescreen
• Repeat labs will be documented using the Diagnostic Form (gray) and submitted as a WISEWOMAN Lab Only claim

*Note: If a participant has a CMP or BMP drawn and there are abnormal findings unrelated to CVD risk and prevention, WISEWOMAN will not reimburse for follow-up labs—if there is a question regarding lab coverage, contact the WISEWOMAN staff*