Increasing contraception use among women receiving teratogenic medications in a rheumatology clinic

Abstract

Teratogenic medications are often prescribed to women of childbearing age with autoimmune diseases. Literature suggests that appropriate use of contraception among these women is low, potentially resulting in high-risk unintended pregnancies. Preliminary review in our clinic showed suboptimal documentation of women's contraceptive use. We therefore designed a quality improvement initiative to target three process measures: documentation of contraception usage and type, contraception counselling and provider action after counselling. We reviewed charts of rheumatology clinic female patients aged 18-45 over the course of 10 months; for those who were on teratogenic medications (methotrexate, leflunomide, mycophenolate and cyclophosphamide), we looked for evidence of documentation of contraception use. We executed multiple plan-do-study-act (PDSA) cycles to develop and evaluate interventions, which centred on interprofessional provider education, modification of electronic medical record (EMR) templates, periodic provider reminders, patient screening questionnaires and frequent feedback to providers on performance. Among eligible patients (n=181), the baseline rate of documentation of contraception type was 46%, the rate of counselling was 30% and interventions after counselling occurred in 33% of cases. Averaged intervention data demonstrated increased provider performance in all three domains: documentation of contraception type increased to 64%, counselling to 45% and provider action to 46%. Of the patients with documented contraceptives, 50% used highly effective, 27% used effective and 23% used ineffective contraception methods. During this project, one unintentional pregnancy occurred in a patient on methotrexate not on contraception. Our interventions improved three measures related to contraception counselling and documentation, but there remains a need for ongoing quality improvement efforts in our clinic. This high-risk population requires increased provider engagement to improve contraception compliance, coupled with system-wide EMR changes to increase sustainability.

Keywords: ambulatory care; continuous quality improvement; implementation science; pdsa; women’s health.

Figure 1

Tools developed for interventions. (A) review of systems dot phrase placed in electronic medical record note templates to prompt providers to ask about patients’ contraception use and (B) screening questionnaire given to patients during check-in to enable patients to self-identify the need to discuss contraception with their provider.

Figure 2

Types of contraception documented. Outer ring represents the total number of patients receiving highly effective contraception, effective contraception or ineffective contraception (n=181). Inner ring describes percentage of patients by each contraception type (n=114).

Figure 3

Run chart for plan-do-study-act (PDSA) cycles. Run chart for the three primary outcome measures throughout the 10 time points of the project. Timing of PDSA cycles are numbered and marked by arrows. PDSA #1: rheumatology grand rounds presentation. PDSA #2: addition of review of systems question. PDSA #3: second rheumatology grand rounds presentation. PDSA #4: paper reminder sheet system. PDSA #5: third rheumatology grand rounds presentation. PDSA #6: clinical faculty meeting discussion. PDSA #7: clinical staff meeting discussion. Documentation rate=number of patients with contraception status identified over total number of eligible patients. In addition to the seven PDSA cycles, data was pulled and analysed at baseline (August), in March, and at the conclusion of the study (end-May). Counselling rate=number of patients who received conception counselling over total number of eligible patients. Provider action rate=number of patients who received further action was taken over the total number of patients who received counselling.