Systematic review of the literature informing the systemic lupus erythematosus indicators project: Reproductive health care quality indicators

Improvement of pregnancy counselling and contraception counselling and documentation in a single rheumatology academic practice: a quality improvement project

The purpose of this quality improvement project was to improve the rate of pregnancy counselling and documentation regarding the risk of being on teratogenic medications, including leflunomide, mycophenolate, methotrexate or cyclophosphamide in women of childbearing age (17–50 years). Our goal was to increase documentation rates by 25% in 6 months. We first performed an EMR chart review of 103 women who were seen in the 6 months prior to intervention by faculty at a single rheumatology academic centre. We then determined how many of those women had documented contraception or pregnancy counselling, which included written documentation anywhere in the note or ICD codes which were specific to pregnancy counselling or contraception counselling. Interventions were then implemented. The percentage of women who had documented pregnancy counselling did not change preintervention and postintervention; preintervention 37% of women received documented pregnancy counselling and postintervention 35% of women received documented pregnancy counselling. The percentage of women who had documented contraception counselling did however change preintervention and postintervention; preintervention 37% of women received documented contraception counselling and postintervention 51% of women received documented contraception counselling, which is a 14% improvement.

Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus

Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.

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

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.

Monitoring of Systemic Lupus Erythematosus Pregnancies: A Systematic Literature Review

OBJECTIVE

Few data exist to guide the frequency and type of monitoring in systemic lupus erythematosus (SLE) pregnancies. A systematic literature review was performed to address this gap in the literature.

METHODS

A systematic review of original articles (1975-2015) was performed using Medline, Embase, and Cochrane Library. We included search terms for SLE, pregnancy, and monitoring. We also hand-searched reference lists, review articles, and grey literature for additional relevant articles.

RESULTS

The search yielded a total of 1106 articles. After removing 117 duplicates, 929 articles that were evidently unrelated to our topic based on title and/or abstract, and 7 that were in a language other than English or French, 53 articles were included for full-text review. Following a more in-depth review, 15 were excluded: 6 did not use any measure of SLE activity and 6 did not specifically address SLE monitoring in pregnancy; 1 case series, 1 review, and 1 metaanalysis were removed. Among the 38 included studies, presence of active disease, antiphospholipid (aPL) antibodies positivity, and abnormal uterine and umbilical artery Doppler studies predicted poor pregnancy outcomes. No studies evaluated an evidence-based approach to the frequency of monitoring.

CONCLUSION

Few existing studies address monitoring for optimal care during SLE pregnancies. The available data imply roles for aPL antibodies measurement (prior to pregnancy and/or during the first trimester), uterine and umbilical artery Doppler studies in the second trimester, and following disease activity. Optimal frequency of monitoring is not addressed in the existing literature.

Low prevalence of contraceptive use among Brazilian women of reproductive age with systemic lupus erythematosus

This was a cross-sectional study of women of reproductive age with systemic lupus erythematosus (SLE) being treated at Bahiana School Rheumatology Service in Brazil. The study aimed to assess the prevalence of contraceptive counselling and use. An interview was performed, and the results were analysed before and after the SLE diagnosis. Eighty-five women were included; the mean age of the group was 32.98 ± 8.39 years. Before SLE diagnosis, most of the patients had used some contraceptive method; mainly oral contraceptives (54%) or hormone injections (21%). After SLE diagnosis, 53% of patients did not use any contraceptive method. Among the remaining patients who continued using contraceptives, 22% used condoms, 11% used combined oral contraceptives and 7% used hormone injections. Although 62% of the patients regularly visited the gynaecologist, 56% were unaware of which contraceptive method could be used safely. Thus, a better contraceptive counselling of women of a reproductive age should be performed after SLE diagnosis. Impact Statement What is already known on this subject? Women diagnosed with SLE have inadequate counselling about family planning. What the results of this study add? Brazilian women with SLE have a low prevalence of contraceptive use after their diagnosis and are exposed to having high-risk pregnancies. What the implications are of these findings for clinical practice and/or further research? The results we found highlight the importance of continued medical educational programmes and establish questions for further studies in order to investigate the interventions used to improve the contraceptive use for women diagnosed with SLE.

Systemic lupus erythematosus diagnosis and management

SLE presents many challenges for clinicians. The onset of disease may be insidious, with many different symptoms and signs, making early and accurate diagnosis challenging. Tests for SLE in the early stages lack specificity; those that are useful later often appear only after organ damage is manifest. Disease patterns are highly variable; flares are not predictable and not always associated with biomarkers. Children with SLE may have severe disease and present special management issues. Older SLE patients have complicating co-morbid conditions. Therapeutic interventions have improved over recent decades, but available drugs do not adequately control disease in many patients, and successful outcomes are limited by off-target effects; some of these become manifest with longer duration of treatment, now in part revealed by improved rates of survival. Despite all of these challenges, advances in understanding the biological basis of SLE have translated into more effective approaches to patient care. This review considers the current state of SLE diagnosis and management, with a focus on new approaches and anticipated advances.

Reliable Pregnancy Testing Before Intravenous Cyclophosphamide: A Quality Improvement Study

BACKGROUND AND OBJECTIVE

Cyclophosphamide is a teratogenic medication used in the treatment of adolescents with autoimmune disorders. This adolescent population is sexually active, does not receive adequate contraceptive care, and is at risk for unintended pregnancy. We undertook a quality improvement initiative to improve rates of pregnancy screening before intravenous cyclophosphamide administration in our adolescent girl patients.

METHODS

Data were collected from the electronic medical record. The primary outcome was completion of a urine pregnancy test before intravenous cyclophosphamide infusion in girls aged 12 to 21 years between July 2011 and June 2015. Data were reviewed quarterly and an iterative quality improvement approach was used. Interventions included staff education, electronic order set updates, and a Maintenance of Certification project. Interrupted time series analysis and multivariable mixed effects logistic regression were used to evaluate trends over time and to adjust for potential confounders.

RESULTS

Thirty girls received 153 cyclophosphamide infusions during the study. Pregnancy testing before medication administration increased from 25% to 100% by study completion. Infusions in the last time period were significantly more likely to be accompanied by a pregnancy test versus those in the first time period (odds ratio: 17.7; 95% confidence interval [CI]: 3.1-101.6) after adjustment for patient age, managing service, infusion setting, and insurance type.

CONCLUSIONS

Our institution achieved a significant increase in standard pregnancy screening in adolescent girls receiving intravenous cyclophosphamide. The interventions most valuable in increasing screening rates were updating electronic order sets, educating staff, and physician engagement in the Maintenance of Certification program.

Who receives contraception counseling when starting new lupus medications? The potential roles of race, ethnicity, disease activity, and quality of communication

OBJECTIVE

Family planning discussions are an important aspect of medical care for women with systemic lupus erythematosus (SLE) as active disease is a risk factor for poor pregnancy outcomes, and the medications used for treatment can be harmful to the fetus when used during conception and pregnancy. Our objective was to examine the impact of patient perception of quality and type of communication on receiving contraception counseling.

METHODS

Data were derived from patients enrolled in the University of California, San Francisco Lupus Outcomes Study. Individuals participate in a yearly structured telephone interview that includes assessment of contraception counseling when starting new medications, and measures of communication and decision making. Logistic regression was performed to identify predictors of not receiving contraception counseling.

RESULTS

Of the 68 women included in this analysis, one-third did not receive contraception counseling when starting new medications. Older age, white race, depressive symptoms, and higher SLE disease activity were independently associated with not receiving contraception counseling. Participants who did not receive contraception counseling rated their physicians lower in shared decision-making (SDM) communication.

CONCLUSIONS

This study demonstrates a gap in family planning counseling among women with SLE starting new medications. Future studies to address these potential areas of intervention, including education about the need for contraception through menopause, and mechanisms to engage in SDM surrounding contraception are needed to improve quality of care for women with lupus.

Application and feasibility of systemic lupus erythematosus reproductive health care quality indicators at a public urban rheumatology clinic

OBJECTIVES

Quality indicators (QIs) are evidence-based processes of care designed to represent the current standard of care. Reproductive health QIs for the care of patients with systemic lupus erythematosus (SLE) have recently been developed, and examine areas such as pregnancy screening for autoantibodies, treatment of pregnancy-associated antiphospholipid syndrome, and contraceptive counseling. This study was designed to investigate our performance on these QIs and to explore potential gaps in care and demographic predictors of adherence to the QIs in a safety-net hospital.

METHODS

We performed a record review of patients with a diagnosis of SLE at Denver Health Medical Center (DH) through an electronic query of existing medical records and via chart review. Data were limited to female patients between the ages of 18 and 50 who were seen between July 2006 and August 2011.

RESULTS

A total of 137 female patients between the ages of 18 and 50 were identified by ICD-9 code and confirmed by chart review to have SLE. Of these, 122 patients met the updated 1997 American College of Rheumatology SLE criteria and had intact reproductive systems. Only 15 pregnancies were documented during this five-year period, and adherence to autoantibody screening was 100 percent. We did not have any patients who were pregnant and met criteria for pregnancy-associated antiphospholipid syndrome. Sixty-five patients (53%) received potentially teratogenic medications, and 30 (46%) had documented discussions about these medications' potential risk upon their initiation. Predictors of whether patients received appropriate counseling included younger age (OR 0.92, CI 0.87-0.98) and those who did not describe English as their primary language (OR 0.24, CI 0.07-0.87) in the multivariate analysis.

CONCLUSIONS

We were able to detect an important gap in care regarding teratogenic medication education to SLE patients of childbearing potential in our public health academic clinic, as only one in two eligible patients had documented appropriate counseling at the initiation of a teratogenic medication.

Side effects unrelated to disease activity and acceptability of highly effective contraceptive methods in women with systemic lupus erythematosus: a randomized, clinical trial

OBJECTIVES

To assess the side effects unrelated to disease activity and the acceptability of combined oral contraceptives (COCs), progestin-only pills (POPs) and copper-releasing intrauterine devices (IUDs) in women with systemic lupus erythematosus (SLE).

STUDY DESIGN

A randomized clinical trial including 162 women with SLE, assigned to COC (n=54), POP (n=54) or IUD (n=54). Follow-up visits were conducted after 1, 2, 3, 6, 9 and 12 months of treatment to monitor the presence of symptoms, changes in body weight and blood pressure as well as the development of health problems other than those relating to lupus. Reasons for discontinuation and satisfaction with the use of the assigned method were recorded at the end of treatment. Statistical analysis included descriptive statistics, repeated measure analyses and Kaplan-Meier curves.

RESULTS

Significantly different discontinuation rates due to any reason [35%, 55%, 29% (p<0.01)] or nonmedical reasons [(11%, 31%, 4% (p<0.05)] were observed among the COC, POP and IUD groups. Nausea was most frequent among COC users, dysmenorrhea among IUD users and acne and hirsutism among POP users. Mean blood pressures remained unchanged. Mild increases in body weight were observed over time in all treatment groups. Most women were satisfied with the use of the assigned contraceptive method.

CONCLUSIONS

Oral contraceptives and IUD are acceptable birth control methods for patients with lupus, when counseling and specialized health attention are provided; however, the acceptability of POP appears to be inferior. Side effects unrelated to lupus disease activity are not frequent reasons to discontinue the contraceptive methods.

IMPLICATIONS

This study delves into an area that has not been explored among patients with lupus. Our findings on the associated side effects and reasons for discontinuing COCs, POPs or copper-bearing IUDs may be useful in improving contraceptive counseling for women with lupus. Furthermore, they also heighten our knowledge on the reasons that may preclude the widespread use of effective contraceptives among lupus patients.

Tolerogenic versus inflammatory activity of peripheral blood monocytes and dendritic cells subpopulations in systemic lupus erythematosus

Abnormalities in monocytes and in peripheral blood dendritic cells (DC) subsets have been reported in systemic lupus erythematosus (SLE). We aim to clarify the tolerogenic or inflammatory role of these cells based on ICOSL or IFN-α and chemokine mRNA expression, respectively, after cell purification. The study included 18 SLE patients with active disease (ASLE), 25 with inactive disease (ISLE), and 30 healthy controls (HG). In purified plasmacytoid DC (pDC) was observed a lower ICOSL mRNA expression in ASLE and an increase in ISLE; similarly, a lower ICOSL mRNA expression in monocytes of ALSE patients was found. However, a higher ICOSL mRNA expression was observed in ASLE compared to HG in myeloid DCs. Interestingly, clinical parameters seem to be related with ICOSL mRNA expression. Regarding the inflammatory activity it was observed in purified monocytes and CD14^−/low CD16⁺ DCs an increase of CCL2, CXCL9, and CXCL10 mRNA expression in ASLE compared to HG. In myeloid DC no differences were observed regarding chemokines, and IFN-α mRNA expression. In pDC, a higher IFN-α mRNA expression was observed in ASLE. Deviations in ICOSL, chemokine, and IFN-α mRNA expression in peripheral blood monocytes and dendritic cells subpopulations in SLE appear to be related to disease activity.

The systematic review team: contributions of the health sciences librarian

While the role of the librarian as an expert searcher in the systematic review process is widely recognized, librarians also can be enlisted to help systematic review teams with other challenges. This article reviews the contributions of librarians to systematic reviews, including communicating methods of the review process, collaboratively formulating the research question and exclusion criteria, formulating the search strategy on a variety of databases, documenting the searches, record keeping, and writing the search methodology. It also discusses challenges encountered such as irregular timelines, providing education, communication, and learning new technologies for record keeping. Rewards include building relationships with researchers, expanding professional expertise, and receiving recognition for contributions to health care outcomes.