Contraceptive counseling and use among women with systemic lupus erythematosus: a gap in health care quality?

Alignment of contraception use with the ACR reproductive health guidelines in women with systemic lupus erythematosus within the RISE registry

OBJECTIVES

Contraception is crucial for safely timing pregnancies in patients with SLE. This study investigated predictors of contraception documentation in patients with SLE, and the alignment of contraception practices with the 2020 American College of Rheumatology (ACR) guidelines, within the Rheumatology Informatics System for Effectiveness (RISE) registry.

MATERIALS AND METHODS

Female patients (aged 18-44 years) with SLE were identified via International Classification of Diseases (ICD)-9/ICD-10 coding within the RISE registry, which includes data from rheumatology clinics across the USA. Eligible patients were required to have ≥1 clinical visit in 2019 (prepandemic) or between 1 April 2020 and 30 March 2021 (mid-pandemic). Adjusted multilevel logistic modelling assessed patient, provider and practice characteristics for associations with contraception documentation. Contraception patterns were identified and compared with the 2020 ACR guidelines.

RESULTS

Contraception documentation rates were similar in the prepandemic and mid-pandemic groups (8.1% and 8.5%, respectively). Higher documentation rates were found in women who were younger, White, and had more visits, as well as those seen within a health system, by a female provider, and within specific regions and electronic health record (EHR) systems. Prescription of a teratogenic medication did not influence contraception documentation or type. Oestrogen-containing contraceptives were prescribed less often to women at high risk for thrombosis (26.2% with thrombotic risk vs 60.6% without, p<0.0001) and history of lupus nephritis (LN) (53.8% with history of LN vs 63.2% without, p=0.024).

CONCLUSIONS

Practices participating in the RISE registry do not currently record contraception in the large majority of women with SLE, although increased documentation in some EHRs suggests that system changes may improve rates of documentation. Women at higher risk for thrombosis were less likely to receive oestrogen, suggesting that warnings against oestrogen use has impacted contraception prescription, although the limited documentation and limited contraception among women taking teratogenic medications suggest a high unmet need.

Issues with pregnancy in systemic lupus

Systemic lupus erythematosus is a disease that affects a large number of young women of childbearing age. Today, pregnancy is considered safe in almost all women with lupus, especially when the disease is under control. However, pregnancies in this population have a higher risk of maternal complications than in the general population. It is therefore important to plan pregnancies as effectively as possible, using effective contraception and pre-pregnancy counselling. In fact, effective, well-tolerated contraception is essential for patients for whom pregnancy cannot be safely envisaged, particularly in the setting of teratogenic treatment or significant disease activity. Preconception counselling is essential and helps to anticipate several aspects of a future pregnancy. Several recent prospective studies have clearly identified risk factors for obstetric complications and disease flare. High level of lupus activity, low complement, primigravida and a history of lupus nephritis are predictive factors of disease flare when antiphospholipid syndrome or antiphospholipid antibodies (specifically for lupus anticoagulant), damage, activity of lupus are predictive for obstetric events. Appropriate therapeutic management is essential, based primarily on the continuation of hydroxychloroquine, although some recent warnings about its use in pregnancy have been discussed controversially. Corticosteroid therapy can be continued at the lowest possible dose, as can certain immunosuppressive drugs. In the case of a history of lupus nephritis, low-dose aspirin is also prescribed. Although still exceptional, the risk of neonatal lupus is also higher, in patients with anti-SSA and anti-SSB antibodies. The aim of this review is to summarise the risk factors for adverse obstetric outcomes and to improve medical and obstetric management in this population of pregnant women with lupus.

A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations

This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.

Frequency of Contraception Documentation in Women With Systemic Lupus Erythematosus and Rheumatoid Arthritis Within the Rheumatology Informatics System for Effectiveness Registry

OBJECTIVE

We sought to understand the frequency of contraception documentation for women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a large US electronic health record (EHR)-based registry and to identify disparities by teratogen prescription and patient race and ethnicity.

METHODS

Contraception documentation from structured data fields within the Rheumatology Informatics System for Effectiveness (RISE) registry was collected for women of childbearing age (18-45 years) in 2018 who had at least 2 visits with International Classification of Diseases, Ninth Revision or Tenth Revision, diagnosis codes for SLE or RA (at any time). Univariate and multivariate analyses compared the frequency of contraception documentation based on patient characteristics including diagnosis, age, race, and teratogenicity of prescribed antirheumatic medications.

RESULTS

In 2018, there were 9,826 women of childbearing age with SLE and 19,009 with RA, of whom 9.1% had any contraception documented. Rates of contraceptive documentation were significantly lower for women with SLE (adjusted odds ratio [OR] 0.84 [95% confidence interval (95% CI) 0.76-0.92]). Women of Hispanic ethnicity and Black and Asian race were all less likely than White women to have contraception documentation. Teratogen prescription was associated with higher rates of contraception documentation for women with RA but not SLE (RA adjusted OR 1.31 [95% CI 1.16-1.47]; SLE adjusted OR 1.08 [95% CI 0.91-1.28]).

CONCLUSION

There are large gaps in contraception documentation within the RISE registry that are particularly stark among women of color. Although these data likely underestimate contraception use, they highlight that most rheumatologists do not have a systematic approach to collecting and recording this information in the EHR.

Association of clinic setting with quality indicator performance in systemic lupus erythematosus: a cross-sectional study

BACKGROUND

Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. We aimed to assess the quality of care processes in different clinic settings, comparing a subspecialty lupus clinic with hospital-based and private general rheumatology clinics.

METHODS

Patients with SLE (n = 258) were recruited in 2016 from a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private rheumatology clinics (n = 55). Data were collected from medical records and patient questionnaires. Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidity assessments, drug monitoring, preventative care and reproductive health. Per-QI performance was measured as a percentage of patients that met the QI relative to the number of patients eligible. Per-patient QI performance was calculated as a percentage of QIs met relative to the number of eligible QIs for each patient. Per-QI and per-patient QI performance were compared between the three clinic settings, and multiple regression performed to adjust for sociodemographic, disease and healthcare factors.

RESULTS

Per-QI performance was generally high across all clinic settings for diagnostic work-up, comorbidity assessment, lupus nephritis, drug monitoring, prednisolone taper, osteoporosis and pregnancy care. Median [IQR] per-patient performance on eligible QIs was higher in the subspeciality lupus clinic (66.7% [57.1-74.1]) than the hospital general rheumatology (52.7% [47.5-58.1]) and private rheumatology (50.0% [42.9-60.9]) clinics (p <0.001) and the difference remained significant after multivariable adjustment. The subspecialty lupus clinic recorded higher per-QI performance for documentation of disease activity, disease damage, cardiovascular risk factor and drug toxicity assessments, pre-immunosuppression hepatitis and tuberculosis screening, new medication counselling, vaccinations, sun avoidance education and contraception counselling.

CONCLUSIONS

SLE patients managed in a subspecialty lupus clinic recorded higher per-patient QI performance compared to hospital general rheumatology and private rheumatology clinics, in part related to better documentation on certain QIs.

Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool

OBJECTIVE

Systemic rheumatic conditions affect reproductive-aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice.

METHODS

This 6-month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists' barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented.

RESULTS

When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients' reproductive goals increased (31%-38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%-21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21-4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow-up (P = 0.003) compared with patients who were not screened with OKQ.

CONCLUSION

Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.

Pregnancy termination in patients with rheumatic diseases

Rheumatic diseases affect women during their reproductive years. Many women with rheumatic diseases become pregnant; some undergo pregnancy termination. However, there are no official guidelines on pregnancy termination in patients with rheumatic diseases. This paper provides an overview of considerations that healthcare professionals must take into account. We highlight areas that require further studies and the importance of pregnancy planning and contraception counseling. Patients with rheumatic diseases need to be informed of adverse maternal and fetal outcomes of pregnancy to make informed reproductive decisions and reduce the need for pregnancy terminations. This article is protected by copyright. All rights reserved.

Racial Differences in Contraception Encounters and Dispensing Among Female Medicaid Beneficiaries With Systemic Lupus Erythematosus

OBJECTIVE

African American and Hispanic women with systemic lupus erythematosus (SLE) have the highest rates of potentially avoidable pregnancy complications, yet racial disparities in family planning among reproductive-age women with SLE have not been well-studied. Our objective was to examine whether there are racial differences in contraception encounters and dispensing among US Medicaid-insured women with SLE.

METHODS

Using Medicaid claims data from 2000-2010, we identified women ages 18-50 years with SLE. We examined contraception encounters and uptake over 24 months. We used multivariable logistic regression to estimate the odds ratio and 95% confidence interval by race/ethnicity of contraception encounters, any contraception dispensing, and highly effective contraception (HEC) use, adjusted for age, region, year, SLE severity, and contraindication to estrogen. We also compared contraception encounters and dispensing among women with SLE to the general population and women with diabetes mellitus.

RESULTS

We identified 24,693 reproductive-age women with SLE; 43% were African American, 35% White, 15% Hispanic, 4% Asian, 2% other race, and 1% American Indian/Alaska Native. Nine percent had a contraceptive visit, 10% received any contraception, and 2% received HEC. Compared to White women, African American and Asian women had lower odds of contraception dispensing, and African American women had lower odds of HEC use. Women with SLE were more likely to receive HEC than the general population and women with diabetes mellitus.

CONCLUSION

In this study of reproductive-age women with SLE, African American and Asian women had lower odds of contraception dispensing and African American women had lower odds of HEC use. Further study is needed to understand the factors driving these racial disparities among this population.

Contraceptive Prevalence and Consulting Service in Women with Systemic Lupus Erythematosus: A Cross-Sectional Study

Background

Systemic lupus erythematosus (SLE), often affects women of childbearing age. Family planning consultation is a major aspect of medical care in these patients because of the risk of disease activation and poor pregnancy and fetal outcomes. The aim of the present study was to evaluate contraceptive prevalence and consulting service in women with SLE.

Methods

In a cross-sectional study, a total of 144 female patients with SLE, ages 15–50, who were presented to rheumatology clinics in Sari, north of Iran, were evaluated. The study was conducted between March 2019 and May 2020. Patients' clinico-demographic profile and fertility information were obtained. Disease activity and damage were assessed by the systemic lupus erythematosus disease activity (SLEDAI) and Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (SDI).

Results

One hundred and forty-four SLE patients of childbearing age participated in this study. From 102 patients with the possibility of pregnancy, 36(35.2%) received contraceptive consultations in last year. Withdrawal was the most prevalent contraceptive method (41.7%), followed by permanent (11.8%), and barrier methods (9%). There were no significant differences in age, disease duration, marriage duration, SDI or SLEDAI scores between the women who received or not received contraceptive counseling (P>0.05).

Conclusion

Many SLE patients did not receive adequate information about contraception, and it may be associated with many adverse effects on disease activity and pregnancy outcomes. Therefore, contraceptive consultation as an important aspect of patient's management is strongly suggested.

Exploring the Preferences of Women Regarding Sexual and Reproductive Health Care in the Context of Rheumatology: A Qualitative Study

OBJECTIVE

To explore the sexual and reproductive health (SRH) care and counseling needs of young women with rheumatic diseases in the context of their rheumatology care.

METHODS

Semistructured qualitative telephone interviews were conducted with female patients with rheumatic diseases ages 18-45 years (n = 30). Women were recruited from outpatient rheumatology clinics in western Pennsylvania. Interviews were audiorecorded and transcribed verbatim. A codebook was inductively developed based on the interview transcripts, and the finalized coding was used to conduct a thematic analysis.

RESULTS

Four themes emerged from interviews: 1) women want rheumatologists to initiate conversations about SRH and to revisit the conversation over time; 2) women desire clear and complete information regarding fetal, pregnancy, and infertility risks associated with their diseases and disease-modifying antirheumatic drugs (DMARDs); 3) women want to be treated holistically, with SRH addressed in the context of their life circumstances and personal values in addition to their rheumatic diseases; 4) women generally feel that they are intermediaries between their rheumatologists and obstetrician-gynecologists (OB/GYNs), but preferred for providers to communicate directly with one another about their SRH.

CONCLUSION

Patients strongly desired rheumatologists to play an active role in their SRH, by initiating family planning conversations, providing SRH education in the context of their diseases and DMARDs, and directly coordinating SRH care with OB/GYNs. To meet patients' SRH needs, further work is needed to clarify the specific role of rheumatologists in providing SRH care and to identify ways to better facilitate communication between rheumatologists and reproductive health care providers.

Views of Mexican outpatients with rheumatoid arthritis on sexual and reproductive health: A cross-sectional study

BACKGROUND

Rheumatoid arthritis (RA) impacts sexual and reproductive health (SRH), which is a prominent component of a patient´s quality of life and highly influenced by the cultural background. The aim of the study was to explore the interest of Mexican outpatients with RA in SRH and to examine patient view on SRH.

METHODS

This cross-sectional study surveyed 303 consecutive outpatients with RA on their perceptions of SRH importance, SRH satisfaction, access to SRH information, preferences regarding SRH communication with healthcare professionals, and understanding of SRH (qualitative open-ended descriptions). Descriptive statistics and inferential analysis were used. Patient knowledge of each dimension of SRH was rated based on pre-specified criteria. Two assessors assigned ten major themes to each patient´s description of both dimensions of SRH.

RESULTS

Patients perceived their SRH as an important component of their general health and wished to address the topic, although few had access to such communication. Female patients assigned lesser importance to SRH, showed lesser degree of satisfaction with SRH, and expressed preference for a truthful physician. Age showed a linear association with individual survey responses, except for satisfaction with reproductive health dimension. There was a linear association between increased age and decreased years of formal education with a lower level of SRH knowledge. Ten major themes emerged for each of the two dimensions of the SRH construct, although most individual descriptions were assigned to one or two major themes.

CONCLUSIONS

Further education and assessment of SRH in Mexican patients with RA is warranted.

Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic

OBJECTIVE

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

METHODS

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

RESULTS

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

CONCLUSION

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

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.

Reproductive health counseling and contraceptive use in Mexican women with rheumatic diseases: a cross-sectional study

BACKGROUND

There is an overall increased risk of adverse pregnancy outcomes and maternal morbidity in patients with most autoimmune rheumatic diseases (ARD); outcomes are generally improved when the pregnancy is planned and the disease is in control.

OBJECTIVE

The objective of the present study was to describe the sexual and reproductive health characteristics and contraceptive use of Mexican women in childbearing age with ARD.

METHODS

We conducted an observational, cross-sectional, and descriptive study. All non-pregnant childbearing age women with an ARD were invited to participate. A self-administered questionnaire of ten items that included questions about sexuality, use of contraceptive methods, pregnancy desire, and contraceptional counseling was applied.

RESULTS

A total of 135 women were evaluated. The median age was 33 (25-39) years. Contraceptive use was referred by 49 (71%) of the patients that had sexual activity the last month, while 20 (28.9%) patients denied use. From the patients who had initiated sexual activity (N = 112), 41 (36.6%) did not use any contraceptive method, and 16 (14%) used a method classified as ineffective. The question about contraceptive counseling was answered by 112 patients. Eighty (70.4%) said they had received counseling from health-professional and 64 (57.1%) from their rheumatologist. A total of 57% of the women with teratogenic drugs did not employ a contraception method.

CONCLUSION

Contraceptive use and reproductive health counseling are suboptimal in Mexican women with ARD. A high proportion of women taking teratogenic drugs did not employ a highly effective contraceptive method. Strategies to improve reproductive and sexual health are necessary.

Effectiveness of reproductive health counseling of women with systemic lupus erythematosus: observational cross-sectional study at an academic lupus clinic

Systemic lupus erythematosus (SLE) affects women of childbearing age. To optimize fetal and maternal outcomes, effective reproductive health counseling is crucial. To analyze the effectiveness of reproductive health counseling in women with SLE and identify gaps in patient educational needs. Cross-sectional study including women aged 18-45 years fulfilling ACR'97 and/or SLICC criteria, followed at an academic lupus clinic. Participants fulfilled a questionnaire evaluating brief obstetric history, knowledge about impact of SLE in pregnancy outcomes, recall of reproductive health counseling, contraception use and reproductive healthcare received. Effectiveness of reproductive health counseling was analyzed, and potential predictors of contraceptive use (age, previous spontaneous abortion, level of knowledge about SLE and reproductive planning) were tested by multiple regression analysis. We enrolled 108 women (mean age: 34.4 ± 7.1 years; mean disease duration: 10.3 ± 7.3 years). 64.8% of the patients recalled receiving information about family planning, and 81% about contraception. Only 38% declared to be well informed about the impact of SLE on pregnancy. In this cohort, 23.2% wanted a pregnancy in the future; the remainder already had the children they wanted or planned a subsequent pregnancy. Contraceptive use was reported by 79.6% of the patients (oral contraceptives by 39.8% and intrauterine device by 20.4%), while 11.1% reported unprotected intercourses. No statistically significant predictors of contraceptive use were identified. In this academic Lupus Clinic, most SLE women of childbearing age received effective reproductive health counseling and use contraceptive methods. Their unmet needs were identified to guide optimization of patient counseling.

Impact of a Multifaceted Educational Program to Improve Provider Skills for Lupus Pregnancy Planning and Management: A Mixed-Methods Approach

Objective

To bring recent advances in pregnancy management in lupus to women nationwide, this multidimensional educational intervention sought to equip community rheumatologists with the needed skills, attitudes, and confidence to manage contraceptive decisions and pregnancy planning for women with lupus.

Methods

The program included an in‐person didactic, training in use of a comprehensive handout to guide contraception and pregnancy conversations, a simulated clinical experience, and access to an innovative website (www.lupuspregnancy.org). The program was analyzed using mixed methods, which included a quantitative survey by e‐mail before and after program completion and multiple qualitative interviews about attendees’ experiences integrating created resources into practice.

Results

The analysis included 68 preintervention surveys and 55 postintervention surveys. For qualitative analysis, eight interviews were completed until thematic saturation was achieved. After completion of the program, there was an increase in providers reporting a systematic approach to preparing a woman with lupus for pregnancy (from 45.6% to 94.6%; P < 0.0001). Confidence in choosing both appropriate contraception and pregnancy‐compatible medications improved significantly. As expected, change in knowledge about contraception was limited. Qualitative themes included the utility of the printable handouts, enthusiasm for the program, increased confidence and, importantly, increased empathy for the patients.

Conclusion

We created a valuable implementation tool that improves self‐reported provider skills and confidence in managing women with lupus who desire pregnancy. Providers now have access to a unique curriculum and resources that encourage providers to have open and accurate conversations about pregnancy, thus creating lasting clinical change.

A questionnaire-based study on contraceptive practice in patients with rheumatic disease found no significant difference in age-matched healthy controls

OBJECTIVE

Birth control is crucial in preventing unplanned pregnancy. The study analyzed contraceptive practice in women and men with rheumatic disease.

METHODS

A questionnaire-based study investigated the actual contraceptive practices in patients of reproductive age from three European countries and compared them to age-matched healthy women and men. Associations between patient characteristics and contraception behavior were analyzed by association analysis.

RESULTS

No significant difference in the frequency of contraception use was found in 133 rheumatic patients compared to 122 healthy controls. The main reason for not using contraception was lack of partner or the wish to become pregnant, whereas the current use of contraception was predominantly to limit family size in general or at this stage of life. Both patients and controls preferred barrier methods (48% and 45%, respectively) followed by hormonal contraceptives (31% and 38%, respectively). Characteristics associated with less use of contraception in patients were living single, having no children, and for being religious, whereas gender and education had no influence. Treatment with teratogenic drugs was no major patient concern, and 13 of 30 female patients using methotrexate, mycophenolate mofetil, or leflunomide did not practice birth control.

CONCLUSION

Patients used contraception less frequently than healthy individuals, and the main reason for use was to limit family size. Contraception should be an integral part of counseling patients of fertile age, since the patient-preferred methods in case of active disease or therapy with teratogenic drugs were unreliable for the prevention of pregnancy.

Perspectives of Adult Rheumatologists Regarding Family Planning Counseling and Care: A Qualitative Study

OBJECTIVE

Little is known about whether and how rheumatologists provide family planning counseling and reproductive health care (FPCC) to reproductive-age women with rheumatic diseases. This qualitative study sought to assess rheumatologists' perspectives, attitudes, and practices regarding FPCC.

METHODS

Semistructured interviews were conducted with a geographically diverse US sample of rheumatologists (n = 12). Interviews were transcribed verbatim, and a code book was inductively developed based on transcript content. Two coders applied the code book to all transcripts, and coding differences were adjudicated to full agreement. The finalized coding was used to conduct a thematic analysis.

RESULTS

Six themes were identified across interviews. Rheumatologists said that they 1) feel responsible for providing some FPCC to patients, 2) experience tension between respecting patients' autonomy and their own anxieties about managing high-risk pregnancies, 3) view patient-initiated conversations as FPCC facilitators, and they regard lack of guidelines and the presence of competing clinical priorities as barriers to FPCC, 4) are reluctant to prescribe contraception, 5) desire greater access to resources to help guide FPCC, and 6) recognize the benefits of multidisciplinary collaboration with gynecologists.

CONCLUSION

Rheumatologists feel a sense of responsibility to provide some aspects of FPCC to reproductive-age female patients. However, their own apprehensions about managing complicated pregnancies may negatively influence how they advise patients about pregnancy planning or avoidance. Rheumatologists do not prescribe contraception but rarely refer patients to gynecologists for contraceptive care. Future work should focus on eliminating barriers and identifying solutions that support rheumatologists' efforts to provide high-quality FPCC to patients.

2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases

OBJECTIVE

To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD).

METHODS

We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary.

RESULTS

This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD.

CONCLUSION

This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

Development of ReproKnow, a reproductive knowledge assessment for women with rheumatic diseases

Background

The objective of this study was to develop an assessment tool, ReproKnow, to evaluate the reproductive health knowledge of women with a wide range of rheumatic diseases.

Methods

The 10-item multiple-choice questionnaire was developed with feedback from a panel of content experts and female patients with rheumatic diseases. Construct validity using known-groups analysis was evaluated through comparison of median total ReproKnow scores between rheumatology fellows and nurses. Female patients aged 18–50 years were recruited to take ReproKnow and demographic questionnaires in two outpatient clinics. Associations between patients’ mean total knowledge scores and demographic characteristics were assessed using independent-sample t-tests. Questions were also categorized by topical area, and the percentages were calculated.

Results

The completion rate of questions in ReproKnow was 100% across all users. Median ReproKnow scores were significantly higher among rheumatology fellows than among nurses (p = 0.045). The 153 patients recruited to the study had at least one of 15 rheumatic diseases. Patients’ mean knowledge score was 5.05 (SD 2.24) out of a possible high score of 10. Patients who were younger, White, and more educated had significantly higher scores than did other patients (p’s < 0.05). Patients who bore children after their disease diagnosis had higher knowledge scores than did women whose children were born prior to their diagnosis; in contrast, women with histories of surgical sterilization or hysterectomy had lower knowledge scores than other women. Knowledge scores of women who used potentially fetotoxic medications did not vary from the remainder of the sample. Patients demonstrated gaps in knowledge about birth outcomes, contraceptive efficacy, and breastfeeding safety.

Conclusions

Initial testing of ReproKnow suggests that it may be a promising tool to assess the reproductive health knowledge of women with diverse rheumatic diseases. Specific knowledge deficits elicited from ReproKnow may be important targets for future educational interventions.

Contraception Use Among Reproductive-Age Women With Rheumatic Diseases

OBJECTIVE

To determine contraception use among a cohort of reproductive-age women (ages 18-50 years) with rheumatic diseases.

METHODS

We conducted a study of administrative data from a single, large medical center between the years 2013 and 2014. Women who had 1 of 21 possible rheumatic disease diagnoses and had at least 2 outpatient rheumatology visits were included in this analysis. We used logistic regression analyses to evaluate adjusted associations between the use of prescription contraception, use of potentially fetotoxic medications, and visits with rheumatologists, primary care providers, and gynecologists.

RESULTS

Of 2,455 women in this sample, 32.1% received any prescription contraception, and 7.9% of women used highly effective prescription methods (intrauterine devices, implants, and surgical sterilization). More than 70% of women took ≥1 type of fetotoxic medication during the 2-year study timeframe. Fetotoxic medication use was not associated with overall use of prescription contraception, but was associated with the use of highly effective contraceptive methods (adjusted odds ratio [OR] 2.26 [95% confidence interval (95% CI) 1.44-3.54]). Women who saw gynecologists or primary care providers were more likely to use prescription contraception overall (adjusted OR 3.35 [95% CI 2.77-4.05] and 1.43 [95% CI 1.18-1.73], respectively). Women who saw gynecologists were more likely to use highly versus moderately effective contraceptive methods (adjusted OR 2.35 [95% CI 1.41-3.94]). Rheumatology visits were not associated with use of prescription contraception in any models.

CONCLUSION

This is the largest study to date to describe contraceptive use among reproductive-age women with rheumatic diseases, and the findings reveal low use of prescription contraception. Urgent efforts are needed to improve contraceptive care and access for some women with rheumatic diseases.

Use of combined hormonal contraceptives among women with systemic lupus erythematosus with and without medical contraindications to oestrogen

OBJECTIVES

To assess the prevalence of combined hormonal contraceptives (CHCs) in reproductive-age women with SLE with and without possible contraindications and to determine factors associated with their use in the presence of possible contraindications.

METHODS

This observational cohort study included premenopausal women ages 18-45 years enrolled in the SLICC Registry ⩽15 months after SLE onset, with annual assessments spanning 2000-2017. World Health Organization Category 3 or 4 contraindications to CHCs (e.g. hypertension, aPL) were assessed at each study visit. High disease activity (SLEDAI score >12 or use of >0.5 mg/kg/day of prednisone) was considered a relative contraindication.

RESULTS

A total of 927 SLE women contributed 6315 visits, of which 3811 (60%) occurred in the presence of one or more possible contraindication to CHCs. Women used CHCs during 512 (8%) visits, of which 281 (55%) took place in the setting of one or more possible contraindication. The most frequently observed contraindications were aPL (52%), hypertension (34%) and migraine with aura (22%). Women with one or more contraindication were slightly less likely to be taking CHCs [7% of visits (95% CI 7, 8)] than women with no contraindications [9% (95% CI 8, 10)].

CONCLUSION

CHC use was low compared with general population estimates (>35%) and more than half of CHC users had at least one possible contraindication. Many yet unmeasured factors, including patient preferences, may have contributed to these observations. Further work should also aim to clarify outcomes associated with this exposure.

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.

Leveraging the electronic health record to improve quality and safety in rheumatology

During the last two decades, improving the quality and safety of healthcare has become a focus in rheumatology. Widespread use of electronic health records (EHRs) and the availability of digital data have the potential to drive quality improvement, improve patient outcomes, and prevent adverse events. In the coming years, developing and leveraging tools within the EHR will be the key to making the next big strides in improving the health of patients with rheumatoid arthritis and other rheumatic diseases, including building EHR infrastructure to capture patient outcomes and developing automated methods to retrieve information from free text of clinical notes.

Impact of Childbearing Decisions on Family Size of Korean Women with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years and has a significant impact on childbearing. We investigated the influence of personal decision on family size among Korean women with SLE and factors that affect the decisions. A case-control study comparing childbearing history and decisions of 112 SLE patients and 135 controls was performed. Women with SLE participating in the Network for Lupus Clinical Research in South Korea and matching controls between ages of 18-45, who are/were married or living with a partner were included. Data regarding socio-demographics, reproductive history, and childbearing decisions were collected through a survey using a standardized questionnaire and medical record review. More women with SLE reported at least one pregnancy (85.7% vs. 71.9%, P = 0.009) or at least one live birth (85.7% vs. 71.9%, P = 0.003) compared with controls. Mean number of pregnancies was significantly higher (2.4 ± 1.6 vs. 1.4 ± 1.3, P < 0.001), and mean number of live births was significantly lower in women with SLE (1.2 ± 0.8 vs. 1.6 ± 0.8, P < 0.001). Significantly more women with SLE made the decision not to have children compared with controls (54.5% vs. 40.7%, P = 0.031), and health-related concerns were the major cause of the decision. Other socio-demographic factors did not influence the decision to limit childbearing in SLE women. The disease-related concerns had significant impact on family size and childbearing decisions among Korean women with SLE.

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.

Understanding and Managing Pregnancy in Patients with Lupus

Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.

Possible Effect of Extended Use of Hormonal Contraception on Increased Levels of Antiphospholipid Antibodies in Infertile Women

Purpose: Increased levels of antiphosholipid antibodies (aPLs) are associated with the autoimmune disorder antiphospholipid syndrome (APS) and are known to play a role in infertility. We investigated the possible effect of prolonged use of hormonal contraception (HC) on autoimmunity after discontinuing HC in women with infertility problems. Material and Methods: We analyzed hormonal status including ovulation and the humoral autoimmune response to eight phospholipids detected by ELISA in 1190 infertile women aged 21-46 (mean age: 29.3) years. Results: Long-term HC did not affect ovulation, but in the absence of ovulation HC masked the hormonal disorders. The majority of patients taking HC for more than 10 years with fertility failure had significantly higher levels of aPLs of the IgG isotype against phosphatidylinositol and phosphatidylserine (p > 0.001) than against β2-glycoprotein I and annexin V. Discussion: Thus, high levels of aPLs are significant for the anticoagulant treatment before and during pregnancy to prevent pregnancy loss.

Receipt of prescription contraception by commercially insured women with chronic medical conditions

OBJECTIVE

To assess differences in receipt of prescription contraception among women with and without chronic medical conditions.

METHODS

This observational study used 3 years of administrative claims records for insured women aged 21-45 years who were enrolled in a commercial insurance company in Michigan between 2004 and 2009. Women were considered to have a chronic medical condition if they had at least two claims for one of the following conditions, in order of prevalence in our study population: hypertension, asthma, hypothyroidism, diabetes, obesity, rheumatoid arthritis, inflammatory bowel disease, or systemic lupus erythematosus. Our primary outcome was receipt of prescription contraception, defined by a pharmacy claim or diagnostic or procedural code. We used multivariable logistic regression to estimate the association of chronic condition status with the odds of receiving prescription contraception within 3 years adjusting for age, community-level socioeconomic status, total outpatient visits, and cervical cancer screening.

RESULTS

Of 11,649 women studied, 16.0% (n=1,862) had at least one of the chronic conditions we considered. Of those with a chronic condition, 33.5% (n=623) received prescription contraception during the 3-year study period compared with 41.1% (n=4,018) of those without a chronic condition (P<.001). After adjusting for covariates, women with a chronic condition remained less likely than women without a chronic condition to have received prescription contraception (adjusted odds ratio 0.85, 95% confidence interval 0.76-0.96, P=.010).

CONCLUSION

Despite a greater risk for adverse outcomes with an unplanned pregnancy, women with these chronic conditions were less likely to receive prescription contraception.

LEVEL OF EVIDENCE

III.

Quality of care in systemic lupus erythematosus: the association between process and outcome measures in the Lupus Outcomes Study

OBJECTIVES

Although process measures to assess quality of care in systemic lupus erythematosus (SLE) are available, their relationship to long-term outcomes has not been studied. Using a prospective, longitudinal cohort study, we examined the associations between high-quality care and two important SLE outcomes, disease activity and damage.

METHODS

Data were derived from the University of California, San Francisco Lupus Outcomes Study. Participants were followed from 2009 through 2013, responding to yearly surveys. Primary outcomes in this study were clinically meaningful increases in disease activity and damage, assessed by the Systemic Lupus Activity Questionnaire (SLAQ) and the Brief Index of Lupus Damage (BILD), respectively. Using multivariable regression, we examined the relationship between high performance on 13 validated quality measures (receipt of ≥85% of quality measures), and disease outcomes, adjusting for disease status, sociodemographic characteristics, healthcare services and follow-up time.

RESULTS

The 737 participants were eligible for a mean of five quality measures (SD 2, range 2-12). There were 155 and 162 participants who had clinically meaningful increases in SLAQ and BILD, respectively. In our models, we found no statistically significant relationship between performance on quality measures and changes in SLAQ. However, receiving higher-quality SLE care was significantly protective against increased disease damage (adjusted OR 0.4, 95% CI 0.4 to 0.7), even after adjusting for covariates.

DISCUSSION

In this community-based cohort, we illustrate for the first time a strong link between processes of care, defined by SLE quality measures, and the subsequent accumulation of disease damage, an important outcome.

Managing lupus patients during pregnancy

Systemic lupus erythematosus (SLE) is an auto-immune disease, primarily affecting young females. Pregnancy in a woman with SLE remains a high-risk situation with higher maternal and foetal mortality and morbidity. Although live births are achieved in majority of the pregnancies, active disease and major organ involvement can negatively affect the outcomes. A higher risk of foetal loss, pre-term birth, intra-uterine growth restriction (IUGR) and neonatal lupus syndromes (NLSs) are major foetal issues. Mothers are faced with disease flares, pre-eclampsia and other complications. Disease flares during SLE pregnancy pose the unique issue of recognition and differentiation between physiologic changes and disease state. Similarly, pre-eclampsia and lupus nephritis may lead to diagnostic confusion. Treatment choices during pregnancy are limited to a few safe drugs, further restricting the options. Refractory pregnancy loss associated with anti-phospholipid antibodies (aPLs) and complete heart block associated with anti-Ro antibodies remain unresolved issues. A multidisciplinary approach, with close monitoring, is essential for optimal outcomes.

Contraceptive method selection by women with inflammatory bowel diseases: a cross-sectional survey

OBJECTIVE

Women with inflammatory bowel diseases (IBDs) utilize contraception at a lower rate than the general population. We sought to identify factors associated with contraceptive use and selection of more effective methods in IBD patients at risk for unintended pregnancy.

STUDY DESIGN

An online survey was distributed to women with IBD in January 2013. Contraceptive methods were categorized by effectiveness and associations with use explored by demographics, disease characteristics and reproductive goals.

RESULTS

A total of 162 respondents were analyzed: 62% had Crohn's disease and 38% ulcerative colitis. Mean age was 31 (range 20-45), 97% identified as White, and 53% were nulliparas. Seventy-four percent were currently using IBD medications. A quarter of participants (23%) used no contraception, 17% used highly effective methods, 41% used short-term hormonal methods, and 19% chose barrier/behavioral methods. Prior IBD-related surgery, biologic therapy use and low education attainment were associated with no contraception use. Of contraceptive users, age, parity, insurance status, IBD surgery and prior immunomodulator use were associated with highly effective method selection.

CONCLUSIONS

A quarter of women with IBD at risk for pregnancy in this study population reported no contraceptive method use. Higher levels of IBD activity influence contraceptive use and method selection, which could guide future patient and provider educational interventions.

IMPLICATIONS

Pregnancy planning is important for women with inflammatory bowel diseases to avoid adverse outcomes in a disease-poor state. Use of contraception assists in avoidance of unintended pregnancy. IBD characteristics are targets for educational interventions to improve uptake of highly effective contraceptive methods.

Hot topics in lupus pregnancy

Systemic lupus erythematosus (SLE) typically affects women in their childbearing age, who have the same fertility rates as the healthy population. The effect of pregnancy on the disease and the effect of SLE on pregnancy and the fetus are highly important issues for the attending physician. Whether lupus flares are more frequent during pregnancy remains controversial. Among the possible effects of SLE on pregnancy are a greater number of abortions, fetal loss, pre-term deliveries and perinatal mortality. The newborn may be affected by the onset of neonatal lupus erythematosus (neonatal LE), either as a skin or blood disease, or by the presence of congenital heart block. The frequent association between SLE and antiphospholipid syndrome represents another risk situation for the mother and the product of conception. Multiples drugs used in SLE patients should be evaluated. Those with teratogenic potential should be withdrawn before pregnancy, and when necessary, appropriate medications should be indicated to treat the mother without compromising the safety of the baby. In conclusion, pregnancies in lupus patients represent a challenge for the physician and must be closely followed up and treated if necessary, during all trimesters and in the puerperium period, to improve outcome.

Quality of care in systemic lupus erythematosus: application of quality measures to understand gaps in care

BACKGROUND

Systemic lupus erythematosus (SLE) affects 1 in 2500 Americans and is associated with significant morbidity and mortality. The recent development of SLE quality measures provides an opportunity to understand gaps in clinical care and to identify modifiable factors associated with variations in quality.

OBJECTIVE

To evaluate performance on SLE quality measures as well as differences in quality of care by demographic, socioeconomic, disease, and health system characteristics.

DESIGN AND PATIENTS

Cross-sectional analysis of data derived from the Lupus Outcomes Study, a prospective, longitudinal study of 814 individuals. Principal data collection was through annual structured telephone surveys between 2009-2010. Data on 13 SLE quality measures was collected. We used regression models to estimate demographic, socioeconomic, disease, and health system characteristics associated with performance on individual and overall quality measures.

OUTCOME MEASURES

Performance on each quality measure and overall performance on all measures for which participants were eligible (pass rate).

RESULTS

Participants were eligible for a mean of five measures (range 2-12). Performance varied from 29 % (assessment of cardiovascular risk factors) to 90 % (sun avoidance counseling). The overall pass rate was 65 % (95 % CI 64 %, 65 %). In unadjusted analyses, younger age, minority race/ethnicity, poverty, shorter disease duration, fewer physician visits, and lack of health insurance, were associated with lower pass rates. Receiving care in public sector managed care organizations was associated with higher pass rates. After adjustment, younger age, having fewer physician visits and lacking health insurance remained significantly associated with lower performance; receiving care in public sector managed care organizations remained associated with higher performance.

CONCLUSIONS

We identified a number of gaps in clinical care for SLE. Factors associated with the health care system, including presence and type of health insurance, were the primary determinants of performance on quality measures in SLE.

Management of pregnancy in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoantibody-mediated systemic autoimmune disease, predominantly affecting young females. Pregnancy is increasingly common in the setting of SLE, as survival and quality of life of patients improve. Although live births can be achieved in the most cases, pregnancy in patients with SLE remains a high-risk condition. Maternal and fetal mortality and morbidity are considerably increased, compared with the general population. Aberrations in pregnancy-related maternal immune adaptations are likely contributors. Active maternal disease, renal involvement, specific autoantibody subsets and advanced organ damage are predictors of poor outcome. Therapeutic options are limited during pregnancy as maternal benefit has to be weighed against fetal risk. Prevention of preterm birth and refractory pregnancy loss, as well as management of established neonatal heart block remain unmet needs. Further research should address these important issues that affect young patients with SLE and their babies.

Healthcare quality in systemic lupus erythematosus: using Donabedian's conceptual framework to understand what we know

Healthcare quality improvement has the potential to reduce the striking disparities in health outcomes among patients with systemic lupus erythematosus (SLE). Donabedian's framework for assessment of healthcare quality, which divides factors impacting quality into structures, processes and outcomes, provides a theoretical framework for research and interventions in quality improvement. This review applies Donabedian's model to current research describing quality of care in SLE, highlighting structures and processes that may lead to improved outcomes. Work remains to be done to develop meaningful metrics to assess quality and to understand the structures and processes that improve outcomes. Quality indicators have emerged as an important tool to measure quality, but further validation is required to define their validity and feasibility in clinical practice, as well as their association with improved outcomes. Implementation science also shows promise as a means to create meaningful systematic improvements in healthcare quality for patients with SLE.

Systemic lupus erythematosus and pregnancy

Although most women with systemic lupus erythematosus can achieve a successful pregnancy, fetal (fetal loss, preterm birth) and maternal (lupus flares, worsening renal function) morbidity remain major problems. Predictors of fetal loss and preterm birth have been identified and are reviewed. Modern management of lupus pregnancy includes identification of high-risk pregnancies with appropriate monitoring and treatment (when indicated) for anti-Ro and antiphospholipid antibodies, frequent assessment of and control of maternal lupus activity, adjustment of medications to avoid those associated with fetal teratogenicity, and the appropriate use of fetal assessment tests to guide intervention for the fetus at risk of intrauterine death.