Reliable Pregnancy Testing Before Intravenous Cyclophosphamide: A Quality Improvement Study

Preventing Teen Pregnancies on Teratogenic Drugs by Quality Improvement and Behavioral Economics

BACKGROUND

Adolescents with chronic disease engage in sexual activity similar to their healthy peers, with generally low utilization of contraception. Adolescents with rheumatic diseases prescribed teratogenic medications may be at risk for unplanned pregnancy.

METHODS

Using structured quality improvement (QI) methods with behavior economic (BE) principles, a multidisciplinary team aimed to implement pregnancy prevention processes for females on high-risk medications. We leveraged BE-inspired interventions including improved accessibility of consents, utilizing distinctly colored consent forms, real-time reminders, peer comparison, and audit and feedback. Our primary aim was to increase the number of days between pregnancies for postmenarcheal females followed in rheumatology clinics who were taking teratogenic medications. Phase 1 focused on annual consenting of female adolescents prescribed teratogenic drugs. Phase 2 emphasized sexual history screening and pregnancy prevention planning at every clinic visit for females ≥12 years on teratogenic medications.

RESULTS

We increased the days between pregnancies for female adolescents prescribed teratogenic medications from 52 days to >900 days by using QI methodology with BE strategies. In phase 1, annual consents for postmenarcheal patients on teratogenic medications improved from 0% in 2017 to 95% in 2021. In phase 2, sexual history screening and pregnancy prevention planning at every clinic visit improved from 2% in 2019 to over 78% in 2021.

CONCLUSIONS

A multiphase, multidisciplinary QI project with integration of behavior economic strategies can improve patient and caregiver counseling to prevent unplanned pregnancies for adolescents on teratogenic medications.

A survey of child neurologists about reproductive healthcare for adolescent women with epilepsy

OBJECTIVE

To evaluate child neurologists' knowledge, attitudes, and practices regarding sexual and reproductive health (SRH) care for adolescent and young adult women with epilepsy (WWE).

METHODS

Child neurologists (including attending physicians, residents, fellows, and advanced practitioners) completed an online survey distributed through subspecialty listservs. We analyzed results using descriptive statistics, chi-square, and logistic regression.

RESULTS

Two hundred eight child neurologists completed the survey. Most believed that child neurologists should counsel young WWE on: teratogenesis (99%, n = 206/207), contraception-antiseizure medication interactions (96%, n = 194/202), pregnancy (95%, n = 198/206), contraception (89%, n = 184/206) and folic acid supplementation (70%, n = 144/205). Fewer respondents felt confident with such counseling (teratogenesis: 90%, n = 188/208, drug interactions: 65%, n = 133/208, pregnancy 75%, n = 156/208, contraception: 47-64%, n = 96-134/208, p < 0.05). Ninety-five percent (n = 172/181) reported ever discussing SRH with typically developing young WWE, compared to 78% (n = 141/181) for young WWE with mild intellectual disability (p < 0.01). One third (n = 56/170) who ever discussed SRH did not do so routinely. Respondents correctly answered 87% ± 5% of knowledge questions about SRH for WWE, 80% ± 4% of questions about teratogenic antiseizure medications, and 61% ± 7% of questions about contraception-antiseizure drug interactions. The greatest barrier to SRH care was time constraints (80%, n = 149/186). The majority (64%, n = 119/186) identified solutions including longer appointment times and co-managing SRH care with other specialties.

CONCLUSIONS

Findings reveal gaps in SRH care by child neurologists for adolescent and young adult WWE, especially those with mild intellectual disability. Provider-identified barriers and solutions may serve as targets to improve SRH care for this population.

Pediatric Subspecialists' Practices and Attitudes Regarding Sexual and Reproductive Healthcare for Adolescent and Young Adult Women Prescribed Teratogenic Medications

OBJECTIVE

To evaluate pediatric subspecialists' practices and attitudes regarding sexual and reproductive healthcare for adolescent and young adult women for whom they prescribe teratogens.

STUDY DESIGN

We surveyed pediatric subspecialists at 1 tertiary care pediatric hospital. Items assessed attitudes and practices related to sexual and reproductive healthcare for adolescent and young adult women prescribed teratogens, and barriers and facilitators to sexual and reproductive healthcare provision. We used descriptive statistics, χ2 tests, and logistic regression to analyze results.

RESULTS

There were 200 subspecialists from 17 subspecialties who completed the survey; 77% reported prescribing teratogens to adolescent and young adult women and 18% reported caring for a patient who became pregnant while taking a teratogen. Overall, 99% indicated that it is important to address sexual and reproductive healthcare. Respondents endorsed confidence in sexual and reproductive healthcare skills, including contraceptive counseling (71%), although 29% never or rarely discuss sexual and reproductive healthcare, and one-third never speak privately to this population. Of providers who discuss sexual and reproductive healthcare, 26% never assess reproductive intentions and 36% do so less often than annually. Nearly one-half never or rarely ask about sexual activity, and 68% never or rarely assess contraceptive knowledge. Barriers to sexual and reproductive healthcare provision included available time (80%) and the presence of family or partners at clinic visits (61%). Facilitators included a quick referral process to sexual and reproductive healthcare providers (92%) and access to lists of local sexual and reproductive healthcare providers (90%).

CONCLUSIONS

Pediatric subspecialists from a single institution report suboptimal sexual and reproductive healthcare provision for adolescent and young adult women prescribed teratogens. Identified barriers and facilitators may guide intervention development to improve sexual and reproductive healthcare for this population.

Physician engagement: a concept analysis

The term "physician engagement" is used quite frequently, yet it remains poorly defined and measured. The aim of this study is to clarify the term "physician engagement." This study used an eight step-method for conducting concept analyses created by Walker and Avant. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched on February 14, 2019. No limitations were put on the searches with regard to year or language. Results identify that the term "physician engagement" is regular participation of physicians in (1) deciding how their work is done, (2) making suggestions for improvement, (3) goal setting, (4) planning, and (5) monitoring of their performance in activities targeted at the micro (patient), meso (organization), and/or macro (health system) levels. The antecedents of "physician engagement" include accountability, communication, incentives, interpersonal relations, and opportunity. The results include improved outcomes such as data quality, efficiency, innovation, job satisfaction, patient satisfaction, and performance. Defining physician engagement enables physicians and health care administrators to better appreciate and more accurately measure engagement and understand how to better engage physicians.

Improving the Safety of Teratogen Prescribing Practices in a Pediatric Rheumatology Clinic

OBJECTIVES

Although teratogenic medications are commonly used to treat rheumatic disease, no standard model currently exists for educating adolescent patients about teratogenic risk or performing routine pregnancy screening. We performed a quality improvement project to increase education and pregnancy screening in girls and women of childbearing age prescribed teratogenic medications in our pediatric rheumatology clinic.

METHODS

Eligible participants included female patients age 10 and older prescribed teratogenic medications in a single-center tertiary care pediatric rheumatology clinic. Seven plan-do-study-act cycles were completed to test the following interventions: visible project reminders, physician and nurse education, progress updates, previsit planning, and development of an electronic health record education template. Chart reviews were performed, and control charts were created for each aim to analyze improvement over time.

RESULTS

At baseline, 57 of 231 (24.7%) clinic encounters of female patients age 10 years and older taking teratogenic medications had education documented within the last 12 months, and 47 of 231 (20.3%) had pregnancy screening performed at the visit. Implementation of our interventions resulted in improvement in documentation of annual teratogen education (904 of 1135; 79.6%) and routine pregnancy screening (940 of 1135; 82.8%), both of which were statistically significant (P < .0001). Control charts revealed special cause with sustained improvement over >1 year.

CONCLUSIONS

The interventions made through this quality improvement project increased the frequency of both teratogen education and urine pregnancy screening in patients taking teratogenic medications. Development of a standardized education template in the electronic health record played a key role in sustaining these improvements over time.

Quality improvement initiatives in rheumatology: an integrative review of the last 5 years

PURPOSE OF REVIEW

We reviewed recent quality improvement initiatives in the field of rheumatology to identify common strategies and themes leading to measurable change.

RECENT FINDINGS

Efforts to improve quality of care in rheumatology have accelerated in the last 5 years. Most studies in this area have focused on interventions to improve process measures such as increasing the collection of patient-reported outcomes and vaccination rates, but some studies have examined interventions to improve health outcomes. Increasingly, researchers are studying electronic health record (EHR)-based interventions, such as standardized templates, flowsheets, best practice alerts and order sets. EHR-based interventions were most successful when reinforced with provider education, reminders and performance feedback. Most studies also redesigned workflows, distributing tasks among clinical staff. Given the common challenges and solutions facing rheumatology clinics under new value-based payment models, there are important opportunities to accelerate quality improvement by building on the successful efforts to date. Structured quality improvement models such as the learning collaborative may help to disseminate successful initiatives across practices.

SUMMARY

Review of recent quality improvement initiatives in rheumatology demonstrated common solutions, particularly involving leveraging health IT and workflow redesign.

Maintenance of Certification and the Challenge of Professionalism

Board certification has been part of the social contract in which physicians commit to maintaining up-to-date scientific knowledge and improving the quality of patient care. However, the maintenance of certification program has been controversial. This review summarizes the philosophical underpinnings, published literature, recent improvements, and future directions of the American Board of Pediatrics maintenance of certification program.