Increasing contraception use among women receiving teratogenic medications in a rheumatology clinic.
Repository Usage Stats
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.
Published Version (Please cite this version)
Sadun, Rebecca E, Melissa A Wells, Stephen J Balevic, Victoria Lackey, Erica J Aldridge, Nicholas Holdgagte, Samya Mohammad, Lisa G Criscione-Schreiber, et al. (2018). Increasing contraception use among women receiving teratogenic medications in a rheumatology clinic. BMJ open quality, 7(3). p. e000269. 10.1136/bmjoq-2017-000269 Retrieved from https://hdl.handle.net/10161/26173.
This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.
I am an adult and pediatric rheumatologist with clinical and research interests in the areas of lupus and transition to adult care. My time is split between the departments of Medicine and Pediatrics. In addition to seeing patients in both environments, I run a dedicated Young Adult Rheumatology Clinic in collaboration with Duke Family Medicine.
I am an Adult and Pediatric Rheumatologist and care for patients with a wide variety of autoimmune and rheumatic diseases, including: systemic lupus, rheumatoid arthritis, juvenile arthritis, vasculitis, and sarcoidosis, among others. I have a special interest in using musculoskeletal ultrasound to optimize diagnosis and treatment decisions at the bedside.
I am also a clinical researcher at the Duke Clinical Research Institute (DCRI). My research interests are in clinical trials and precision medicine through population pharmacokinetic/pharmacodynamic modeling. I obtained my PhD in Pharmaceutical Sciences from the UNC Eshelman School of Pharmacy. I serve as the principal investigator on several grants studying hydroxychloroquine and azathioprine pharmacokinetics and exposure-response in lupus, as well as principal investigator or co-investigator for several clinical trials at the DCRI. Additionally, I am an Assistant Scientific Director for the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry- the largest registry of children with rheumatic diseases in North America.
My clinical interests include systemic lupus erythematosus (SLE) and inflammatory myopathies, specifically dermatomyositis, polymyositis, and the anti-synthetase syndrome. Additionally, I maintain a general rheumatology continuity clinic for individuals with rheumatoid arthritis, vasculitis, and other forms of inflammatory arthritis and autoimmune diseases. In 2007, I co-founded the Duke Lupus Clinic with Dr. Megan Clowse. We have continued this clinic with the aim to improve the health and quality of life for individuals living with lupus.
My primary research interests are in education and in SLE. My particular interest within education is learner assessment. I was previously funded by a Clinician Scholar Educator Award through the Rheumatology Research Foundation of the American College of Rheumatology. My CSE project explored validation of a rheumatology objective structured clinical examination (ROSCE). I previously participated on the ACR/NBME rheumatology in-training examination working group for 3 years. I work closely with my Rheumatology Program Director collaborators at UNC Chapel Hill, Wake Forest University and the Medical University of South Carolina through our Carolinas Fellows Collaborative. Members of this group composed the competency-based goals and objectives (CBGO) for all learning activities of rheumatology fellowship training programs, which were adopted by the American College of Rheumatology and are posted on their website. I currently Chair the ACR Curriculum Subcommittee of the Committee on Training and Workforce.
My research in lupus has included the Duke Lupus Registry population. Our recent work focuses on creating and defining the type 1 and type 2 lupus paradigms for classifying lupus disease activity. Additional interests through the Duke Lupus Clinic include elucidating clinician-level factors that can influence medication adherence as well as determining how health literacy and numeracy impact adherence and patient level outcomes. Additionally, I have collaborated closely with Dr. Megan Clowse, who studies reproductive health in women with autoimmune diseases, for many years. We have combined her subject matter expertise with my educational skills to create HOP-STEP, a program to teach patients with lupus and their rheumatologists about pregnancy planning to improve health outcomes. We have created lupuspregnancy.org, which houses many resources and videos designed to teach rheumatologists to better partner with women with lupus to have open and honest discussions about pregnancy planning. Our ultimate aim is to improve the health outcomes for women with lupus and their offspring.
Dr. Megan Clowse is an Associate Professor of Medicine in the Division of Rheumatology and Immunology. Her clinical research focuses on the management of rheumatic diseases in pregnancy. She has cared for over 600 pregnancies in women with rheumatic disease, collecting information on these pregnancies initially in the Duke Autoimmunity in Pregnancy Registry and Repository, and now the MADRA (Maternal Autoimmune Disease Research Alliance) registry and repository. She served on the Core Leadership Team for the inaugural American College of Rheumatology's Reproductive Health Guidelines, published January 2020. Dr. Clowse created www.LupusPregnancy.org, a website dedicated to improving lupus pregnancy planning and management for patients and rheumatologists.
Dr. Clowse was the founding director of the Duke Lupus Clinic, where she continues to see patients each week and mentor junior faculty researchers. The team has developed a new approach to lupus classification and management and is currently collecting and analyzing patient- and physician-reported measures to better clarify this construct.
As the Co-Director of Duke Forge, Dr. Clowse has shepherding multiple Department of Medicine-funded studies to identify and build innovative approaches to using health data to improve patient care.
Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.