Background/Purpose: Reproductive health quality indicators (QIs) for systemic lupus erythematosus (SLE) have recently been developed: anti-ssA, anti-ssB, and phospholipid antibody (aPL) screening prior to pregnancy; appropriate treatment of pregnancy associated anti-phospholipid antibody syndrome (PAPS); and counseling regarding risk and contraception in women taking potentially teratogenic medications (methotrexate, azathioprine, leflunomide, mycophenolate mofetil, cyclosporine, cyclophosphamide, or thalidomide).  We examined performance on these QIs, their feasibility for use in a safety net rheumatology clinic, as well as sociodemographic predictors of higher performance.   

Methods: Using data from the Denver Health (DH) electronic health record (EHR), we identified rheumatology clinic patients seen between July 2006 and August 2011 who had SLE, were female, and were between the ages of 18-50 years. We queried sociodemographic and other data from the EHR including age, race/ethnicity, primary language, use of interpreter services, and primary payer. Manual EHR review was conducted to determine adherence to the QIs.  As a measure of feasibility, we tracked the time spent extracting the QIs. We calculated performance on each measure.  For the QI regarding teratogenicity counseling, which had the largest number of eligible patients, we used either chi-square or Student’s t-tests to identify the relationship between demographic characteristics and performance.

Results: 137 female SLE patients aged 18-50 years were identified. Of these, 15 were postmenopausal or status post tubal ligation or hysterectomy. Twelve pregnancies were documented during this 5-year period.  Performance on the QI regarding anti-ssA, anti-ssB or aPL testing was 100%.  We were unable to assess QI#2 as no pregnant patient met criteria for PAPS. 65 patients (53%) received potentially teratogenic medications. Only 30 of these patients (46%) had documented discussions about these medications’ potential risk to a developing fetus upon their initiation. Age was the only sociodemographic or other variable and that predicted performance on QI#3. Patients who received teratogenicity counseling were younger on average than those who did not (29 + 8 and 35 + 10 respectively, p-value = 0.0073).  The chart review time was 46 hours.

Conclusion: The new SLE reproductive health QIs allowed us to detect an important gap in counseling regarding the teratogenic risk of medications in our public health academic clinic. Greater attention to this issue is needed as only about half the patients of childbearing age received appropriate counseling, with older reproductive age women having the largest gap in care.  Although extraction of the QIs was technically feasible, the time for manual EHR review was long.  Electronic specification of these measures may be one way to reduce their collection burden in the future.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/application-and-feasibility-of-proposed-systemic-lupus-erythematosus-reproductive-health-care-quality-indicators-at-a-public-urban-rheumatology-clinic/