Background/Purpose:  Autoimmune and inflammatory diseases occur more often in women than in men, and often these women are of childbearing age. Many of the medications prescribed for such diseases are teratogenic. Discussions regarding contraception and pregnancy planning are crucial for patients on these medications. The use of effective contraception in these women is low. We aimed at understanding barriers to counseling, improving documentation, and increasing the use of effective contraception at our academic medical center outpatient Rheumatology clinic.

Methods:  As part of the quality improvement initiative, we performed an IRB exempt chart review on women between 18-45 years on methotrexate, mycophenolate, leflunomide or cyclophosphamide seen at our outpatient Rheumatology clinic from January 2015 to January 2016. We surveyed providers to understand the barriers preventing consistent discussion and documentation of recommendations for contraception. We also surveyed patients to assess plans for pregnancy, choice of current contraception, and barriers to use of effective contraception. We used the Plan-Do-Study-Act (PDSA) methodology to implement cycles of change using input from stakeholders. These PDSA cycles include standardized documentation tools, templates, targeted alerts and nursing-led education.

Results:   At baseline, 182 women took at least one teratogenic medication. Most women received methotrexate (76%), followed by leflunomide (13%), mycophenolate (9%) and cyclophosphamide (2%). We sampled 25% of the women on methotrexate (n=30) and found that only 33% used highly effective contraception (tubal ligation or intrauterine device), 24% used hormonal methods (contraceptive pills or implants) and 43% did not have a form of contraception documented. Of the 17 patients on mycophenolate, 29% used highly effective contraception (tubal ligation or intrauterine device), 24% used hormonal methods (contraceptive pills or implants) and 47% did not have a form of contraception documented. Surveying the providers (n=13) we found that 46% had a patient who got pregnant while on a teratogenic medication ,even though the majority felt that they were consistently counseling their patients (85%). Of all clinic providers, only 23% were registered on the mycophenolate risk evaluation mitigation strategy (REMS).

Conclusion:  We have identified a cohort of patients on teratogenic medications who are either not using, or have no documentation of contraception type in the electronic medical record. There is room for improvement in documentation of contraception type, counseling about the use of contraception, and the rate of use of highly effective contraception. Effective intervention strategies to improve these parameters are discussed.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-counseling-documentation-and-adherence-to-highly-effective-birth-control-in-women-on-teratogenic-medications-at-a-rural-medical-center-a-quality-improvement-initiative/