Background/Purpose: Hydroxychloroquine (HCQ) is considered a minimal risk drug in the treatment arsenal for rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and other rheumatic diseases; however it has a well-documented risk of retinal toxicity in approximately 1% of patients following 5 years of use. Adequate ophthalmologic examination monitoring can limit the impact of toxicity on vision by early detection. The American College of Rheumatology’s position statement regarding screening for HCQ retinopathy recommends baseline ophthalmologic examination within the first year of treatment and annual examinations after 5 years of therapy as the minimum for healthy patients. It was recognized that multiple patients in a busy county hospital system receiving treatment with HCQ lacked retinopathy screening exams. A quality improvement project to ascertain the factors that lead to failure within this system was devised with the goal of improving compliance with the accepted guidelines.

Methods: In this busy county hospital outpatient rheumatology clinic we performed a chart review to evaluate provider, patient, and system factors to determine where the level of breakdown in achieving baseline eye examinations occurred. A referral to ophthalmology clinic was required for the provider to adequately fulfill their role. A scheduled appointment with ophthalmology was required for the system to meet its responsibility. The patients’ role was assessed by their appointment attendance. A physician-initiated, patient driven intervention was instituted in which rheumatology physicians provided the ophthalmology clinic phone number and asked the patient to call to schedule their appointment.  Compliance with screening guidelines was re-assessed 1 year later.

Results: The average age of the 60 patients was 48 years and included 30 RA, 20 SLE, and 10 other connective tissue diseases. Prior to the intervention, 32 patients (53%) had completed a baseline retinal toxicity exam, 2 (3%) were not referred, 6 (10%) had no-showed an appointment, and 20 (33%) had a referral without an appointment scheduled. Failure occurred at the system level. Following the intervention, of the 53 patients still taking HCQ, now 36 (68%) had completed their screening visit, 0 (0%) were not referred, 1 (0.2%) had no-showed, and 16 (30%) were referred with no appointment. Pre- intervention 25 of the remaining 53 were compliant with screening examination and eleven more patients became compliant post-intervention, a statistically significant improvement determined by McNemar’s test (p=0.0026).

Conclusion: In this quality improvement project the major barrier to patients receiving baseline eye exams for HCQ toxicity was found to be a system issue. The physician-initiated, patient driven intervention was successful in improving compliance in the 1 year time frame of study. In addition to this intervention, future efforts will be aimed at inter-departmental communication and education between ophthalmology and rheumatology regarding the necessity of timely retinal evaluations.