Improving Hydroxychloroquine Dosing and Toxicity Screening at a Tertiary Care Ambulatory Center: A Quality Improvement Initiative

Abstract

Objective Hydroxychloroquine (HCQ) is a commonly used weight-based medication with a risk of retinal toxicity when prescribed at doses above 5 mg/kg/day. The objectives of our study were: (1) To characterize the frequency of inappropriate HCQ dosing and retinopathy screening and (2) to improve guideline-based management by implementing quality improvement (QI) strategies. Methods A retrospective chart review was performed to obtain baseline analysis of HCQ dosing, weight documentation, and retinal toxicity screening to characterize current practices. The primary aim was to increase the percentage of patients appropriately dosed from 30% to 90% over a tenmonth period. The secondary aim was to increase the percentage of documented retinal screening from 59% to 90%. The process measure was the number of patients with a documented weight in the chart. The balancing measure was the physician’s perceived increase in time spent with each patient due to implemented interventions. QI methodology was used to implement sequential change ideas: (1) HCQ weight-based dosing charts to facilitate prescription regimens, (2) addition of scales to patient rooms to facilitate weight documentation, and (3) electronic medical record ‘force function’ involving weight documentation and auto-dosing prescription. Results The percentage of patients being weighed increased from 40% to 92% after ten months. Appropriate HCQ dosing improved from 30% to 89%. Retinal screening documentation improved by 33%. Conclusion Dosing charts in clinic rooms, addition of weight scales, and EMR force function autodosing prescriptions significantly improved appropriate HCQ dosing practices. These interventions are generalizable and can promote safe and guideline-based care.

Adherence to Weight‐Based Dosing Guidelines in Patients Receiving Hydroxychloroquine for Systemic Lupus Erythematosus and Rheumatoid Arthritis: Results of a Quality Improvement Initiative

“…Reminder systems, repeated feedback, and the use of a combination of interventions simultaneously have been demonstrated within the quality improvement literature as effective methods for changing clinical practice ( 12 ). Other approaches, including electronic health record (EHR) systems that provide reminders or “force functions” can encourage compliance with dosing guidelines as well ( 13 ). However, not all practices have access to such EHRs or programmers to implement such a process.…”

The place of hydroxychloroquine in modern dermatology

“…Earlier, as the substance does not distribute in adipose tissue, it was recommended to convert the dose according to the proper body weight, and therefore it was higher (6.5 mg/kg). However, it has been noted that this may result in drug overdose and a higher risk of side effects (especially retinopathy) in people with a low body mass index [38,71,72]. It is important to emphasize that the studies confirming the effectiveness of HCQ were carried out at the dose of 6.5 mg/kg [38].…”

“…Wcześniej ze względu na brak dystrybucji substancji w tkance tłuszczowej rekomendowano przeliczanie dawki na należną masę ciała i dlatego była ona wyższa (6,5 mg/kg). Zauważono jednak, że może to skutkować przedawkowaniem leku u osób z obniżonym wskaźnikiem masy ciała, a tym samym większym ryzykiem wystąpienia działań niepożądanych, szczególnie retinopatii [38,71,72]. Należy podkreślić, że badania potwierdzające skuteczność HCQ były przeprowadzane przy stosowaniu dawki 6,5 mg/kg [38].…”

The Effect of an Electronic Medical Record Intervention on Hydroxychloroquine Prescribing Habits and Surveyed Providers’ Opinions of the 2016 American Academy of Ophthalmology Guidelines in the Rheumatology and Dermatology Practices of an Academic Institution

“…Finally, as previous research has demonstrated improved rates of compliance with these dosing guidelines when auto-dosing functions are introduced into the electronic medical record (EMR), we conducted a prospective, non-controlled study to determine if a new tool in the EMR, could affect compliance with these guidelines. (16)…”