Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool

Abstract

Objective Systemic rheumatic conditions affect reproductive‐aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice. Methods This 6‐month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists’ barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented. Results When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients’ reproductive goals increased (31%‐38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%‐21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21‐4.85). Screened patients were more likely to have their contraceptive method documented ( P < 0.001) and more likely to have been referred to OB/GYN for follow‐up ( P = 0.003) compared with patients who were not screened with OKQ. Conclusion Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.

A scoping review of the format, content, effectiveness and acceptability of reproductive life planning tools

“…Most of the seven studies (35, 45, 46, 48, 52, 54) reporting documentation of reproductive counselling measured a significant increase after implementation of the RLP with intervention arm rates ranging from 58.4% in a study of the OKQ (54) to a maximum of 93.1% in a study of the MyPath tool (51). Knowledge and awareness also appeared to increase across the seven studies measuring this outcome.…”

Challenges in Family Planning and Pregnancy for Women with Rheumatic Diseases

“…16,17 One 6-month quality improvement study demonstrated the feasibility of implementing One Key Question in an academic rheumatology setting; although uptake was low, the use of any pregnancy intention screening tool was associated with increased contraceptive documentation and OB/GYN referrals. 18 Furthermore, the European League Against Rheumatism (EULAR) recommendations highlight the importance of counselling women with SLE and/or APS about fertility issues and pregnancy prevention in high-risk scenarios. 19 Guidelines and prior studies highlight the need for rheumatologists to collaborate with OB/GYNs in the delivery of reproductive healthcare for patients with RD.…”

“…[22][23][24] While rheumatologists do feel responsible for contraceptive counselling, 20 they may be uncomfortable with this area and may not provide adequate counselling. 12,18,20,23,25 Young women with RD often turn to OB/GYNs for information and support. 13 A 2021 US electronic health record-based study found documentation of contraceptive counselling to be poorly standardized and inadequate.…”

Screening to understand pregnancy preferences and offer referrals and treatment (SUPPORT): Results of a pilot quality improvement initiative

“…OKQ has shown mixed effects on patient satisfaction, low uptake in an EMR-based primary care intervention and was associated with a decrease in documented pregnancy intention screening in a recent pilot study of veterans’ healthcare [ 6 – 9 ]. A recent pilot study by our group found that in an intervention among rheumatologists, 9% of eligible patients were screened with OKQ and screening responses were correlated with contraceptive documentation and referrals; however, that pilot did not include the full OKQ training for providers [ 10 ]. A large cohort study included a contraceptive preferences survey as a research procedure and not a standard component of the clinical encounter and found that the PATH questions predicted contraceptive method choice, with those expressing a desire to wait to become pregnant and less happiness at the idea of pregnancy now being more likely to choose the most effective contraceptive methods [ 11 ].…”