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While many medications in rheumatology are known or suspected to be teratogenic, there are no standards on educating rheumatology patients about this risk or on screening for pregnancy, wrote Ashley M. Cooper, MD, and her colleagues at Children’s Mercy Kansas City, Mo. Their report is in the April issue of Pediatrics.
“This is problematic in pediatric rheumatology because nearly half of adolescents report a history of sexual intercourse, but only 57% report condom use and 27% another form of contraception,” they wrote, pointing out that the United States also has one of the highest rates of teen pregnancy among industrialized nations; 80% are unplanned.
The intervention consisted of a number of approaches. Posters listing teratogenic medications were put in exam rooms, physicians received education about the Food and Drug Administration–mandated mycophenolate Risk Evaluation and Mitigation Strategy (REMS), and scripts were developed for staff to inform patients of teratogenic risks with medications, as well as prompts for referral to birth control clinics.
Researchers also implemented a standardized EHR template to allow clinical staff to review medication-specific teaching points and document the discussion with the patient. There also was a previsit planning process to review everything before the clinic day began, and identify patients for education or pregnancy screening.
After 8 months of the intervention – during which 1,366 eligible patient encounters occurred in rheumatology patients aged 10 years and older– researchers saw a significant increase in those encounters where teratogen education was recorded, from 25% before the intervention to 80% at 23 months after it. Pregnancy screening also increased among eligible patients, from 20% preintervention to 83% at 23 months after the first intervention.
Three patients became pregnant during the intervention period; all of the pregnancies were picked up by the screening process. In all cases, the teratogenic medication was immediately stopped; one patient underwent elective termination, one delivered a healthy term infant, and one patient was lost to follow-up. Two of the three had received education during the previous year.
“The strategies used in this project have implications that reach beyond rheumatology because teratogenic medications are commonly prescribed by other subspecialties,” the authors wrote.
Dr. Cooper and her associates noted that an original previsit checklist was later abandoned because it was viewed as being too much of a time imposition on staff at the beginning of a busy clinic day.
“The new process had higher staff buy-in because it was used to address multiple quality improvement projects and hospital requirements, some linked to provider remuneration,” they wrote.
No funding or conflicts of interest were declared.
SOURCE: Cooper AM et al. Pediatrics 2019; 143(4):e20180803. doi: 10.1542/peds.2018-0803.