Preventing Pregnancies for Patients on Teratogenic MedicationsPreventing Pregnancies for Patients on Teratogenic Medications https://pediatricsnationwide.org/wp-content/uploads/2019/05/AdobeStock_91559062-header-1024x575.jpg 1024 575 Emily Siebenmorgen Emily Siebenmorgen https://pediatricsnationwide.org/wp-content/uploads/2023/05/Emily.Siebenmorgen-scaled-e1684876333147.jpg
- January 06, 2023
- Emily Siebenmorgen
In a recent study from Nationwide Children’s Hospital, researchers increased the time between pregnancies for patients on teratogenic medications from an average of 52 days to over 900 days through quality improvement (QI) and behavioral economics.
Teratogenic medications such as methotrexate and mycophenolate are often used to treat rheumatic diseases. They can also result in fetal abnormalities or pregnancy loss if taken during pregnancy.
Adolescent patients with chronic illness tend to be as sexually active as their healthy peers. However, previous national studies have shown contraceptive prescription and counseling on the teratogenic nature of their medications occurs in less than a third of females aged 14 to 25 in both primary care and specialty clinic settings. 2, 3
“Initially, we had absolutely no protocol for talking about pregnancy risks and prevention while on teratogenic medications – these conversations have many barriers including time constraints during clinic visits and provider/parent comfort level with such a sensitive topic,” Kelly Wise, PharmD, BCACP and co-first author of the study says.
Dr. Wise explains this lack of protocol was leading to undesired outcomes in the clinic.
“We identified that we consistently had three pregnancies per year on teratogenic medications, so it was clear that we had a gap in care surrounding patient and parent education and sexual history screening for females on teratogenic medications,” she says.
The team went through two large workflow changes to correct their education and documentation practices. The first phase focused on increasing completion of an annual consent form acknowledging elevated risks of pregnancy complications while taking teratogenic medications.
“We were quick to identify that pre-visit planning was a tremendous opportunity to identify patients with expiring consents, so we put a lot of effort into correcting that process and improving it even more,” Dr. Wise says.
During the study, the team used behavioral economic-inspired interventions to improve completion of consent forms, including improving form accessibility, utilizing distinctly colored forms and real-time reminders during the patient visit through EPIC software. Dr. Wise notes that implementing these interventions required support from the full health care team.
“Sometimes our office visits can last up to three hours, so adding an extra step for providers is often difficult for buy-in,” Dr. Wise explains. “It was helpful to have a team-based approach, with administration, nurse and pharmacist support to identify who was due for consents.”
The second phase focused on increasing documentation of sexual history screening and pregnancy prevention during clinic visits. The team developed an electronic health record smartform for providers to document sexual history, pregnancy intention and a pregnancy prevention plan at each visit, complete with orders for screening tests and referrals to adolescent medicine.
Part of this second phase ran during the Covid-19 pandemic, causing the team to tailor documentation interventions for telehealth settings.
“I think the biggest factor in a telehealth visit is making sure that you have privacy when the provider is asking the patient about their sexual health, because that is crucial,” Dr. Wise says.
In a clinic environment, parents are asked to leave the room so the patient and provider can have that one-on-one conversation. In virtual settings, parents were still asked to leave the room, but patients were also encouraged to use headphones while responding to “yes” or “no” questions to maintain confidentiality.
Through their interventions, the team surpassed their initial goal of 200 days between pregnancies, had consents signed during 95% of eligible visits, and documented counseling in 78% of eligible visits, up from baselines of 0% and 2%, respectively.
Dr. Wise emphasizes these QI interventions can be applied in other institutions and in areas outside of rheumatology.
“We’ve already been contacted by multiple clinics within Nationwide Children’s that deal with teratogenic medications – including neurology, cardiology and dermatology – to learn from what we’ve done and hopefully implement similar practices without re-inventing the wheel. This is a project that many subspecialties should implement; they just need to get buy-in from their whole team.”
After successfully incorporating these interventions into clinical care for three years, the team emphasizes this project’s sustainability and its value for this patient population.
“This QI project looks simple on paper, but it was a huge shift in how our providers talk to our patients,” Dr. Wise says. “We know that we need to prevent pregnancies on these medications now more than ever, and we’ve shown it can be done.”
1. Mruk VM, Wise KA, Driest K, Oberle EJ, Ardoin SP, Yildirim-Toruner C, Sivaraman V, Stevens J, McGinnis A, Gallup J, Mitchell B, Lemle S, Jones S, Maher J, Berlan ED, Barbar-Smiley F. Preventing Teen Pregnancies on Teratogenic Drugs by Quality Improvement and Behavioral Economics. Pediatrics. 2022 Dec. 6:e2021054294. doi: 10.1542/peds.2021-054294
2. Schwarz EB, Maselli J, Norton M, Gonzales R. Prescription of teratogenic medications in United States ambulatory practices. The American Journal of Medicine. 2005 Nov.;118(11):1240-9. doi: 10.1016/j.amjmed.2005.02.029.
3. Stancil SL, Miller M, Briggs H, Lynch D, Goggin K, Kearns G. Contraceptive Provision to Adolescent Females Prescribed Teratogenic Medications. Pediatrics. 2016 Jan.;137(1). doi: 10.1542/peds.2015-1454.
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