口袋女优

A new standardized pregnancy screening tool helped rheumatology practices better assess patient reproductive goals and improved the quality of documentation and the likelihood of referrals to OB/GYNs.

Results from a 6-month pilot study appear in .

The tool -- known as One Key Question (OKQ) -- prompts rheumatologists to ask female patients ages 18-49 years about their pregnancy intentions.

When comparing 32 of 43 pre-implementation responses with 29 of 41 post-implementation responses, the proportion of rheumatologists who reported being "very comfortable" with assessing their patients' reproductive goals increased (31%-38%) and the proportion reporting challenges to OB/GYN referrals decreased (41%-21%).

However, uptake of the tool was low in practice: just 83 of 957 (9%) of eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (OR 2.42, 95% CI 1.21-4.85).

Candace Feldman, MD, MPH, ScD, and Elizabeth Janiak, ScD, are both researchers at Brigham and Women's Hospital and Harvard Medical School. Both also served as coauthors of the paper and recently discussed the OKQ initiative and the study findings with the Reading Room. The exchange has been edited for length and clarity.

What were the key questions or challenges you were hoping to address with OKQ?

Feldman and Janiak: Screening patients with systemic rheumatic conditions regarding their pregnancy intentions is essential to ensuring that appropriate counseling and contraception access is provided and to ensuring that the rheumatic condition is under good control prior to conception.

While rheumatologists are aware of the importance of pregnancy intention screening among reproductive-age patients, they often lack the comfort level and the tools to readily screen their patients. We found that fewer than one-third of rheumatologists at a large academic center felt very comfortable assessing their patients' reproductive health preferences.

Our study occurred at a large academic rheumatology practice. We flagged the charts of reproductive-aged patients who were assigned female sex at birth and had a systemic rheumatic disease, in order to prompt the rheumatologist to ask the question, and developed tools to easily respond to and document the answer.

How does OKQ work?

Feldman and Janiak: We introduced a simple pregnancy intention screening tool, One Key Question: "Would you like to become pregnant in the next year?"

For example, if a patient responded with "no," the provider was encouraged to ask and document contraception use or consider referral to an OB/GYN for assistance.

If a patient responded with "yes," the provider was encouraged to review the current rheumatic disease-related medications to ensure they were compatible with pregnancy, and to consider referral to OB/GYN for preconception counseling.

How would you describe OKQ's performance in this study?

Feldman and Janiak: We found that while overall uptake of this screening tool was low, among those providers who did use it, the quality of electronic medical record documentation was superior to those who did not use it, and the patients screened were more likely to have documented receipt of contraception and to be referred to OB/GYN, compared to those who were not screened.

Introduction of this tool also improved provider comfort with screening and decreased barriers to OB/GYN referral.

What are some possible barriers to wider uptake?

Feldman and Janiak: One challenge was that this screening tool was not incorporated as an alert in the electronic medical record.

It is possible that providers saw the initial prompt when they opened their patient's chart but since they were not reminded again during the actual encounter, it was missed. It is also possible that the question was asked but not documented in the note and we are underestimating its use.

Integration of this tool into a Best Practice Alert in the electronic medical record may improve uptake. However, barriers to broader uptake regardless of the alert system include limited visit time and competing priorities, particularly among patients with complex, systemic rheumatic conditions.

What are some other take-home messages for rheumatology providers, particularly those who may be interested in improving pregnancy screenings in their own practices?

Feldman and Janiak: There are many possible ways to ask patients about their reproductive health goals, which are likely to be similarly effective and essential to both ask and document these preferences in the electronic medical records.

Some reproductive-age patients with rheumatic conditions may not think to discuss these issues with their rheumatologist, despite the direct relevance of their rheumatic condition to their reproductive health and vice versa. It is therefore critical that rheumatologists feel comfortable initiating these conversations and have access to resources and OB/GYN care to be able to address questions that may arise.

Is there anything else you would like to make readers aware of?

Feldman and Janiak: Since the recent Supreme Court decision to overturn the national right to abortion in the United States, patients with chronic disease may soon have fewer options to terminate health- and life-threatening pregnancies. This makes prevention and planning more important than ever.

Clinical implications

• A new tool provides one question to determine pregnancy intentions in women with rheumatic diseases.
• Comfort level and OB/GYN referrals improved among providers who used the tool.
• Discussing pregnancy with patients who have rheumatic diseases is critical -- and could become even more so in light of current political circumstances.

Read the study here and expert commentary on the clinical implications here.