The new standardized screening tool for pregnancy helped rheumatology practitioners better assess patients’ reproductive goals. It also improved documentation quality and increased the likelihood of referring to OB/GYNs.
These results are from a 6-month pilot trial. ACR Open Rheumatology.
One Key Question (OKQ), the tool, prompts rheumatologists ask female patients aged 18-49 about their plans for pregnancy.
Comparing 32 of the 43 pre-implementation answers with 29 of the 41 post-implementation replies, we found that the proportion of rheumatologists reporting being “very comfortable” in assessing patients’ reproductive goals rose (31%-38%%) while the proportion reporting difficulties with OB/GYN referrals dropped (41%-21%).
However, the tool was rarely used in practice. Just 83 out of 957 (9%) eligible patients had OKQ documentation in their chart. Male providers were less likely to screen female providers (OR 2.42; 95%CI 1.21-4.85).
Candace Feldman MD, MPH and ScD are both researchers at Brigham and Women’s Hospital and Harvard Medical School. Both were coauthors of this paper. They recently spoke with The Harvard Medical School about the OKQ initiative as well as the study results. Reading Room. This exchange has been edited to be more concise and clear.
What were your key questions and challenges with OKQ?
Janiak and Feldman: It is crucial to screen pregnant patients with systemic conditions relating to their intentions to have children.
Although rheumatologists know the importance of screening for pregnancy intent among patients of reproductive age, many lack the skills and comfort to do so. A large academic center found that less than one-third felt comfortable in assessing patients’ reproductive health preferences.
Our study took place at an extensive academic rheumatology office. We took note of the charts of patients in their reproductive years who had been assigned female sex at birth. This was to prompt the rheumatologist, who developed tools to quickly respond and record the answer.
What is OKQ?
Janiak and Feldman: We have created a simple screening tool for pregnancies. The One Key Question is: “Would this be your dream to become pregnant in next year?”
If a patient answered “no”, the provider was encouraged ask for documentation of contraception use and to refer to an OB/GYN.
If a patient answered “yes”, the provider was encouraged review current rheumatic diseases-related medications to make sure they are compatible with pregnancy and to refer to OB/GYN to provide preconception counseling.
Comment would you describe OKQ’s performance in this research?
Janiak and Feldman: Our findings showed that, while the overall adoption of this screening tool was low among providers, it was more effective than the quality of electronic record documentation. We also found that patients who were screened had a higher likelihood of having documented contraception receipt and being referred to OB/GYNs than those who were not screened.
This tool was also introduced to improve provider comfort and reduce barriers to OB/GYN referrals.
What barriers might exist to greater uptake?
Janiak and Feldman: This screening tool was not included in the electronic medical records as an alert.
Although providers may have seen the prompt at the beginning of the encounter, they didn’t remember it again when they actually encountered the patient. We are also assuming that the question was not asked, but recorded in the note.
Integrating this tool into the electronic medical record as a Best Practice Alert may increase uptake. The alert system is not without its limitations. Patients with complex and systemic rheumatic diseases may have competing priorities or visit times that are too short.
What are some other take-home messages that rheumatologists could share with their clients, especially those who may be interested to improve pregnancy screenings in their practices?
Janiak and Feldman: There are many options for asking patients about their reproductive goals. They are likely to be effective and necessary to both ask these questions and to document them in the electronic medical record.
Rheumatologists may not be able to talk to patients of reproductive age with rheumatic diseases, even though they are directly related to their reproductive health. Rheumatologists must feel confident in initiating these conversations, and should have access to resources and OB/GYN support to answer any questions.
Are there any other things you’d like to share with readers?
Janiak and Feldman: Patients with chronic diseases may soon be able to have less options for terminating life- or health-threatening pregnancies, due to the recent Supreme Court ruling. This makes planning and prevention even more important.
Clinical implications
- One question is all that’s needed to determine the intentions of women suffering from rheumatological diseases to become pregnant.
- The tool helped providers improve their comfort level and OB/GYN referrals.
- It is crucial to discuss pregnancy with patients suffering from rheumatic disease. This could be even more important given current political conditions.
The study can be viewed here. Expert commentary is available on the clinical implications.
Feldman said that he was provided with research support by Brigham and Women’s Hospital and Bristol Myers Squibb Foundation, for studies that were not directly related to this work.
