{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T22:50:00Z","timestamp":1782773400151,"version":"3.54.5"},"reference-count":14,"publisher":"BMJ","issue":"3","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2018,6,9]]},"published-print":{"date-parts":[[2018,7]]},"abstract":"<jats:p>Teratogenic medications are often prescribed to women of childbearing age with autoimmune diseases. Literature suggests that appropriate use of contraception among these women is low, potentially resulting in high-risk unintended pregnancies. Preliminary review in our clinic showed suboptimal documentation of women\u2019s contraceptive use. We therefore designed a quality improvement initiative to target three process measures: documentation of contraception usage and type, contraception counselling and provider action after counselling. We reviewed charts of rheumatology clinic female patients aged 18\u201345 over the course of 10 months; for those who were on teratogenic medications (methotrexate, leflunomide, mycophenolate and cyclophosphamide), we looked for evidence of documentation of contraception use. We executed multiple plan-do-study-act (PDSA) cycles to develop and evaluate interventions, which centred on interprofessional provider education, modification of electronic medical record (EMR) templates, periodic provider reminders, patient screening questionnaires and frequent feedback to providers on performance. Among eligible patients (n=181), the baseline rate of documentation of contraception type was 46%, the rate of counselling was 30% and interventions after counselling occurred in 33% of cases. Averaged intervention data demonstrated increased provider performance in all three domains: documentation of contraception type increased to 64%, counselling to 45% and provider action to 46%. Of the patients with documented contraceptives, 50% used highly effective, 27% used effective and 23% used ineffective contraception methods. During this project, one unintentional pregnancy occurred in a patient on methotrexate not on contraception. Our interventions improved three measures related to contraception counselling and documentation, but there remains a need for ongoing quality improvement efforts in our clinic. This high-risk population requires increased provider engagement to improve contraception compliance, coupled with system-wide EMR changes to increase sustainability.<\/jats:p>","DOI":"10.1136\/bmjoq-2017-000269","type":"journal-article","created":{"date-parts":[[2018,7,25]],"date-time":"2018-07-25T10:44:57Z","timestamp":1532515497000},"page":"e000269","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":25,"title":["Increasing contraception use among women receiving teratogenic medications in a rheumatology clinic"],"prefix":"10.1136","volume":"7","author":[{"given":"Rebecca E","family":"Sadun","sequence":"first","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Duke Health, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa A","family":"Wells","sequence":"additional","affiliation":[{"name":"Colorado Center for Arthritis and Osteoporosis, Boulder, Colorado, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen J","family":"Balevic","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Duke Health, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria","family":"Lackey","sequence":"additional","affiliation":[{"name":"Arthritis and Osteoporosis Consultants of the Carolinas, Charlotte, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica J","family":"Aldridge","sequence":"additional","affiliation":[{"name":"Baptist Medical Group Rheumatology, Pensacola, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Holdgagte","sequence":"additional","affiliation":[{"name":"Lowcountry Rheumatology, Charleston, South Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samya","family":"Mohammad","sequence":"additional","affiliation":[{"name":"EmergeOrtho, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisa G","family":"Criscione-Schreiber","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Duke Health, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan E B","family":"Clowse","sequence":"additional","affiliation":[{"name":"Division of Rheumatology, Department of Medicine, Duke Health, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mamata","family":"Yanamadala","sequence":"additional","affiliation":[{"name":"Division of Geriatrics, Department of Medicine, Duke Health, Durham, North Carolina, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2018,7,25]]},"reference":[{"key":"2025083110113993000_7.3.e000269.1","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-009-1215-2"},{"key":"2025083110113993000_7.3.e000269.2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/32.3.227"},{"key":"2025083110113993000_7.3.e000269.3","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1002\/acr.20402","article-title":"Contraceptive counseling and use among women with systemic lupus erythematosus: a gap in health care quality?","volume":"63","author":"Yazdany","year":"2011","journal-title":"Arthritis Care Res"},{"key":"2025083110113993000_7.3.e000269.4","doi-asserted-by":"publisher","DOI":"10.1002\/art.24356"},{"key":"2025083110113993000_7.3.e000269.5","doi-asserted-by":"publisher","DOI":"10.1002\/art.20248"},{"key":"2025083110113993000_7.3.e000269.6","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1002\/acr.20327","article-title":"Systematic review of the literature informing the systemic lupus erythematosus indicators project: reproductive health care quality indicators","volume":"63","author":"Gillis","year":"2011","journal-title":"Arthritis Care Res"},{"key":"2025083110113993000_7.3.e000269.7","doi-asserted-by":"publisher","DOI":"10.1177\/0961203314552832"},{"key":"2025083110113993000_7.3.e000269.8","doi-asserted-by":"publisher","DOI":"10.1177\/0961203315596079"},{"key":"2025083110113993000_7.3.e000269.9","doi-asserted-by":"publisher","DOI":"10.1097\/00019514-200401000-00002"},{"key":"2025083110113993000_7.3.e000269.10","unstructured":"Center for Disease Control and Prevention (CDC). Contraception. 2015 http:\/\/www.cdc.gov\/reproductivehealth\/unintendedpregnancy\/contraception.htm (Last accessed 29 Feb 2016)."},{"key":"2025083110113993000_7.3.e000269.11","doi-asserted-by":"crossref","first-page":"60","DOI":"10.3109\/01443615.2013.817982","article-title":"Use of contraception by women treated with leflunomide due to rheumatic arthritis","volume":"34","author":"Banas","year":"2014","journal-title":"J Obstet Gynaecol"},{"key":"2025083110113993000_7.3.e000269.12","unstructured":"Accreditation Council for Graduate Medical Education (ACGME). ACGME program requirements for graduate medical education in rheumatology (Internal Medicine). 2011 (Last accessed 10 Jul 2017)."},{"key":"2025083110113993000_7.3.e000269.13","first-page":"47","article-title":"Managing copy functionality and information integrity in the EHR","volume":"83","author":"Warner","year":"2012","journal-title":"J Ahima"},{"key":"2025083110113993000_7.3.e000269.14","first-page":"50","article-title":"Avoid EHR note \u2019cloning while maintaining efficiency","volume":"91","author":"Terry","year":"2014","journal-title":"Med Econ"}],"container-title":["BMJ Open Quality"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjoq-2017-000269","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T17:11:51Z","timestamp":1756660311000},"score":1,"resource":{"primary":{"URL":"https:\/\/qir.bmj.com\/lookup\/doi\/10.1136\/bmjoq-2017-000269"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,7]]},"references-count":14,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2018,7,25]]},"published-print":{"date-parts":[[2018,7]]}},"alternative-id":["10.1136\/bmjoq-2017-000269"],"URL":"https:\/\/doi.org\/10.1136\/bmjoq-2017-000269","relation":{},"ISSN":["2399-6641"],"issn-type":[{"value":"2399-6641","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,7]]}}}