1972: Enhancing Patient Safety: Improving Contraceptive Counseling for Patients on Teratogenic Medications in the Rheumatology Clinic

Background/Purpose: The American College of Rheumatology (ACR) recommends contraceptive counseling for reproductive-age women with rheumatic and musculoskeletal diseases (RMDs), especially those on teratogenic medications. These medications are associated with major birth defects, making it critical to ensure effective contraception counseling for these patients
At the time of the pre-intervention assessment, among 109 patients with rheumatologist diagnoses seen in the UCSF rheumatology clinic who were treated with leflunomide, mycophenolate, or methotrexate, only 41% had contraception use documented and only 35% had documentation of contraception counseling. This project aimed to increase contraceptive counseling documentation to over 70% for all rheumatologic patients on teratogenic medications within the next nine months.

Methods: Eligibility criteria for counseling included patients with any rheumatologic condition who were maintained on methotrexate, mycophenolate, or leflunomide and were being followed at the UCSF Rheumatology Clinic at the Parnassus location, either through in-person or telehealth visits.
The team used the Lean Improvement Methodology to identify the gaps in contraceptive screening and counseling (Figure 1). Most identified gaps led to targeted Interventions which include
- Development of a standardized documentation SmartPhrase in the electronic health record (EHR)
- Collaboration with the complex contraception clinic withing the OB/GYN department to create patient-facing educational materials
- Training of nursing staff to conduct contraceptive counseling
- Workflow redesign to include counseling across visit types (telemedicine and in-person)
- Monthly audits tracked counseling documentation rates among patients prescribed the three targeted teratogenic medications.

Results: Over the course of the project, we reviewed our findings every six weeks by monitoring the in-process metric, which was the percentage of eligible patients missed during each intervention cycle. This was measured to evaluate progress and determine if further changes were necessary. In the first two months, despite implementing targeted interventions, approximately 60% of eligible patients were still missed for contraceptive counseling. This gap was primarily due to challenges in capturing patients seen via telehealth, a limitation of the existing clinic workflow. After identifying this issue, we revised the workflow, enabling nurses with training in contraceptive counseling to proactively identify our target patient sample whether they were receiving care via telehealth and in-person. These changes significantly improved outcomes: documented contraceptive counseling rates rose from 35% (N=109) at baseline to 82% (N=331) (Figure 2), and the proportion of missed eligible patients dropped from 64% in November 2024 to 1.82% in April 2024 (Figure 3). Whenever counseling occurred, contraceptive use was documented in 100% of cases, indicating whether or not the patient was using contraception.

Conclusion: A multidisciplinary, systems-based approach led to a substantial improvement in contraceptive counseling rates for patients on teratogenic medications.