How to Provide Sexual and Reproductive Health Care to Patients: Focus Groups With Rheumatologists and Rheumatology Advanced Practice Providers

RESULTS

Study participants. Twenty-two rheumatology clinicians participated in the study (12 rheumatologists and 10 APPs), of 39 clinicians who were approached (Table 1). APP participants were all female, as compared to 58% of rheumatologists. Thirteen clinicians worked within academic practice settings (60%), 7 clinicians worked in community practices, and 2 clinicians were employed by the Veterans Affairs (VA) healthcare system. Clinicians had practiced rheumatology for an average of 6 years (range 1-17 yrs). All clinicians cared for patients with gestational capacity.

Themes. Four solutions emerged from the focus groups, described below and in Table 2.

Solution 1. Rheumatology clinicians recommended preparing patients to engage in SRH conversations before and during clinic visits.

Rheumatology clinicians agreed that patients’ family planning goals were important to discuss during clinic visits. One rheumatologist said, “You hope for some normalcy for your patients, you want your young, female patients to have great disease control and have the possibility of pregnancy if they desire that.” Another rheumatologist reflected, “I’d be more happy with [patients] planning to become pregnant. At least it gives me a little bit back. Like some of that control. You can’t prevent every outcome, but at least you sort of know what you’re working with… [instead of] after the fact.”

However, some clinicians struggled to consistently address SRH with patients. As one rheumatologist stated, “I often ask people around the time that I’m making medication changes or maybe with a new diagnosis, but life often changes over time. And sometimes in the busyness of moving through a clinic day, I may not revisit that after I’ve already asked that 1 time.” A rheumatology APP explained that in a “15-minute appointment,” she is “trying to cover a lot of material” and SRH care is not “always first and foremost.”

SRH conversations with patients could be lengthy, and several clinicians noted that many patients could not clearly articulate their family planning goals or needs within the limited available time. Clinicians offered solutions to make these conversations more efficient, most of which focused on preparing patients to discuss family planning goals before the clinic visit. Clinicians proposed that previsit forms could query, “are you planning pregnancy” or “do you want to discuss fertility or birth control with your doctor?” As 1 rheumatologist explained, “We [clinicians] are also ready, hav[ing] seen that checklist ahead of time. So, it gets the conversation rolling as soon as the appointment starts.” Personalized health apps that were available in some healthcare systems were another proposed mechanism by which these forms could be disseminated.

In general, participants felt that patients should complete these forms approximately every 6 months, as family planning goals were likely to change over time.

Some clinicians also suggested creating posters in rheumatology clinics with the message, “Are you planning to become pregnant? Tell your provider.” Clinic posters are a “media that a lot of people are used to and comfortable with and it’s a quick reminder,” explained an APP.

Solution 2. Consultation systems are needed to facilitate rapid SRH care with women’s health providers. Rheumatology clinicians acknowledged the importance of collaborative family planning care with traditional SRH providers (eg, obstetricians and gynecologists [OB-GYNs], particularly with respect to contraception prescription. One rheumatologist stated, “I feel comfortable counseling and giving [patients] my advice about what would be the best approach and the best contraception method based on their disease and risk factors. But I would defer prescribing [contraception] to women’s health [providers] or to their OB-GYN.” Other clinicians expressed less comfort with contraception counseling, as described by a rheumatologist, “I think I can do the general counseling but with more specific counseling from their gynecologist.”

However, most of the rheumatologists and APPs did not have professional relationships with OB-GYN colleagues to whom they could refer patients or ask clinical questions. An APP expressed, “We don’t have a relationship with [an] OB-GYN… it would just be so helpful because some of our patients also have overlapping antiphospholipid syndrome and it makes it really scary. We want so badly to talk to [OB-GYNs] about birth control but not really having the tools to know what [is] safe to give them… I mean some of our patients have actually had blood clots, and it makes it really scary not having an OB-GYN to kind of talk it through. It’s been an ongoing struggle in our department.” Other clinicians described patients who had become pregnant while using fetotoxic antirheumatic drugs, and the difficulties they had encountered in trying to facilitate abortion care.

Clinicians felt it would be helpful to establish a relationship with a “designated OB-GYN provider” who “might be used by all of the rheumatologists in the practice.” This would ensure that “as a group, we’ll know what to do in these scenarios.” Several clinicians recommended using the electronic health record (EHR) to refer patients to these designated OB-GYNs. However, clinicians acknowledged that each of these solutions would require relationship-building with OB-GYNs—a potential barrier to implementation.

Solution 3. Rheumatology clinicians advise development of training opportunities and easy-to-access resources to address SRH knowledge gaps. Clinicians consistently endorsed knowledge gaps around contraception. Several APPs described that they were asked to counsel young, female patients about family planning by senior, usually male rheumatologists in their practices, who assumed they were more knowledgeable about contraception and SRH care. However, as 1 APP said, “I don’t have enough birth control experience, so I cannot give in-depth counseling to my patients. I don’t feel I have enough knowledge to offer a lot of advice [about] which would be the best and most convenient for the patient or possible side effects if they do start birth control. My issue [is] lack of training.”

Clinicians also desired more information about medication safety at various reproductive transition points. A rheumatologist expressed, “I think for a lot of our medications, there’s just not a lot of data out there, and so that’s kind of an area that I always struggle with—what’s the best medication for patients who are flaring during pregnancy, postpregnancy, or during the prepregnancy period of time.”

Several clinicians used existing SRH educational resources from the ACR and the Organization of Teratology Information Specialists, among others (Table 3).^2,10 Clinicians overwhelmingly desired streamlined resources to access information about SRH management that were located in a single website or app. One rheumatologist mentioned, “It would be good to just have everything in 1 indexed place.” An APP also suggested that a helpful online resource would include “quick references for med safety and comparison,” “patient education links,” and “pregnancy information” that were all specific to rheumatology clinicians. One rheumatologist suggested that webinars or a certification “might make us more confident” to provide SRH care. Other rheumatologists suggested that SRH care education should be “integrated into your [fellowship] curriculum and into your faculty development, like grand rounds or education sessions about contraception, about pregnancy, or reproductive health care and patients with RDs.”

Solution 4. Rheumatology clinicians recommend that educational materials about SRH in the rheumatology context are provided for patients. Clinicians felt that patients had key knowledge gaps about SRH that undermined their health care, especially about the risks associated with teratogenic medication use. A rheumatologist described, “[I had a] patient who was on cyclophosphamide. Then she got pregnant despite all the education. And even after that, she’s still not amenable to contraceptives…I think the barriers are not only physician-related. They could be also related to the patients themselves.” Clinicians generally felt that “good, solid educational material” was needed for patients. However, 1 APP expressed a common sentiment: “It’s just so hard sometimes to find patient education. If there was just 1 easy place to give a printout like psoriatic arthritis in pregnancy and rheumatoid arthritis and pregnancy—just something for patients that’s tangible that they can take with them and have for their own education and teaching. So they understand what we’re concerned about too.”

Clinicians envisioned that RD foundations or the ACR could develop “information sheets for pregnant patients” that are “easy to read, easy to understand,” and “really talk about risk numerically.” Clinicians felt that some resources should be digital, “easily accessible, and [in a] nonlogin [website].”

Comparing responses by clinician type. Rheumatologists and APPs differed somewhat in their preferred approaches to optimizing SRH care. The rheumatologists offered more suggestions centered on education and training to expand their competencies in SRH care, whereas APPs expressed more preferences for EHR prompts and consultation pathways to operationalize SRH care within their clinical practices.