S. Koppikar, MD, FRCPC, C. Farrer, PT, MSc, N. Gakhal, MD, MSc, FRCPC, Division of Rheumatology, University of Toronto, and Division of Rheumatology, Women's College Hospital;
S. Gottheil, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada.
J Rheumatol. 2021 Jan 1;48(1):138-144. doi: 10.3899/jrheum.191265. Epub 2020 Apr 1.
Hydroxychloroquine (HCQ) is a commonly used weight-based medication with a risk of retinal toxicity when prescribed at doses above 5 mg/kg/day. The objectives of our study were (1) to characterize the frequency of inappropriate HCQ dosing and retinopathy screening, and (2) to improve guideline-based management by implementing quality improvement (QI) strategies.
A retrospective chart review was performed to obtain baseline analysis of HCQ dosing, weight documentation, and retinal toxicity screening to characterize current practices. The primary aim was to increase the percentage of patients appropriately dosed from 30% to 90% over a 10-month period. The secondary aim was to increase the percentage of documented retinal screening from 59% to 90%. The process measure was the number of patients with a documented weight in the chart. The balancing measure was the physician's perceived increase in time spent with each patient due to implemented interventions. QI methodology was used to implement sequential change ideas: (1) HCQ weight-based dosing charts to facilitate prescription regimens; (2) addition of scales to patient rooms to facilitate weight documentation; and (3) electronic medical record (EMR) "force function" involving weight documentation and autodosing prescription.
The percentage of patients being weighed increased from 40% to 92% after 10 months. Appropriate HCQ dosing improved from 30% to 89%. Retinal screening documentation improved by 33%.
Dosing charts in clinic rooms, addition of weight scales, and EMR force function autodosing prescriptions significantly improved appropriate HCQ dosing practices. These interventions are generalizable and can promote safe and guideline-based care.
羟氯喹（HCQ）是一种常用的基于体重的药物，如果剂量超过 5mg/kg/天，有发生视网膜毒性的风险。我们研究的目的是：（1）描述 HCQ 剂量不当和视网膜病变筛查的频率，（2）通过实施质量改进（QI）策略，改善基于指南的管理。
对病历进行回顾性图表审查，以获得 HCQ 剂量、体重记录和视网膜毒性筛查的基本分析，以描述当前的实践情况。主要目标是在 10 个月内将适当剂量的患者比例从 30%提高到 90%。次要目标是将记录的视网膜筛查比例从 59%提高到 90%。过程指标是病历中记录体重的患者数量。平衡指标是由于实施干预措施，医生认为每个患者花费的时间增加了多少。使用质量改进方法实施连续变化的想法：（1）HCQ 基于体重的剂量图表，以方便处方方案；（2）在患者房间添加秤，以方便体重记录；（3）电子病历（EMR）“强制功能”，涉及体重记录和自动处方。
经过 10 个月，称重患者的比例从 40%增加到 92%。适当的 HCQ 剂量从 30%提高到 89%。视网膜筛查记录的改善了 33%。
在诊室中使用剂量图表、添加体重秤和 EMR 强制功能自动处方显著改善了 HCQ 剂量的适当性。这些干预措施具有普遍性，可以促进安全和基于指南的护理。
