Department of Rheumatology, Nationwide Children's Hospital, Columbus, OH, USA.
Department of Ophthalmology, The Ohio State University, Columbus, OH, USA.
Lupus. 2021 Feb;30(2):269-279. doi: 10.1177/0961203320979038. Epub 2020 Dec 13.
Hydroxychloroquine (HCQ) is commonly used in the treatment of various autoimmune diseases related to its many benefits and favorable safety profile. Although HCQ retinopathy was considered to be uncommon, a prevalence of 7.5% was described in a recent study making early detection critical. The most updated screening guidelines by the American Academy of Ophthalmology were published in 2016; however, it lacked pediatric-specific recommendations and the overall compliance with screening guidelines was poor in previous studies. We developed a quality improvement (QI) initiative aiming to create institutional screening recommendations. Additionally, to increase eye screening in pediatric rheumatology clinic for patients receiving HCQ from 65% to 85% in 12 months and to sustain that rate for at least 6 months.
We formed a multidisciplinary team of pediatric rheumatologists and ophthalmologists, clinical pharmacist, clinic nurses, QI specialist, quality data technician and administrative staff. We included patients receiving HCQ and who were evaluated at Nationwide Children's Hospital rheumatology clinic. A key driver diagram was formulated to identify barriers to compliance and determine possible interventions. Main interventions included summarizing screening guidelines in a step by step algorithm, increasing awareness of these guidelines among patients and providers, improving collaboration and communication with ophthalmologists, and initiating pre-visit planning.
Baseline performance data included 164 patients. Fifty-four (33%) of those patients were at high risk for HCQ retinopathy. Of them, 50% were on HCQ dose of >5 mg/kg/day and 31.5% had been taking HCQ for ≥5 years. Two center line shifts were noticed over the course of the project. The target of 85% compliance was reached in February 2019 and was sustained until December 2019.
Our study highlights the importance of interdisciplinary communication to increase awareness of screening guidelines among medical providers and patients. Pre-visit planning played a major role in identifying patients and opportunities for optimizing eye screening in patients at risk for HCQ retinopathy. Collaboration between rheumatologists and ophthalmologists is crucial in managing patients on HCQ. The implementation of same-day eye screening allowed this collaboration to be more efficient. Future efforts are being directed at monitoring and improving utilization of the effective interventions.
羟氯喹（HCQ）由于具有多种益处且安全性良好，常用于治疗各种与自身免疫相关的疾病。尽管 HCQ 视网膜病变并不常见，但最近的一项研究表明其患病率为 7.5%，因此早期发现至关重要。美国眼科学会于 2016 年发布了最新的筛查指南；然而，该指南缺乏针对儿科的具体建议，并且之前的研究中整体筛查指南的遵循情况较差。我们开展了一项质量改进（QI）计划，旨在制定机构筛查建议。此外，我们的目标是在 12 个月内将接受 HCQ 治疗的儿科风湿病患者的眼部筛查率从 65%提高到 85%，并至少持续 6 个月。
我们成立了一个由儿科风湿病医生和眼科医生、临床药师、诊所护士、QI 专家、质量数据技术员和行政人员组成的多学科团队。我们纳入了在 Nationwide Children's Hospital 风湿病诊所接受 HCQ 治疗且正在接受评估的患者。我们制定了一个关键驱动因素图，以确定符合率低的原因，并确定可能的干预措施。主要干预措施包括：总结筛查指南，制定逐步算法；提高患者和医务人员对这些指南的认识；改善与眼科医生的合作与沟通；并启动预诊计划。
基线绩效数据包括 164 名患者。其中 54 名（33%）患者有发生 HCQ 视网膜病变的高风险。这些患者中，50%的 HCQ 剂量>5mg/kg/天，31.5%的患者已经服用 HCQ>5 年。在项目进行过程中，我们注意到了 2 个中心线偏移。2019 年 2 月达到了 85%的目标，并一直持续到 2019 年 12 月。
我们的研究强调了跨学科沟通的重要性，以提高医务人员和患者对筛查指南的认识。预诊计划在确定有风险的患者和优化 HCQ 视网膜病变高危患者的眼部筛查机会方面发挥了重要作用。风湿病医生和眼科医生之间的合作对于管理 HCQ 治疗患者至关重要。实施当日眼部筛查使这种合作更加高效。未来的工作将致力于监测和改进有效的干预措施的使用情况。
