Abstract
BackgroundPregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease. Many clinicians face a situation of heightened sensitivity to the potential risks and uncertainties associated with the effect of pharmacological treatment on pregnancy outcomes. This may create an environment vulnerable to clinical inertia, whereby behavioural factors such as cognitive heuristics and biases, and other factors such as attitudes to risk and emotion can contribute. This systematic review was undertaken to assess if clinical inertia has been investigated/identified in this setting and took a behavioural science approach to identify and understand the potential determinants of clinical inertia in this treatment setting.MethodsA systematic literature search was conducted to identify publications which investigated or described clinical inertia or its determinants (e.g. heuristics, biases etc.). Results were coded for thematic analysis using two inter-related behavioural models: the COM-B model and the Theoretical Domains Framework.ResultsWhilst studies investigating or describing clinical inertia in this treatment setting were not identified, the behavioural analysis revealed a number of barriers to the pharmacological management of women of fertile age affected by chronic inflammatory disease. Factors which may be influencing clinician’s behaviour were identified in all domains of the COM-B model. The primary factors identified were a lack of knowledge of treatment guidelines and fears concerning the safety of medications for mother and fetus. Lack of experience of treating pregnant patients was also identified as a contributing factor to undertreatment.ConclusionUsing a behavioural approach, it was possible to identify potential factors which may be negatively influencing clinician’s behaviour in this treatment setting, although specific research was limited.
Highlights
Pregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease
Literature search and paper selection The literature search was carried out using the PubMed NCBI database in March 2018
All authors agreed on the major search terms and that if a search specific to Chronic rheumatic disease (CRD) (RA, psoriatic arthritis (PsA), axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS)) produced a low yield of results, the search terms would be extended to include other Chronic inflammatory disease (CID) ( Crohn’s disease, ulcerative colitis and psoriasis)
Summary
Pregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease. Many clinicians face a situation of heightened sensitivity to the potential risks and uncertainties associated with the effect of pharmacological treatment on pregnancy outcomes This may create an environment vulnerable to clinical inertia, whereby behavioural factors such as cognitive heuristics and biases, and other factors such as attitudes to risk and emotion can contribute. Clinical inertia has typically been described in health conditions which take a ‘treat-to-target’ approach, such as Type 2 diabetes, hypertension and dyslipidaemia [6,7,8] It was initially defined by Phillips et al in 2001 as “failure of health care providers to initiate or intensify therapy when indicated” [9], but it has since been suggested that it be expanded to encompass other behaviours, such as prescription of preventative therapies and management of risk factors and complications [10]. As a consequence of clinical inertia, patients can experience suboptimal management of their condition which carries increased risk of subsequent adverse health outcomes
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