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Mendoza-Pinto C, Etchegaray-Morales I, Munguía-Realpozo P, Osorio-Peña ÁD, Méndez-Martínez S, Ramírez-Lara E, Zárate-Arellano D, Solis-Poblano JC, Ayón-Aguilar J, García-Carrasco M. Low disease activity state associated with fewer incident vertebral fractures in Mestizo women with systemic lupus erythematosus. Lupus 2023; 32:1328-1334. [PMID: 37705367 DOI: 10.1177/09612033231202878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Low disease activity state (LDAS) has been linked to a significant reduction in flares and damage accrual in patients with systemic lupus erythematosus (SLE); however, the effect of LDAS on the risk of vertebral fractures (VFs) in subjects with SLE is unknown, considering that low bone mineral density (BMD) and VF are frequent in SLE. OBJECTIVE to evaluate whether achieving LDAS ≥50% of the observation time prevents new VF and BMD changes in Mestizo women. METHODS We carried out a longitudinal, observational, and retrospective study. Mestizo women with SLE were included for a median of an 8-year follow-up. LDAS was described as Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score ≤4, prednisone ≤7.5 mg/day, and stable immunosuppressive therapies. BMD measurements and lateral thoracic and lumbar radiographs for a semiquantitative analysis for VF were assessed at baseline and during the follow-up. Uni- and multivariable interval-censored survival regression models were carried out. RESULTS We included 110 patients: 35 (31.8%) had new VF. A total of 56 patients (50.1%) achieved LDAS ≥50% of the time during the follow-up and achieved a significantly lesser risk of incident VF (HR = 0.16; 95% CI, 0.06-0.49). After adjusting by age, BMI, menopause, prevalent VF, baseline BMD, cumulative glucocorticoid use, and anti-osteoporotic therapy, LDAS-50 was significantly related to a decrease in the risk of a new VF (HR = 0.39; 95% CI, 0.16-0.98). There was no association between LDAS and BMD measurement changes. When only patients on LDAS but not in remission (n = 43) were evaluated for the risk of incident VF, both uni- and multivariate analyses were significant (HR = 0.12; 95 CI, 0.04-47; p = 0.001, and HR = 0.26; 95% CI, 0.7-0.88; p = 0.03). CONCLUSIONS LDAS ≥50% of the time was significantly associated with a diminished risk of new VF in Mestizo women with SLE, even in patients not in remission. However, LDAS did not help modify BMD changes over time.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ángel David Osorio-Peña
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | | | - Edith Ramírez-Lara
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
| | - Diana Zárate-Arellano
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Juan Carlos Solis-Poblano
- Department of Haematology, Specialties Hospital UMAE, Mexican Social Security Institute, Puebla, Mexico
| | - Jorge Ayón-Aguilar
- Coordination of Health Research, Mexican Social Security Institute, Puebla, Mexico
| | - Mario García-Carrasco
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
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Ko D, Forrest N, Mai Q, Pawlowski A, Balsley K, Chung A, Ramsey-Goldman R, Walunas TL. Electronic health record data use in the assessment of quality indicators for glucocorticoid osteoporosis screening in systemic lupus erythematosus. Lupus 2022; 31:1516-1522. [PMID: 35861184 PMCID: PMC9588551 DOI: 10.1177/09612033221116726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether electronic health record (EHR) data components could be identified and used to assess bone health quality indicators in patients with systemic lupus erythematosus as a foundation for population health management. METHODS We identified patients in our EHR system who had diagnosis codes for lupus from 2012 to 2017 and characterized them based on the frequency and dosage of prescribed glucocorticoid medications. The medical records of patients who received repeated high-dose glucocorticoid orders were further reviewed for osteoporosis, osteoporotic fractures, receipt of appropriate preventive screening, and orders for protective medications based on established quality indicators. Descriptive statistics were calculated to summarize results. RESULTS We identified 617 patients with a lupus diagnosis; 414 received glucocorticoid prescriptions, 189 received chronic, high-dose; and 83 received chronic, low-dose prescription orders. Of those with chronic high-dose glucocorticoid prescriptions, 14% had an osteoporosis diagnosis, 3% had an osteoporotic fracture, 51% received a prescription for calcium/vitamin D, 43% had bone mineral density screening orders, 20% received a spine radiograph order, 29% had a documented T-score, 12% received a prescription for osteoporosis medication, and 6% had a documented osteoporosis screening. We were able to identify data elements in the EHR for all nine components of the osteoporosis management quality indicator. CONCLUSIONS It is possible to identify data in the EHR for all attributes of the quality indicator for osteoporosis in lupus patients who receive chronic high-dose glucocorticoids. However, missing data and need to extract data from text-based notes may make development of population management tools challenging.
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Affiliation(s)
- Danette Ko
- Division of Rheumatology, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Noah Forrest
- Center for Health Information Partnerships, Institute for Public Health and Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Quan Mai
- Division of Rheumatology, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anna Pawlowski
- Division of Rheumatology, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kate Balsley
- Center for Health Information Partnerships, Institute for Public Health and Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anh Chung
- Division of Rheumatology, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rosalind Ramsey-Goldman
- Division of Rheumatology, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Theresa L Walunas
- Center for Health Information Partnerships, Institute for Public Health and Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of General Internal Medicine, Department of Medicine, 12244Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Hayashi K, Sada KE, Asano Y, Katayama Y, Ohashi K, Morishita M, Miyawaki Y, Watanabe H, Katsuyama T, Narazaki M, Matsumoto Y, Yajima N, Yoshimi R, Shimojima Y, Ohno S, Kajiyama H, Ichinose K, Sato S, Fujiwara M, Wada J. Real-world data on vitamin D supplementation and its impacts in systemic lupus erythematosus: Cross-sectional analysis of a lupus registry of nationwide institutions (LUNA). PLoS One 2022; 17:e0270569. [PMID: 35767524 PMCID: PMC9242469 DOI: 10.1371/journal.pone.0270569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 06/13/2022] [Indexed: 12/25/2022] Open
Abstract
Background Although vitamin D concentration is reportedly associated with the pathogenesis and pathology of systemic lupus erythematosus (SLE), benefits of vitamin D supplementation in SLE patients have not been elucidated, to our knowledge. We investigated the clinical impacts of vitamin D supplementation in SLE. Methods A cross-sectional analysis was performed using data from a lupus registry of nationwide institutions. We evaluated vitamin D supplementation status associated with disease-related Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) as a parameter of long-term disease activity control. Results Of the enrolled 870 patients (mean age: 45 years, mean disease duration: 153 months), 426 (49%) received vitamin D supplementation. Patients with vitamin D supplementation were younger (43.2 vs 47.5 years, P < 0.0001), received higher doses of prednisolone (7.6 vs 6.8 mg/day, P = 0.002), and showed higher estimated glomerular filtration rates (79.3 vs 75.3 mL/min/1.73m2, P = 0.02) than those without supplementation. Disease-related SDI (0.73 ± 1.12 vs 0.73 ± 1.10, P = 0.75), total SDI, and SLE Disease Activity Index (SLEDAI) did not significantly differ between patients receiving and not receiving vitamin D supplementation. Even after excluding 136 patients who were highly recommended vitamin D supplementation (with age ≥ 75 years, history of bone fracture or avascular necrosis, denosumab use, and end-stage renal failure), disease-related SDI, total SDI, and SLEDAI did not significantly differ between the two groups. Conclusions Even with a possible Vitamin D deficiency and a high risk of bone fractures in SLE patients, only half of our cohort received its supplementation. The effect of vitamin D supplementation for disease activity control was not observed.
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Affiliation(s)
- Keigo Hayashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Clinical Epidemiology, Kochi Medical School, Nankoku, Japan
- * E-mail:
| | - Yosuke Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yu Katayama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiji Ohashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiko Morishita
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruki Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takayuki Katsuyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mariko Narazaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinori Matsumoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuyuki Yajima
- Department of Medicine, Division of Rheumatology, Showa University School of Medicine, Tokyo, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeru Ohno
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Hiroshi Kajiyama
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Michio Fujiwara
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Sreedharan S, Li N, Littlejohn G, Buchanan R, Nikpour M, Morand E, Hoi A, Golder V. Association of clinic setting with quality indicator performance in systemic lupus erythematosus: a cross-sectional study. Arthritis Res Ther 2022; 24:150. [PMID: 35733186 PMCID: PMC9214991 DOI: 10.1186/s13075-022-02823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. We aimed to assess the quality of care processes in different clinic settings, comparing a subspecialty lupus clinic with hospital-based and private general rheumatology clinics. METHODS Patients with SLE (n = 258) were recruited in 2016 from a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private rheumatology clinics (n = 55). Data were collected from medical records and patient questionnaires. Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidity assessments, drug monitoring, preventative care and reproductive health. Per-QI performance was measured as a percentage of patients that met the QI relative to the number of patients eligible. Per-patient QI performance was calculated as a percentage of QIs met relative to the number of eligible QIs for each patient. Per-QI and per-patient QI performance were compared between the three clinic settings, and multiple regression performed to adjust for sociodemographic, disease and healthcare factors. RESULTS Per-QI performance was generally high across all clinic settings for diagnostic work-up, comorbidity assessment, lupus nephritis, drug monitoring, prednisolone taper, osteoporosis and pregnancy care. Median [IQR] per-patient performance on eligible QIs was higher in the subspeciality lupus clinic (66.7% [57.1-74.1]) than the hospital general rheumatology (52.7% [47.5-58.1]) and private rheumatology (50.0% [42.9-60.9]) clinics (p <0.001) and the difference remained significant after multivariable adjustment. The subspecialty lupus clinic recorded higher per-QI performance for documentation of disease activity, disease damage, cardiovascular risk factor and drug toxicity assessments, pre-immunosuppression hepatitis and tuberculosis screening, new medication counselling, vaccinations, sun avoidance education and contraception counselling. CONCLUSIONS SLE patients managed in a subspecialty lupus clinic recorded higher per-patient QI performance compared to hospital general rheumatology and private rheumatology clinics, in part related to better documentation on certain QIs.
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Affiliation(s)
- Sidha Sreedharan
- Monash University, Melbourne, Australia. .,Monash Health, Melbourne, Australia.
| | - Ning Li
- Monash University, Melbourne, Australia
| | | | | | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Eric Morand
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Alberta Hoi
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Vera Golder
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
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5
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Mendoza-Pinto C, García-Carrasco M, Juárez-Melchor D, Munguía-Realpozo P, Etchegaray-Morales I, Santiago-Martín N, Ayón-Aguilar J, Méndez-Martínez S. A Retrospective Analysis of Longitudinal Changes in Bone Mineral Density in Women with Systemic Lupus Erythematosus. Calcif Tissue Int 2021; 109:363-371. [PMID: 33864471 DOI: 10.1007/s00223-021-00845-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023]
Abstract
Most prospective studies of bone mineral density (BMD) in systemic lupus erythematosus (SLE) patients have been of relatively short duration, with a maximum of 6 years. To describe long-term changes in BMD in women with SLE and identify risk factors associated with BMD loss. We retrospectively evaluated 132 adult Mexican-Mestizo women with SLE who underwent dual X-ray absorptiometry (DXA). Demographic and clinical data were collected and BMD at the lumbar spine (L1-L4) and total hip were collected at baseline and during the follow up. At baseline, the mean age of participants was 43.4 ± 12.5 years, 50.8% had osteopenia and 11% osteoporosis. The median follow-up was 13 (IQR 10.2-14.0) years. During follow up, 79% of patients used glucocorticoid (GCT). The mean percentage of changes in BMD during follow up were: - 14.03 ± 11.25% (- 1.49%/year) at the lumbar spine, and - 15.77 ± 11.57% (- 1.78%/year) at the total hip, with significant changes (p < 0.001 for both comparisons). Multivariate analysis showed older age, GCT use at baseline, and transition to the menopause during the follow-up were significantly associated with greater reductions in BMD. This retrospective longitudinal study found significant BMD loss at the lumbar spine and hip. Older age, menopausal transition and GCT use were independently associated with BMD decline in women with SLE.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit-CIBIOR, Specialities Hospital, CMN., Mexican Social Security Institute, Puebla, Mexico
- Rheumatology and Immunology Department, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Mario García-Carrasco
- Systemic Autoimmune Diseases Research Unit-CIBIOR, Specialities Hospital, CMN., Mexican Social Security Institute, Puebla, Mexico.
- Rheumatology and Immunology Department, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico.
| | - Daniela Juárez-Melchor
- Systemic Autoimmune Diseases Research Unit-CIBIOR, Specialities Hospital, CMN., Mexican Social Security Institute, Puebla, Mexico
- Postgraduate Unit, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit-CIBIOR, Specialities Hospital, CMN., Mexican Social Security Institute, Puebla, Mexico
- Rheumatology and Immunology Department, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Rheumatology and Immunology Department, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Nicolás Santiago-Martín
- Rheumatology and Immunology Department, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Jorge Ayón-Aguilar
- Research in Health Coordination, Mexican Social Security Institute, Puebla, Puebla, Mexico
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Boone JB, Wheless L, Camai A, Tanner SB, Barnado A. Low prevalence of bone mineral density testing in patients with systemic lupus erythematosus and glucocorticoid exposure. Lupus 2020; 30:403-411. [PMID: 33307984 DOI: 10.1177/0961203320979735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
SummaryPatients with systemic lupus erythematosus (SLE) have an increased risk of developing osteoporosis and fractures due to systemic inflammation and glucocorticoids (GCs). Professional organizations recommend bone mineral density (BMD) testing in SLE patients on GCs, especially within 6 months of initiation. Using a validated algorithm, we identified SLE patients in an electronic health record cohort with long-term GC exposure (≥90 days). Our primary outcome was ever BMD testing. We assessed the impact of patient and provider factors on testing. We identified 693 SLE cases with long-term GC exposure, 41% of whom had BMD testing performed. Only 18% of patients had BMD testing within 6 months of GC initiation. In a logistic regression model for BMD testing, male sex (OR = 0.49, 95% CI 0.27 - 0.87, p = 0.01) was associated with being less likely to have BMD testing after adjusting for race and ethnicity. In contrast, older age (OR = 1.04, p < 0.001) and nephritis (OR = 1.83, p = 0.003) were associated with being more likely to have BMD testing after adjusting for race and ethnicity. Bone health in SLE patients remains an area in need of improvement with attention to patients who are younger and male.
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Affiliation(s)
- J B Boone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lee Wheless
- Department of Dermatology, Data Science Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Camai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - S Bobo Tanner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - April Barnado
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Aguirre A, Trupin L, Margaretten M, Goglin S, Noh JH, Yazdany J. Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic. J Rheumatol 2020; 47:1712-1720. [PMID: 32062597 PMCID: PMC7429246 DOI: 10.3899/jrheum.190472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population. METHODS The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care. RESULTS There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets. CONCLUSION Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.
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Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, Clinical Fellow, Division of Rheumatology, Department of Medicine, University of California, San Francisco;
| | - Laura Trupin
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Mary Margaretten
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Sarah Goglin
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
| | - Jung Hee Noh
- J.H. Noh, RN, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jinoos Yazdany
- L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco
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8
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Kernder A, Richter JG, Fischer-Betz R, Winkler-Rohlfing B, Brinks R, Schneider M, Chehab G. Quality of care predicts outcome in systemic lupus erythematosus: a cross-sectional analysis of a German long-term study (LuLa cohort). Lupus 2020; 29:136-143. [PMID: 31992161 PMCID: PMC6993135 DOI: 10.1177/0961203319896626] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective Our aim was to study the quality of medical care in patients with systemic lupus erythematosus (SLE) to understand gaps and to analyze the association with outcome of the disease. Methods Information on demographics and medical care was assessed by self-reported questionnaires among SLE patients (LuLa cohort, 2011, n = 580). In total, 21 aspects of medical care were analyzed. Univariate analysis selected 10 predictor variables for further analysis: (1) urine examination and (2) blood test in the previous year, (3) taking antimalarials, (4) taking vitamin D and calcium if the dosage of prednisolone was greater than 7.5 mg/day, counseling regarding (5) lipid metabolism, (6) vaccination, and (7) blood pressure, and treatment of the comorbidities (8) hypertension, (9) osteoporosis and (10) lipid metabolism disorder. The association of these 10 items with the outcome of the disease, assessed in 2015, was analyzed by linear regression analysis, adjusted for age, disease duration and sex. Results On average six of the 10 items were met (±1.7). Receiving more clinical care in 2013 was predictive for low disease activity (SLAQ, p = 0.024, β = –0.104, corr. R2 = 0.048), low progress in disease-related damage (Delta Brief Index of Lupus Questionnaire, p = 0.048, β = –0.132, corr. R2 = 0.036) and high health-related quality of life (SF-12 physical, p = 0.035, β = 0.100, corr. R2 = 0.091) in 2015. Conclusion Our study illustrates a link between the quality of care and the SLE outcome parameters disease activity, disease-related damage and quality of life. Consistent considerations of these care parameters, which are recommended in several management guidelines, could therefore be a good approach to improve the outcome of patients with SLE.
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Affiliation(s)
- A Kernder
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
| | - J G Richter
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
| | - R Fischer-Betz
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
| | | | - R Brinks
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
| | - M Schneider
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
| | - G Chehab
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Düsseldorf, Germany
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9
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Arora S, Yazdany J. Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2020; 46:623-638. [PMID: 32981640 DOI: 10.1016/j.rdc.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.
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Affiliation(s)
- Shilpa Arora
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, 1001 Potrero Avenue, Suite 3300, San Francisco, CA 94110, USA.
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Aggarwal I, Li J, Trupin L, Gaynon L, Katz PP, Lanata C, Criswell L, Murphy LB, Dall'Era M, Yazdany J. Quality of Care for the Screening, Diagnosis, and Management of Lupus Nephritis Across Multiple Health Care Settings. Arthritis Care Res (Hoboken) 2020; 72:888-896. [PMID: 31058460 DOI: 10.1002/acr.23915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/30/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We examined quality measures for screening, diagnosis, and treatment of lupus nephritis (LN) among participants of the California Lupus Epidemiology Study across 25 different clinical sites to identify gaps in quality of care. METHODS Data from 250 participants with lupus were analyzed across 3 sources (medical records, physician examination, and patient interviews). Overall performance on 8 quality measures was calculated separately for participants with and without LN. We used generalized estimating equations in which the outcome was performance on measures, adjusting for participant demographics, lupus disease severity, and practice characteristics. RESULTS Of 148 patients without LN, 42% underwent screening laboratory tests for nephritis, 38% underwent lupus activity serum studies, and 81% had their blood pressure checked every 6 months. Of 102 LN patients, 67% had a timely kidney biopsy, at least 81% had appropriate treatment, and 78% achieved target blood pressure within 1 year of diagnosis. Overall performance in participants across quality measures was 54% (no LN) and 80% (LN). Significantly higher overall performance for screening measures for LN was seen at academic (63.4-73%) versus community clinics (37.9-38.4%). Similarly, among those with LN, higher performance in academic (84.1-85.2%) versus community clinics (54.8-60.2%) was observed for treatment measures. CONCLUSION In this quality-of-care analysis across 25 diverse clinical settings, we found relatively high performance on measures for management of LN. However, future work should focus on bridging the gaps in lupus quality of care for patients without nephritis, particularly in community settings.
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Affiliation(s)
| | - Jing Li
- University of California, San Francisco
| | | | - Lisa Gaynon
- California Pacific Medical Center, San Francisco
| | | | | | | | - Louise B Murphy
- Centers for Disease Control and Prevention, Atlanta, Georgia
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11
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Sapkota S, Baig S, Hess T, O'Connell AM, Menk J, Shyne M, Fazeli P, Ensrud K, Shmagel A. Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care? Lupus 2020; 29:263-272. [PMID: 31996109 DOI: 10.1177/0961203320903086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard. METHODS We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription. RESULTS A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098). CONCLUSIONS In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.
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Affiliation(s)
- S Sapkota
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
| | - S Baig
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - T Hess
- University of Minnesota Medical School, University of Minnesota, Minneapolis, USA
| | | | - J Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - M Shyne
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - P Fazeli
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
| | - K Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, USA.,Center for Care Delivery and Outcome Research, Minneapolis VA Health Care System, Minneapolis, USA
| | - A Shmagel
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
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Yajima N, Tsujimoto Y, Fukuma S, Sada KE, Shimizu S, Niihata K, Takahashi R, Asano Y, Azuma T, Kameda H, Kuwana M, Kohsaka H, Sugiura-Ogasawara M, Suzuki K, Takeuchi T, Tanaka Y, Tamura N, Matsui T, Mimori T, Fukuhara S, Atsumi T. The development of quality indicators for systemic lupus erythematosus using electronic health data: A modified RAND appropriateness method. Mod Rheumatol 2019; 30:525-531. [PMID: 31111758 DOI: 10.1080/14397595.2019.1621419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective: Quality indicators (QIs) are tools that standardize evaluations in terms of the minimum acceptable quality of care, presumably contributing for the better management of patients with systemic lupus erythematosus (SLE). This study aimed to develop QIs for SLE using electronic health data.Methods: The modified RAND/UCLA Appropriateness Method was used to develop the QIs. First, a literature review was conducted. Second, the candidate QI items that were available to be evaluated using the electronic health data were extracted. Third, the appropriateness of the items was assessed via rating rounds and panelists' discussions.Results: We found 3621 articles in the initial search. Finally, 34 studies were reviewed, from which 17 potential indicators were extracted as candidate QIs. Twelve indicators were selected as the final QI set through the process of appropriateness. The median appropriateness of these 12 indicators was at least 7.5, and all of them were without disagreement. The QI included assessment of disease activity, treatment of SLE, drug toxicity monitoring, treatment of glucocorticoid complications, and assessment of SLE complications.Conclusion: We formulated 12 QIs for the assessment of patients with SLE based on electronic medical data. Our QI set would be a practical tool as a quality measure.
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Affiliation(s)
- Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Yasushi Tsujimoto
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan.,Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Kakuya Niihata
- Department of Hygiene and Preventive Medicine, Fukushima Medical University, Fukushima, Japan
| | - Ryo Takahashi
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yoshihide Asano
- Department of Dermatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Teruhisa Azuma
- Shirakawa Satellite for Teaching And Research in General Medicine, Fukushima Medical University, Shirakawa, Japan
| | - Hideto Kameda
- Division of Rheumatology, Toho University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School, Tokyo, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mayumi Sugiura-Ogasawara
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshihiro Matsui
- Department of Lifetime Clinical Immunology Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Rheumatology, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara Hospital, Sagamihara, Japan
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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13
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Bultink IEM. Bone Disease in Connective Tissue Disease/Systemic Lupus Erythematosus. Calcif Tissue Int 2018; 102:575-591. [PMID: 28900675 PMCID: PMC5904226 DOI: 10.1007/s00223-017-0322-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 09/05/2017] [Indexed: 01/07/2023]
Abstract
This article reviews recent advances in the research of the mechanisms of bone loss, as well as clinical features, economic impact and therapeutic implications of osteoporosis and fractures in patients with systemic lupus erythematosus (SLE) as an illustration of bone disease in a complex systemic autoimmune connective tissue disease. Recent studies demonstrated an increased incidence of osteoporosis and peripheral and vertebral fractures in patients with SLE. The aetiology of bone loss in SLE is multifactorial, including clinical osteoporosis risk factors, systemic inflammation, serological factors, metabolic factors, hormonal factors, possibly genetic factors and medication-induced adverse effects. The incidence of symptomatic fractures in patients with SLE is increased 1.2-4.7-fold and age, disease duration, glucocorticoid use, previous cyclophosphamide use, seizures and a prior cerebrovascular event have been identified as important risk factors. Moreover, a high prevalence of morphometric vertebral fractures was demonstrated, while one in three of these patients has normal bone density, which finding points to the multifactorial aetiology of fractures in SLE. The clinical consequences and economic burden of osteoporosis and fractures as glucocorticoid treatment-related adverse events and the high frequency of glucocorticoid therapy underline the importance of reducing glucocorticoid treatment and prescribing steroid-sparing agents. No data on fall risk and its determinants and the relationship with the occurrence of fractures in patients with SLE are currently available. Fall risk might be increased in lupus patients for several reasons. In addition, the recently reported high prevalence (20%) of frailty in SLE patients may contribute to the increased fracture incidence. Therefore, the relationships between fall risk, frailty and fracture occurrence in SLE might be interesting subjects for future studies.
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Affiliation(s)
- Irene E M Bultink
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Hafez EA, ElBakry SA, Ibrahim SI, Morad CS, Hamza SA, Abd El-Khalik DM. Assessment of fracture risk in a cohort of Egyptian female Systemic Lupus erythematosus patients. THE EGYPTIAN RHEUMATOLOGIST 2018; 40:85-91. [DOI: 10.1016/j.ejr.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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15
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Golder V, Morand EF, Hoi AY. Quality of Care for Systemic Lupus Erythematosus: Mind the Knowledge Gap. J Rheumatol 2017; 44:271-278. [DOI: 10.3899/jrheum.160334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is a prototypical chronic multiorgan autoimmune disorder that can lead to significant burden of disease and loss of life expectancy. The disease burden is the result of a complex interplay between genetic, biologic, socioeconomic, and health system variables affecting the individual. Recent advances in biological understanding of SLE are yet to translate to transformative therapies, and genetic and socioeconomic variables are not readily amenable to intervention. In contrast, healthcare quality, a variable readily amenable to change, has been inadequately addressed in SLE, despite evidence in other chronic diseases that quality of care is strongly associated with patient outcomes. This article will analyze the available literature on the quality of care relevant to SLE, identify knowledge gaps, and suggest ways to address this in future research.
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16
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Harris JG, Maletta KI, Kuhn EM, Olson JC. Evaluation of quality indicators and disease damage in childhood-onset systemic lupus erythematosus patients. Clin Rheumatol 2016; 36:351-359. [PMID: 28013435 DOI: 10.1007/s10067-016-3518-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/11/2016] [Accepted: 12/14/2016] [Indexed: 01/30/2023]
Abstract
The aim of this study was to describe compliance with select quality indicators and assess organ-specific dysfunction in a childhood-onset systemic lupus erythematosus population by using a validated damage index and to evaluate associations between compliance with quality indicators and disease damage. A retrospective chart review was performed on patients diagnosed with systemic lupus erythematosus prior to age 18 followed at a single center in the USA from 1999 to 2012 (n = 75). Data regarding quality indicators and outcome variables, including the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, were collected. The median disease duration was 3.8 years. The proportion of patients or patient-years in which care complied with the proposed quality measures was 94.4% for hydroxychloroquine use, 84.3% for vitamin D recommendation,75.8% for influenza vaccination (patient-years), 67.2% for meningococcal vaccination, 49.0% for ophthalmologic examination (patient-years), 31.7% for pneumococcal vaccination, and 28.6% for bone mineral density evaluation. Disease damage was present in 41.3% of patients at last follow-up, with an average damage index score of 0.81. Disease damage at last follow-up was associated with minority race/ethnicity (p = 0.008), bone mineral density evaluation (p = 0.035), and vitamin D recommendation (p = 0.018). Adherence to quality indicators in a childhood-onset systemic lupus erythematosus population is varied, and disease damage is prevalent. This study highlights the importance of quality improvement initiatives aimed at optimizing care delivery to reduce disease damage in pediatric lupus patients.
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Affiliation(s)
- Julia G Harris
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA. .,University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA.
| | - Kristyn I Maletta
- Department of Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Evelyn M Kuhn
- Department of Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Judyann C Olson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Casey C, Chung CP, Crofford LJ, Barnado A. Rheumatologists' perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers. Clin Rheumatol 2016; 36:97-102. [PMID: 27878408 DOI: 10.1007/s10067-016-3487-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/06/2016] [Accepted: 11/13/2016] [Indexed: 11/26/2022]
Abstract
Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.
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Affiliation(s)
- Carolyn Casey
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA
| | - April Barnado
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA.
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Wang X, Yan S, Liu C, Xu Y, Wan L, Wang Y, Gao W, Meng S, Liu Y, Liu R, Xu D. Fracture risk and bone mineral density levels in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Osteoporos Int 2016; 27:1413-1423. [PMID: 26753541 DOI: 10.1007/s00198-015-3449-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/01/2015] [Indexed: 12/16/2022]
Abstract
Previous studies suggested possible bone loss and fracture risk in patients with systemic lupus erythematosus (SLE). The aim of this systematic review and meta-analysis was to assess the strength of the relationship of SLE with fracture risk and the mean difference of bone mineral density (BMD) levels between SLE patients and controls. Literature search was undertaken in multiple indexing databases on September 26, 2015. Studies on the relationship of SLE with fracture risk and the mean difference of BMD levels between SLE patients and controls were included. Data were combined using standard methods of meta-analysis. Twenty-one studies were finally included into the meta-analysis, including 15 studies on the mean difference of BMD levels between SLE patients and controls, and 6 studies were on fracture risk associated with SLE. The meta-analysis showed that SLE patients had significantly lower BMD levels than controls in the whole body (weighted mean difference [WMD] = -0.04; 95 % CI -0.06 to -0.02; P < 0.001), femoral neck (WMD = -0.06; 95 % CI -0.07 to -0.04; P < 0.001), lumbar spine (WMD = -0.06; 95 % CI -0.09 to -0.03; P < 0.001), and total hip (WMD = -0.05; 95 % CI -0.06 to -0.03; P < 0.001). In addition, the meta-analysis also showed that SLE was significantly associated with increased fracture risk of all sites (relative risk [RR] = 1.97, 95 % CI 1.20-3.25; P = 0.008). Subgroup analysis by adjustment showed that SLE was significantly associated with increased fracture risk of all sites before and after adjusting for confounding factors (unadjusted RR = 2.07, 95 % CI 1.46-2.94, P < 0.001; adjusted RR = 1.22, 95 % CI 1.05-1.42, P = 0.01). Subgroup analysis by types of fracture showed that SLE was significantly associated with increased risks of hip fracture (RR = 1.99, 95 % CI 1.55-2.57; P < 0.001), osteoporotic fracture (RR = 1.36, 95 % CI 1.21-1.53; P < 0.001), and vertebral fracture (RR = 2.97, 95 % CI 1.71-5.16; P < 0.001). This systematic review and meta-analysis provides strong evidence for the relationship of SLE with bone loss and fracture risk.
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Affiliation(s)
- X Wang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - S Yan
- Department of Anorectal Surgery, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, China
| | - C Liu
- Clinical Laboratory, First Affiliated Hospital, Nanjing Medical University, Nanjing, 210029, China
| | - Y Xu
- Occupational Safety and Health Research Center of the State Administration of Work Safety, Beijing, 100000, China
| | - L Wan
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - Y Wang
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - W Gao
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - S Meng
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - Y Liu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China
| | - R Liu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China.
| | - D Xu
- Department of Rheumatology and Immunology, The Affiliated Hospital of Weifang Medical University, Weifang, 261000, Shandong Province, China.
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Abstract
PURPOSE OF REVIEW This manuscript will provide a review of recent publications, examining the correlation of systemic lupus erythematosus (SLE) with changes in bone health and associated osteoporosis, highlighting prevalence, etiology, diagnosis, and treatment. RECENT FINDINGS Studies suggest that bone loss and fractures are associated with SLE, related not only to the disease itself, but also with low vitamin D and treatment side-effects. Understanding the mechanisms of glucocorticoids on bone and the immunologic relationship of vitamin D, as well as recognizing the role of chronic inflammation on bone, allows for better understanding of skeletal side-effects. Further awareness of the association of poor bone health has led to an increased need for prevention and treatment. New imaging and treatment are emerging, although not recommended currently. SUMMARY Loss of bone density culminating in osteoporosis and fracture is a frequent comorbidity in SLE patients at any age and is multifactorial in etiology. Awareness and diagnosis is crucial because of its prevalence and morbidity. Prevention is safe and effective in this high-risk population where diagnostic measures and interventions are underutilized and guidelines are lacking.
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Affiliation(s)
- Cuoghi Edens
- aDepartment of Pediatrics, Division of Pediatric Infectious Diseases and Rheumatology, Rainbow Babies and Children's Hospital bDepartment of Internal Medicine, Division of Rheumatology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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Okamoto Y, Katsumata Y, Baba S, Kawaguchi Y, Gono T, Hanaoka M, Kawasumi H, Yamanaka H. Validation of the Japanese version of the Systemic Lupus Activity Questionnaire that includes physician-based assessments in a large observational cohort. Lupus 2015; 25:486-95. [DOI: 10.1177/0961203315617844] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/26/2015] [Indexed: 11/17/2022]
Abstract
The Systemic Lupus Activity Questionnaire (SLAQ) is a patient-reported outcome for systemic lupus erythematosus (SLE). We aimed to translate it into Japanese and further investigate its validity and reliability. The English version of the SLAQ was translated into Japanese and administered to Japanese SLE patients at our university clinic. Physicians assessed disease activity using the SLE Disease Activity Index 2000 (SLEDAI-2K). The patients were prospectively followed for repeat assessment a year later. Ultimately, 255 patients participated. The patients’ 10-point ratings of disease activity and SLAQ scores were significantly correlated (Spearman’s ρ = 0.53). The SLAQ score was weakly correlated with the SLE Disease Activity Index 2000 (SLEDAI-2K)-nolab (omitting laboratory items; ρ = 0.18) but not with the SLEDAI-2K ( ρ = 0.02). These results suggested its convergent and discriminant validity. The SLAQ demonstrated acceptable internal consistency (Cronbach’s α = 0.80), and good test–retest reliability (intraclass correlation coefficient = 0.85). The effect sizes and the standardized response means of the SLAQ were as follows: clinical worsening, 0.26 and 0.31, and improvement, −0.39 and −0.41, respectively, which indicated a small but significant responsiveness. The Japanese version of the SLAQ demonstrated acceptable reliability and validity; its performance was comparable to that of the original version.
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Affiliation(s)
- Y Okamoto
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Y Katsumata
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - S Baba
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Y Kawaguchi
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - T Gono
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - M Hanaoka
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Kawasumi
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - H Yamanaka
- The Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
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Sapir T, Rusie E, Greene L, Yazdany J, Robbins ML, Ruderman EM, Carter JD, Patel B, Moreo K. Influence of Continuing Medical Education on Rheumatologists' Performance on National Quality Measures for Rheumatoid Arthritis. Rheumatol Ther 2015; 2:141-151. [PMID: 27747535 PMCID: PMC4883265 DOI: 10.1007/s40744-015-0018-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction In recent years researchers have reported deficits in the quality of care provided to patients with rheumatoid arthritis (RA), including low rates of performance on quality measures. We sought to determine the influence of a quality improvement (QI) continuing education program on rheumatologists’ performance on national quality measures for RA, along with other measures aligned with National Quality Strategy priorities. Performance was assessed through baseline and post-education chart audits. Methods Twenty community-based rheumatologists across the United States were recruited to participate in the QI education program and chart audits. Charts were retrospectively audited before (n = 160 charts) and after (n = 160 charts) the rheumatologists participated in a series of accredited QI-focused educational activities that included private audit feedback, small-group webinars, and online- and mobile-accessible print and video activities. The charts were audited for patient demographics and the rheumatologists’ documented performance on the 6 quality measures for RA included in the Physician Quality Reporting System (PQRS). In addition, charts were abstracted for documentation of patient counseling about medication benefits/risks and adherence, lifestyle modifications, and quality of life; assessment of RA medication side effects; and assessment of RA medication adherence. Results Mean rates of documented performance on 4 of the 6 PQRS measures for RA were significantly higher in the post-education versus baseline charts (absolute increases ranged from 9 to 24% of patient charts). In addition, after the intervention, significantly higher mean rates were observed for patient counseling about medications and quality of life, and for assessments of medication side effects and adherence (absolute increases ranged from 9 to 40% of patient charts). Conclusion This pragmatic study provides preliminary evidence for the positive influence of QI-focused education in helping rheumatologists improve performance on national quality measures for RA. Electronic supplementary material The online version of this article (doi:10.1007/s40744-015-0018-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tamar Sapir
- PRIME Education, Inc., 8201 West McNab Road, Tamarac, FL, 33321, USA.
| | - Erica Rusie
- PRIME Education, Inc., 8201 West McNab Road, Tamarac, FL, 33321, USA
| | - Laurence Greene
- PRIME Education, Inc., 8201 West McNab Road, Tamarac, FL, 33321, USA
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, Box 0920, 3333, California St., Suite 270, San Francisco, CA, 94143-0920, USA
| | - Mark L Robbins
- Division of Rheumatology, Harvard Vanguard Medical Associates/Atrius Health, 40 Holland Street, Somerville, MA, 02144, USA
| | - Eric M Ruderman
- Division of Rheumatology, Northwestern University Feinberg School of Medicine, 675 N Saint Clair, Suite 14-100, Chicago, IL, 60611, USA
| | - Jeffrey D Carter
- PRIME Education, Inc., 8201 West McNab Road, Tamarac, FL, 33321, USA
| | - Barry Patel
- Indegene, 222 Chastain Meadows Ct, Suite 300, Kennesaw, GA, 30144, USA
| | - Kathleen Moreo
- PRIME Education, Inc., 8201 West McNab Road, Tamarac, FL, 33321, USA
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22
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Yazdany J, Marafino BJ, Dean ML, Bardach NS, Duseja R, Ward MM, Dudley RA. Thirty-day hospital readmissions in systemic lupus erythematosus: predictors and hospital- and state-level variation. Arthritis Rheumatol 2014; 66:2828-36. [PMID: 25110993 DOI: 10.1002/art.38768] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 06/26/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) has one of the highest hospital readmission rates among chronic conditions. This study was undertaken to identify patient-level, hospital-level, and geographic predictors of 30-day hospital readmissions associated with SLE. METHODS Using hospital discharge databases from 5 geographically dispersed states, we studied all-cause readmission of SLE patients between 2008 and 2009. We evaluated each hospitalization as a possible index event leading up to a readmission, our primary outcome. We accounted for clustering of hospitalizations within patients and within hospitals and adjusted for hospital case mix. Using multilevel mixed-effects logistic regression, we examined factors associated with 30-day readmission and calculated risk-standardized hospital-level and state-level readmission rates. RESULTS We examined 55,936 hospitalizations among 31,903 patients with SLE. Of these hospitalizations, 9,244 (16.5%) resulted in readmission within 30 days. In adjusted analyses, age was inversely related to risk of readmission. African American and Hispanic patients were more likely to be readmitted than white patients, as were those with Medicare or Medicaid insurance (versus private insurance). Several clinical characteristics of lupus, including nephritis, serositis, and thrombocytopenia, were associated with readmission. Readmission rates varied significantly between hospitals after accounting for patient-level clustering and hospital case mix. We also found geographic variation, with risk-adjusted readmission rates lower in New York and higher in Florida as compared to California. CONCLUSION We found that ~1 in 6 hospitalized patients with SLE were readmitted within 30 days of discharge, with higher rates among historically underserved populations. Significant geographic and hospital-level variation in risk-adjusted readmission rates suggests potential for quality improvement.
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Affiliation(s)
- Jinoos Yazdany
- San Francisco General Hospital and University of California, San Francisco
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23
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Kuchuk NO, Hoes JN, Bijlsma JWJ, Jacobs JWG. Glucocorticoid-induced osteoporosis: an overview. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/ijr.14.24] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yazdany J, Trupin L, Schmajuk G, Katz PP, Yelin EH. Quality of care in systemic lupus erythematosus: the association between process and outcome measures in the Lupus Outcomes Study. BMJ Qual Saf 2014; 23:659-66. [PMID: 24614054 DOI: 10.1136/bmjqs-2013-002494] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Although process measures to assess quality of care in systemic lupus erythematosus (SLE) are available, their relationship to long-term outcomes has not been studied. Using a prospective, longitudinal cohort study, we examined the associations between high-quality care and two important SLE outcomes, disease activity and damage. METHODS Data were derived from the University of California, San Francisco Lupus Outcomes Study. Participants were followed from 2009 through 2013, responding to yearly surveys. Primary outcomes in this study were clinically meaningful increases in disease activity and damage, assessed by the Systemic Lupus Activity Questionnaire (SLAQ) and the Brief Index of Lupus Damage (BILD), respectively. Using multivariable regression, we examined the relationship between high performance on 13 validated quality measures (receipt of ≥85% of quality measures), and disease outcomes, adjusting for disease status, sociodemographic characteristics, healthcare services and follow-up time. RESULTS The 737 participants were eligible for a mean of five quality measures (SD 2, range 2-12). There were 155 and 162 participants who had clinically meaningful increases in SLAQ and BILD, respectively. In our models, we found no statistically significant relationship between performance on quality measures and changes in SLAQ. However, receiving higher-quality SLE care was significantly protective against increased disease damage (adjusted OR 0.4, 95% CI 0.4 to 0.7), even after adjusting for covariates. DISCUSSION In this community-based cohort, we illustrate for the first time a strong link between processes of care, defined by SLE quality measures, and the subsequent accumulation of disease damage, an important outcome.
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Affiliation(s)
- Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA
| | - Laura Trupin
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA
| | - Gabriela Schmajuk
- Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California, USA
| | - Patricia P Katz
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Edward H Yelin
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA Institute for Health Policy Studies, University of California, San Francisco, California, USA
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25
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Yazdany J, Schmajuk G, Robbins M, Daikh D, Beall A, Yelin E, Barton J, Carlson A, Margaretten M, Zell J, Gensler LS, Kelly V, Saag K, King C. Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question. Arthritis Care Res (Hoboken) 2013; 65:329-39. [PMID: 23436818 PMCID: PMC4106486 DOI: 10.1002/acr.21930] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 12/10/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients. METHODS We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force. RESULTS One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member-wide survey, whereas 33% of those in the nested random sample participated; respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion. CONCLUSION The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high-value care.
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Affiliation(s)
- Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, Box 0920, San Francisco, CA 94143-0920, USA.
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26
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Yazdany J, Trupin L, Tonner C, Dudley RA, Zell J, Panopalis P, Schmajuk G, Julian L, Katz P, Criswell LA, Yelin E. Quality of care in systemic lupus erythematosus: application of quality measures to understand gaps in care. J Gen Intern Med 2012; 27:1326-33. [PMID: 22588825 PMCID: PMC3445683 DOI: 10.1007/s11606-012-2071-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 03/09/2012] [Accepted: 03/29/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) affects 1 in 2500 Americans and is associated with significant morbidity and mortality. The recent development of SLE quality measures provides an opportunity to understand gaps in clinical care and to identify modifiable factors associated with variations in quality. OBJECTIVE To evaluate performance on SLE quality measures as well as differences in quality of care by demographic, socioeconomic, disease, and health system characteristics. DESIGN AND PATIENTS Cross-sectional analysis of data derived from the Lupus Outcomes Study, a prospective, longitudinal study of 814 individuals. Principal data collection was through annual structured telephone surveys between 2009-2010. Data on 13 SLE quality measures was collected. We used regression models to estimate demographic, socioeconomic, disease, and health system characteristics associated with performance on individual and overall quality measures. OUTCOME MEASURES Performance on each quality measure and overall performance on all measures for which participants were eligible (pass rate). RESULTS Participants were eligible for a mean of five measures (range 2-12). Performance varied from 29 % (assessment of cardiovascular risk factors) to 90 % (sun avoidance counseling). The overall pass rate was 65 % (95 % CI 64 %, 65 %). In unadjusted analyses, younger age, minority race/ethnicity, poverty, shorter disease duration, fewer physician visits, and lack of health insurance, were associated with lower pass rates. Receiving care in public sector managed care organizations was associated with higher pass rates. After adjustment, younger age, having fewer physician visits and lacking health insurance remained significantly associated with lower performance; receiving care in public sector managed care organizations remained associated with higher performance. CONCLUSIONS We identified a number of gaps in clinical care for SLE. Factors associated with the health care system, including presence and type of health insurance, were the primary determinants of performance on quality measures in SLE.
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Affiliation(s)
- Jinoos Yazdany
- Rosalind Russell Medical Research Center for Arthritis, University of California, San Francisco, CA 94143-0920, USA.
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27
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Lawson EF, Yazdany J. Healthcare quality in systemic lupus erythematosus: using Donabedian's conceptual framework to understand what we know. ACTA ACUST UNITED AC 2012; 7:95-107. [PMID: 22448191 DOI: 10.2217/ijr.11.65] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Healthcare quality improvement has the potential to reduce the striking disparities in health outcomes among patients with systemic lupus erythematosus (SLE). Donabedian's framework for assessment of healthcare quality, which divides factors impacting quality into structures, processes and outcomes, provides a theoretical framework for research and interventions in quality improvement. This review applies Donabedian's model to current research describing quality of care in SLE, highlighting structures and processes that may lead to improved outcomes. Work remains to be done to develop meaningful metrics to assess quality and to understand the structures and processes that improve outcomes. Quality indicators have emerged as an important tool to measure quality, but further validation is required to define their validity and feasibility in clinical practice, as well as their association with improved outcomes. Implementation science also shows promise as a means to create meaningful systematic improvements in healthcare quality for patients with SLE.
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Affiliation(s)
- Erica F Lawson
- University of California, San Francisco, Department of Pediatrics, Division of Rheumatology, 3333 California Street, Box 0920, San Francisco, CA 94143, USA
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28
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Mosca M, Tani C, Aringer M, Bombardieri S, Boumpas D, Cervera R, Doria A, Jayne D, Khamashta MA, Kuhn A, Gordon C, Petri M, Schneider M, Shoenfeld Y, Smolen JS, Talarico R, Tincani A, Ward MM, Werth VP, Carmona L. Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice. Autoimmun Rev 2011; 10:383-8. [PMID: 21224016 DOI: 10.1016/j.autrev.2010.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
The assessment of systemic lupus erythematosus (SLE) patients in routine clinical practice is mainly based on the experience of the treating physician. This carries the risk of unwanted variability. Variability may have an impact on the quality of care offered to SLE patients, thereby affecting outcomes. Recommendations represent systematically developed statements to help practitioners in reducing variability. However, major difficulties arise in the application of recommendations into clinical practice. In this respect, the use of quality indicators may raise the awareness among rheumatologists regarding potential deficiencies in services and improve the quality of health care. The aim of this study was to develop a set of quality indicators (QI) for SLE by translating into QIs the recently developed EULAR Recommendations for monitoring SLE patients in routine clinical practice and observational studies. Eleven QIs have been developed referring to the use of validated activity and damage indices in routine clinical practice, general evaluation of drug toxicity, evaluation of comorbidities, eye evaluation, laboratory assessment, evaluation of the presence of chronic viral infections, documentation of vaccination and of antibody testing at baseline. A disease specific set of quality assessment tools should help physicians deliver high quality of care across populations. Routine updates will be needed.
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Affiliation(s)
- M Mosca
- Rheumatology Unit, Department of Internal Medicine, University of Pisa, Italy.
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Abstract
PURPOSE OF REVIEW There is an increased risk of osteoporotic fractures and osteonecrosis often at a young age among patients with certain systemic autoimmune diseases. The loss of bone mineral density and bone integrity seen with these diseases often cannot be explained by traditional risk factors alone. In this review, we focus on rheumatoid arthritis and systemic lupus erythematosus, two systemic autoimmune diseases in which skeletal manifestations have been well described. RECENT FINDINGS There is recent evidence that autoimmunity and its associated inflammation and vitamin D deficiency play key roles in the pathogenesis of adverse skeletal effects. SUMMARY Understanding these processes carries implications for the prevention and treatment of osteoporosis and osteonecrosis among patients with autoimmune diseases.
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Affiliation(s)
- Diane L Kamen
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA.
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30
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Kamen DL. Vitamin D in lupus - new kid on the block? BULLETIN OF THE NYU HOSPITAL FOR JOINT DISEASES 2010; 68:218-222. [PMID: 20969555 PMCID: PMC4185297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Vitamin D is an essential steroid hormone, with well established effects on mineral metabolism, skeletal health, and recently established effects on the cardiovascular and immune systems. Vitamin D deficiency is highly prevalent and evidence is mounting that it contributes to the morbidity and mortality of multiple chronic diseases, including systemic lupus erythematosus (SLE). Patients with SLE avoid the sun because of photosensitive rashes and potential for disease fare, so adequate oral supplementation is critical. This review will describe the prevalence of vitamin D deficiency in patients with SLE, identify risk factors for deficiency, describe the consequences of deficiency, and review current vitamin D recommendations for patients with rheumatic diseases.
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Affiliation(s)
- Diane L Kamen
- Medical University of South Carolina College of Medicine, Charleston, South Carolina 29425, USA.
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