Are outcomes better in a specialized lupus clinic compared with care provided in a general rheumatology setting? New research from Rush University, Chicago, studies this important care management question and finds the specialized clinic does indeed produce better outcomes.1
You Might Also Like
Explore This IssueJuly 2019
Also By This Author
A big part of the difference may be due to the added experience specialty clinic clinicians receive by seeing a larger volume of lupus patients than general rheumatology clinicians. In other words, practice may be a key to improved outcomes, because the heterogeneous clinical manifestations of systemic lupus erythematosus (SLE), the complexities of diagnosis and treatment, the high morbidity rates and the toxic side effects of medications all challenge the clinician to provide time-consuming multidisciplinary care and follow-up, notes the study’s lead author, Shilpa Arora, MD, John H. Stroger Jr. Hospital of Cook County, Chicago. Measurably higher quality care has also been linked to improved patient outcomes, including survival rates.
The relationship between patient volume and outcomes has been widely studied in other contexts, such as surgical procedures, but not so much in ambulatory settings. “In particular, comparative outcomes from existing specialized lupus clinics have not been studied before,” Dr. Arora notes.
The new study involved a cross-sectional, retrospective chart review of 150 consecutive consenting patients who met the ACR classification criteria for lupus in two settings at Rush University Medical Center: 1) a dedicated lupus clinic (77 patients), and 2) a general rheumatology clinic (73 patients).2 Eleven Rush rheumatologists provided the care and supplied data on patient volume over four months. The researchers found patients who received care at Rush’s dedicated lupus clinic were more likely to receive better care (defined by the total number of well-established lupus quality measures achieved) compared with those receiving care in the general rheumatology clinic.
What Is Quality Lupus Care?
Dr. Arora says we don’t know how many specialty lupus clinics currently operate in the U.S., although major academic medical centers in metropolitan areas often have one or work with field physicians with a special professional interest in lupus.
The measurement of lupus quality of care has not been clearly delineated, Dr. Arora says. “When we say quality of care in lupus, what do we mean?” The ACR has endorsed quality measures for rheumatoid arthritis, gout and glucocorticoid-induced osteoporosis, but not lupus.
Definitions of quality and outcomes are still emerging. Co-author Jinoos Yazdany, MD, MPH, a rheumatologist at the University of California, San Francisco, and her team led efforts to develop and validate quality measures and assess their relationships to long-term outcomes through the UCSF Lupus Outcomes Study, supported by the National Institutes of Health (NIH).3,4 The Rush study proposed 20 quality measures encompassing different aspects of lupus patient care (e.g., diagnosis, counseling, preventive measures, treatment and follow-up) shown to affect outcomes.
“Previous studies have utilized patient data from telephonic surveys to better understand quality of care in lupus,” Dr. Arora says. “We updated the telephonic survey for the purposes of self-administration by patients. Then we pretested the tool. [Because] patient recall may pose issues of under-ascertainment, in our study we also performed medical chart reviews to confirm and supplement the information provided by the patients, comparing performance of these quality measures between the lupus clinic patients and general rheumatology clinic lupus patients.” All are processes measures, focusing on what healthcare providers do when delivering care, Dr. Arora says. “Our analysis looked at how many of the targets are being met.”
One important take-home message from the new research is the importance of using measures to capture efforts aimed at prevention, she says. Several lupus quality measures showed that preventive care, such as offering vitamin D or bone mineral density tests to patients receiving steroids, was more often provided to patients seen in the lupus clinic. Similarly, the preventive task of offering vaccinations against influenza and pneumococcal infection may remain overlooked, even though lupus patients are at higher risk of infection due to their disease and immunosuppression from medications.
Assessment for cardiovascular risk is often neglected when providing high-complexity care for lupus, she says. Patients seen in the lupus specialty clinic received steroids less often, despite similar disease activity, perhaps because lupus specialists better recognize steroids’ short- and long-term side effects.