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Lupus quality of care: Unmet needs for bridging the gaps across multiple healthcare settings

Comment on: 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 Healthcare Settings. Arthritis Care Res (Hoboken) 2019 May 6. doi: 10.1002/acr.23915. [Epub ahead of print]

Commented by: Luís Inês, MD, PhD. Rheumatologist, CHUC Lupus Clinic, Rheumatology Dpt., Centro Hospitalar Universitário de Coimbra, Portugal. SLEuro general secretary.

In this study, Aggarval et al aimed to investigate if there are gaps in quality of care for patients with lupus nephritis (LN) across multiple healthcare settings (academic and community rheumatology practices) in the USA.

For this purpose, the investigators analysed data from 250 patients with SLE, participants of the California Lupus Epidemiology Study, a prospective cohort recruited from patients followed across 25 different academic and community rheumatology clinics and residing in the San Francisco Bay area (California, USA). The study cohort included participants with diverse socioeconomic and ethnic backgrounds. Investigators assessed quality measures for screening, diagnosis and treatment of LN, determined through medical records review. The SLE quality indicators applied in this study were derived from a set previously developed by expert consensus and in accordance with the American College of Rheumatology 2012 guidelines for monitoring and treating LN.

Of 250 participants, 46.8% were followed at a University Clinic, and 40.8% developed LN. Overall performance in quality measures was 80% and 54% for patients with and without LN, respectively. Significantly higher overall quality performance was seen at academic clinics versus community clinics, both for screening (63.4-73% vs. 37.9-38.4%) and treatment measures (84.1%-85.2% vs. 54.8%-60.2%).

Major findings of this study include:

  • A significant gap in quality of care measures between academic versus community rheumatology settings
  • Similar good performance between two academic settings, one of which a county hospital and the other a university private hospital, despite the fact that the first had much lower resources for clinical care.

The authors conclude that there are important gaps in care, particularly for screening for LN among SLE patients and that performance is higher in academic settings.

Commentator’s viewpoint: It is important to develop recommendations for the management of patients with SLE, such as those recently updated by EULAR. There are still important unmet needs for new drugs to treat refractory cases of SLE, both generalised and LN. Survival of SLE patients remains relatively low as compared to the general population. However, this study highlights the fundamental need to disseminate already available good clinical practices, in order to optimise the outcomes of patients with SLE. This study extends results from a previous one from the same research group, suggesting that higher quality of care for SLE patients is provided by a dedicated lupus clinic as compared to a general rheumatology setting [1]. These studies also suggest that the major barrier is not relatively lower resources, but rather organizational workflow factors, that can be better standardized in dedicated clinics with a higher volume of SLE patients.

The healthcare system is fundamentally different in the USA as compared to most of Europe; despite these differences, similar challenges for healthcare providers are likely true in Europe. In addition to developing management recommendations, lupus dedicated clinicians should promote strategies for improving structured, high quality healthcare that can benefit all SLE patients in the general population, and not only those that can be followed at dedicated lupus clinics.


  1. Arora S, Nika A, Trupin L, Abraham H, Block J, Sequeira W, Yazdany J, Jolly M. Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic? Arthritis Care Res (Hoboken) 2018; 70(12):1771-1777.