Comment on: Quality indicators for systemic lupus erythematosus based on the 2019 EULAR recommendations: development and initial validation in a cohort of 220 patients.
Commented by: Angela Tincani, Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili and University of Brescia, Italy
Systemic lupus erythematosus (SLE) is a very complex disease and in the last 20 years the European League Against Rheumatism (EULAR) supported the development of several sets of recommendations based on published data as well as on expert opinion especially when the literature evidence was scarce or absent. These efforts aimed to provide practical indications to the physicians for diagnosis and management of the different clinical aspects of the disease. However, it is not easy to understand how much these recommendations has really changed the everyday clinical approach to SLE. To cover this sensitive topic, this work describes quality indicators (QIs), based on the 2019 update of EULAR recommendations on diagnosis and management of SLE, to measure the quality of care received by patients. It is of note that QIs identify exactly what is necessary to do, when it has to be done and who is responsible to do it.
44 QIs were derived from the 2019 EULAR recommendations and from the pertinent systematic literature review. The evaluations of the 44 candidates QIs was performed both through a score derived from existing evidence and from the opinion of 12 experts that were asked to vote on their validity and feasibility in 2 subsequent rounds. The results were calculated according to a modified Delphi method (Research and development corporation/University of California Los Angeles) able to combine literature evidence and expert’s opinions.
The selection work led to the identification of 18 QIs that were divided into 3 groups: one on screening and diagnosis (5 QIs), one on treatment (5 QIs) and one on monitoring (8 QIs) (table 1 of the paper).
In the second part of the paper, the adherence to the 18 QIs and its relationship with disease outcomes was verified on a group of 220 patients, 60 % from an inception cohort and 40% from a prevalent cohort.
The results showed that adherence to QIs was variable, some examples are reported below. Complete laboratory diagnosis was performed in an average of 48.5% of the cohort, and the most frequently missed tests were those for antiphospholipid antibodies. Disease activity evaluation, considered important at least 3 times a year, was performed only in an average of 14.1% and damage evaluation, considered necessary once a year, in an average of 28.6% of the patients. Reproductive health and pregnancy counselling showed a low adherence as well as preventive measures for cardiovascular disease, infection (vaccinations) and osteoporosis. In contrast, QIs for lupus nephritis generally obtained a high adherence score. This finding is consistent with the observation that adherence was shown higher in patients with severe disease compared to those with mild/moderate disease.
The outcome evaluation was assessed through a composite index (CAO) based on the occurrence of flares, hospitalization and damage progression measured by the SLICC/ACR Damage index (SDI). Lower adherence to QIs in the last year was related to a significant increase of the CAO. As expected, patients in remission or low disease activity showed less damage accrual CAO but, interestingly also vaccinations appear protective toward CAO in the last year of observation. Higher probability of CAO was observed in patients monitored for SDI and cardiovascular risk factors.
Even if the paper suffers some limitation (detailed in the text), it is important for the SLE specialists. In fact, we all aim to know how much is increased or can increase the care of SLE patients. Here it is shown that some of the QIs derived by well documented and well accepted recommendations such as the vaccinations necessity or the value to perform cardiovascular risk factor stratification have still a scares adherence. And the benefits for patients receiving these cares appears evident. One could object that this information is already present in the medical literature. However, up to now, the knowledge apparently did not change the physician’s attitude. Therefore, this paper needs to be carefully considered.
Reference: Chavatza K, Kostopoulou M, Nikolopoulos D, et al. Quality indicators for systemic lupus erythematosus based on the 2019 EULAR recommendations: development and initial validation in a cohort of 220 patients. Ann Rheum Dis. 2021 Jun 23:annrheumdis-2021-220438. doi: 10.1136/annrheumdis-2021-220438. Epub ahead of print. PMID: 34162597.