Dissertation committee:
Δημήτριος Μπούμπας, Καθηγητής, Iατρική Σχολή, ΕΚΠΑ
Δημήτριος Βασιλόπουλος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Σωτήριος Τσιόδρας, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Χαράλαμπος Παπαγόρας, Επίκουρος Καθηγητής, Ιατρική Σχολή, ΔΠΘ
Αντώνιος Φανουριάκης, Επίκουρος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Γεώργιος Μπερτσιάς, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, Πανεπιστήμιο Κρήτης
Πρόδρομος Σιδηρόπουλος, Καθηγητής, Ιατρική Σχολή, Πανεπιστήμιο Κρήτης
Summary:
Background
Quality of healthcare is defined as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (IOM 1999). The definition applies both to healthcare practitioners and to all settings of care (hospitals, nursing homes and physicians’ offices). Measurement of quality can help to identify problems caused by overuse, underuse or misuse of health resources. QIs are popular tools used to measure the degree of quality of care received by patients and are derived from guidelines, SLR or expert panel consensus, through the use of a systematic approach representing the current standard of care. In contrast to most guidelines or recommendations, QIs pertain to measurable aspects of healthcare, describing exactly what to do, when to do it and who is responsible for doing it, with respect to disease
management and monitoring.
Methods
A total of 44 candidate QIs corresponding to diagnosis, monitoring and treatment, were independently rated for validity and feasibility by 12 experts and analysed by a modified Research and Development Corporation/University of California Los Angeles model. Adherence to the final set of QIs and correlation with disease outcomes (flares, hospitalisations and organ damage) was tested in a cohort of 220 SLE patients with a median monitoring of 2 years (IQR 2–4), at least 1 year of follow up and at least four visits over the last year.
Results
The panel selected a total of 18 QIs as valid and feasible. On average, SLE patients received 54% (95% CI 52.3% to 56.2%) of recommended care, with adherence ranging from 44.7% (95% CI 40.8% to 48.6%) for diagnosis-related QIs to 84.3% (95% CI 80.6% to 87.5%) for treatment-related QIs. From subgroup analysis patients with severe disease were more likely to receive the indicated care (57.2%) compared with patients with moderate (53.9%) or mild (49.3%) disease (p=0.006). Similarly, higher adherence rates were observed in patients with short (<2 years) vs longer (≥2 years) disease duration (54.8% and 49.3% respectively, p=0.02). Sustained remission or low disease activity were achieved in 26.8% (95% CI 21.1% to 33.2%). Tapering of prednisone dose
to less than 7.5 mg/day was achieved in 93.6% (95% CI 88.2% to 97.0%) while 73.5% (95% CI 66.6% to 79.6%) received the recommended hydroxychloroquine dose. Higher adherence to monitoring-related QIs was associated with reduced risk for a composite adverse outcome (flare, hospitalisation or damage accrual) during the last year of observation (OR 0.97 per 1% adherence rate, 95% CI 0.96 to 0.99). As a spin-off this work, we also sought to determine the proportion of SLE patients with residual disease activity during their most recent visit, and whether patients with residual
activity were offered therapy intensification. Our data suggest that about 40% of patients have evidence of residual disease activity and could qualify for novel treatments. Most treatment changes were triggered by active renal, joint, and skin disease, whereas the predictive value of SLEDAI-2K as a metric of disease activity was modest
Conclusion
We developed QIs for assessing and improving the care of SLE patients. Initial real-life data suggest face validity, but a variable degree of adherence and a need for further improvement. The low rates of CVD protection and reproductive health counselling are consistent with data from previous studies; rates for sunscreen protection and individual components for osteoporosis and vaccination (influenza, pneumococcal) QIs are also consistent with published data. In reference to potential causes related to better performance in certain indicators, we found that QI adherence rates were higher in
patients with disease duration shorter than 2 years and in patients with severe disease. These observations may reflect the fact that physicians are more likely to adhere early after diagnosis to ensure better disease control, and in patients who are more likely to develop irreversible organ damage, respectively. In summary, we have developed a set of EULAR recommendations based QIs for SLE patient care, following a comprehensive SLR and supported by expert opinion. These QIs may be used as a ‘checklist’ to be fulfilled in an outpatient setting, in order to improve SLE patient care by facilitating the implementation of the EULAR recommendations
