Validation and evaluation of the German Brief Index of Lupus Damage (BILD)--a self-reported instrument to record damage in systemic lupus erythematosus

Delayed diagnosis adversely affects outcome in systemic lupus erythematosus: Cross sectional analysis of the LuLa cohort

Objective

Despite increased physician’s awareness and improved diagnostic and serological testing in the recent years, the interval between the initial symptoms and the diagnosis of Systemic lupus erythematosus (SLE) is still very long. Our aim was to study this delay and its association to the outcome of the disease.

Methods

Information on demographics, onset of first symptoms, first physicians visit and time of diagnosis was assessed by self-reported questionnaires among SLE patients in Germany (LuLa cohort, n = 585) in the year 2012. Disease activity (Systemic Lupus Activity Questionnaire; SLAQ), disease related damage (Brief Index of Lupus Damage; BILD), health related quality of life (Short Form 12) and fatigue (FSS) were chosen as proxies for outcome. Linear regression analysis was used to analyze the association of the delay in diagnosis to the outcome, adjusted for age, disease duration and sex.

Results

Mean duration between the onset of symptoms and the diagnosis of SLE was 47 months (SD 73). The longer the time to diagnosis, the higher the disease activity (β = 0.199, p < 0.0001), the disease-related damage (β = 0.137, p = 0.002) and fatigue (β 0.145, p = 0.003) and the lower the health-related quality of life (physical β = −0.136, p = 0.004, mental β = −0.143, p = 0.004).

Conclusion

In systemic lupus erythematosus, longer time to diagnosis was associated with worse outcome. Concepts in care with the intention to shorten the time to diagnosis are needed to improve the long-term outcome of the disease.

Quality of care predicts outcome in systemic lupus erythematosus: a cross-sectional analysis of a German long-term study (LuLa cohort)

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.

Translation, cultural adaptation and validation of the Italian version of the Brief Index of Lupus Damage: the BILDit

Objectives

The Brief Index of Lupus Damage (BILD) is an instrument of self-evaluation of organ damage for systemic lupus erythematosus (SLE) patients. The objectives of this study were the translation, cultural adaptation and validation of the Italian version of the BILD (BILDit).

Methods

The process of translation and cultural adaptation followed published guidelines. The BILDit was pretested in a pilot study with 30 SLE patients in order to evaluate acceptability, reliability, comprehension and feasibility, and then validated in consecutive SLE patients attending our clinic.

Results

A total of 167 SLE patients were enrolled. In the pilot study, the BILDit demonstrated good acceptability, feasibility and comprehensibility and a very high degree of reliability (Cronbach’s α = 1). In the validation cohort, the BILDit showed a significant positive correlation with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI; ρ = 0.69; p < 0.001). Analysing the item-by-item correlation between the BILDit and the SDI, a good correlation ( p < 0.001) was found for 73.1% of the items. In the multivariate analysis, the BILDit showed a significant positive correlation with age and disease duration ( p < 0.01).

Conclusions

The BILDit seems to be an acceptable and reliable instrument for patient self-evaluation of disease damage, with a good correlation with the SDI. It can be considered as a screening tool for the evaluation of organ damage starting from the patient’s perceptive.

Pediatric Immunization Practices in Nephrotic Syndrome: An Assessment of Provider and Parental Knowledge

Background: Children with nephrotic syndrome (NS) are at high risk for vaccine-preventable infections due to the immunological effects from the disease and concurrent treatment with immunosuppressive medications. Immunizations in these patients may be deferred due to their immunosuppressive treatment which may increase the risk for vaccine-preventable infections. Immunization practices in children with NS continue to vary among pediatric nephrologists. This raises the question of whether children with NS are receiving the recommended vaccinations at appropriate times. Therefore, it is critical to understand the practices and patient education provided by physicians to patients on the topic of vaccinations. Methods: After informed consent, parents/guardians of 153 pediatric patients (<18 years old) diagnosed with NS from 2005 to 2018 and 50 pediatric nephrologists from 11 participating centers completed anonymous surveys to evaluate immunization practices among pediatric nephrologists, assess the vaccine education provided to families of children with NS, assess the parental knowledge of immunization recommendations, and assess predictors of polysaccharide pneumococcal vaccine adherence. The Advisory Committee on Immunization Practices (ACIP) Immunization 2019 Guideline for those with altered immunocompetence was used to determine accuracy of vaccine knowledge and practices. Results: Forty-four percent of providers self-reported adherence to the ACIP guidelines for inactive vaccines and 22% to the guidelines for live vaccines. Thirty-two percent of parents/guardians reported knowledge that aligned with the ACIP guidelines for inactive vaccines and 1% for live vaccines. Subjects residing in the Midwest and provider recommendations for vaccines were positive predictors of vaccine adherence (p < 0.001 and p 0.02, respectively). Conclusions: Vaccine recommendation by medical providers is paramount in vaccine adherence among pediatric patients with NS. This study identifies potential educational opportunities for medical subspecialty providers and family caregivers about immunization recommendations for immunosuppressed patients.

Vaccination coverage in systemic lupus erythematosus-a cross-sectional analysis of the German long-term study (LuLa cohort)

Objectives

Vaccinations are an important measure to prevent infections in immunocompromised patients. The knowledge of vaccination coverage and reasons for non-vaccination in patients with SLE is scarce. The aim of this study was to assess coverage rates of selected vaccinations in a representative sample of SLE patients and to identify predictors for non-vaccination.

Methods

In 2013, information on selected vaccinations (coverage, application and reservations) and on demographics, clinical parameters and health beliefs was assessed by means of a self-reported questionnaire among a representative sample of SLE patients in Germany (LuLa cohort).

Results

Five hundred and seventy-nine patients participated. Vaccination status was primarily checked by their general practitioner (57.3%). Of all the patients, 24.9% did not get their vaccination status checked at all, 16.1% had generally been advised against the use of vaccinations by a physician, and 37.5% stated that they had rejected vaccinations themselves. Their main reasons were fears of developing a lupus flare (21.8%) or adverse events (13.5%). A greater belief by patients in the doctor controlling one's health and the general benefit of medication prevented the rejection of vaccines. Vaccination coverage was low for all recorded vaccinations (tetanus 65.8%, influenza 45.2%, pneumococcus 32.2% and meningococcus 6.1%). Older age was predictive of receiving influenza and pneumococcal vaccination. The same applies for CSs >7.5 mg for receiving influenza vaccination.

Conclusion

Vaccination coverage in SLE patients is poor and reflects insufficient implementation of national and international recommendations. Rheumatologists need to recognize patients' reservations against vaccinations, to communicate their importance and safety and to give individual recommendations to patients and their health-care providers.

Trial registration

German Clinical Trials Register, www.germanctr.de, DRKS00011052.

Medical adherence in patients with systemic lupus erythematosus in Germany: predictors and reasons for non-adherence – a cross-sectional analysis of the LuLa-cohort

Objective

Adherence to medication has a major impact on treatment control and success especially in chronic diseases but often remains unrecognized. Besides clinical, socioeconomic, disease-related and treatment-related parameters, general and personal health beliefs, as well as perception of health, can affect adherence. Our aim was to investigate the adherence to lupus-specific medications in German lupus patients and to assess influencing factors including detrimental or beneficial effects of health perceptions and beliefs.

Methods

The Lupus Erythematosus (LE) Long-Term Study (LuLa-study) is a nationwide longitudinal study among German Caucasian patients with systemic lupus erythematosus who have been assessed annually using a self-reported questionnaire since 2001. In 2013, we included questions concerning medical adherence (Morisky Medication Adherence Scale; MMAS-4), beliefs about medication prescribed (BMQ), illness perception and about the patients’ health locus of control (HLC). We present a cross-sectional analysis to assess predictors of adherence using a multivariable stepwise logistic regression.

Results

Five hundred and seventy-nine patients participated, 81 of whom did not take any lupus-specific medication and 40 of whom did not complete the MMAS-4 and were therefore omitted. Only 62.7% reported high adherence. Unintentional behaviour for low medical adherence exceeded the intentional behaviour by far. The use of azathioprine (OR: 1.85; 95% CI: 1.02–3.34), prednisone <7.5 mg (OR: 1.56; 95% CI: 0.97–2.49), a higher age (OR: 1.06; 95% CI: 1.03–1.08) and higher external HLC (OR: 1.15; 95% CI: 1.01–1.30) proved conducive for high adherence in our multivariable model. On the contrary, the general perception of medication being harmful or addictive (OR: 0.89; 95% CI: 0.82–0.97) was detrimental.

Conclusion

A low belief that one's own health is determined by healthcare providers (external HLC) and the belief of the harmfulness of medication were independent predictors of low adherence besides age and the choice of the medical agent. The recognition of these potential obstacles in physician–patient relationships is essential to ameliorate adherence. Provision of sufficient information and education might help to reach the best possible outcome.

[Clinical practice guidelines for systemic lupus erythematosus: Recommendations for general clinical management]

Systemic lupus erythematosus (SLE) is a complex rheumatic multisystemic disease of autoimmune origin with significant potential morbidity and mortality. It is one of the most common autoimmune diseases with an estimated prevalence of 20-150 cases per 100,000 inhabitants. The clinical spectrum of SLE is wide and variable both in clinical manifestations and severity. This prompted the Spanish Ministry of Health, Social Services and Equality to promote and fund the development of a clinical practice guideline (CPG) for the clinical care of SLE patients within the Programme of CPG in the National Health System which coordinates GuiaSalud. This CPG is is intended as the reference tool in the Spanish National Health System in order to support the comprehensive clinical management of people with SLE by all health professionals involved, regardless of specialty and level of care, helping to standardize and improve the quality of clinical decisions in our context in order to improve the health outcomes of the people affected. The purpose of this document is to present and discuss the rationale of the recommendations on the general management of SLE, specifically, clinical follow-up, general therapeutic approach, healthy lifestyles, photoprotection, and training programmes for patients. These recommendations are based on the best available scientific evidence, on discussion and the consensus of expert groups.

[Possibilities and limits of patient-reported outcome exemplified by systemic lupus erythematosus and the LuLa study]

BACKGROUND

Over the last three decades patient reported outcomes (PRO) have become increasingly more important for the assessment of the course of diseases and therapy response. It represents the generic term for instruments which elicit information on various disease dimensions by direct questioning of patients and thereby collate subjective estimations and perceptions.

AIM OF THE STUDY

This article presents the current situation with respect to the utilization of PRO. The advantages and disadvantages of individual instruments are discussed exemplified by systemic lupus erythematosus (SLE) and the LuLa study.

CONCLUSION

The PRO instrument collates subjective estimations of various aspects of diseases directly from the patients. The PRO is mainly used to survey (health-related) quality of life but can also be used to reflect other disease-associated aspects. Various institutions promote the use of PRO in clinical trials for assessment of approval for pharmaceutical and medical products because ultimately only benefits for the patients are of relevance. The development of PRO instruments requires the same extensive psychometric testing as physicians instruments to measure clinical endpoints. Because of the heterogeneous sociodemographic composition of patient collectives, particular attention has to be given to cultural and linguistic adaptation. In addition to common challenges, such as missing values, under-reporting, over-reporting and response shift, subjective opinions can be influenced by other contextual factors, such as life situations unrelated to the disease. Alteration of internal standards or conceptualization can lead to interpretation difficulties in the long-term. Determinants of discordant estimations between physicians and patients need to be considered when using PRO but none of the aspects is generally better than the other.

Longitudinal validation of the Brief Index of Lupus Damage

OBJECTIVE

To provide further validation of the Brief Index of Lupus Damage (BILD), assessing its sensitivity to change in disease status and ability to predict mortality risk.

METHODS

Data were from the University of California, San Francisco Lupus Outcomes Study (n = 958), in which the BILD was administered twice, approximately 5 years apart. We examined disease activity and health care utilization among participants who completed the BILD twice (n = 745). We identified increases in disease activity and utilization that would suggest a disease flare between the 2 BILD administrations and compared their occurrence by BILD score increases (0, 1, 2, 3, >3). Deaths were ascertained when annual interviews were attempted. Kaplan-Meier life-table analysis compared mortality rates for 4 groups of initial BILD scores (0, 1, 2, ≥3), and differences were tested using a log rank test. Using Cox proportional hazards models, we estimated the risk of death associated with higher BILD scores.

RESULTS

BILD score increases were associated with spikes in disease activity (P = 0.05) and physician visits (P = 0.004) over baseline, and with hospitalizations (P < 0.001) during the intervening years. Of those with BILD score increases >3, 84% were hospitalized prior to the second BILD. During followup, there were 60 deaths (6.3%). BILD scores of 2 (hazard ratio [HR] 6.1, 95% confidence interval [95% CI] 1.3-30.0) and ≥3 (HR 10.8, 95% CI 2.5-46.2) were associated with higher risk of death.

CONCLUSION

This analysis provides evidence of the predictive validity of the BILD and its ability to detect change. While not intended to replace clinical evaluation of disease damage, the BILD appears to be a useful tool for research.