Intervention to Improve Quality of life for African-AmericaN lupus patients (IQAN): study protocol for a randomized controlled trial of a unique a la carte intervention approach to self-management of lupus in African Americans

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. The complex relationships between race and ethnicity and social determinants of health (SDOH) in influencing SLE and its course are increasingly appreciated. Multiple SDOH have been strongly associated with lupus incidence and outcomes and contribute to health disparities in lupus. Measures of socioeconomic status, including economic instability, poverty, unemployment, and food insecurity, as well as features of the neighborhood and built environment, including lack of safe and affordable housing, crime, stress, racial segregation, and discrimination, are associated with race and ethnicity in the US and are risk factors for poor outcomes in lupus. In this scientific statement, we aimed to summarize current evidence on the role of SDOH in relation to racial and ethnic disparities in SLE and SLE outcomes, primarily as experienced in the U.S. Lupus Foundation of America's Health Disparities Advisory Panel, comprising 10 health disparity experts, including academic researchers and patients, who met 12 times over the course of 18 months in assembling and reviewing the data for this study. Sources included articles published from 2011 to 2023 in PubMed, Centers for Disease Control and Prevention data, and bibliographies and recommendations. Search terms included lupus, race, ethnicity, and SDOH domains. Data were extracted and synthesized into this scientific statement. Poorer neighborhoods correlate with increased damage, reduced care, and stress-induced lupus flares. Large disparities in health care affordability, accessibility, and acceptability exist in the US, varying by region, insurance status, and racial and minority groups. Preliminary interventions targeted social support, depression, and shared-decision-making, but more research and intervention implementation and evaluation are needed. Disparities in lupus across racial and ethnic groups in the US are driven by SDOH, some of which are more easily remediable than others. A multidimensional and multidisciplinary approach involving various stakeholder groups is needed to address these complex challenges, address these diminish disparities, and improve outcomes.

Quality of life measures in Systemic Lupus Erythematosus: A systematic review

In this study we systematically investigated the health-related quality of life (HRQoL) tools, which have been most often used over the last five years to evaluate the QoL in patients with systemic lupus erythematosus (SLE), focusing on their items and applications. A detailed literature search was conducted: the inclusion criteria were as follows: 1) studies including at least 50 patients; 2) studies including at least 25 patients with SLE; 3) quality of life testing with validated measures. The systematic review was based on 119 studies for a total of 32,449 SLE patients and 3092 controls. A total of 35 different patients-reported quality of life measures, applied in cohorts of patients with SLE, were retrieved with the 36-item Medical Outcome Short Form (SF-36) (63 studies of 119 =52.95%), Lupus Quality of Life (LupusQoL) (17 studies =14.3%) and Lupus Patient-Reported Outcome (LupusPRO) (12 studies =10%) being the most commonly used tools. Overall, this systematic review of the literature indicated that quality of life in patients with SLE appears to be poor and generally lower compared to both the general population and patients with other chronic conditions, as was shown by a few studies that used SF-36 and LupusPRO. The use of HRQoL scoring in SLE is gaining increasing interest and is used both in randomized controlled trials and in real-life. Future efforts are needed to improve the understanding of the impact of the disease burden on quality of life from the patient’s perspective.

A Focus Group Study of Self-Management in Patients With Glomerular Disease

INTRODUCTION

Patients with glomerular disease experience symptoms that impair their physical and mental health while managing their treatments, diet, appointments and monitoring general and specific indicators of health and their illness. We sought to describe the perspectives of patients and their care partners on self-management in glomerular disease.

METHODS

We conducted 16 focus groups involving adult patients with glomerular disease (n = 101) and their care partners (n = 34) in Australia, Hong Kong, the United Kingdom, and United States. Transcripts were analyzed thematically.

RESULTS

We identified the following 4 themes: empowered in autonomy (gaining confidence through understanding, taking ownership of disease and treatment, learning a positive health approach); overwhelmed by compounding treatment burdens (financially undermined and depleted, demoralized by side effects and harms, frustrated by fragmented and inflexible care, fear of possible drug harms); striving for stability and normalcy (making personal sacrifices, maximizing life participation, attentiveness to bodily signs, avoiding precarious health states, integrating medicines into routines); and necessity of health-sustaining relationships (buoyed by social support, fulfilling meaningful responsibilities, sharing and normalizing experiences, seeking a trusting and respectful alliance).

CONCLUSION

Patients with glomerular disease and their care partners value their capacity for autonomy and disease ownership, stability of their health, and relationships that support self-management. Strategies directed at strengthening these factors may increase self-efficacy and improve the care and outcomes for patients with glomerular disease.

Longitudinal Study of Fatigue, Stress, and Depression: Role of Reduction in Stress Toward Improvement in Fatigue

OBJECTIVE

Fatigue is common among individuals with systemic lupus erythematosus (SLE), but the causes are not well understood. Our objective was to examine perceived stress and depressive symptoms as predictors of fatigue in SLE.

METHODS

Data from 2 years of the Lupus Outcomes Study (n = 650 patients), obtained through annual structured interviews, were used. Fatigue was measured with the Short Form 36 (SF-36) vitality scale along with a variety of self-report measures of disease, depression, and stress. Multivariate linear regression models examined predictors of changes in fatigue. Model 1 tested the association of time 1 (T1) depression with time 2 (T2) fatigue; model 2 added T1 perceived stress to model 1, and final models added T1-to-T2 decrease in stress. All analyses controlled for T1 fatigue, age, sex, self-report of fibromyalgia, pain, and SLE duration, activity, and damage.

RESULTS

Mean ± SD age was 51 ± 12 years, 92% of participants were women, and 68% were white. The mean ± SD SF-36 fatigue score was 55 ± 24. T1 depression significantly predicted T2 fatigue. When T1 stress was added, stress (β = 1.7 [95% confidence interval (95% CI) 1.1, 2.2]; P < 0.0001) significantly predicted T2 fatigue, but depression was no longer significant. The addition of T1-to-T2 decrease in stress was associated with a clinically meaningful decline in fatigue (β = -11.8 [95% CI -15.6, -8.9]; P < 0.0001).

CONCLUSION

While depressive symptoms initially predicted subsequent fatigue, the effects were mediated by stress. A decrease in stress, in addition, was associated with a clinically meaningful decrease in fatigue. These results suggest that perceived stress plays an important role in SLE fatigue and may be an important focus of interventions for fatigue.

Effects of web-based education and counselling for patients with systemic lupus erythematosus: self-efficacy, fatigue and assessment of care

OBJECTIVE

The aim of this study was to determine the effect of web-based education and counselling for patients with systemic lupus erythematosus on self-efficacy, fatigue and assessment of care.

METHODS

The study was conducted as a randomized controlled trial. The study sample consisted of 80 patients divided into two groups: the experimental group (n = 40) and a control group (n = 40). Randomization was performed by simple random sampling. At the beginning of the study (month 0), data-collection forms were administered to both groups. Web-based education was carried out for the first three months, and counselling and information updates were given for the next three months for the experimental group. In the intervention process, the control group just received standard care. After six months, data-collection forms were administered to both groups again.

RESULTS

The mean age of the participants in the experimental and control groups was 35.58 ± 8.40 years and 39.00 ± 12.71 years, respectively. In both groups, 95% of patients were women. Wilcoxon's test was used for within-group comparisons before and after the study. The Mann-Whitney U-test was used to evaluate the difference between the two groups before the intervention and between the two groups after the intervention. We found that there was a significant improvement in fatigue, self-efficacy and assessment of chronic illness care in the experimental group at the end of the study (p < 0.05).

CONCLUSIONS

The intervention had a positive effect on self-efficacy, fatigue and satisfaction with chronic illness. In accordance with the results, similar studies should be conducted for different patient groups in order to strengthen the results.

Exploring the Perceived Impact of the Chronic Disease Self-Management Program on Self-Management Behaviors among African American Women with Lupus: A Qualitative Study

Objective

To qualitatively explore the processes through which the Chronic Disease Self‐Management Program (CDSMP)—a peer‐led, group‐based educational intervention for people with chronic conditions—affects self‐management behaviors among African American women with systemic lupus erythematosus (SLE).

Methods

Using a longitudinal pre‐ and postintervention design, we conducted two waves of one‐on‐one, semistructured interviews with 24 purposefully sampled participants. Wave 1 interviews explored self‐management behaviors at baseline; wave 2 interviews focused on changes in these behaviors postintervention. Transcripts were analyzed using thematic analysis methods.

Results

Study participants perceived the CDSMP to be a valuable resource that helped them improve fundamental self‐management behaviors, including exercise, relaxation, diet, and medication adherence. We found, with few exceptions, that in this sample, women's reported changes in self‐management behaviors did not vary by participant age, education, SLE disease severity, or depression status. Our analysis suggests that the CDSMP had the most widespread perceived effects on relaxation and exercise. Strategies that generated improvements in relaxation and exercise included goal setting, action planning, encouragement to pursue low‐impact physical activity, and introduction of mindfulness techniques to better manage SLE symptoms.

Conclusion

Our findings suggest that African American women with SLE perceived the CDSMP as an effective educational self‐management intervention. The program can potentially catalyze improvements in self‐management behaviors in this population, regardless of demographic or disease characteristics.

Lupus nephritis

Lupus nephritis (LN) is a form of glomerulonephritis that constitutes one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). Most patients with SLE who develop LN do so within 5 years of an SLE diagnosis and, in many cases, LN is the presenting manifestation resulting in the diagnosis of SLE. Understanding of the genetic and pathogenetic basis of LN has improved substantially over the past few decades. Treatment of LN usually involves immunosuppressive therapy, typically with mycophenolate mofetil or cyclophosphamide and with glucocorticoids, although these treatments are not uniformly effective. Despite increased knowledge of disease pathogenesis and improved treatment options, LN remains a substantial cause of morbidity and death among patients with SLE. Within 10 years of an initial SLE diagnosis, 5-20% of patients with LN develop end-stage kidney disease, and the multiple comorbidities associated with immunosuppressive treatment, including infections, osteoporosis and cardiovascular and reproductive effects, remain a concern. Clearly, early and accurate diagnosis of LN and prompt initiation of therapy are of vital importance to improve outcomes in patients with SLE.

Mobile health technologies for the management of systemic lupus erythematosus: a systematic review

OBJECTIVE

We aimed to perform a standardized review of available mobile health (mHealth) applications (apps) for systemic lupus erythematosus (SLE) and to conduct a systematic review of the literature on mHealth technologies in SLE.

METHODS

Google Play and AppStore in the United States of America were queried and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Web of Science, EMBASE, Medline, and Cochrane databases were systematically searched from inception through June 2019.

RESULTS

Of 324 mHealth apps found, 20 were eligible for inclusion; 10 focused on education, 7 offered tools to track patient-reported symptoms, 5 included interactive online communities, and 1 enabled emoji sharing. The reviewed apps scored poorly on the MARS quality scale with a mean score 2.3 (0.6) out of 5. Of 1147 studies identified in the literature review, 21 were eligible for inclusion; 11 studies (52.4%) focused on the development and use of mHealth for providing patient information, while only 2 (9.5%) were randomized trials of mHealth interventions.

CONCLUSIONS

Although there is growing interest in the development of mHealth technologies to support SLE patients, currently available tools are of poor quality and limited functionality, and the literature examining this area is sparse.

Multidisciplinary care in patients with systemic lupus erythematosus: a randomized controlled trial in China

Background For the large number of systemic lupus erythematosus (SLE) patients in China, it is critical to carry out effective disease management to improve the treatment effect and reduce disease burden. A pharmacist-led multidisciplinary care model has not been reported in Chinese SLE patients before. Objective To assess the effect of patient-centered, pharmacist-led, multidisciplinary care on clinical outcomes and satisfaction with health care in Chinese SLE patients. Setting: The South Campus, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China. Method Participants were 143 systemic lupus erythematosus patients randomly assigned to either the intervention group (multidisciplinary care: physician, pharmacist and nurse) or the control group (usual care only). Main outcome measures The primary outcome was scores on the systemic lupus erythematosus disease activity index-2000, the satisfaction with information about medicines scale, and the EuroQol five-dimension questionnaire, assessed at baseline and 12 months. Results Between October 1, 2017 and October 1, 2018, 42 participants were included in the intervention group and 40 in the control group. At 12 months, results for the systemic lupus erythematosus disease activity index-2000 differed significantly between the intervention group and the control group (0 vs. 2, P = 0.027). Patient satisfaction with health care was also significantly greater in the intervention group than in the control group (92.9 vs. 0%, P = 0.000). According to the EuroQol five-dimension questionnaire, health quality was also improved (0.94 vs. 0.85, P = 0.006). Conclusion Our multidisciplinary care team significantly improved clinical outcomes and satisfaction with drug information in Chinese systemic lupus erythematosus patients.

Diet and lupus: what do the patients think?

Objectives

Cardiovascular disease is the leading cause of mortality in patients with systemic lupus erythematosus. Therefore, using diet to control blood lipid levels and modify cardiovascular disease risk could be a promising therapeutic strategy to control disease symptoms. The primary objective of this study was to learn about systemic lupus erythematosus patient experiences with diet, including their opinion on considering diet as a therapeutic option. The secondary objective was to obtain this information in a cost- and time-effective manner.

Methods

A lay summary and a 15-question diet-based online survey were publicly available for 3 weeks. Social media was used to promote the survey through relevant charities, hospitals and research groups.

Results

A total of 300 responses were received, 284 from patients with systemic lupus erythematosus. Patients reported that there was a lack of clinical counselling regarding diet, with only 24% stating their doctor had spoken to them about diet. Despite this, 100% of patients stated they would change their diet if they knew it would help their symptoms and 83% would take part in a future diet-based clinical trial. Text analysis of patient research suggestions identified a particular interest in using diet to treat fatigue and manage disease flares.

Conclusions

This project successfully gathered patient information regarding diet and systemic lupus erythematosus over a short timeframe using an anonymous social media platform. The survey provided evidence that patients support further research and potential diet intervention studies investigating the effect of diet on the symptoms of systemic lupus erythematosus.

My life with lupus: contextual responses of African-American women with systemic lupus participating in a peer mentoring intervention to improve disease self-management

OBJECTIVE

The current article seeks to examine the ways in which African-American women with systemic lupus erythematosus (SLE) describe their disease experience and how they cope with their disease. This qualitative study provides deeper insight into whether experiences of African-American women with SLE differ from previous qualitative study findings.

METHODS

Qualitative data were gathered using interviews and a focus group, from participants in the Peer Approaches to Lupus Self-management (PALS) programme. Data were analysed for themes related to disease experience and how participants cope with their disease. Twenty-seven African-American women with SLE were recruited into the peer mentoring programme, of which 7 served as mentors and 20 served as mentees. A 12-week peer mentoring intervention delivered by phone and based on the Chronic Disease Self-Management and Arthritis Self-Management Programs.

RESULTS

Three categories encompassing a total of 10 subcategories emerged from analyses: (A) interpersonal, familialandromantic relationships; (B) individual experiences of living with SLE; and (C) physician-patient relationships.

CONCLUSION

We gained insight on several issues related to patient perspectives of African-American women with SLE, and the context surrounding their thoughts and feelings related to lupus, including their providers, families and other social support networks. Additional research efforts could explore and address the thematic domains and respective subthemes identified here. Although limited due to the preliminary nature of the study, this information can be used to create future evidence-based interventions to decrease the impact of SLE on African-American patients.

Impact of systemic lupus erythematosus on oral health-related quality of life

Oral symptoms in systemic lupus erythematosus (SLE) patients are often unexplored and affect the health-related quality of life. The aims of this study were: (a) to evaluate the oral health condition of SLE patients compared to control subjects without rheumatic diseases; (b) to determine the consequences of oral health condition in the quality of life of these two groups. Individuals with SLE ( n = 75) and without SLE ( n = 78) (control group), paired for gender and age, underwent complete oral examination. Sociodemographic and clinical information was obtained, and interviews were conducted using the Brazilian version of the oral health impact profile. The activity and damage of SLE disease were assessed, respectively, by the systemic lupus erythematosus disease activity index 2000 and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index for systemic lupus erythematosus. When we analysed the oral health condition and hygiene habits of the participants, SLE patients exhibited an increased number of missing teeth despite their higher frequency of tooth brushing. No significant differences were verified in other habits and clinical parameters evaluated such as smoking, flossing, salivary flux, periodontitis, decayed and filled teeth. Patients with SLE presented with worse oral health-related quality of life than controls ( P = 0.011). The significant difference was on individuals' physical disability ( P = 0.002). The determinant of the negative impact on the oral health-related quality of life was prosthesis wearing ( P < 0.05). Overall, the oral health impact profile score was higher in individuals with moderate SLE damage compared to SLE individuals with no damage ( P = 0.043). Patients with SLE had a negative impact of oral condition on their quality of life. The evaluation of the oral health-related quality of life might be useful to monitor the effects of SLE on oral condition.