América Uribe

Relationship between adherence to study and clinic visits in systemic lupus erythematosus patients: data from the LUMINA cohort.

The aim of this study was to examine the relationship between nonadherence with study visits and with regularly scheduled clinic visits after adjusting for other patient and disease characteristics. One hundred and forty-one LUMINA patients with appointment data in the institutions’ computerized systems (UAB and UTH) were studied. ‘No shows’ were assessed as the percentage of appointments not attended for either rheumatology, other clinics and LUMINA visits (from zero to 100%). Eighty-nine percent of the patients were women, 40% were Caucasians, 55% African-Americans and 5% Hispanics. ‘No shows’ to rheumatology were associated with non-Caucasian ethnicity, younger age, single marital status, lack of home ownership, ‘no shows’ to other clinics and to the LUMINA study, greater disease activity and to some disease manifestations (serositis, renal involvement, positive anti-dsDNA antibodies). In multivariable analyses, features predictive of rheumatology ‘no shows’ were lack of home ownership, ‘no shows’ to LUMINA study visits, renal involvement and serosal manifestations. Nonadherence with study visits and with regularly scheduled care at rheumatology clinics were associated. Other factors predictive of nonadherence to recommended care were lack of home ownership (a measurement of low socioeconomic status) and the presence of disease manifestations (i.e., renal or serosal involvement). These data should be considered when caring for patients with SLE.

The managed care versus fee for service dilemma and its impact on the outcome of lupus.

T he impact of socioeconomic and nonsocioeconomic factors on the outcome of lupus has been recognized by a number of different investigators over the years, but the exact contribution of one set of factors versus the other remains unclear to date (1,2). The tight association between nonwhite ethnicity and lower socioeconomic status in the United States as well as in other countries with relatively large ethnic minorities makes it difficult to sort out the role of each set of factors in determining the outcome in lupus (3–8). In fact, some discrepancies ascribed to ethnic/racial/biologic factors were subsequently determined to be caused by income differences. For instance, in studies conducted in North Carolina in the 1980s, race was singled out as the most important explanatory variable for a more serious disease and for a decreased probability of survival among black lupus patients compared with white lupus patients (9). Nevertheless, when the data were re-examined several years later and socioeconomic status was determined by data derived from the patients’ addresses (geocoding), income was identified as the most important factor rather than ethnicity/race (10). Furthermore, the impact of socioeconomic factors on the outcome of lupus is not limited to mortality. For example, Karlson et al. (11) reported data from a crosssectional multicenter study of lupus using a 2 2 design (high/low socioeconomic status and white/ African-American ethnicity). Income and education were found to be associated with both disease activity as measured by the systemic lupus activity measure and damage as measured by the Systemic Lupus International Collaborating Clinics Damage Index. Ethnicity was not a factor. In our own lupus cohort (LUMINA), poverty has been found to be the single most important factor in multivariable analyses of mortality (12), and a number of socioeconomic variables have been associated with disease activity over the course of the disease (13). The data presented by Mayor et al. (14) in this issue are certainly of great interest because they clearly show, within a relatively homogeneous population, the impact of changes in the delivery of healthcare to the indigent in Puerto Rico. Before 1994, this group obtained primary, secondary, and tertiary care directly from the government through its Department of Health. In 1994, a gradual shift to a managed care system took place; under the new system, aimed at extending insurance coverage to the uninsured and at reducing the overall cost of healthcare in Puerto Rico, insurance companies assumed the financial risks associated with the delivery of healthcare to the indigent (15,16). The implementation of a managed care system in Puerto Rico resulted in indigent patients having limited access to specialists; however, there are limited data about the impact of this change on the course and outcome of common chronic disorders among this population. For example, a patient satisfaction survey conducted among the caregivers of children with special needs attending a tertiary orthopedic fa-