Background/Purpose:

  Lupus nephritis not only decreases survival, but also its costs are substantial, likely due in part to deficits in care (Carls et al., 2009). A previous study by Yazdany et al (2014) showed that care varied with individual factors such as age and race.

  We assessed the quality of care provided to LN patients at our rheumatology clinic according to the 2012 ACR guidelines, and analyzed whether race, age, and/or insurance status influence care.

Methods:

  A retrospective chart review is performed on patients identified by the ICD9 code for LN (583.81). We exclude patients without a definite diagnosis of LN based on ACR criteria or with limited records. Since quality indicators were first published in 2009, patient data from 1/1/2010 to 10/31/2014 is collected.

  Data is recorded as % adherence to the 2012 ACR guidelines (Hahn et al., 2012), which include renal biopsy indications, adjunctive treatments, and induction and maintenance therapy.

  Active LN is defined by the 2012 ACR criteria, and a treatment response or relapse is defined by the 2006 ACR criteria. Inclusion and exclusion criteria, outlined by the 2012 ACR guidelines, are adhered to. Chi-squared test compares treatment compliance among insurance status, race, and age. Wilcoxon rank-sum test and Kruskal-Wallis test analyzes age as a continuous variable in relation to treatment compliance. Statistical analysis is performed using SAS 9.3®.

Results:

  A total of 30 patients meeting ACR criteria for LN were included. Renal biopsy was done in 90% of patients. HCQ was offered to 100% of patients. In patients with proteinuria (n=26), 70% were treated with renin-angiotensin system blockade. A statin was given to 31% of patients (n=16), and an anti-hypertensive was given to 79% of patients (n= 14).

  In patients with class III or IV disease (N=19), all patients were given appropriate induction. Maintenance glucocorticoids (GCs) were given to 95% (n=18) of patients. The majority was followed for 6 months before a treatment change (68%), and had induction within 1 month of diagnosis (68%).

  In patients with class IV or IV/V disease (N=15), all patients were given appropriate induction and maintenance GCs were given to 64% (n=9) of patients, although 3 patients were not on the higher-range dosage.

  In patients with class V disease (N=9), 22% of patients (n=2) were treated according to guidelines.

  In patients treated with induction therapy for 6 months (N=25), 15 patients (60%) responded. Of those that did not (n=10), therapy was not switched in 5 patients (50%).

  No significant association was found between race, age, or insurance type and compliance to any of the measures.

Conclusion:

  There was good compliance to renal biopsy and adjunctive treatments, except for statins. This may be due to overlooking the utility of statins in LN for younger patients.

  There was good compliance to initiating induction, maintenance GCs, early induction therapy, and monitoring for 6 months.

  Our study was limited by its small sample size, which may have obscured significant associations.

  An electronic system that collects data relevant to LN response criteria in a central location may improve therapy adjustments. Also, provider education in class V induction may improve adherence.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/adherence-to-acr-guidelines-in-the-management-of-lupus-nephritis-a-quality-improvement-initiative/