Osteoporosis screening, prevention, and treatment in systemic lupus erythematosus: application of the systemic lupus erythematosus quality indicators

Abstract

Objective: Osteoporosis and fragility fractures are associated with significant morbidity for patients with systemic lupus erythematosus (SLE). New quality indicators (QIs) for SLE advise bone mineral density testing, calcium and vitamin D use, and antiresorptive or anabolic treatment for specific subgroups of patients receiving high-dose steroids.

Methods: Subjects were participants in the University of California, San Francisco Lupus Outcomes Study, an ongoing longitudinal study of patients with physician-confirmed SLE, in 2007-2008. Patients responded to an annual telephone survey and were queried regarding demographic, clinical, and other health care-related variables. Multiple logistic regression was used to predict receipt of care per the QIs described above.

Results: One hundred twenty-seven patients met the criteria for the formal definitions of the denominators for QI I (screening) and QI II (calcium and vitamin D); 91 met the formal criteria for QI III (treatment). The proportions of patients receiving care consistent with the QIs were 74%, 58%, and 56% for QIs I, II, and III, respectively. In a sensitivity analysis of all steroid users (n = 427 for QI I and II and n = 224 for QI III), rates were slightly lower. Predictors of receiving care varied by QI and by denominator; however, female sex, older age, white race, and longer disease duration were associated with higher-quality care.

Conclusion: Bone health-related care in this community-based cohort of SLE patients is suboptimal. Quality improvement efforts should address osteoporosis prevention and care among all SLE patients, especially those receiving high-dose, prolonged steroids.

Figure 1

The x-axis is marked by the quality indicators I, II, and III for the FORMAL and ALL STEROID denominators. a: Patients taking at least 7.5 mg of prednisone per day for at least 3 months. b: Patients taking at least 7.5 mg of prednisone per day for at least 1 month, and either a history of osteoporosis or fragility fracture. c: Patients taking any dose of steroid for any period of time within the prior 12 months. d: Patients taking any dose of steroid for any period of time within the prior 12 months and either a history of osteoporosis or fragility fracture. Percent of eligible patients to receive each osteoporosis care-related quality indicator among patients from the UCSF Lupus Outcomes Study in the FORMAL and ALL STEROID denominators