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Lupus. 2018 Jun;27(7):1169-1176. doi: 10.1177/0961203318763529. Epub 2018 Mar 19.

Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population.

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1 National Clinician Scholars Program, 12228 Yale School of Medicine, Yale University , New Haven, CT, USA.
2 Arthritis Program, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, 1242 Centers for Disease Control and Prevention , Atlanta, GA, USA.
3 Departments of Medicine and Epidemiology, Division of Rheumatology, 12239 Emory University School of Medicine , Atlanta, GA, USA.
4 Institute for Circumpolar Health Studies, University of Alaska Anchorage, Anchorage, AK, USA.
5 Department of Medicine, 479331 Oklahoma City Area Indian Health Service , Oklahoma City, OK, USA.
6 Rheumatology Research Group, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK.
7 Division of Community Health Services, 48644 Alaska Native Tribal Health Consortium , Anchorage, AK, USA.


Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.


Indians; Lupus erythematosus; North American; diagnosis; disease management; primary care; specialist; systemic

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