The relationship of socioeconomic status, race, and modifiable risk factors to outcomes in patients with systemic lupus erythematosus

Abstract

Objective. To study the relationship of race, socioeconomic status (SES), clinical factors, and psychosocial factors to outcomes in patients with systemic lupus erythematosus (SLE).Methods. A retrospective cohort was assembled, comprising 200 patients with SLE from 5 centers. This cobort was balanced in terms of race and SES. Patients provided information on socioeconomic factors, access to health care, nutrition, self-efficacy for disease management, health locus of control, social support, compliance, knowledge about SLE, and satisfaction with medical care. Outcome measures included disease activity (measured by the Systemic Lupus Activity Measure), damage (measured by the SLICC/ACR damage index), and health status (measured by the SF-36). Results. In multivariate models that were controlled for race, SES, center, psychosocial factors, and clinical factors, lower self-efficacy for disease management (P 5 O.OOOl), less social support (P < 0.005), and younger age at diagnosis (P < 0.007) were associated with greater disease activity. Older age at diagnosis (P 5 O.OOOl), longer duration of SLE (P 5 O.OOOl), poor nutrition (P < 0.002), and higher disease activity at diagnosis (P < 0.007) were associated with more damage. Lower self-efiicacy for disease management was associated with worse physical function (P S 0. OOOl) and worse mental health status (P S 0.OOOl).Conclusion. Disease activity and health status were most strongly associated with potentially modifiable psychosocial factors such as self-efficacy for disease management. Cumulative organ damage was most highly associated with clinical factors such as age and duration of disease. None of the outcomes measured were associated with race. These results suggest that education and counseling, coordinated with medical care, might improve outcomes in patients with SLE.The relationship of race and socioeconomic status (SES) to poor outcomes in patients with systemic lupus erythematosus (SLE) has been debated for more than 20 years. Six studies have shown an association between lower SES and higher morbidity or mortality in patients with SLE (1-6). In addition, 2 studies have shown higher morbidity and mortality in black patients with SLE (3,7). However, the association of race and SES with outcome was confounded by SES in 3 other studies ( 1 3 ) .Whether or not race and socioeconomic factors are independent risk factors for poor outcomes, attribution of risk to socioeconomic factors does little to

A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus

“…Global physical function was improved by 7 points on the SF-36; although this change was not statistically significant, it is greater than the minimum clinically significant change suggested for interpreting change scores in rheumatoid arthritis trials (59). The clinical trial results confirm cross-sectional findings from research done by our group and other investigators, and support the importance of psychosocial factors in outcome in SLE (8)(9)(10)(11)(12)(13)(14)(15).…”

“…Self-efficacy has been correlated with SLE outcome in several studies (8)(9)(10)(11)(12)(13)(14)(15) and has been found to consistently predict health-related outcomes in prospective studies (60). In this trial, we demonstrated that self-efficacy could be enhanced by our intervention and that it was a key predictor of mental health status and fatigue outcomes.…”

“…This reliable scale (Cronbach's ␣ ϭ 0.84) assesses instrumental, emotional, and informational support. In our research (8) it is significantly associated with health status in lupus patients. Problem solving was measured by an 11-item coping measure, adapted from the method described by Stone and Neale (51) for rheumatic disease patients (52).…”

“…Not surprisingly, the sample comprised predominantly white and collegeeducated patients. A secondary analysis of our previous study (8) of 200 patients, balanced for ethnicity and socioeconomic status, indicated that social support was most beneficial for patients whose disease was mild, whose income was greater than poverty level, and whose ethnicity was white and educational level was higher (65). This describes our current study population well, and it is possible that our intervention may be less effective in a more socially disadvantaged population.…”

“…In systemic lupus erythematosus (SLE), lower socioeconomic status is also an important factor in determining outcome (2)(3)(4)(5)(6)(7). In 1997, we demonstrated that self-efficacy for disease management and social support were most strongly associated with disease activity and health status outcomes in SLE even when controlling for medical, behavioral, and various socioeconomic variables (8). What was more significant, perhaps, was that both self-efficacy and social support could likely be improved with targeted interventions, thus making these factors the first examples of modifiable, nonmedical risk factors associated with SLE outcomes.…”