Table 1.

Summary of selected studies assessing quality of care in SLE. Table demonstrates the range of healthcare quality topics studied and how they link to different aspects and levels of quality measurement described in Figure 2.

Aspects of Healthcare Quality^*	Levels of Quality Measurement^**	Study	n	Topic and Outcome Measured	Result
Accessibility Equity	Structure Outputs	Yazdany, et al¹¹ Tonner, et al¹² Gillis, et al¹³	755 982 980	Access to care measured by number of specialist physician visits and distance traveled.	Patients with lower SES, no insurance, and lacking access to a SLE specialist had fewer visits for SLE care^11,12, travelled farther¹³, and were more likely to attend the ER¹³.
Accessibility Effectiveness Acceptability, Equity	Structure Outputs Outcomes	Law, et al¹⁴ Moses, et al¹⁵ Dua, et al¹⁶	654 386 83	Patient perception of barriers to care, unmet care needs, and satisfaction with care.	50% of patients identified barriers to accessing care¹⁴; 94% of patients had unmet psychological needs¹⁵; and satisfaction with care was associated with improved HRQoL¹⁶.
Effectiveness	Processes	Gladman, et al⁷	515	Occurrence of disease activity measurable by laboratory testing only.	25% of patients had a clinically silent event (renal, serological, or hematological) over a period of 2 yrs.
Effectiveness Equity	Processes	Yazdany, et al¹⁷ Yazdany, et al¹⁸ Schmajuk, et al¹⁹ Demas, et al²⁰ Quinzanos, et al²¹	685 801 127 200 137	Receipt of evidence-based care processes measured as performance on SLE quality indicators⁵¹.	60%–70% received cancer surveillance¹⁷; 50%–60% received immunization^17,18; 56%–86% received osteoporosis prevention and management^19,20; 40%–46% had contraceptive counseling^17,21; and 26%–29% had assessment of cardiovascular risk factors^18,20. Lower SES, fewer physician visits, and lack of insurance were associated with poorer performance.
Accessibility Effectiveness, Equity	Processes	Yazdany, et al²² Tsang, et al²³	1711 190	Receipt of appropriate medication.	Use of antimalarial medication was suboptimal²³. Lack of health insurance was associated with poor receipt of treatment for LN²².
Effectiveness Efficiency	Outputs	McInnes, et al²⁴ Nee, et al²⁵		Cost-utility analysis of treatment for LN.	Higher treatment costs of newer or combination therapy were balanced by reduced need for dialysis, transplantation, and improved work capacity^24,25.
Effectiveness	Processes, Outcomes	Yazdany, et al²⁶	737	Effect of SLE quality indicator performance on damage accrual.	Higher performance on SLE quality indicators was protective against damage accrual.
Accessibility Equity, Safety	Processes Outcomes	Ward²⁷ Ward²⁸ Plantinga, et al²⁹	7971 702 6594	Development of ESRF due to LN. Care of ESRF due to LN.	Patients lacking health insurance had a higher incidence²⁸ and faster progression²⁷ to ESRF, as well as inadequate ESRF care²⁸.
Effectiveness Equity, Safety	Processes Outputs	Yazdany, et al³⁰ Ward³¹	31,903 2123	Hospitalization.	16.5% of patients with SLE were readmitted within 30 days³⁰. Older age and low SES associated with higher rate of avoidable hospitalizations^30,31.
Accessibility Effectiveness Equity, Safety	Processes Outcomes	Ward³² Ward³³	9989 15,509	In-hospital mortality.	Uninsured patients had lower in-hospital mortality rates at highly experienced hospitals³², and in the care of more experienced physicians³³.

↵* Measurable aspects of healthcare quality: accessibility, effectiveness, efficiency, acceptability, equity, safety, and accountability (for detailed description, see Figure 2).
↵** Based on Donabedian’s framework of levels of healthcare: structure, processes, outputs, and outcomes (for detailed description, see Figure 2). SLE: systemic lupus erythematosus; LN: lupus nephritis; ESRF: endstage renal failure; SES: socioeconomic status; ER: emergency room; HRQOL: health-related quality of life.