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Introduction: Disease expression and outcomes in rheumatoid arthritis (RA) vary among different ethnic groups. There are limited data on the impact of age on disease severity and outcomes among Hispanics. Thus, we determined the demographic characteristics, clinical manifestations, comorbidities, pharmacologic profile, and functional status among Puerto Ricans with RA of different age groups., Methods: A cross-sectional study was conducted in 214 Puerto Rican patients with RA (per American College of Rheumatology classification criteria). Demographic features, health-related behaviors, cumulative RA manifestations, treatment profiles, disease activity (Disease Activity Score 28), comorbid conditions, and functional status (Health Assessment Questionnaire) were determined at study visit. Three age groups were studied: <40, 40-59, and > or =60 years. Data were examined using univariable and multivariable (logistic regression) analyses., Results: The mean (SD) age of the study population was 56.5 (13.6) years with a mean disease duration (SD) of 10.8 (9.7) years; 180 patients (84.1%) were women. In the multivariable analyses, patients aged > or =60 years were more likely to have joint deformities, extra-articular manifestations, and comorbidities such as dyslipidemia, arterial hypertension, diabetes mellitus, vascular events, osteoarthritis, low back pain, and osteoporosis. In addition, older patients used corticosteroids more frequently. No differences were found for the use of disease-modifying anti-rheumatic drugs or biologic agents., Conclusions: Puerto Rican RA patients aged > or =60 years present a severe type of disease having more joint damage, extra-articular manifestations, and comorbidities than younger patients. These disparities must be considered when establishing effective therapy for older RA patients.

Introduction: The clinical outcome and therapeutic response to immunosuppressive agents vary among patients with lupus nephritis of different ethnic populations. Thus, we evaluated the efficacy of two established treatment protocols for lupus nephritis (low-dose versus standard-dose cyclophosphamide) in Puerto Ricans with systemic lupus erythematosus (SLE)., Methods: A retrospective cohort of 49 adult patients with SLE treated with intravenous low or standard-dose cyclophosphamide for clinical or biopsy confirmed lupus nephritis was studied. Demographic parameters, clinical manifestations, autoantibodies and pharmacological treatments were determined prior to cyclophosphamide treatment. Renal parameters, disease activity, damage accrual and corticosteroid use were determined before and after treatment. Cyclophosphamide-associated adverse events were also examined. Univariable and bivariable analyses were used to evaluate group differences., Results: Thirty-nine SLE patients received the standard-dose treatment and ten patients the low-dose therapy. Prior to cyclophosphamide infusion, demographic parameters, clinical manifestations, autoantibodies profile, disease damage and pharmacologic treatments were similar in both groups. Disease activity was higher in the low-dose group. After cyclophosphamide therapy, significant improvement of renal parameters (increase in the glomerular filtration rate and decrease in hematuria, pyuria, urinary cellular casts, proteinuria and hypertension) were observed only for patients that received the standard-dose therapy. Disease activity and corticosteroids requirement decreased in both groups after treatment. No differences were observed for adverse events associated with cyclophosphamide., Conclusions: The standard-dose cyclophosphamide therapy appears to be more effective, and similar in terms of drug safety, than the low-dose regime for lupus nephritis in Puerto Ricans with SLE.

Objective: To determine the features predictive of time to integument damage in patients with systemic lupus erythematosus (SLE) from a multiethnic cohort (LUpus in MInorities, NAture versus nurture [LUMINA])., Methods: LUMINA SLE patients (n = 580) age > or =16 years, with a disease duration of < or =5 years at baseline (T0), of African American, Hispanic, and Caucasian ethnicity were studied. Integument damage was defined per the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (scarring alopecia, extensive skin scarring, and skin ulcers lasting at least 6 months); factors associated with time to its occurrence were examined by Cox proportional univariable and multivariable (main model) hazards regression analyses. Two alternative models were also examined: in model 1, all patients, regardless of when integument damage occurred (n = 94), were included; in model 2, a time-varying approach (generalized estimating equation) was employed., Results: Thirty-nine (6.7%) of 580 patients developed integument damage over a mean +/- SD total disease duration of 5.9 +/- 3.7 years, and were included in the main multivariable regression model. After adjusting for discoid rash, nailfold infarcts, photosensitivity, and Raynaud's phenomenon (significant in the univariable analyses), disease activity over time (hazard ratio [HR] 1.17, 95% confidence interval [95% CI] 1.09-1.26) was associated with a shorter time to integument damage, whereas hydroxychloroquine use (HR 0.23, 95% CI 0.12-0.47) and Texan-Hispanic (HR 0.35, 95% CI 0.14-0.87) and Caucasian ethnicities (HR 0.37, 95% CI 0.14-0.99) were associated with a longer time. Results of the alternative models were consistent with those of the main model, although in model 2, the association with hydroxychloroquine was not significant., Conclusion: Our data indicate that hydroxychloroquine use is possibly associated with a delay in integument damage development in patients with SLE.

Objective: To determine the factors associated with increased levels of fatigue over the course of the disease in systemic lupus erythematosus (SLE) patients from LUpus in MInorities: NAture versus nurture, a longitudinal multiethnic cohort., Methods: Patients with SLE (according to the American College of Rheumatology revised and updated criteria) age >/=16 years with a disease duration

Objective: To determine the features predictive of atherosclerotic cardiovascular damage in patients with SLE., Methods: SLE LUMINA (LUpus in MInorities: NAture vs nurture) patients (n = 637), aged >or=16 years, disease duration

Objective: To assess whether hydroxychloroquine can delay renal damage development in lupus nephritis patients., Methods: Lupus nephritis patients (n = 256) from the LUpus in MInorities, NAture versus nurture study (n = 635), a multiethnic cohort of African Americans, Hispanics, and Caucasians, age > or =16 years with disease duration < or =5 years at baseline (T0) were studied. Renal damage was defined using the Systemic Lupus International Collaborating Clinics Damage Index (> or =1 of the following lasting at least 6 months: estimated/measured glomerular filtration rate <50%, 24-hour proteinuria > or =3.5 gm and/or end-stage renal disease, regardless of dialysis or transplantation). Patients with renal damage before T0 were excluded (n = 53). The association between hydroxychloroquine use and renal damage (as defined, or omitting proteinuria) was estimated using Cox proportional regression analyses adjusting for potential confounders. Kaplan-Meier survival curves based on hydroxychloroquine intake or the World Health Organization (WHO) class glomerulonephritis were also derived., Results: Sixty-three (31.0%) of the 203 patients included developed renal damage over a mean +/- SD disease duration of 5.2 +/- 3.5 years. The most frequent renal damage domain item was proteinuria. Patients who received hydroxychloroquine (79.3%) exhibited a lower frequency of WHO class IV glomerulonephritis, had lower disease activity, and received lower glucocorticoid doses than those who did not take hydroxychloroquine. After adjusting for confounders, hydroxychloroquine was protective of renal damage occurrence in full (hazard ratio [HR] 0.12, 95% confidence interval [95% CI] 0.02-0.97, P = 0.0464) and reduced (HR 0.29, 95% CI 0.13-0.68, P = 0.0043) models. Omitting proteinuria provided comparable results. The cumulative probability of renal damage occurrence was higher in those who did not take hydroxychloroquine and those classified as WHO class IV glomerulonephritis (P < 0.0001)., Conclusion: After adjusting for possible confounding factors, the protective effect of hydroxychloroquine in retarding renal damage occurrence in systemic lupus erythematosus is still evident.

Objective: Damage accrual in SLE has been previously shown to be an independent predictor of mortality. We sought to discern which SLICC Damage Index (SDI) domains are the most important predictors of survival in SLE., Methods: SLE patients (ACR criteria), age > or =16 years, disease duration < or =5 years at enrolment, of African-American, Hispanic or Caucasian ethnicity were studied. Disease activity was assessed using the SLAM-Revised (SLAM-R) at diagnosis. Damage was ascertained using the SDI at the last visit. The SDI domains associated with time to death (and interaction terms) were examined by univariable and multivariable Cox proportional hazards regression analyses; those significant in the multivariable analyses were added to the final two models (with and without poverty) that included other variables known to be associated with shorter survival., Results: A total of 635 SLE patients were studied of whom 97 (15.3%) have died over a mean (s.d.) total disease duration of 5.7 (3.7) years. Patients were predominantly women [570 (89.8%)]; their mean (s.d.) age was 36.5 (12.6) years; 126 (19.8%) had developed renal damage, 62 (9.3%) cardiovascular, 48 (7.8%) pulmonary and 34 (5.4%) peripheral vascular damage. When excluding poverty from the multivariable model, the renal domain of the SDI was independently associated with a shorter time to death (hazard ratio = 1.65; 95% CI 1.03, 2.66)., Conclusions: The renal domain of the damage index is associated with a shorter time to death when poverty, a strong predictor of this outcome, is removed from the model. Preventing renal damage in lupus patients has long-term prognostic implications.

Objective: To examine the clinical and genetic correlates of hemolytic anemia and its impact on damage accrual and mortality in systemic lupus erythematosus (SLE) patients., Methods: SLE patients (American College of Rheumatology [ACR] criteria) of Hispanic (Texan or Puerto Rican), African American, and Caucasian ethnicity from the LUMINA (LUpus in MInorities, NAture versus nurture) cohort were studied. Hemolytic anemia was defined as anemia with reticulocytosis (ACR criterion). The association between degrees of hemolytic anemia and socioeconomic/demographic, clinical, pharmacologic, immunologic, psychological, and behavioral variables was examined by univariable and multivariable (proportional odds model) analyses. Genetic variables (FCGR and Fas/Fas ligand polymorphisms) were examined by 2 degrees of freedom test of association and Cochran-Armitage trend tests. The impact of hemolytic anemia on damage accrual and mortality was examined by multivariable linear and Cox regression analyses, respectively., Results: Of 628 patients studied, 90% were women, 19% were Texan Hispanic, 16% were Puerto Rican Hispanic, 37% were African American, and 28% were Caucasian. Sixty-five (10%) patients developed hemolytic anemia at some time during the disease course, 83% at or before diagnosis. Variables independently associated with degrees of hemolytic anemia were African American ethnicity, thrombocytopenia, and the use of azathioprine. Hemolytic anemia was associated with damage accrual after adjusting for variables known to affect this outcome; however, hemolytic anemia was not associated with mortality., Conclusion: The association of hemolytic anemia with thrombocytopenia suggests a common mechanism in their pathophysiology. Hemolytic anemia is an early disease manifestation and is associated with African American ethnicity and the use of azathioprine; it appears to exert an impact on damage but not on mortality.

Objective: To examine the utilization of health services and prescription patterns among patients with systemic lupus erythematosus (SLE) followed by primary care physicians and rheumatologists in Puerto Rico., Methods: The insurance claims submitted by physicians to a health insurance company of Puerto Rico in 2003 were examined. The diagnosis of lupus was determined by using the International Classification of Diseases, Ninth Revision, code for SLE (710.0). Of 552,733 insured people, 665 SLE patients were seen by rheumatologists, and 92 were followed by primary care physicians. Demographic features, selected co-morbidities, healthcare utilization parameters, and prescription patterns were examined. Fisher exact test, chi2 test, and analysis of variances were used to evaluate differences between the study groups., Results: SLE patients followed by rheumatologists had osteopenia/osteoporosis diagnosed more frequently than did patients followed by primary care physicians. The frequency of high blood pressure, diabetes mellitus, hypercholesterolemia, coronary artery disease, and renal disease was similar for both groups. Rheumatologists were more likely to order erythrocyte sedimentation rate, anti-dsDNA antibodies, and serum complements. No differences were observed for office or emergency room visits, hospitalizations, and utilization of routine laboratory tests. Rheumatologists prescribed hydroxychloroquine more frequently than did primary care physicians. The use of nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, glucocorticoids, azathioprine, cyclophosphamide, and methotrexate was similar for both groups., Conclusion: Overall, the utilization of health services and prescription patterns among SLE patients followed by primary care physicians and rheumatologists in Puerto Rico are similar. However, rheumatologists ordered SLE biomarkers of disease activity and prescribed hydroxychloroquine more frequently than did primary care physicians.

Objectives: To examine the influence of hormone replacement therapy (HRT) in the occurrence of vascular arterial and venous thrombotic events in postmenopausal women with systemic lupus erythematosus (SLE)., Patients and Methods: SLE women aged > or =16 years, disease duration < or =5 years from LUMINA, a multiethnic, longitudinal outcome study, were included. Menopause was defined at disease onset as the presence of amenorrhea >6 months and/or oophorectomy, and/or increased follicle stimulating hormone values, and/or HRT use regardless of the presence or absence of climacteric symptoms (hot flashes). Patients were divided into HRT ever users and nonusers. Patients with positive antiphospholipid antibodies (n = 9) or vascular arterial events (n = 1) occurring before HRT use were excluded. The occurrence of vascular arterial and venous thrombotic events was compared between HRT users and HRT nonusers and its role examined by logistic regression after adjusting for "confounding by indication" using propensity score or logistic regression analyses., Results: Seventy-two postmenopausal women, 32 (44%) HRT users and 40 (56%) HRT nonusers, were studied. HRT use was associated with fewer vascular arterial but not venous thrombotic events (P = 0.021) in the univariable analyses. However, after adjusting for the propensity score, HRT use was no longer significant (P = 0.064). Comparable results were obtained by logistic regression., Conclusions: HRT use was not associated with the occurrence of vascular arterial events in the LUMINA patients. HRT use in women with SLE should be individualized, but our data suggest its use may be safe if antiphospholipid antibodies are not present or vascular arterial events have not previously occurred.

Objective: In patients with systemic lupus erythematosus (SLE), hydroxychloroquine prevents disease flares and damage accrual and facilitates the response to mycophenolate mofetil in those with renal involvement. A study was undertaken to determine whether hydroxychloroquine also exerts a protective effect on survival., Methods: Patients with SLE from the multiethnic LUMINA (LUpus in MInorities: NAture vs nurture) cohort were studied. A case-control study was performed within the context of this cohort in which deceased patients (cases) were matched for disease duration (within 6 months) with alive patients (controls) in a proportion of 3:1. Survival was the outcome of interest. Propensity scores were derived by logistic regression to adjust for confounding by indication as patients with SLE with milder disease manifestations are more likely to be prescribed hydroxychloroquine. A conditional logistic regression model was used to estimate the risk of death and hydroxychloroquine use with and without the propensity score as the adjustment variable., Results: There were 608 patients, of whom 61 had died (cases). Hydroxychloroquine had a protective effect on survival (OR 0.128 (95% CI 0.054 to 0.301 for hydroxychloroquine alone and OR 0.319 (95% CI 0.118 to 0.864) after adding the propensity score). As expected, the propensity score itself was also protective., Conclusions: Hydroxychloroquine, which overall is well tolerated by patients with SLE, has a protective effect on survival which is evident even after taking into consideration the factors associated with treatment decisions. This information is of importance to all clinicians involved in the care of patients with SLE.

Objective: To determine if overall health status as assessed by the Short Form 6D (SF-6D) index, a preference-based generic measure of health, is associated with the occurrence of damage accrual and mortality in patients with systemic lupus erythematosus (SLE)., Methods: We studied SLE patients (American College of Rheumatology criteria) from the LUpus in MInorities, NAture versus nurture cohort (LUMINA), a longitudinal multiethnic cohort. The contribution of the SF-6D as assessed at enrollment to damage accrual at the last visit and mortality was examined. All variables previously shown to be determinants of damage accrual and mortality and corroborated by univariable analyses were adjusted for in multivariable models (Poisson and Cox proportional hazards regressions, respectively). Damage accrual and mortality were the dependent variables. Similar analyses were performed examining the associations of the Short Form 36 summary measures (physical component summary [PCS], mental component summary [MCS]) with these outcomes., Results: In 552 patients, the SF-6D was negatively associated with damage accrual and mortality in the univariable analyses; the association with damage was confirmed in the multivariable analyses (chi(2) = 9.020, P = 0.002) but the association with mortality was not confirmed (hazard ratio 0.495, 95% confidence interval 0.041-6.038). When the PCS and MCS were evaluated, the PCS, but not the MCS, was found to be associated with damage but not with mortality., Conclusion: The SF-6D (and the PCS) as measured early in the disease course were found to independently predict damage accrual at the last visit, but not mortality. Although the SF-6D was originally conceived as a utility measure, it may be used to accurately assess overall health status in patients with SLE.

Objective: To examine the prevalence of systemic lupus erythematosus (SLE) and its associated comorbidities in patients from Puerto Rico using a database from a health insurance company., Methods: The insurance claims submitted by physicians in 2003 to a health insurance company of Puerto Rico were examined. Of 552,733 insured people, 877 had a diagnosis of SLE (code 710.0) per the International Classification of Diseases, Ninth Revision (ICD-9). Demographic parameters and selected comorbidities were determined. The diagnosis of comorbities was ascertained using the ICD-9 code, the Current Procedural Terminology-4 code (for disease-specific procedures) and/or the Medi-Span Therapeutic Classification System (for disease-specific pharmacologic treatment). Fisher exact test and chi were used to evaluate differences between SLE patients groups., Results: The mean age was 42.0 +/- 13.5, and the female-to-male ratio was 12.5:1. The overall prevalence of SLE was 159 per 100,000 individuals. The prevalence for females was 277 per 100,000 women and for males it was 25 per 100,000 men. The most common comorbidities were high blood pressure (33.7%), osteopenia/osteoporosis (22.2%), hypothyroidism (19.0%), diabetes mellitus (11.6%), and hypercholesterolemia (11.6%). Overall, high blood pressure, diabetes mellitus, hypercholesterolemia, and coronary artery disease were more prevalent in SLE patients older than 54 years. Osteopenia/osteoporosis was more prevalent in women than in men., Conclusions: The prevalence of SLE in Puerto Rico is very high. High blood pressure, diabetes mellitus and hypercholesterolemia, hypothyroidism, and osteopenia/osteoporosis are common comorbidities in these patients. Identification and management of these comorbidities are critical for optimal medical care to this population.

Objective: The aim of this study was to examine the impact of an increased body mass index (BMI) on disease activity, damage accrual, fatigue, self-reported health-related quality of life (HRQOL), and fibromyalgia in patients with lupus using longitudinal data from LUMINA, a large multiethnic cohort., Methods: SLE patients (>/=4 ACR revised criteria), /=30 kg/m). An increased BMI was associated with older age, less social support, higher degree of helplessness, depression, more abnormal illness-related behaviors, poorer self-reported HRQOL, fatigue, and fibromyalgia, but not with disease activity or damage accrual by univariable analyses. In multivariable analyses, BMI was independently associated with fibromyalgia but not with disease activity, fatigue, or self-reported HRQOL., Conclusions: An increased BMI is independently associated with presence of fibromyalgia but not with disease activity, damage accrual, fatigue or self-reported quality of life in patients with SLE. Optimizing weight merits investigation to see if it can significantly impact this pervasive SLE-associated manifestation.

The aim of this study was to determine if macrophage inflammatory protein (MIP) 1alpha, MIP-1beta, and RANTES (regulated upon activation normally T-cell expressed and secreted) serum concentrations are associated with clinical manifestations, disease activity, and damage accrual in patients with systemic lupus erythematosus (SLE). A cross-sectional study was performed in 62 SLE patients (per American College of Rheumatology criteria) participating in a longitudinal study and 20 healthy subjects. MIP-1alpha, MIP-1beta, and RANTES serum concentrations were determined by enzyme-linked immunosorbent assay. Demographic parameters, clinical manifestations, serologic features, pharmacologic treatments, disease activity, and damage accrual were determined at study visit. Disease activity was assessed with the Systemic Lupus Erythematosus Activity Measure (SLAM), and disease damage was assessed with Systemic Lupus International Collaborating Clinic Damage Index (SDI). The relation between the variables was studied with the Student t test and the Pearson r correlation test. SLE patients were more likely to have higher concentrations of MIP-1beta and RANTES than healthy individuals. In addition, they had a trend to have higher concentrations of MIP-1alpha. Patients with discoid lupus were more likely to have higher levels of MIP-1alpha. Elevation of MIP-1beta correlated with higher SDI score. No association was found between serum chemokines levels and disease activity. In conclusion, SLE patients have higher serum levels of MIP-1beta and RANTES than healthy individuals. MIP-1alpha is associated with discoid lupus, and MIP-1beta correlates with damage accrual in SLE. This study suggests that chemokines may have a role in the pathogenesis of SLE.

Objective: To examine the clinical differences and the type and extent of organ damage in late- versus early-onset systemic lupus erythematosus (SLE)., Methods: A nested case-control study was performed in the context of LUMINA (LUpus in MInorities, NAture versus nurture), a large, longitudinal, multiethnic cohort. Patients who developed SLE at or after the age of 50 years were considered cases. Two controls (patients who developed SLE at age < or = 49 years) per case, matched for sex and disease duration, were randomly chosen. Selected baseline socioeconomic/demographic, behavioral, and psychological features, self-reported quality of life, and cumulative clinical data (clinical manifestations, laboratory data, disease activity, damage, and mortality) were compared between cases and controls. Multivariable analyses with late-onset lupus, damage accrual, and mortality as dependent variables were then performed., Results: Two hundred seventeen patients were studied. Of them, 73 were cases. Cases were more likely to have neurologic involvement, arterial thrombotic events, osteoporosis, and hypertriglyceridemia, while renal involvement and anti-Sm antibodies were less frequent. Disease activity at baseline was lower among cases. Cases also exhibited more cardiovascular and ocular damage. Late-onset lupus was an independent predictor of damage accrual (t-test = 2.23, P = 0.028), any damage at last visit (odds ratio [OR] 23.32, 95% confidence interval [95% CI] 3.98-141.56) (P < 0.001), and mortality (OR 10.74, 95% CI 3.07-37.56) (P < 0.001)., Conclusion: Patients with late-onset lupus exhibit distinct clinical features. Although disease activity tends to be lower in these patients, they tend to accrue more damage and experience higher mortality than patients with early-onset lupus. These findings probably reflect the contribution exerted by other comorbid conditions in the overall impact of lupus in these patients.

Objective: To determine if different categories of erythrocyte sedimentation rate (ESR) elevation are associated with disease activity and/or damage in systemic lupus erythematosus (SLE)., Methods: We studied 2317 study visits in 553 SLE patients (> or = 4 American College of Rheumatology criteria, < or = 5 years' disease duration at enrollment) from a multiethnic (Hispanic, African American, and Caucasian) longitudinal study of outcome. A study visit was done every 6 months for the first year and annually thereafter. Erythrocyte sedimentation rate (ESR) was measured using the Westergren method; results were expressed in 4 categories: < 25 (normal), 25-50 (mild elevation), 51-75 (moderate elevation), and > 75 (marked elevation) mm/h. Anti-dsDNA antibodies were measured at enrollment with the Crithidia luciliae assay. Disease activity was assessed with the Systemic Lupus Activity Measure (SLAM) and the Physician's Global Assessment (PGA). Because ESR is one of the measures evaluated in the SLAM, it was excluded from the total SLAM score. Disease damage was assessed with the Systemic Lupus International Collaborating Clinics damage index (SDI). The relationship between the SLAM (total and PGA) and SDI scores (at baseline and for all visits) and anti-dsDNA antibodies (at enrollment) with ESR was examined by univariable and generalized estimating equation (GEE) regression analyses. Ethnicity, age, and sex were entered in all regression models., Results: The cohort consisted of 89.7% women with mean age 36.8 (SD 12.6) years and disease duration 4.6 (SD 3.2) years. GEE analyses showed that increasing levels of ESR and anti-dsDNA antibody positivity were independently associated with SLAM and PGA scores, at enrollment and for all visits. Overall, the associations of ESR with SLAM and PGA scores were stronger than for the presence of anti-dsDNA antibodies. At baseline, there was no relationship of ESR elevation or anti-dsDNA positivity with SDI scores. However, when all visits were studied, moderate and marked elevations of ESR were independently associated with SDI scores., Conclusion: Mild, moderate, and marked ESR elevations are strongly associated with disease activity in SLE. Moderate and marked ESR elevations are also associated with damage accrual. These associations are stronger than those for the presence of anti-dsDNA antibodies. Our data suggest that ESR could be used to assess disease activity and predict organ/system damage in a relatively rapid and inexpensive manner in SLE.

Objective: To assess the validity, reliability, and feasibility of the Systemic Lupus Activity Measure-Revised (SLAM-R), the Mexican version of the Systemic Lupus Erythematosus Disease Activity Index (MEX-SLEDAI), and a Modified SLEDAI-2000 (SLEDAI-2K) compared with the SLEDAI-2K in a multiethnic population of patients with SLE., Methods: We studied 92 SLE patients from 3 US geographic areas (Alabama, Texas, and Puerto Rico). Assessment occurred during regular outpatient, inpatient, or study encounters. A trained physician scored the 4 instruments and also assessed disease activity globally [physician global assessment (PGA)]. Convergent (with SLEDAI-2K) and construct validity (with PGA) were determined by Spearman rank (rs) correlation test. Level of agreement between the instruments was assessed using Bland-Altman plots. Discriminant validity (distinguishing clearly active vs mildly/nonactive disease) was assessed considering the SLEDAI-2K (and the PGA) as the gold standard. Feasibility was explored by cost analyses., Results: The SLAM-R, the MEX-SLEDAI, and the Modified SLEDAI-2K were highly correlated with the SLEDAI-2K (rs = 0.566, 0.755, 0.924, respectively) and with the PGA (rs = 0.650, 0.540, 0.634, respectively). The 3 instruments showed good agreement with the SLEDAI-2K (Bland-Altman plots). The Modified SLEDAI-2K had better discriminant validity than the SLAM-R and the MEX-SLEDAI. The Modified SLEDAI-2K was the least expensive instrument., Conclusion: The SLAM-R, the MEX-SLEDAI, and the Modified SLEDAI-2K are adequate options for assessment of SLE disease activity; they are also less costly than the SLEDAI-2K.

This study was designed to explore the impact of a managed care system on the morbidity and mortality rates in a systemic lupus erythematosus (SLE) cohort in Puerto Rico. The clinical manifestations and outcome measures of public SLE patients, before and after implementation of the managed care system, were compared with those of SLE patients treated in a private fee-for-service system. Of the cohort of 171 patients, 103 (60%) were treated in the public system and 68 (40%) in the private sector. Except for higher prevalence of hematuria, renal insufficiency, and serositis in the public group, both groups had a similar prevalence of clinical manifestations, Systemic Lupus Erythematosus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage score, and mortality rate before introduction of the managed care system. Six years after implementation of the managed care system, medically indigent patients were more likely to have photosensitivity (90% vs. 75%), malar rash (85% vs. 65%), hematuria (43% vs. 24%), nephrotic syndrome (17% vs. 6%), and end-stage renal disease (8% vs. 0%). They also had a higher mortality rate (10% vs. 2%) and SLICC/ACR damage index score (1.5 vs. 0.8). In summary, SLE patients treated in the public system of Puerto Rico demonstrated higher morbidity and mortality after being treated in a managed care system compared with patients managed in a private fee-for-service system. Different from the fee-for-service system, the managed care system seeks medical care cost reductions that could affect the management and outcome of SLE patients. These differences could also be related to the higher disease severity before implementation of the managed care system and lower socioeconomic status of the public group. Nevertheless, the public managed care system in Puerto Rico requires continuous evaluation to ensure SLE patients better access to specialty and subspecialty healthcare and optimal pharmacologic treatments.