Algorithmic Intervention Improves Access to SLE Specialty Care

The institution of an algorithmic approach to diagnostic testing for systemic lupus erythematosus (SLE) improved access to specialty care in a safety net system providing health care to the underserved, according to findings published in the September 2016 issue of American Journal of Clinical Pathology.¹ The study was led by Lei Chen, MD, of the Department of Pathology and Laboratory Medicine at the University of Texas Health Science Center in Houston, Texas. The algorithm was jointly created by clinical pathologists and rheumatologists based on clinical guidelines for autoantibody testing in systemic autoimmune rheumatic disorders.²

The first step of the algorithm consisted of testing for antinuclear antibody (ANA) positivity. Patients who tested positive were then assessed for SLE-associated autoantibodies, including anti–double-stranded DNA, anti-Smith, anti-ribonucleoprotein, anti-Ro (SSA), and anti-La antibodies (SSB).

ANA-positive patients received further laboratory testing for hepatitis and thyroid disease, as these conditions can mimic SLE. Patients who tested negative for ANA received a medical records review by a clinical pathologist in order to rule out ANA-negative SLE, a rare entity, and then referred back to their primary care physicians (PCPs) for further evaluation.

A random selection of patient records from 2011 documenting initial visits to the Harris Health System rheumatology clinic was used to establish baseline indicators of SLE testing. These records showed that prior to the institution of the testing algorithm, only 10 of out of 51 patients (19.6%) had the full array of laboratory studies considered necessary to make a diagnosis.

Use of the SLE algorithm, in combination with testing supervision, data review, and interpretation provided by a clinical pathologist, facilitated a drop in the approval rate for rheumatology consultation from 55% to 12% with no evidence of missed rheumatologic conditions. The wait for a rheumatology consult for patients with suspected SLE dropped from 4 to 6 months to 2 to 3 months.

Initially, the SLE algorithm was manually deployed by referral center nurses who were trained in its use. The process was later automated so that PCPs could initiate the algorithm with one electronic click. Use of the algorithm was made mandatory for PCPs wishing to have patients with suspected SLE evaluated by the rheumatology department.

Based on the success of this project, additional algorithms with clinical pathology supervision and consult for other disease states are currently being developed.

Summary and Clinical Applicability

“Our algorithm approach to SLE testing simplifies the ordering process for PCPs, enabling them to place one order to perform the laboratory evaluation for this condition,” wrote the authors.

“Patients need to undergo only one laboratory visit to collect all of the specimens needed to make a SLE diagnosis, thus decreasing the costs associated with multiple visits and blood draws. It also ensures that all relevant laboratory tests are performed prior to the first rheumatologist visit so that management decisions can be made during the initial visit. Thus, unnecessary visits to phlebotomists and rheumatologists are avoided to improve diagnosis efficiency.”

Limitations and Disclosures

This project was partially funded by the Delivery System Reform Incentive Program through the Harris Health System.

References

1. Chen L, Welsh KJ, Chang B, et al. Algorithmic approach with clinical pathology consultation improves access to specialty care for patients with systemic lupus erythematosus. Am J Clin Pathol. 2016;146(3):312-318.
2. Stinton LM, Fritzler MJ. A clinical approach to autoantibody testing in systemic autoimmune rheumatic disorders. Autoimmun Rev. 2007;7(1):77-84. 

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