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Development of a Set of Lupus-Specific Ambulatory Care Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study


Feldman CH1, Speyer C1, Ashby R2, Bermas B3, Bhattacharyya S4, Chakravarty E5, Everett B6, Ferucci E7, Hersh AO8, Marty FM9, Merola JF1, Ramsey-Goldman R10, Rovin BH11, Son MB12, Tarter L1, Waikar S13, Yazdany J14, Weissman JS15, Costenbader KH1. Arthritis Care Res (Hoboken). 2019 Oct 18. doi: 10.1002/acr.24095. [Epub ahead of print]

Author Information

1 Brigham and Women's Hospital, Department of Medicine, Division of Rheumatology, Immunology and Allergy &, Harvard Medical School, Boston, MA.

2 Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Boston, MA.

3 University of Texas Southwestern, Division of Rheumatology, Dallas, TX.

4 Brigham and Women's Hospital, Department of Neurology, Boston, MA.

5 Oklahoma Medical Research Foundation, Division of Arthritis and Clinical Immunology, Oklahoma City, OK.

6 Brigham and Women's Hospital, Department of Medicine, Division of Cardiology &, Harvard Medical School, Boston, MA.

7 Alaska Native Tribal Health Consortium, Anchorage, AK.

8 University of Utah, Division of Pediatric Rheumatology.

9 Brigham and Women's Hospital, Department of Medicine, Division of Infectious Diseases &, Harvard Medical School, Boston, MA.

10 Feinberg School of Medicine, Northwestern University, Division of Rheumatology, Chicago, IL.

11 Ohio State University Wexner Medical Center, Division of Nephrology, Columbus, OH.

12 Boston Children's Hospital, Division of Immunology, Harvard Medical School, Boston, MA.

13 Brigham and Women's Hospital, Division of Renal Medicine and Harvard Medical School, Boston, MA.

14 University of California, Division of Rheumatology, San Francisco, San Francisco, CA.

15 Brigham and Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, MA.



Individuals with systemic lupus erythematosus (SLE) are at high risk for infections, SLE- and medication-related complications. We defined a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received.


We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of sixteen nationally-recognized U.S.-based experts from eight subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held two survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions.


Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into four categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8), reproductive health-related complications (6) and SLE-related complications (5).


We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients received high quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.