Between February-May 2018 colleagues from more than 50 units across the UK took part in an audit of BSR's guidelines for the management of adults with SLE.

The audit was a major success. The care of more than 1000 people with lupus was assessed, resulting in the largest ever nationwide audit of a rare rheumatic disease. Units in four main regions took part - the North West, North East and the West and East Midlands; 18 additional units from across the rest of the UK also joined in.

The audit used standards derived from our guideline, the NICE Technology Appraisal for Belimumab in SLE and the NHS England Commissioning Policy for Rituximab in SLE.

Results for participating units were benchmarked against the results for the total audit population. Compliance targets for each audit standard were developed by the audit working group. The analysis was undertaken by Dr Fiona Pearce (Clinical Lecturer in Rheumatology), with local reports compiled by the lead Specialty Registrar for the audit in participating regions and units.

Quality improvement
Quality improvement (QI) initiatives work best when bespoke to and led by individual departments. To facilitate this, Dr Charlotte Sharp and Dr Jayne Little, Specialty Registrars in the North West, outlined principles, shared links and created materials and presented at Annual Conference.

Resources were developed specifically for this lupus audit and are available below. All doctors in training are now expected to participate in an annual QI project; BSR supports members in doing this.

Audit standards

  • 80% of patients should have a record of disease activity at each clinic visit
  • 90% of patients should have appropriate urine protein quantification
  • 90% of patients with inactive disease should be on <7.5mg maintenance prednisolone/day
  • 95% of patients on hydroxychloroquine should be on <6.5mg/kg/day
  • 80% of eligible patients should be on hydroxychloroquine
  • 90% of patients treated with biologics should be recruited to BILAG BR
  • 90% of patients should have documented evidence of screening for cardiovascular risk, defined as measurement of BP and lipids in the last year

QI areas of focus

  • Monitoring for eye disease in patients on hydroxychloroquine
  • Documentation of discussion of UV protection with patient
  • Documentation of smoking status
  • Documentation of contraception and pregnancy issues in female patients of reproductive age
  • Documentation of IHD
  • Documentation of diabetes
  • Documentation of TIA
  • Documentation of hypertension

Driver diagrams

Each audit standard comes with an accompanying example driver diagram. Driver diagrams show step-by step approaches that identify multiple small interventions that influence the primary aim.

There is additional general explanation of driver diagrams here.

There will be different context-specific facilitators and barriers to high quality care at each site. Driver diagrams should be modified for local circumstances and involve input from across the MDT.

We expect there to be additional areas for individual sites and not all will be applicable to every site.

The driver diagrams can be edited and some spaces are left blank. Instructions for completion and further resources are in the ‘instructions’ tab at the bottom of the page within each diagram.

1. Driver diagram - disease activity
2. Driver diagram – urinalysis
3. Driver diagram – steroid dose
4. Driver diagram – HCQ dose
5. Driver diagram – BILAG BR
6. Driver diagram – BP
7. Driver diagram – lipids
8. Driver diagram – blank, for your own use

Clinic prompts

This clinic prompt was developed using evidence from the 2018 multi-regional audit of our guideline for the management of adults with SLE.

The items prioritised for inclusion are those that are likely to have the strongest impact on patient care via improving compliance with the guideline.

The prompt is intended to support decision-making and could also be used as a training tool at induction and for educational interventions.

The prompt could also be used as a tool for local audits of the management of SLE in adults.