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Systemic lupus erythematosus (SLE) is a systemic autoimmune disease involving multiple organs throughout the body. The health care–seeking behaviors, disease progression of SLE, and patients' knowledge of and attitudes toward SLE have not been characterized in China.
The aim of this study was to depict the health care–seeking behaviors, disease progression, and medications in patients with SLE and to examine the factors associated with their disease flares, knowledge, and attitudes toward SLE in China.
We conducted a cross-sectional survey in 27 provinces in China. Descriptive statistical methods were used to depict the demographic characteristics, health care–seeking behaviors, medications, and health status. Multivariable logistic regression models were used to identify the factors associated with disease flares, medication changes, and attitudes toward SLE. An ordinal regression model was used to examine the factors associated with the knowledge of the treatment guidelines.
We recruited 1509 patients with SLE, and 715 had lupus nephritis (LN). Approximately 39.96% (603/1509) of the patients with SLE were primarily diagnosed with LN, and 12.4% (112/906) developed LN (mean time 5.2 years) from non-LN. Patients whose registered permanent residences or workplaces in other cities from the same province and adjacent provinces seeking health care accounted for 66.9% (569/850) and 48.8% (479/981) of the patients with SLE in the provincial capital cities, respectively. Mycophenolate mofetil was the most commonly used immunosuppressive drug in patients without LN (185/794, 23.3%) and patients with LN (307/715, 42.9%). Femoral head necrosis (71/228, 31.1%) and hypertension (99/229, 43.2%) were the most common adverse event (AE) and chronic disease during treatment, respectively. Change of hospitals for medical consultation (odds ratio [OR] 1.90, 95% CI 1.24-2.90) and development of 1 chronic disease (OR 3.60, 95% CI 2.04-6.24) and AE (OR 2.06, 95% CI 1.46-2.92) and more were associated with disease flares. A pregnancy plan (OR 1.58, 95% CI 1.18-2.13) was associated with changes in medication. Only 242 (16.03%) patients with SLE were familiar with the treatment guidelines, and patients with LN tended to be more familiar with the disease (OR 2.20, 95% CI 1.81-2.68). After receiving treatment, 891 (59.04%) patients changed their attitudes toward SLE from fear to acceptance, and patients with college education or higher (OR 2.09, 95% CI 1.10-4.04) were associated with a positive attitude toward SLE.
A large proportion of patients seeking health care in the provincial capital cities of China migrated from other cities. Persistent monitoring of potential AEs and chronic diseases during SLE treatment and managing patients who changed hospitals for medical consultation are essential for controlling disease flares. Patients had insufficient knowledge about SLE treatment guidelines and would benefit from health education to maintain a positive attitude toward SLE.
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease involving multiple organs throughout the body [
Disease flare is a state of increased disease activity and has been reported to occur in more than 20% of the patients within 2 years after remission [
The updated 2020 Chinese guidelines for the diagnosis and treatment of SLE and the 2019 Chinese guidelines for the diagnosis and treatment of LN (hereafter referred to as the treatment guidelines) are further divided to standardize the diagnosis and treatment standards, which not only provide a basis for the diagnosis and treatment of SLE but also provide a transparent guide for patients with SLE [
The data set in our study was based on an electronic-based questionnaire designed by rheumatologists, epidemiologists, statisticians, and clinicians from multiple centers. The survey was primarily answered by 20 patients and adjusted according to their feedback, and the final version consisted of 4 parts and 51 questions. The first part of the survey was the basic introduction to the study, which required the patient to read the relevant operations carefully and be familiar with the purpose of the study. The second part was about the baseline characteristics of the patients; the third part was about the time of diagnosis, health status, and medications; and the last part was about the knowledge of the treatment guidelines and attitudes toward SLE. The set of questions included fill-in-the-blank, multiple-choice questions with only 1 answer, and multiple-choice questions with several possible answers. To compare the regularity of disease occurrence, we designed the survey by using a large number of time indicators (eg, when were you first diagnosed with SLE and when were you first diagnosed with LN). The detailed contents of the survey are shown in
Ethics approval for this study was obtained from the ethics committee of the Third Affiliated Hospital of Sun Yat-sen University (reference [2021] 02-312-01) on October 19, 2021. All patients signed the informed consent before participating and answering the questions in this study. Information such as the objectives, methods, and expected outcomes from this study was presented in the consent form. The privacy and confidentiality protection description for the participants was provided in the consent form.
This survey was designed using a web-based questionnaire tool (WJX), and a quick response code was generated for distribution in hospitals in China. The survey was filled out by patients with SLE who scanned the quick response code under the guidance of the doctors at each visit. The study period was from June 2021 to December 2021, and data were collected from 105 hospitals and 27 provinces. The inclusion criteria were inpatients or outpatients who were diagnosed with SLE and who signed informed consent. Detailed information on the settings is shown in Table S1 of
To ensure the completeness and credibility of the survey, we made each question mandatory to answer. The key questions were asked in a way (eg, from the diagnosis of the disease to treatment, how many chronic diseases have you developed) such that they were verified by the questions in the subsequent sections (eg, the chronic disease(s) you have developed is/are). The survey had to be filled out in the presence of at least one research doctor. If a patient was not familiar with the way of using the tool or did not understand the way of answering in the relevant columns, the doctor would fill it out.
Health care–seeking behavior refers to the seeking of health care in the provincial capital cities and changing of hospitals during treatment (ie, patients sought health care in a hospital different from where they were primarily diagnosed and treated). Disease progression refers to disease flares and the development of AEs and chronic diseases. Disease flares refer to developing LN from non-LN and relapse in all patients with SLE. The Systemic Lupus Erythematosus Disease Activity Index was used to measure relapse in patients without LN if the score increased by at least 4. The reoccurrence of proteinuria or rapid increase of serum creatinine levels was considered as relapse for patients diagnosed with LN [
Knowledge of the disease was measured by familiarity with the treatment guidelines, which consisted of 3 categories: unfamiliar, less familiar, and familiar. Patients who had not heard of the treatment guidelines were considered unfamiliar. Patients who did not read the treatment guidelines but obtained limited diagnostic and treatment information from other sources were considered less familiar. Patients who read the treatment guidelines in detail and judged their own conditions and guided their medication based on the treatment guidelines were regarded to be familiar with the treatment guidelines. Attitudes toward the disease varied from diagnosis to treatment and were categorized into 4 types: fear throughout treatment (fear →fear), from fear to acceptance (fear →acceptance), from acceptance to fear (acceptance→fear), and acceptance throughout treatment (acceptance→acceptance).
Descriptive statistical methods were used to depict the demographic and clinical characteristics of patients with no LN and patients with LN. Proportions were calculated and presented in a graphical and tabular form. Progression of SLE, patients’ health behaviors that included self-discontinuation of patients who stopped the treatment prematurely, irregular treatment of patients who had irregular follow-up and medications, knowledge of the treatment guidelines, and attitudes toward the disease were depicted in a Sankey diagram. Multivariable-adjusted logistic regression models were used to explore the factors associated with the development of LN from non-LN, relapse, and changes in medication. An ordinal regression model was adopted to examine the factors associated with the knowledge of the treatment guidelines. One of the key assumptions of the ordinal regression model is the parallel regression assumption, which requires the coefficients in the cumulative binary logistic regression models to be consistent. The Brant test compares the separate fits to binary logistic regression models and hence was suitably used for assessing the parallel regression assumption for ordinal regression [
The data of 1509 patients were collected: 794 (52.62%) patients without LN and 715 (47.38%) patients with LN, with a mean age of 34.9 years and 34.6 years, respectively (
Characteristics of the patients with systemic lupus erythematosus (N=1509).
|
Patients with no LNa (n=794) | Patients with LN (n=715) | |||||
Age (years), mean (SD) | 34.9 (10.4) | 34.6 (10) | .63 | ||||
Age (years) at diagnosis, mean (SD) | 29.0 (10.6) | 28.4 (10) | .22 | ||||
|
.34 | ||||||
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Male | 46 (5.8) | 51 (7.1) |
|
|||
|
Female | 748 (94.2) | 664 (92.9) |
|
|||
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.19 | ||||||
|
Junior high school or lower | 262 (33) | 260 (36.4) |
|
|||
|
Senior high school | 191 (24.1) | 280 (25.2) |
|
|||
|
College or higher | 341 (42.9) | 275 (38.5) |
|
|||
|
.01 | ||||||
|
<3000 | 352 (44.3) | 372 (52) |
|
|||
|
3000-4999 | 294 (37) | 231 (32.3) |
|
|||
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≥5000 | 148 (18.7) | 112 (15.7) |
|
|||
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|||||||
|
Hydroxychloroquine | 682 (85.9) | 596 (83.4) | .20 | |||
|
Glucocorticoids | 622 (78.3) | 589 (82.4) | .06 | |||
|
<.001 | ||||||
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No | 568 (71.5) | 396 (55.4) |
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|||
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Yes | 226 (28.5) | 319 (44.6) |
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<.001 | ||||||
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None | 615 (77.5) | 464 (64.9) |
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Once | 121 (15.2) | 152 (21.3) |
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|||
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Twice | 39 (4.9) | 63 (8.8) |
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Three times or more | 19 (2.4) | 36 (5) |
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|
.60 | ||||||
|
No | 542 (68.3) | 478 (66.9) |
|
|||
|
Yes | 252 (31.7) | 237 (33.1) |
|
|||
|
.003 | ||||||
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No | 694 (87.4) | 589 (82.4) |
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|||
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One | 88 (11.1) | 98 (13.7) |
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|||
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Two or more | 12 (1.5) | 28 (3.9) |
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|||
|
<.001 | ||||||
|
No | 704 (88.7) | 576 (80.6) |
|
|||
|
One | 65 (8.2) | 94 (13.1) |
|
|||
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Two or more | 25 (3.1) | 45 (6.3) |
|
|||
|
.77 | ||||||
|
No | 419 (52.8) | 371 (51.9) |
|
|||
|
Yes | 375 (47.2) | 344 (48.1) |
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|||
|
<.001 | ||||||
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Unfamiliar | 432 (54.4) | 245 (34.3) |
|
|||
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Less familiar | 263 (33.1) | 327 (45.7) |
|
|||
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Familiar | 99 (12.5) | 143 (20) |
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|||
|
.03 | ||||||
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Fear→fear | 35 (4.4) | 33 (4.6) |
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|||
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Fear→acceptance | 485 (61.1) | 406 (56.8) |
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|||
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Acceptance→fear | 27 (3.4) | 47 (6.6) |
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Acceptance→acceptance | 247 (31.1) | 229 (32) |
|
aLN: lupus nephritis.
bCNY ¥1=US $0.15.
cSystemic Lupus Erythematosus Disease Activity Index ≥4 for patients without LN and reoccurrence of proteinuria in patients diagnosed with LN.
dSwitching therapy among immunosuppressive drugs and biological agents after the initial treatment due to various reasons such as pregnancy plan, drug effectiveness, or serious adverse events.
ePatients sought health care in a hospital different from where they were primarily diagnosed and treated.
fThe development of adverse events or chronic diseases during the treatment compared to that before patients were diagnosed with systemic lupus erythematosus.
gThe attitude of patients from diagnosis to treatment: fear throughout treatment (fear→fear), from fear to acceptance (fear→acceptance), from acceptance to fear (acceptance→fear), and acceptance throughout treatment (acceptance→acceptance).
Progression of systemic lupus erythematosus, health behaviors, patients' knowledge of, and attitudes toward the disease. CD: chronic disease; LN: lupus nephritis; SLE: systemic lupus erythematosus.
The distribution of the responses of patients with SLE and the proportions of patients seeking health care in hospitals in provincial capital cities determined by their registered permanent residence or workplaces are presented in
Distribution of the responses of patients with systemic lupus erythematosus in provinces and the health-seeking behaviors in patients from adjacent provinces when considering the registered permanent residences (A) or the workplaces (B), and the proportion of patients from different cities in provincial capital cities when considering the registered permanent residences (C) or the workplaces (D).
The most common medication used by patients without LN at the time of the study was mycophenolate mofetil (185/794, 23.3%), followed by methotrexate (150/794, 18.9%) and cyclosporine (98/794, 12.3%). These 3 types of immunosuppressive drugs were also the most commonly used in patients without LN at the time of diagnosis, with 19.9% (158/794) on mycophenolate mofetil, 17.9% (142/794) on methotrexate, and 10.1% (80/794) on cyclosporine, respectively (
Concerning the development of AEs and chronic diseases, femoral head necrosis (71/228, 31.1%), cataracts (63/228, 27.6%), and retinal macular degeneration (29/228, 12.7%) were the most common serious AEs that occurred during the treatment, while hypertension (99/229, 43.2%), dyslipidemia (45/229, 19.7%), and chronic gastritis (32/229, 14%) were the 3 common chronic diseases developed during the treatment (Table S2 and Table S3 of
Medication use in patients with systemic lupus erythematosus at diagnosis and treatment during the time of this study. CPFA: continuous plasma filtration absorption; LN: lupus nephritis; PE: plasma exchange.
Change of hospitals (odds ratio [OR] 1.90, 95% CI 1.24-2.90) and development of 1 chronic disease (OR 3.60, 95% CI 2.04-6.24) or 2 or more chronic diseases (OR 4.67, 95% CI 2.13-9.95) were associated with LN development (
Only patients with LN (OR 2.20, 95% CI 1.81-2.68) were associated with familiarity with the knowledge of the treatment guidelines (
Multivariable-adjusted logistic regression analysis of factors associated with disease flares and changes in medicationa.
|
LN developmentb (n=906), odds ratio (95% CI) | Relapsec (n=1448), odds ratio (95% CI) | Changes in medicationd (N=1509), odds ratio (95% CI) | ||||
Age | 0.98 (0.95-1.00) | 1.00 (0.99-1.01) | 1.02 (1.00-1.03)e | ||||
|
|||||||
|
Male | Reference | Reference | Reference | |||
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Female | 1.06 (0.47-2.79) | 1.00 (0.63-1.62) | 1.58 (0.95-2.72) | |||
|
|||||||
|
Junior high school or lower | Reference | Reference | Reference | |||
|
Senior high school | 1.41 (0.80-2.50) | 1.31 (0.97-1.81) | 1.33 (0.95-1.86) | |||
|
College or higher | 1.28 (0.73-2.27) | 1.16 (0.85-1.58) | 1.72 (1.24-2.39)e | |||
|
|||||||
|
<3000 | Reference | Reference | Reference | |||
|
3000-4999 | 0.71 (0.43-1.15) | 0.92 (0.70-1.20) | 1.18 (0.89-1.57) | |||
|
≥5000 | 0.60 (0.30-1.14) | 0.75 (0.52-1.08) | 1.03 (0.71-1.50) | |||
|
|||||||
|
No | Reference | Reference | Reference | |||
|
Yes | 1.90 (1.24-2.90)e | 2.23 (1.75-2.84)e | 1.95 (1.52-2.50)e | |||
|
|||||||
|
No | Reference | Reference | Reference | |||
|
One | 1.73 (0.98-2.97) | 2.06 (1.46-2.92)e | 2.86 (2.04-4.02)e | |||
|
Two or more | 2.13 (0.73-5.87) | 4.29 (1.77-12.06)e | 4.50 (2.19-9.83)e | |||
|
|||||||
|
None | Reference | Reference | Reference | |||
|
One | 3.60 (2.04-6.24)e | 3.43 (2.34-5.09)e | 1.90 (1.31-2.75)e | |||
|
Two or more | 4.67 (2.13-9.95)e | 2.70 (1.51-4.92)e | 2.61 (1.50-4.59)e | |||
|
|||||||
|
No | Reference | Reference | Reference | |||
|
Yes | 0.87 (0.52-1.45) | 1.01 (0.76-1.34) | 1.58 (1.18-2.13)e | |||
|
|||||||
|
Non–lupus nephritis | N/Ai | Reference | Reference | |||
|
Lupus nephritis | N/A | 2.03 (1.61-2.56)e | 1.78 (1.40-2.27)e |
aAll factors were mutually adjusted.
bLN: lupus nephritis. The development from non–lupus nephritis to lupus nephritis and the numbers in the analysis included patients with non–lupus nephritis and lupus nephritis in the later stage, excluding patients diagnosed with lupus nephritis.
cSystemic Lupus Erythematosus Disease Activity Index ≥4 for patients without lupus nephritis and reoccurrence of proteinuria in patients diagnosed with lupus nephritis. Patients who received treatment without achieving remission were excluded from the analysis.
dSwitching therapy among immunosuppressive drugs and biological agents after the initial treatment due to various reasons such as pregnancy plan, drug effectiveness, or serious adverse events.
eSignificant estimates (95% CI).
fCNY ¥1=US $0.15.
gPatients sought health care in a hospital different from where they were primarily diagnosed and treated.
hThe development of adverse events or chronic diseases during treatment compared to before patients were diagnosed with systemic lupus erythematosus.
iNot applicable.
Ordinal logistic regression analysis of factors associated with knowledge of the treatment guidelines and logistic regression of factors associated with the attitude toward the diseasea.
|
Knowledge of the treatment guidelines | Attitudes toward the diseaseb | ||
|
Familiar or less familiar versus unfamiliar (N=1509), odds ratio (95% CI) | Fear→acceptance versus fear→fear (n=959), odds ratio (95% CI) | Acceptance→fear versus acceptance→acceptance (n=550), odds ratio (95% CI) | |
Age | 0.99 (0.98-1.00) | 1.02 (0.99-1.05) | 0.96 (0.93-0.99)c | |
|
||||
|
Male | Reference | Reference | Reference |
|
Female | 1.33 (0.89-1.99) | 0.53 (0.08-1.82) | 2.27 (0.76-9.80) |
|
||||
|
Junior high school or lower | Reference | Reference | Reference |
|
Senior high school | 1.08 (0.83-1.31) | 2.06 (1.05-4.23)c | 0.63 (0.31-1.22) |
|
College or higher | 1.04 (0.80-1.34) | 2.09 (1.10-4.04)c | 0.71 (0.35-1.40) |
|
||||
|
<3000 | Reference | Reference | Reference |
|
3000-4999 | 1.19 (0.95-1.50) | 1.43 (0.80-2.63) | 0.75 (0.40-1.36) |
|
≥5000 | 1.28 (0.94-1.73) | 2.23 (0.90-6.37) | 0.75 (0.28-1.80) |
|
||||
|
No | Reference | Reference | Reference |
|
Yes | 0.92 (0.74-1.13) | 1.15 (0.68-2.00) | 0.99 (0.53-1.76) |
|
||||
|
No | Reference | Reference | Reference |
|
One | 0.83 (0.61-1.12) | 0.93 (0.45-2.13) | 2.73 (1.36-5.35)c |
|
Two or more | 0.80 (0.42-1.52) | 0.37 (0.13-1.26) | 0.94 (0.05-5.93) |
|
||||
|
None | Reference | Reference | Reference |
|
One | 0.95 (0.69-1.32) | 0.66 (0.32-1.44) | 1.10 (0.45-2.44) |
|
Two or more | 1.25 (0.77-2.02) | 0.77 (0.25-2.96) | 1.92 (0.58-5.48) |
|
||||
|
No | Reference | Reference | Reference |
|
Yes | 0.79 (0.63-1.00) | 1.21 (0.65-2.27) | 1.76 (0.95-3.28) |
|
||||
|
Non-LNg | Reference | Reference | Reference |
|
LN | 2.20 (1.81-2.68)c | 1.07 (0.64-1.80) | 1.86 (1.11-3.16)c |
aAll factors were mutually adjusted.
bAttitudes of patients from diagnosis to treatment: fear throughout treatment (fear→fear), from fear to acceptance (fear→acceptance), from acceptance to fear (acceptance→fear), and acceptance throughout treatment (acceptance→acceptance).
cSignificant estimates (95% CI).
dCNY ¥1=US $0.15.
ePatients sought health care in a hospital different from where they were primarily diagnosed and treated.
fThe development of adverse events or chronic diseases during the treatment compared to that before patients were diagnosed with systemic lupus erythematosus.
gLN: lupus nephritis.
A noteworthy finding in our study is that 55.6% (473/850) of the patients with SLE who sought health care in the provincial capital cities migrated from other cities in the same province when considering their registered permanent residences. When considering the workplace, hospitals in provincial capital cities also lured 42.9% (421/981) of the patients with SLE from the same provinces to seek health care even if the workplaces of these patients were not located in the capital city. In addition, compared with general provincial capitals, high-income provincial capitals also attracted patients from adjacent provinces such as Guangzhou and Xi’an. This can be partly explained by the push-pull theory, as the provincial capital city has more resources in the province, including more hospital options, more medical experts, and better medical technology, which could be considered as the social factors for patients to achieve better quality of life [
Factors associated with relapse in patients with SLE have been reported in many studies, including the increased anti-double-stranded deoxyribonucleic acid, B lymphocyte stimulator, renal organ involvement, deficiency of hydroxychloroquine, premature discontinuation, and poor compliance [
A novel finding in our study is that switching from the first hospital where patients were primarily diagnosed and treated was associated with their risk of development of LN and relapse and was significantly associated with changes in their medications. This finding implies that the hospital that the patient first visited may have provided improper treatment. Requesting more meticulous care and treatment for patients with a record of switching hospitals from other cities, especially in the provincial capital cities, is imperative because the major public hospitals have a large number of patients from other cities, with outpatient visits and hospitalizations increasing. A study in 1 hospital in Kunming city, a provincial city in the Yunnan province, showed that outpatient visits and hospitalizations increased from 188,530 and 6620 in 2001 to 369,510 and 12,380 in 2010, respectively [
Apart from factors such as older age, higher education, development of at least 1 AE and chronic disease, change of hospitals, and LN development that were associated with changes in medication, nearly half of the patients with SLE had a pregnancy plan, which was also a significant factor (OR 1.58, 95% CI 1.18-2.13). It has been confirmed that using CYC leads to ovarian failure [
The familiarity with treatment guidelines reflects a patient’s knowledge of the disease to a certain extent [
Patients’ attitudes toward SLE, on the whole, reflected acceptance, with approximately 90.58% (1367/1509) of the patients expressing a positive attitude during the treatment period, although nearly half of the patients felt fear at the time of diagnosis. An important factor was patients with LN who had a higher risk of developing a fearful attitude at diagnosis than patients without LN. One way to improve the patient’s attitude is by providing health education. Studies have indicated that good education is associated with higher knowledge of diseases and increased self-awareness of one’s health and assessment of health care [
Our findings have some limitations and must be interpreted with caution. First, although we set the time points for collecting variables, the chronological order of the factors and the outcomes might not be explicit. For example, we dynamically described a change in the development of chronic diseases before and after the diagnosis of SLE. However, whether its increase occurs before or after the development of LN or relapse has not been elucidated. This limitation is because, on the one hand, the study design was cross-sectional. On the other hand, even in the existing medical database, the corresponding time point is relatively vague; therefore, reverse causality or simultaneity may appear. Second, a more detailed measurement of health emotions may improve health decision-making [
In our study, a large proportion of patients seeking health care in provincial capital cities migrated from other cities in the same province and the adjacent provinces. Mycophenolate mofetil was the most commonly used immunosuppressive drug in the treatment of patients without LN and patients with LN at the time of this study. Femoral head necrosis was the most common AE, followed by cataract and retinal macular degeneration, while hypertension, dyslipidemia, and chronic gastritis were the 3 common chronic diseases developed during the treatment. Change of the hospital where patients were primarily diagnosed and treated and the development of AEs and chronic diseases were associated with disease flares and changes in medication. A pregnancy plan was also associated with changes in medication. Patients had insufficient knowledge about the treatment guidelines, and patients without LN tended to be less familiar with the treatment guidelines compared to patients with LN. Patients with SLE who had college education or higher were associated with a positive attitude rather than those who had only a junior high school education or lower. Our findings suggest that disease flares should be controlled by monitoring potential AEs and chronic diseases during treatment and by effectively managing patients who switched hospitals for their medical consultation. In addition, patients would benefit from health education to maintain a positive attitude toward SLE.
Survey used in this study.
Supplementary Tables 1-5. Table S1 shows the settings of patients with systemic lupus erythematosus from registered permanent residences or workplaces in mainland China. Table S2 and Table S3 present the number of adverse events and chronic diseases developed in patients with systemic lupus erythematosus during the treatment, respectively. Brant test for each parameter regarding the parallel regression assumption in an ordinal logistic regression model is reflected in Table S4, and Table S5 is the use of medications in patients with systemic lupus erythematosus regarding the pregnancy plan at the time of the study.
adverse event
cyclophosphamide
lupus nephritis
odds ratio
systemic lupus erythematosus
We thank all the doctors and patients who participated in our study. This work was supported by the Ten and Five Project of the Third Affiliated Hospital of Sun Yat-sen University (grant SW201901) and the Distinguished Young Scholar Candidates Program of the Third Affiliated Hospital of Sun Yat-sen University (grant A2675).
The data are not publicly available due to the potential violation that may compromise the privacy of the research participants. However, data may be available upon proper request from the corresponding author.
ZD contributed to the study design, data analysis, and manuscript drafting. EHYL contributed to the study design, data interpretation, manuscript revision, revision, and approval. ZL contributed to study design, manuscript revision, and approval. The other authors were responsible for data collection and interpretation. All authors critically approved the final manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The surveys of 7 older patients (age range 67-86 years) among the 1509 participants were filled out by their doctors because these patients could not operate the digital survey or understand the questions. The surveys were answered by doctors in the presence of these patients who also confirmed the responses. There was no conflict of interest for the doctors who assisted the 7 older patients.