Racial Differences in Patient-provider Communication, Patient Self-efficacy, and Their Associations With Systemic Lupus Erythematosus-related Damage: A Cross-sectional Survey.



Despite significant racial disparities in systemic lupus erythematosus (SLE) outcomes, few studies have examined how disparities may be perpetuated in clinical encounters. We aimed to explore associations between areas of clinical encounters - patient-provider communication and patient self-efficacy - with SLE-related damage, in order to identify potential areas for intervention to reduce SLE outcome disparities.


We collected cross-sectional data from a tertiary SLE clinic including patient-provider communication, general self-efficacy, self-efficacy for managing medications and treatments, patient-reported health status, and clinical information. We compared racial groups and used logistic regression to assess race-stratified association of patient-provider communication and patient self-efficacy with having SLE-related damage.


Among 121 patients (37% White, 63% African American), African Americans were younger, more likely to be on Medicaid, and less likely to be college educated, married, or living with a partner or spouse. African Americans reported less fatigue and better social function, took more complex SLE medication regimens, had lower fibromyalgia (FM) scores, and had higher SLE disease activity and SLE-related damage scores. African Americans reported similar self-efficacy compared to White patients, but they reported more hurried communication with providers, which was reflected in their perception that providers used words that were difficult to understand. Perceiving providers use difficult words and lower general self-efficacy were associated with having SLE-related damage among African American but not White patients.


African Americans had more severe SLE and perceived more hurried communication with providers. Both worse communication and lower self-efficacy were associated with having SLE-related damage among African American but not White patients, suggesting that these factors should be investigated as potential interventions to reduce SLE racial disparities.





Published Version (Please cite this version)


Publication Info

Sun, Kai, Amanda M Eudy, Lisa G Criscione-Schreiber, Rebecca E Sadun, Jennifer L Rogers, Jayanth Doss, Amy L Corneli, Hayden B Bosworth, et al. (2021). Racial Differences in Patient-provider Communication, Patient Self-efficacy, and Their Associations With Systemic Lupus Erythematosus-related Damage: A Cross-sectional Survey. The Journal of rheumatology, 48(7). pp. 1022–1028. 10.3899/jrheum.200682 Retrieved from https://hdl.handle.net/10161/28697.

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Kai Sun

Assistant Professor of Medicine

My clinical interests are in general rheumatology, lupus, and musculoskeletal ultrasound. My research interest is in healthcare disparities and medication adherence in rheumatology.


Amanda Marie Eudy

Assistant Professor in Medicine

Lisa Giorgina Criscione-Schreiber

Professor of Medicine

My clinical interests include systemic lupus erythematosus (SLE) and inflammatory myopathies, specifically dermatomyositis, polymyositis, and the anti-synthetase syndrome.  Additionally, I maintain a general rheumatology continuity clinic for individuals with rheumatoid arthritis, vasculitis, and other forms of inflammatory arthritis and autoimmune diseases.  In 2007, I co-founded the Duke Lupus Clinic with Dr. Megan Clowse.  We have continued this clinic with the aim to improve the health and quality of life for individuals living with lupus. 

My primary research interests are in education and in SLE.  My particular interest within education is learner assessment.  I was previously funded by a Clinician Scholar Educator Award through the Rheumatology Research Foundation of the American College of Rheumatology.  My CSE project explored validation of a rheumatology objective structured clinical examination (ROSCE).  I previously participated on the ACR/NBME rheumatology in-training examination working group for 3 years.  I work closely with my Rheumatology Program Director collaborators at UNC Chapel Hill, Wake Forest University and the Medical University of South Carolina through our Carolinas Fellows Collaborative. Members of this group composed the competency-based goals and objectives (CBGO) for all learning activities of rheumatology fellowship training programs, which were adopted by the American College of Rheumatology and are posted on their website. I currently Chair the ACR Curriculum Subcommittee of the Committee on Training and Workforce.                                 

My research in lupus has included the Duke Lupus Registry population.  Our recent work focuses on creating and defining the type 1 and type 2 lupus paradigms for classifying lupus disease activity.  Additional interests through the Duke Lupus Clinic include elucidating clinician-level factors that can influence medication adherence as well as determining how health literacy and numeracy impact adherence and patient level outcomes.  Additionally, I have collaborated closely with Dr. Megan Clowse, who studies reproductive health in women with autoimmune diseases, for many years.  We have combined her subject matter expertise with my educational skills to create HOP-STEP, a program to teach patients with lupus and their rheumatologists about pregnancy planning to improve health outcomes.  We have created lupuspregnancy.org, which houses many resources and videos designed to teach rheumatologists to better partner with women with lupus to have open and honest discussions about pregnancy planning.  Our ultimate aim is to improve the health outcomes for women with lupus and their offspring. 


Rebecca Eli Sadun

Assistant Professor of Medicine

I am an adult and pediatric rheumatologist with clinical and research interests in the areas of lupus and transition to adult care.  My time is split between the departments of Medicine and Pediatrics.  In addition to seeing patients in both environments, I run a dedicated Young Adult Rheumatology Clinic in collaboration with Duke Family Medicine.


Hayden Barry Bosworth

Professor in Population Health Sciences

Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)  at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities. 

Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.

Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy


Megan Elizabeth Bowles Clowse

Associate Professor of Medicine

Dr. Megan Clowse is an Associate Professor of Medicine in the Division of Rheumatology and Immunology.  Her clinical research focuses on the management of rheumatic diseases in pregnancy. She has cared for over 600 pregnancies in women with rheumatic disease, collecting information on these pregnancies initially in the Duke Autoimmunity in Pregnancy Registry and Repository, and now the MADRA (Maternal Autoimmune Disease Research Alliance) registry and repository.  She served on the Core Leadership Team for the inaugural American College of Rheumatology's Reproductive Health Guidelines, published January 2020.  Dr. Clowse created www.LupusPregnancy.org, a website dedicated to improving lupus pregnancy planning and management for patients and rheumatologists.  

Dr. Clowse was the founding director of the Duke Lupus Clinic, where she continues to see patients each week and mentor junior faculty researchers.  The team has developed a new approach to lupus classification and management and is currently collecting and analyzing patient- and physician-reported measures to  better clarify this construct.  

As the Co-Director of Duke Forge, Dr. Clowse has shepherding multiple Department of Medicine-funded studies to identify and build innovative approaches to using health data to improve patient care. 

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