Implementation Science in Pediatric Rheumatology: A Path to Health Equity

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities

BACKGROUND

Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities.

METHODS

A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated.

RESULTS

Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation.

CONCLUSIONS

This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Health disparities in outcomes of pediatric systemic lupus erythematosus

Healthcare disparities exist throughout the United States, and disparities in healthcare delivery are responsible for a substantial portion of preventable morbidity and mortality. SLE disproportionately affects racial and ethnic minoritized groups, including Blacks, Hispanics, and Asians/Pacific Islanders. Specifically, Black females have a 3 to 4-fold increased risk of developing SLE than White females. Population studies funded through the Centers for Disease Control have examined variations in disease outcomes among the different populations around the United States. For example, studies have shown that lupus nephritis, anti-phospholipid syndrome, and thrombocytopenia are more likely to affect racial and ethnic minorities than Whites. In addition, the Center for Disease Control WONDER (Wide-ranging Online Data for Epidemiologic Research) database found SLE was the seventh leading cause of death for all women aged 15-25 years and the fifth leading cause of death for African American and Hispanic females. From these studies, we know SLE primarily affects racial and ethnic minorities, but we do not know why these groups are at increased risk of developing the disease or have worse outcomes. By examining the underlying mechanisms of health disparities within our patient populations and mitigation strategies, we will further understand and provide better treatment for our patients. This review will discuss current research related to health disparities and health outcomes in childhood-onset SLE (cSLE).