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Buckley L, Ware E, Kreher G, Wiater L, Mehta J, Burnham JM. Outcome Monitoring and Clinical Decision Support in Polyarticular Juvenile Idiopathic Arthritis. J Rheumatol 2019; 47:273-281. [PMID: 31308202 DOI: 10.3899/jrheum.190268] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Inconsistent assessment and treatment may impair juvenile idiopathic arthritis (JIA) outcomes. We aimed to improve polyarticular JIA (rheumatoid factor-positive and -negative) outcomes by standardizing point-of-care disease activity monitoring and implementing clinical decision support (CDS) to reduce treatment variation. METHODS We performed a quality improvement initiative in an outpatient pediatric rheumatology practice. The interventions, implemented from April to November 2016, included standardized disease activity measurement, disease activity target review, and phased introduction of polyarticular JIA CDS to guide medication selection, dosing, treatment duration, and tapering. Process measures included visit-level target attestation (goal: 50%) and CDS use (goal: 15%). Our goal was to reduce the polyarticular JIA clinical Juvenile Arthritis Disease Activity Score (cJADAS-10) by at least 10%. Included patients had at least 2 visits from April 2016 through July 2017, and were classified as having early (≤ 6 mos) or established disease (> 6 mos). RESULTS Patients with polyarticular JIA (n = 97; 81% established disease) were observed for 10.3 months (interquartile range: 6.4-12.3). Target attestation and CDS use occurred in a mean of 77% and 45% of polyarticular JIA visits, respectively. The median cJADAS-10 decreased significantly in both early (16.5 to 2.7, p < 0.001) and established polyarticular JIA (2.1 to 1.0, p = 0.01). A high proportion of patients with early disease received biologic therapy (73.7%). In established disease, although prescription of nonbiologic and biologic disease-modifying antirheumatic drugs remained similar overall, adalimumab prescribing increased (12.8% to 23.1%, p = 0.008). CONCLUSION Implementation of structured disease activity monitoring and CDS in polyarticular JIA was associated with significant reductions in disease activity scores in both early and established disease.
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Affiliation(s)
- Lisa Buckley
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Eileen Ware
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Genna Kreher
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Lisa Wiater
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Jay Mehta
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Jon M Burnham
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. .,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia.
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