多关节型幼年特发性关节炎的结局监测和临床决策支持。
Outcome Monitoring and Clinical Decision Support in Polyarticular Juvenile Idiopathic Arthritis.
机构信息
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.
出版信息
J Rheumatol. 2020 Feb;47(2):273-281. doi: 10.3899/jrheum.190268. Epub 2019 Jul 15.
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.
目的
不一致的评估和治疗可能会影响幼年特发性关节炎（JIA）的结果。我们旨在通过标准化即时护理疾病活动监测并实施临床决策支持（CDS）来改善多关节炎 JIA（类风湿因子阳性和阴性）的结果，以减少治疗差异。
方法
我们在一家门诊儿科风湿病诊所进行了一项质量改进计划。干预措施于 2016 年 4 月至 11 月实施，包括标准化疾病活动测量、疾病活动目标审查以及逐步引入多关节炎 JIA CDS 以指导药物选择、剂量、治疗持续时间和逐渐减少。过程措施包括访视水平目标证明（目标：50%）和 CDS 使用（目标：15%）。我们的目标是使多关节炎 JIA 的临床幼年关节炎疾病活动评分（cJADAS-10）至少降低 10%。纳入的患者在 2016 年 4 月至 2017 年 7 月期间至少有 2 次就诊，分为早期（≤6 个月）或已建立疾病（>6 个月）。
结果
共观察了 97 例多关节炎 JIA 患者（81%为已建立疾病），观察期为 10.3 个月（四分位间距：6.4-12.3）。目标证明和 CDS 使用分别在多关节炎 JIA 就诊的平均 77%和 45%的情况下发生。早期（16.5 至 2.7，p <0.001）和已建立的多关节炎 JIA（2.1 至 1.0，p = 0.01）中 cJADAS-10 的中位数均显著降低。大多数早期疾病患者接受了生物治疗（73.7%）。在已建立的疾病中，尽管非生物和生物疾病修饰抗风湿药物的处方总体上相似，但阿达木单抗的处方增加（12.8%至 23.1%，p = 0.008）。
结论
在多关节炎 JIA 中实施结构化疾病活动监测和 CDS 与早期和已建立的疾病中疾病活动评分的显著降低相关。
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