Determinants of disease activity change over time in Enthesitis related arthritis: effect of structured outcome monitoring and clinical decision support.

TitleDeterminants of disease activity change over time in Enthesitis related arthritis: effect of structured outcome monitoring and clinical decision support.
Publication TypeJournal Article
Year of Publication2020
AuthorsTirelli F, Xiao R, Brandon TG, Burnham JM, Chang JC, Weiss PF
JournalPediatr Rheumatol Online J
Date Published2020 Oct 15
KeywordsAdolescent, Algorithms, Antirheumatic Agents, Arthritis, Juvenile, Child, Decision Support Systems, Clinical, Female, Glucocorticoids, Historically Controlled Study, Humans, Injections, Intra-Articular, Male, Methotrexate, Outcome Assessment, Health Care, Patient Care Planning, Quality Improvement, Retrospective Studies, Severity of Illness Index, Tumor Necrosis Factor Inhibitors

BACKGROUND: We aimed to test if standardized point-of-care outcome monitoring and clinical decision support (CDS), as compared to standard care, improves disease activity and patient-reported pain in children with enthesitis-related arthritis (ERA).

METHODS: This was a retrospective cohort study of outcomes of children with ERA after phased implementation of I) standardized outcome monitoring with CDS for polyarticular JIA, and II) CDS for ERA, compared to a pre-intervention group of historical controls. We used multivariable mixed-effects models for repeated measures to test whether implementation phase or other disease characteristics were associated with change over time in disease activity, as measured by the clinical juvenile arthritis disease activity score (cJADAS), and pain.

RESULTS: One hundred fifty-two ERA patients (41% incident cases) were included with a median age of 14.9 years. Implementation of standardized outcome monitoring or ERA-specific CDS did not result in significant differences in cJADAS or pain over time compared to the pre-intervention cohort. Higher cJADAS at the index visit, pain and more tender entheses were significantly associated with higher cJADAS scores over time (all p < 0.01), while biologic use was associated with lower cJADAS (p = 0.02). Regardless of intervention period, incident ERA cases had a greater rate of cJADAS improvement over time compared to prevalent cases (p < 0.01), but pain persisted over time among both incident and prevalent cases.

CONCLUSIONS: There was no significant effect of point-of-care outcome monitoring or CDS interventions on disease activity or pain over time in children with ERA in this single center study. Future efforts to improve disease outcomes using standardized outcome monitoring and CDS will need to consider the importance of addressing pain as a target in addition to spondyloarthritis-specific disease activity metrics.

Alternate JournalPediatr Rheumatol Online J
PubMed ID33059694
PubMed Central IDPMC7558695