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

Francesca Tirelli,Joyce C Chang,Jon M Burnham,Rui Xiao,Timothy G Brandon,Pamela F Weiss

doi:10.1186/s12969-020-00472-3

Abstract

BackgroundWe 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).MethodsThis 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.ResultsOne 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.ConclusionsThere 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.

Highlights

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 enthesitisrelated arthritis (ERA)
Therapeutic strategies for ERA are largely based on knowledge from adult spondyloarthritis, and variability in treatment approach has been described among pediatric rheumatologists [4, 6]
A recent study conducted at our center demonstrated that the implementation of a TTT strategy with standardized outcome monitoring augmented by clinical decision support treatment algorithms determined a significant improvement in disease activity and patient reported outcomes for children with polyarticular Juvenile idiopathic arthritis (JIA) [13]

Summary

Introduction

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 enthesitisrelated arthritis (ERA). In the CAMERA trial [12], a CDS system was used to adjust methotrexate dosages in patients with early rheumatoid arthritis in a TTT intervention; this strategy had greater clinical efficacy compared to standard of care. A recent study conducted at our center demonstrated that the implementation of a TTT strategy with standardized outcome monitoring augmented by clinical decision support treatment algorithms determined a significant improvement in disease activity and patient reported outcomes for children with polyarticular JIA [13]

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