Designing and Testing Treat to Target as a New Care Model in JIA Across a Network of Pediatric Rheumatology Centers

Esi Morgan¹, Janalee Taylor ², Tingting Qiu ³, Nancy Griffin ², Anne Paul ², Catherine Bingham ⁴, Danielle Bullock ⁵, Kerry Ferraro ⁶, Y Goh ⁷, Mileka Gilbert ⁸, Olha Halyabar ⁹, Karla Jones ¹⁰, Melanie Kohlheim ¹¹, Daniel J. Lovell ¹², Darby MacDonald ¹⁰, Emily Smitherman ¹³, Anjie Vago ¹⁴, Jennifer Weiss ¹⁵, Cagri Yildirim-Toruner ¹⁰, Angela Young ¹⁶, Michelle Batthish ¹⁷, Beth Gottlieb ¹⁸, Julia Harris ¹⁹, Melissa Hazen ²⁰, Ronald Laxer ⁷, Tzielan Lee ²¹, Melissa Mannion ²², Judyann Olson ²³, MIchael Shishov ²⁴, Sheetal Vora ²⁵ and Jonathan Burnham ²⁶, ¹Cincinnati Children’s Hospital, University of Cincinnati, Cinncinati, OH, ²Cincinnati Children's Hospital, Cincinnati, OH, ³Cincinnati Children's Hospital Medical Center, Cincinnati, OH, ⁴Penn State Hershey Children's, Hershey, ⁵University of Minnesota, Minneapolis, MN, ⁶PR-CON Parent Working Group, Fort Washington, PA, ⁷Hospital for Sick Children, Toronto, ON, Canada, ⁸Medical Univeristy of South Carolina, Charleston, SC, ⁹Boston Children's Hospital, Boston, ¹⁰Nationwide Children's Hospital, Columbus, OH, ¹¹PR-COIN Parent Working Group, Columbus, OH, ¹²Pediatric Rheumatology Collaborative Study Group (PRCSG), Cincinnati Children’s Hospital Medical Center, Cincinnati, ¹³University of Alabama at Birmingham, Birmingham, AL, ¹⁴PR-COIN Parent Working Group, Hershey, PA, ¹⁵Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, NJ, ¹⁶PR-COIN Parent Working Group, Lexington, KY, ¹⁷McMaster University, Hamilton, Canada, ¹⁸Cohen Children's Hospital, New Hyde Park, NY, ¹⁹Children's Mercy Hospital, Kansas City, MO, ²⁰Boston Children's Hospital, Boston, MA, ²¹Stanford University School of Medicine, Palo Alto, ²²Children's of Alabama, Birmingham, ²³Medical College of WIsconsin, Milwaukee, WI, ²⁴Phoenix Children's, Phoenix, AZ, ²⁵Levine Children's, Charlotte, NC, ²⁶The Children's Hospital of Philadelphia, Philadelphia, PA

Meeting: 2019 ACR/ARP Annual Meeting

Keywords: doctor-patient relationship and A3 Adenosine receptor, juvenile idiopathic arthritis (JIA), quality improvement, treat to target

Session Information

Date: Sunday, November 10, 2019

Title: Health Services Research Poster I – ACR/ARP

Session Type: Poster Session (Sunday)

Session Time: 9:00AM-11:00AM

Background/Purpose: In 2018 an international task force published a recommended Treat to Target (T2T) approach to juvenile idiopathic arthritis (JIA) treatment. In February 2019, 17 centers participating in the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) began a collaborative improvement project using quality improvement (QI) methods to test and implement T2T interventions. Based upon published literature and one center pilot experience, PR-COIN designed an approach to introduce interventions to support successful and reliable deployment of three T2T component processes: standardized disease activity assessment, setting a treatment target with patient/family, and use of polyarticular JIA (Poly-JIA) clinical decision support (CDS). Our objective is to implement T2T with high reliability in 80% of PR-COIN centers by October 2019.

Methods: With patient/family partners, PR-COIN co-produced educational materials to train providers on implementation of T2T and to introduce families to the concept. The network adapted an evidence and consensus-based treatment algorithm, and designed a step-by-step implementation plan to support local implementation with a data submission platform to evaluate the interventions. Interactive monthly webinars feature best practices and performance reports, and QI/T2T process coaching. The interventions are being implemented in three steps: 1) standardized assessment and review of components of the clinical juvenile arthritis disease activity score (cJADAS10), including the physician global assessment, active joint count, patient assessment, 2) use shared decision making (SDM) concepts to select treatment target with the family and compare it to current disease activity and 3) use of CDS. Sites progress to the next step once reliable process implementation ( >80%) is demonstrated in a representative sample of patients with Poly-JIA.

Results: As of April 2019, 16 centers are participating. All centers completed on-site training, 9/16 (56%) submitted at least one QI tool, and 11/16 (69%) eligible centers submitted performance data. A sample of patient-level data indicate 157/279 (56%) of patients are receiving Step 1 activities (Figure 1). Four of the sixteen centers (25%) are performing Step 1 activities with high reliability and have progressed to Step 2, with 4 / 35 (13%) of sampled patients engaged in SDM to set treatment targets (Figure 2). Figures show aggregate data alongside an example single center performance. Centers are demonstrating progressive improvement over time towards the reliability criteria to full implementation of T2T and performance goals.

Conclusion: Introduction of novel interventions required for fidelity of T2T implementation in pediatric rheumatology clinical practice requires a tiered approach with demonstrated commitment from trained providers, buy-in from leadership, and an identified QI lead. Co-producing support materials with families, infrastructure to support QI, and reliable data submission are key to success. We predict that center-level cJADAS10 improvement will correlate with reliability of the implementation of interventions.

Figure 1 PR-COIN T2T Abstract

Figure 1. Network Aggregate and One Example Center’s Progress on Step 1

Figure 2 PR-COIN T2T Abstract

Figure 2. Network Aggregate and One Example Center’s Progress on Step 2

Disclosure: E. Morgan, None; J. Taylor, None; T. Qiu, None; N. Griffin, None; A. Paul, None; C. Bingham, None; D. Bullock, None; K. Ferraro, None; Y. Goh, None; M. Gilbert, None; O. Halyabar, None; K. Jones, None; M. Kohlheim, None; D. Lovell, Abbott, 5, 9, AbbVie, 5, 9, Amgen, 5, 9, AstraZeneca, 5, Astra-Zeneca Pharm, 5, Biogen, 5, Boehringer Ingelheim, 5, Boeringher Ingelheim, 5, Bristol-Myers Squibb, 5, 9, Celgene, 5, Forest Research, 9, Forest Research Institute, 5, Genentech, 5, 8, GlaxoSmithKline, 5, Hoffmann-La Roche, 5, 9, Horizon, 5, Jannsen, 5, Janssen, 5, 9, Johnson & Johnson, 5, Novartis, 5, 9, Pfizer, 5, 9, Roche, 5, 9, Takeda, 5, 9, UBC, 5, Wyeth Pharm, 5, 8; D. MacDonald, None; E. Smitherman, None; A. Vago, None; J. Weiss, None; C. Yildirim-Toruner, None; A. Young, None; M. Batthish, None; B. Gottlieb, None; J. Harris, None; M. Hazen, None; R. Laxer, None; T. Lee, None; M. Mannion, None; J. Olson, None; M. Shishov, None; S. Vora, None; J. Burnham, None.

To cite this abstract in AMA style:

Morgan E, Taylor J, Qiu T, Griffin N, Paul A, Bingham C, Bullock D, Ferraro K, Goh Y, Gilbert M, Halyabar O, Jones K, Kohlheim M, Lovell D, MacDonald D, Smitherman E, Vago A, Weiss J, Yildirim-Toruner C, Young A, Batthish M, Gottlieb B, Harris J, Hazen M, Laxer R, Lee T, Mannion M, Olson J, Shishov M, Vora S, Burnham J. Designing and Testing Treat to Target as a New Care Model in JIA Across a Network of Pediatric Rheumatology Centers [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/designing-and-testing-treat-to-target-as-a-new-care-model-in-jia-across-a-network-of-pediatric-rheumatology-centers/. Accessed .

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