Background/Purpose:  Rheumatologic diseases affect 300,000 children in the United States and are associated with significant morbidity.^1,2  Due to a national shortage of pediatric rheumatologists (PR),² an estimated half of US children with rheumatologic disease are being cared for by adult rheumatologists (AR).^2,3 However, many AR report being uncomfortable caring for children and do not perceive themselves as up to date.⁴  How variations in treatment relate to subspecialty, fellowship training, and information resources are not known.

Methods:  Two parallel, cross sectional mail surveys with a focus on juvenile idiopathic arthritis (JIA) were administered to a random sample of 193 PR and 500 AR using the American College of Rheumatology membership file. Bivariate analysis was conducted for items common to both surveys.  

Results: The response rate was 62.1% for AR (N=306) and 72.3% for PR (N=138).   Only 23% of responding AR (N=69) reported caring for children with JIA. Of these, 94% strongly agreed/agreed that they are comfortable diagnosing JIA; however, only 76% report being comfortable treating JIA. Clinical vignettes highlighted several prescribing differences (Table 1).  Forty-eight percent of AR, and 31% of PR, felt medications to treat JIA did not have clear dosing guidelines. Though PR initiated DMARDs and biologics earlier, after three months the selected treatments for JIA were quite similar. Co-management of JIA patients by adult and pediatric rheumatologists is infrequent and its acceptance seems limited.  

Conclusion: Nearly a quarter of surveyed adult rheumatologists care for children with JIA, with most limiting their practice to older children. There was more discomfort in treating JIA than diagnosing it, and there were significant prescribing differences.  Both adult and pediatric providers reported a lack of adequate dosing/treatment resources.  Easily accessible and up-to-date treatment and dosing guidelines, as well as exposure to pediatric rheumatology in fellowship, would further enhance the care of children with JIA and facilitate collaboration between adult and pediatric providers.   1.  Sacks JJ. Helmick CG. Luo YH. Ilowite NT. Bowyer S. Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001-2004. Arthritis Rheum. 2007; 57(8): 1439-1445. 2. Duke EM. Report to Congress. The Pediatric Rheumatology Workforce: A Study of the Supply and Demand for Pediatric Rheumatologists. http://bhpr.hrsa.gov/healthworkforce/reports/ped_rheumatology/ 3. Mayer ML, Sandborg CI and Mellins ED. Role of pediatric and internist rheumatologists in treating children with rheumatic diseases. Pediatrics 2004; 113(3): 173-181. 4. Sherry DD, Wallace CA, Kahn S. Pediatric rheumatology in adult rheumatology practices in Washington State. Arthritis Rheum. 1996; 39(7):1218-1221.