Use of a treat-to-target approach, combined with a tool to support clinical decisions, significantly lowered disease activity in children with polyarticular juvenile idiopathic arthritis (pJIA) regardless of race and disease duration, a study shows.
However, pre-existing racial disparities such as higher disease activity in Black patients persisted over time, even though these children showed drops in disease activity similar to other racial groups.
Further research is needed to better understand racial differences in JIA at the level of both the health system and patient-physician interactions, the researchers said.
The study, “Longitudinal assessment of racial disparities in juvenile idiopathic arthritis disease activity in a treat-to-target intervention,” was published in the journal Pediatric Rheumatology and conducted by scientists at the University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia (CHOP).
“Children with polyarticular JIA are more likely than those with other categories of JIA to experience prolonged periods of active disease,” the researchers wrote. As such, it is key to determine the best treatment options and strategies for this patient population.
While increasing evidence suggests that pJIA patients may benefit more from early treatment with biologic and synthetic disease-modifying anti-rheumatic drugs (DMARDs), there is still great variability in the timing and use of such therapies.
In addition, a previous U.S. study showed that African-American children with pJIA were nearly twice as likely to have joint damage than their white counterparts.
With rheumatoid arthritis, several factors were also suggested to lead to worse outcomes among African-American adults, such as genetic factors, lesser access to care, lower rates of DMARD use, and an implicit bias in health care delivery, the scientists wrote.
Better delivery of care and more productive interactions between healthcare providers and patients may help to reduce these racial disparities.
The CHOP investigators evaluated racial discrepancies in disease activity among children with pJIA during a treat-to-target (TTT) intervention with a clinical decision support (CDS) algorithm.
This type of intervention is a way of improving patient care that involves standardized disease activity measurement to reach a clear goal (target), a review of disease activity at the point of care, and treatment adjustment through a decision support algorithm to reduce variability.
Importantly, TTT strategies have been shown to result “in better disease control in children with JIA compared to unstructured treatment,” the researchers wrote.
They retrospectively analyzed the demographic and clinical data of 159 children with pJA (74% white, 13% Black, and 13% Asian or other), treated using a TTT-CDS strategy at CHOP from 2016 to 2019.
As part of the intervention’s standardized assessment, disease activity was measured with the clinical Juvenile Arthritis Disease Activity Score (cJADAS-10), which considers active joint count, physician global assessment, and a parent/patient global assessment. Patient-reported pain, mobility, and upper extremity function were also assessed over time.
Children’s median age at TTT-CDS implementation was 12, and they were followed for a median of 30 months (about 2.5 years). Most had been diagnosed with pJIA for more than six weeks (prevalent cases), while 36% were diagnosed within the previous six weeks (incident cases).
Results showed that at the initial visit, Black children had significantly higher disease activity compared with white children and to all other children combined, and these differences were mainly driven by the physician and patient global scores.
Black children also showed significantly higher pain scores and lesser mobility than their white counterparts.
The intervention resulted in significant reductions in disease activity, irrespective of race and disease duration, supporting its overall effectiveness.
Notably, disease activity remained higher among Black children — as assessed by both physician and patient/caregiver — compared with white children. This was particularly evident among incident cases, as Black children also showed significantly worse pain and mobility.
In nearly half (47%) of the cases, physicians attested to using the CDS tool in at least half of patient visits — a degree of use that was associated with a 3.9-point greater reduction in disease activity among Black children that were prevalent cases, compared with white children.
“Efforts to improve uptake of CDS and systematically influence [physician]-patient communication about treatment decisions deserve further exploration as a potential strategy to reduce disease activity among black children and other underserved minorities with JIA,” the researchers wrote.
In addition, the chances of using biologic therapies rose over time across the entire patient population, and CDS use in 50% or more patient visits was linked also to a significantly increased rate of change in biologics use.
“Future prospective studies are also needed to determine whether broader implementation of approaches to standardize disease monitoring and treatment can reduce racial health care disparities across real-world clinical settings,” the team added.
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