Objective: To describe the selection, development, and implementation of quality measures (QMs) for juvenile idiopathic arthritis (JIA) by the Pediatric Rheumatology Care and Outcomes Improvement Network (PR‐COIN), a multihospital learning health network using quality improvement methods and leveraging QMs to drive improved outcomes across a JIA population since 2011.Methods: An American College of Rheumatology–endorsed multistakeholder process previously selected initial process QMs. Clinicians in PR‐COIN and parents of children with JIA collaboratively selected outcome QMs. A committee of rheumatologists and data analysts developed operational definitions. QMs were programmed and validated using patient data. Measures are populated by registry data, and performance is displayed on automated statistical process control charts. PR‐COIN centers use rapid‐cycle quality improvement approaches to improve performance metrics. The QMs are revised for usefulness, to reflect best practices, and to support network initiatives.Results: The initial QM set included 13 process measures concerning standardized measurement of disease activity, collection of patient‐reported outcome assessments, and clinical performance measures. Initial outcome measures were clinical inactive disease, low pain score, and optimal physical functioning. The revised QM set has 20 measures and includes additional measures of disease activity, data quality, and a balancing measure.Conclusion: PR‐COIN has developed and tested JIA QMs to assess clinical performance and patient outcomes. The implementation of robust QMs is important to improve quality of care. PR‐COIN's set of JIA QMs is the first comprehensive set of QMs used at the point‐of‐care for a large cohort of JIA patients in a variety of pediatric rheumatology practice settings.

Objective: Juvenile idiopathic arthritis (JIA) is complicated by morbidity, with suboptimal rates of prolonged remission, decreased health-related quality of life, and functional limitations. The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), a North American learning health network, has a centralized registry of patients with JIA to track quality measures. We assessed for health disparities in our collaborative JIA population by evaluating our performance on disease activity outcomes, overall well-being, and pain by race and ethnicity, age, sex, and JIA subtype. Methods: A cross-sectional analysis of patients in the PR-COIN registry was conducted to estimate the association between race and ethnicity groups and outcomes including physician global assessment of disease activity (PGA), patient/parent global assessment of overall well-being (PtGA), active joint count, 10-joint clinical Juvenile Arthritis Disease Activity Score (cJADAS10), arthritis-related pain intensity score, and morning stiffness duration. Results: Data from 9601 patients were analyzed. Current age was positively and significantly associated with higher scores of pain intensity, PGA, PtGA, and cJADAS10. Non-Hispanic Black patients had statistically higher cJADAS10 scores compared to non-Hispanic White patients, in addition to statistically higher pain intensity scores, and PGA and PtGA scores. Female patients had statistically higher scores compared to male patients for all outcome variables assessed. Conclusion: We found disparities in outcomes of patients with JIA related to race and ethnicity, sex, and age. This information is imperative to drive further improvement efforts and understand possible causes of these differences to close disparity gaps and improve outcomes for all patients with JIA.

Objective: We evaluate tofacitinib efficacy and safety in patients with juvenile idiopathic arthritis (JIA) stratified by concomitant methotrexate and prior biologic disease‐modifying antirheumatic drug (bDMARD) treatment. Methods: In this two part, double‐blind, randomized withdrawal Phase 3 trial (NCT02592434), patients (2–<18 years) with JIA received open‐label tofacitinib (5 mg twice daily/weight‐based equivalent) in Part 1 (Day 1–Week 18). Those eligible were randomized to continue tofacitinib or switch to placebo in Part 2 (Weeks 18–44). In this post hoc analysis, patients were stratified by concomitant methotrexate (MTX+/−) and prior bDMARD treatment (bDMARD+/−). Efficacy outcomes included JIA disease flare, JIA/American College of Rheumatology (ACR) 50/70 response rates, and JIA/ACR clinical inactive disease (CID). Safety was assessed throughout the trial. Results: Of 225 patients in Part 1, 147 (65.3%) were MTX+; 85 (37.8%) were bDMARD+. Across subgroups, JIA flare rate at Week 44 was lower with tofacitinib than placebo: patients who were MTX+ (29.8% vs 47.5%), patients who were MTX− (32.3% vs 73.1%), patients who were bDMARD+ (29.0% vs 70.4%), patients who were bDMARD− (31.6% vs 48.3%). Greater JIA/ACR50/70 and JIA/ACR‐CID responses with tofacitinib than with placebo were observed across subgroups. In tofacitinib‐treated patients, adverse events (AEs) were more common in the subgroups of patients who were MTX− (85.9%) and patients who were bDMARD+ (81.2%) than the subgroups of patients who were MTX+ (74.1%) and patients who were bDMARD− (76.4%). Similar findings were observed with serious AEs/discontinuations due to AEs. Conclusion: Tofacitinib was efficacious for patients regardless of baseline concomitant MTX treatment or prior bDMARD exposure; MTX may have a protective effect for flare upon tofacitinib withdrawal. Safety was consistent with the known tofacitinib profile, and no new risks were identified in these subgroups.

Background/Objectives: Recognizing workforce shortages and adverse impacts of trainee emotional exhaustion, we aimed to measure baseline levels of wellness, resilience, and burnout among pediatric rheumatology fellows as well as to understand the feasibility of implementing a narrative medicine intervention in this population. Methods: This study involved pre- and post-participation questionnaires for pediatric rheumatology fellows in the United States and Canada who participated in a narrative medicine intervention. Survey components included the Mini Z Burnout Survey, the Mayo Well-being Index and the Connor-Davidson Resilience Scale (CD-RISC), baseline demographics and self-reported burnout-related factors. Results: All sixteen invited fellows completed the pre-participation survey, and 15 of the 16 participants completed the narrative intervention. The median (range) baseline CD-RISC resilience score was 73.5 (44–88), and the baseline Mini-Z Burnout Survey showed high levels of burnout with a median (range) of 34 (17–44). The median (range) score of the baseline Mayo Well-being Index was 3 (0–7), with scores of ≥4 associated with physicians at risk of suicidal ideation and/or serious thoughts of leaving medicine. Following participation in the narrative medicine intervention, surveys showed a shift toward feelings that work is meaningful, as well as a shift toward feelings of having time for personal and family life. Conclusions: In this pilot study, baseline levels of wellness, resilience, and burnout among pediatric rheumatology fellows highlighted target areas to mitigate burnout and maximize resilience among fellows. Narrative medicine is a feasible and acceptable intervention, and future larger studies should investigate the possible impact of narrative medicine on burnout among pediatric rheumatology fellows.

Background: Physician burnout threatens clinician well-being, job satisfaction, retention, and access to care. Pediatric rheumatology faces documented workforce shortages, yet little specialty-specific information exists regarding physician well-being, burnout symptoms, and workplace characteristics. Methods: We conducted a cross-sectional descriptive survey of CARRA-registered pediatric rheumatologists in North America between January and March 2024. Participants completed the Mayo Clinic Well-Being Index (WBI), followed by the AMA Organizational Biopsy^® survey incorporating the Mini-Z 2.0 and demographic/workplace questions. Descriptive statistics summarized physician well-being, burnout symptoms, and workplace characteristics. Differences in WBI scores across response categories for two WBI anchor items assessing work–life integration and work meaningfulness were evaluated using ANOVA. AMA workplace data were available only in aggregate form and could not be linked to individual WBI responses. Results: Of 330 invited pediatric rheumatologists, 164 (49.7%) completed the WBI survey and 145 (88.4%) completed the redirected AMA survey. The mean WBI score was 2.7 (SD 1.9), and 36.0% scored ≥4. On the Mini-Z single-item measure, 48.3% of respondents endorsed at least one category consistent with burnout symptoms; by comparison, 64.0% endorsed the WBI item asking whether they had felt burned out from work during the past month. Frequently reported workplace challenges included documentation burden (56.6%), EHR-related frustration (59.3%), and after-hours EHR work (55.2%). Work–life integration was significantly associated with WBI scores (ANOVA p < 0.001), whereas meaningfulness of work was not (p = 0.26). Conclusions: Indicators of burnout symptoms and occupational distress were common among the responding pediatric rheumatologists. Frequently reported workplace challenges and the observed association between work–life integration and WBI scores identify potential areas for future organizational well-being initiatives.

Background/Objectives: Canadian Advanced Physiotherapist Practitioner (APP) roles have existed for over 25 years in pediatric rheumatology. The APP can manage many common pediatric rheumatic conditions most often in Shared-Care Models (SCMs) with pediatric rheumatologists (PRs). The quality of care children receive in an APP SCM compared to traditional care is unknown. The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) tracks quality measures as Key Performance Indicators (KPIs) in juvenile idiopathic arthritis (JIA) care. This study aimed to analyze the frequency of KPIs documented in a pediatric rheumatology APP SCM from a single center and compare to PR-COIN’s performance targets to assess the quality and safety of care. Methods: A retrospective chart review of JIA cases managed in a pediatric rheumatology APP SCM over a 2-year period was conducted. KPIs for disease activity, safety monitoring and access to care were evaluated. Frequency of KPI documentation by the APP were compared to target performance goals (≥40, ≥70 or ≥80% documentation rate depending on KPI) and with PR-COIN data from the Same Center (SC) (three rheumatologists) and PR-COIN (15 centers). Results: Documented KPIs were compared between the APP SCM, SC and PR-COIN registry (138; 140; 11,431 eligible visits, respectively) between June 2022–May 2024. Demographics were similar between groups. Increased percentages of patients with polyarticular rheumatoid factor positive and psoriatic subtypes were seen by APP compared to SC and PR-COIN. Documentation frequency of all disease activity and safety monitoring KPI performance goals were either higher in the APP SCM or comparable to SC and PR-COIN. Conclusions: The pediatric rheumatology APP SCM exceeded PR-COIN performance goals for KPI documentation, establishing a high level of quality and safety of care for children with JIA when managed in this model of care. Next steps include replicating this study in other pediatric rheumatology centers with an APP SCM.