Focus on drug adherence, follow-up reduces racial disparities in juvenile arthritis
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WASHINGTON — A focus on patient follow-up, standardized medication adherence and barriers assessments can reduce racial and ethnic disparities in juvenile idiopathic arthritis, according to a speaker at ACR Convergence 2024.
“We know that JIA outcomes are suboptimal and that racial/ethnic disparities exist, which are not simply biological,” Dori Abel, MD MSHP, attending physician in the division of rheumatology at the Children's Hospital of Philadelphia (CHOP), told Healio. “There are so many factors, including pervasive disparities in health care delivery, that impact outcomes.”
Abel added that her group has been assessing JIA outcomes in the Philadelphia area since 2016.
“We identified racial/ethnic disparity gaps at our center, which was initially most notable between the non-Hispanic Black and non-Hispanic white JIA populations,” she said. “We therefore began to think about identifying processes we could modify to improve our health care delivery and ultimately improve outcomes.”
According to Abel, the clinical Juvenile Arthritis Disease Activity Score (cJADAS) among the entire JIA population at CHOP was initially 2.9, with greater values observed in non-Hispanic Black patients (mean = 5), compared with non-Hispanic white patients (mean = 2.6). To reduce this score in the group overall, and among non-Hispanic Black patients in particular, the researchers began implementing a new equity plan starting in early 2023.
The researchers identified four key drivers of disparities in JIA management, including consistent outcome documentation, application of JIA best practices, providing access to at-risk patients and team awareness and agency. Protocols to combat these disparities, including patient outreach and engagement, were instituted in mid-2023. These included monthly outreach to patients overdue for follow up, standardized medication adherence assessments, monthly cJADAS distribution and quarterly data assessment workshops for maintenance of certification (MOC) credit.
Key measures included a cJADAS completion goal of more than 80%, a disease activity target attestation goal of more than 90%, a medication adherence assessment documentation goal of more than 50%, a monthly outreach for overdue visits goal of more than 75%, and MOC participation. The primary outcome was population-level mean cJADAS.
By May 2024, the JIA population at the CHOP tertiary care center included 870 patients, with 68% reporting as non-Hispanic white and 7% as non-Hispanic Black. The (cJADAS) documentation rate was greater than 80% at this timepoint, according to Abel.
Results showed that office outreach was reported in 47% of eligible participants, with 194 appointment visits scheduled. The researchers additionally reported that 154 total assessments were conducted by 17 providers.
In the final analysis, overall mean cJADAS fell from 2.9 to 2.7, according to the researchers. Among non-Hispanic Black patients, mean cJADAS improved from 5 to 4.4, while among non-Hispanic white patients, the number fell from 2.6 to 2.4.
Overall, the disparity gap between the white and Black patients closed by 0.4 units, or 17%, according to the researchers.
“Best practices such as patient outreach for appointment scheduling, standardized medication adherence and barriers assessments, and routinely assessing outcomes for our patients — with a particular focus on disadvantaged patient populations — had a dramatic significant impact on outcome improvement and disparity gap reduction,” Abel said. “There was a significant improvement in the patient/caregiver assessment of wellbeing, suggesting that our intervention impacted factors important to our patients’ daily lives.
“Stratifying data by demographic variables can reveal importance differences in health care delivery and outcomes, catalyzing improvement efforts,” she added. “Improving JIA outcomes and reducing disparities is challenging, yet we demonstrate that it is feasible using an equity-driven approach. Even seemingly small population-level improvements in disease activity translate to greater numbers achieving inactive disease.”
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Abel D. Abstract #2529. Presented at: ACR Convergence 2024; Nov. 14-19, 2024; Washington, D.C.
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