A162: Pre‐visit Planning and Quality Improvement in Juvenile Idiopathic Arthritis
Authors: Aziz Rabheh abdul , Christman Amy , Jones Karla , Ardoin Stacy P. , Bout‐Tabaku Sharon M. 
Published: March 2014

Background/Purpose:

Pre visit planning (PVP) is a tool used in the management of chronic illnesses. Healthcare providers are given the necessary information prior to the visit, to provide efficient and effective care at the visit. PVP addresses key aspects of the individual patient's needs, provides data for decision making and ensures standard of care with the intent of improving clinical outcomes.

PVP has improved diabetic care to achieve clinical targets that reduce cardiovascular events and improved care of pediatric inflammatory bowel disease.

In pediatric rheumatology, PVP is becoming important in quality improvement (QI) initiatives. We describe PVP for children with juvenile idiopathic arthritis (JIA) and characterize outcomes at a single site within the Pediatric Rheumatology Care and Outcomes Improvement Network (PR‐COIN).

Methods:

Nationwide Children's Hospital rheumatology clinic has 4600 annual visits, with JIA being the most common diagnosis. PVP is a platform to unify and implement QI priorities: compliance with uveitis screening guidelines, lab monitoring, optimum pharmacotherapy, and disease activity assessment (PGA) scores.

PVP started in February 2013 after buy‐in from all providers and staff. The team includes one administrative staff (who prepares PVP forms and obtains eye visit records), three nurses, three nurse practitioners, 4 physicians who review the PVP forms, and one QI administrative champion. A one‐page PVP form was developed, containing the most important information for a patient visit. The team completes PVP forms two weeks prior to the visit which are made available to the providers on the day of the visit.

The PVP form uses a checklist format documenting whether a letter was received from the ophthalmologist about the latest eye exam result, most recent labs to determine medication toxicity, a list of current medications, recommendations on optimum medication doses and a PGA score. The team meets twice a month to evaluate process improvement. Data is entered into the PR‐COIN registry and monthly reports are generated for individual sites.

Results:

In November 2013, 190 or 36 % of eligible patients were enrolled in PR‐COIN compared to 17% in October 2012. Compliance with the uveitis screening, measured by the number of patients with completed uveitis screens per recommended guidelines, remained stable at 70% from November 2012 to September 2013. Lab monitoring, measured by the number of patients on non‐biologic DMARDS who had toxicity labs performed within the prior three months, remained stable from 100% in Nov 2012 to 100% in Sept 2013. The number of patients with clinically inactive disease on medication increased from 19.6 % in November 2012 to 27.8 % in September 2013, representing a trend in improvement but not yet reaching statistical significance.

Conclusion:

PVP within PR‐COIN allows us to provide effective patient care, implement ongoing QI goals and link process to measureable outcomes. On a broader scale we can strive for 100% compliance with uveitis screening, as we do with lab monitoring. On an individual level, we can target patients who are not in remission on medications and improve their outcomes.