Treatment preferences in juvenile idiopathic arthritis – a comparative analysis in two health care systems

Background Variations in the treatment of juvenile idiopathic arthritis (JIA) may impact on quality of care. The objective of this study was to identify and compare treatment approaches for JIA in two health care systems. Methods Paediatric rheumatologists in Canada (n=58) and Germany/Austria (n=172) were surveyed by email, using case-based vignettes for oligoarticular and seronegative polyarticular JIA. Data were analysed using descriptive statistics; responses were compared using univariate analysis. Results Total response rate was 63%. Physicians were comparable by age, level of training and duration of practice, with more Canadians based in academic centres. For initial treatment of oligoarthritis, only approximately half of physicians in both groups used intra-articular steroids. German physicians were more likely to institute DMARD treatment in oligoarthritis refractory to NSAID (p<0.001). Canadian physicians were more likely to switch to a different DMARD rather than a biologic agent in polyarthritis refractory to initial DMARD therapy. For oligoarthritis and polyarthritis, respectively, 86% and 90% of German physicians preferred regular physiotherapy over home exercise, compared to 14% and 15% in Canada. Except for a Canadian preference for naproxen in oligoarthritis, no significant differences were found for NSAID, intra-articular steroid preparations, initial DMARD and initial biologic treatment. Conclusions Treatment of oligo- and polyarticular JIA with DMARD is mostly uniform, with availability and funding obviously influencing physician choice. Usage of intra-articular steroids is variable within physician groups. Physiotherapy has a fundamentally different role in the two health care systems.

Other (please specify) 6. Please describe your type of practice.

In which country do you mainly practice?
A Please consider the following hypothetical patient: A 3 year old girl is presented in your practice. The parents report that for the last 2 months she has had a swollen right knee and is limping, especially in the morning. Further history elicits no trauma or preceding infection. On examination you find an effusion in both knees and both ankles with no contracture, with an otherwise normal general and musculoskeletal examination. Bloodwork shows normal CBC, liver/kidney parameters and inflammatory parameters, and a positive ANA, but a negative RF and negative HLA-B27. An eye examination (including slit lamp examination) 2 days previously was unremarkable. You diagnose her with oligoarticular JIA. 8. Which of the following medications would you prefer for your initial treatment? 9. What would be your recommendation regarding physiotherapy and activity in this patient? Hospital-based, academic n m l k j B Please consider the following hypothetical patient: A patient with the same characteristics as the one described under A was treated by another Pediatric Rheumatologist with an NSAID. After her family moved, she presents in your office, 6 months after onset of her symptoms.
She still complains of morning stiffness, and you find an effusion in both knees. The remaining examination including the ankles is unremarkable. A recent eye examination was unremarkable.

Which of the following medications would you prefer for treatment at this time ?
C Please consider the following hypothetical patient: A patient with the same characteristics as the one described under A was treated by another Pediatric Rheumatologist with an NSAID. After her family moved, she presents in your office, 6 months after onset of her symptoms.
She has no joint complaints, but she was diagnosed with chronic anterior uveitis refractory to topical steroids 3 months after her initial visit.
The musculoskeletal examination including ankles and knees is unremarkable.

Which of the following medications would you prefer for treatment at this time ?
D Please consider the following hypothetical patient: A 14 year old female patient presents in your office. She reports that for the last 3 months she has increasing swelling of both knees, ankles, wrists and elbows, with morning stiffness lasting for approximately 2 hours. Further history elicits no trauma or preceding infection. On examination you find effusions in a total of 9 joints, with an otherwise normal general and musculoskeletal examination. Bloodwork shows normal CBC, liver and kidney parameters, elevated inflammatory parameters (ESR), and a positive ANA, but a negative RF and negative HLA-B27. An eye examination (including slit lamp examination) 2 days previously was unremarkable. You diagnose her with seronegative polyarticular JIA. 12. Which of the following medications would you prefer for initial treatment?

What would be your recommendation regarding physiotherapy and activity in this patient?
E Please consider the following hypothetical patient: A patient with the same characteristics as the one described in D was treated by another Pediatric Rheumatologist with a DMARD. After her family moved, she presents in your office, one month after start of DMARD treatment. She has ongoing joint complaints, and the physical examination still shows 8 active joints. 16. Assuming that the patient described in E remains unchanged on subsequent presentations, approximately how long would you treat with NSAID, DMARD or steroids before you would consider a biologic agent?

Assuming that the patient described in E remains unchanged on subsequent presentations, approximately how long after institution of the DMARD treatment
The following questions are designed to assess your preferences for various medications within their respective groups.