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Favier LA, Taylor J, Loiselle Rich K, Jones KB, Vora SS, Harris JG, Gottlieb BS, Robbins L, Lai JT, Lee T, Kohlheim M, Gill J, Bouslaugh L, Young A, Griffin N, Morgan EM, Modi AC. Barriers to Adherence in Juvenile Idiopathic Arthritis: A Multicenter Collaborative Experience and Preliminary Results. J Rheumatol 2018; 45:690-696. [PMID: 29419467 PMCID: PMC5932234 DOI: 10.3899/jrheum.171087] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Nonadherence is currently an underrecognized and potentially modifiable obstacle to care in juvenile idiopathic arthritis (JIA). The purpose of our study was to design and implement a standardized approach to identifying adherence barriers for youth with JIA across 7 pediatric rheumatology clinics through the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) and to assess the frequency of adherence barriers in patients and their caregivers across treatment modalities. METHODS An iterative process using coproduction among parents and providers of patients with JIA was used to design the Barriers Assessment Tool to screen for adherence barriers across 4 treatment modalities (i.e., oral medications, injectable medications, infusions, and physical/occupational therapy). This tool was implemented in 7 rheumatology clinics across the United States and patient responses were collected for analysis. RESULTS Data were collected from 578 parents and 99 patients (n = 44 parent-child dyads). Seventy-seven percent (n = 444) of caregivers and 70% (n = 69) of patients reported at least 1 adherence barrier across all treatment components. The most commonly reported adherence barriers included worry about future consequences of therapy, pain, forgetting, side effects, and embarrassment related to the therapy. There was no significant difference between endorsement of barriers between parents and adolescents. CONCLUSION Implementing a standardized tool assessing adherence barriers in the JIA population across multiple clinical settings is feasible. Systematic screening sheds light on the factors that make adherence difficult in JIA and identifies targets for future adherence interventions in clinical practice.
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Affiliation(s)
- Leslie A Favier
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA.
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati.
| | - Janalee Taylor
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Kristin Loiselle Rich
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Karla B Jones
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Sheetal S Vora
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Julia G Harris
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Beth S Gottlieb
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Lisa Robbins
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Jamie T Lai
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Tzielan Lee
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Melanie Kohlheim
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Jennifer Gill
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Laura Bouslaugh
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Angela Young
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Nancy Griffin
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Esi M Morgan
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
| | - Avani C Modi
- From the Division of Rheumatology, and Division of Behavioral and Clinical Psychology, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; University of Cincinnati, Cincinnati, Ohio; Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio; Division of Rheumatology, Levine Children's Hospital, Charlotte, North Carolina; Division of Rheumatology, Children's Mercy Hospital, Kansas City, Missouri; Division of Rheumatology, Cohen Children's Medical Center, New York, New York; Division of Rheumatology, Penn State Children's Hospital, Hershey, Pennsylvania; Division of Rheumatology, Stanford Children's Hospital, Palo Alto, California; The Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), Cincinnati, Ohio, USA
- L.A. Favier, MD, Division of Rheumatology, and the Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati; J. Taylor, MSN, APRN, CNP, Division of Rheumatology, Cincinnati Children's Hospital Medical Center; K. Loiselle Rich, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati; K.B. Jones, APRN, Division of Rheumatology, Nationwide Children's Hospital; S.S. Vora, MD, Division of Rheumatology, Levine Children's Hospital; J.G. Harris, MD, Division of Rheumatology, Children's Mercy Hospital; B.S. Gottlieb, MD, MS, Division of Rheumatology, Cohen Children's Medical Center; L. Robbins, BSN, CPN, Division of Rheumatology, Penn State Children's Hospital; J.T. Lai, MD, Division of Rheumatology, Stanford Children's Hospital; T. Lee, MD, Division of Rheumatology, Stanford Children's Hospital; M. Kohlheim, Parent Representative, PR-COIN; J. Gill, LSW, Parent Representative, PR-COIN; L. Bouslaugh, Parent Representative, PR-COIN; A. Young, Parent Representative, PR-COIN; N. Griffin, BSN, MPA, PR-COIN, and the James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; E.M. Morgan, MD, MSCE, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and PR-COIN, and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center; A.C. Modi, PhD, Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, and University of Cincinnati
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