To the Editor:

We thank Connelly and colleagues for their interest in our article on quality measures for the process of care for children with JIA and also for the very thoughtful discussion of the assessment of pain in this population. We certainly agree that pain is a complex construct that is of central importance in both the impact of arthritis on children and our treatment of these children. The authors provide very thoughtful and helpful recommendations regarding the methods by which pain could be assessed, as well as various dimensions of pain that are important for consideration in children with arthritis. They also highlight the important and evolving work of the National Institutes of Health–sponsored Patient Reported Outcomes Measurement Information System cooperative network to develop new tools for the assessment of pain in children.

Although we agree with all the observations, it is important to note that we, the authors of the quality measures article, made a deliberate decision to not be overly prescriptive about the selection of the tools to assess each of the quality measures. We only provided suggestions or examples. This was done intentionally because pediatric rheumatology units exist within pediatrics departments and well-established children's hospitals. Many of those institutions, to be in compliance with regulatory agencies or local hospital initiatives, will subsequently have in place institution-wide methods to assess several of the quality measures, including routine assessment of pain. Accordingly, what may make the most sense for a specific pediatric rheumatology unit is the use of the institution-wide pain assessment approach at their respective location. However, the information provided by Connelly et al will be an excellent resource for pediatric rheumatology units as they choose a particular approach to pain assessment. Furthermore, in those instances in which pain becomes a focus of a quality improvement intervention, then a more nuanced and multilayered approach to assessment of pain may be implemented.

Lastly, the information provided by Connelly et al will be especially relevant to those multi-institutional learning collaboratives addressing quality improvement in pediatric rheumatology, such as the Pediatric Rheumatology Care and Outcomes Improvement Network. As groups of pediatric rheumatologists begin to work together on quality improvement initiatives and consideration is given to the selection of tools, this information from Connelly et al will be very helpful in the consideration of assessment of pain.

Daniel J. Lovell MD, MPH*, Michael Henrickson MD, MPH*, Esi Morgan DeWitt MD, MSCE*, Jill Segerman MEd*, Janalee Taylor MSN, RN, CNS*, Edward H. Giannini MSc, DrPH*, Murray H. Passo MD†, Timothy Beukelman MD, MSCE‡, Suzanne L. Bowyer MD§, Beth S. Gottlieb MD, MS¶, Norman T. Ilowite MD**, Yukiko Kimura MD††, Leonard D. Stein MD‡‡, Richard K. Vehe MD§§, * Cincinnati Children's Hospital Medical Center, Cincinnati, OH, † Medical University of South Carolina, Charleston, SC, ‡ University of Alabama at Birmingham, Birmingham, AL, § Indiana University, Indianapolis, IN, ¶ Steven & Alexandra Cohen Children's Medical Center of New York, New Hyde Park, NY, ** Children's Hospital at Montefiore, Bronx, NY, †† Hackensack Medical Center, Hackensack, NJ, ‡‡ University of North Carolina, Chapel Hill, NC, §§ University of Minnesota, Twin Cities, MN.