Increasing evidence supports that early initiation of biologics may dramatically improve disease course and reduce glucocorticoid exposure for children with systemic juvenile idiopathic arthritis (JIA). We characterized variation in the use of first‐line biologic and glucocorticoid therapy and identified drivers of variation in children hospitalized with new‐onset systemic JIA. We conducted a retrospective cohort study of children hospitalized with new‐onset systemic JIA from 2008‐2019 utilizing a comparative pediatric database from 52 tertiary care children’s hospitals. Subjects and treatment receipts were identified using International Classification of Diseases (ICD)‐9 and ICD‐10 discharge diagnosis codes, pharmacy billing data and clinical transaction classification codes.

Mixed‐effects logistic regression was used to identify patient and hospital‐level factors associated with receipt of glucocorticoids and biologics. 534 children with new‐onset systemic JIA hospitalized during the study period met inclusion criteria. Twenty‐nine percent received biologics and 58% received glucocorticoids. Biologic use increased over time (p < 0.001), methotrexate use decreased (p < 0.01), and glucocorticoid use remained unchanged. Biologics and glucocorticoid use varied significantly between hospitals. High annual hospital volume, intensive care unit stay, and later discharge year were significantly associated with biologic exposure. Medium‐high and high annual hospital volume were significantly associated with less glucocorticoid exposure.

Despite increasing evidence demonstrating improved outcomes with first‐line treatment with biologics, we found significant treatment variation across hospitals with many children not receiving biologics and a persistent high rate of glucocorticoid exposure. These results underscore the need for comparative efficacy studies and improved treatment standardization.