Rheumatology Advance Access originally published online on January 4, 2008
Rheumatology 2008 47(2):194-199; doi:10.1093/rheumatology/kem326
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Evaluating the adequacy of disease control in patients with rheumatoid arthritis: a RAND appropriateness panel
1Geffen School of Medicine, University of California at Los Angeles, 2Cerner LifeSciences Beverly Hills, 3UCLA School of Public Health, Los Angeles, CA, 4Johns Hopkins University, Baltimore, MD, 5Maine PHO and MMC PHO, Portland, ME, 6Providence Hospital, Portland, OR, 7University of Colorado Health Sciences Center, Denver, CO, 8University of Texas, Southwestern School of Medicine, 9Radiant Research, Dallas, TX, 10Center for Rheumatology, Immunology, and Arthritis, Fort Lauderdale, FL, 11Duke University Medical Center, Durham, NC, 12AZ Arthritis Rheum Assoc, Paradise Valley, AZ and 13Brigham and Women's Hospital, Boston, MA, USA.
Correspondence to: D. E. Furst, Carl M Pearson Professor of Rheumatology, Geffen School of Medicine, University of California at Los Angeles, 1000 Veteran Ave Rm 32-59, Los Angeles, CA 90095-1670, USA. E-mail: defurst{at}mednet.ucla.edu
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Abstract |
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Objectives. There is a lack of agreement on assessing disease activity in patients with RA and determining when the RA treatment should be changed or continued. A panel of rheumatologists was convened to develop guidelines to assess adequacy of disease control, focusing on the use of disease-modifying anti-rheumatic drugs.
Methods. The Research and Development/University of California in Los Angleles (RAND/UCLA) Appropriateness Method was used to evaluate disease control adequacy. After a literature review, 108 scenarios were developed to simulate situations most likely to be encountered in clinical practice and rated on a 9-point scale by a 10-member expert panel.
Results. Final appropriateness rankings for the scenarios were as follows: 37% ‘appropriate’, 48% ‘inappropriate’, and 16% ‘neutral’. The panelists felt that patients with disease control in the ‘appropriate’ range have adequate control with their current therapy, whereas those in the ‘inappropriate’ range should be considered for a change in therapy. Those in ‘neutral’ areas should have their therapy reviewed carefully. The panelists recommended that the clinically active joint count should be considered the most important decision factor. In patients with no clinically active joints, regardless of other factors no change in therapy was felt to be warranted. Patients with five or more active joints should be considered inadequately treated, and in patients with one to four active joints other variables must be considered in the decision to change therapy.
Conclusion. These preliminary guidelines will assist the clinician in determining when a patient's clinical situation warrants therapy escalation and when continuing the current regimen would be appropriate.
KEY WORDS: Rheumatoid arthritis, Standards of care, Practice guidelines, Treatment
Submitted 4 January 2007;
revised version accepted 2 November 2007.
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