“The current set of guidelines clearly represents an improvement in the methodologic rigor of the ACR guidelines and recommendations process,” write Drs. Bathon and Cohen in their editorial. “However, the strict adherence to the RAND/UCLA method leaves gaps in practice algorithms that could potentially be filled by other methods.” Bathon says this is the main point of disagreement on the value of the new guidelines. “How do we make clinical trial data relevant in daily practice?” she asks. Dr. Bathon says that there are remaining questions for physicians, patients, and payers, but adds that the new evidence-based guidelines do represent “an important tool for reimbursement.” The guidelines protect the patient from insurance carriers who may want to deny coverage for the treatment, because the DMARDs are now identified as sanctioned and endorsed treatments.
“The guidelines should definitely facilitate care for patients,” says Dr. Solomon. “The physician who wants to prescribe DMARDs for a patient no longer should have to justify this use to insurance companies.”
In response to concerns about not including some therapies in these recommendations, Dr. Solomon notes that the ACR task force panel had a defined task and excluding other treatments such as steroids was pragmatic. “Steroid use presents a number of issues and likely requires its own set of guidelines,” he says. Dr. Saag says, “A number of treatments have a low prevalence of use and limited evidence base to demonstrate safety and efficacy. We did not feel that we had sufficient data to provide recommendations in all cases.”
Dr. Saag emphasizes that the guidelines will continue to be updated based on scientific evidence and practice patterns in rheumatology. He adds that the ACR is working with the AMA Physician Consortium for Performance Improvement and the National Committee for Quality Assurance to develop performance measures based in part on the new guidelines. Draft performance measures were available online for public comment through June 27and should be finalized by fall.
Terry Hartnett is a medical journalist based in Pittsburgh.
References
- Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008; 59(6):762-784.
- Bathon JM, Cohen SB. The 2008 American College of Rheumatology recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis: Where the rubber meets the road. Arthritis Rheum. 2008; 59(6):757-759.
