Evaluating the adequacy of disease control in patients with rheumatoid arthritis: a RAND appropriateness panel.
OBJECTIVE
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 Angeles (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.


CONCLUSIONS
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.
Furst
D E
DE
Geffen School of Medicine, University of California at Los Angeles, 1000 Veteran Ave Rm 32-59, Los Angeles, CA 90095-1670, USA. defurst@mednet.ucla.edu
Halbert
R J
RJ
Bingham
C O
CO
Fukudome
S
S
Anderson
L
L
Bonafede
P
P
Bray
V
V
Cohen
S B
SB
Sherrer
Y R S
YR
St Clair
E W S
EW
Tesser
J R P
JR
Weinblatt
M
M
Dubois
R W
RW
D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000145:classification / Q000592:standards / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D002986:Clinical Trials as Topic / Q000592:standards; D003695:Delivery of Health Care; D005069:Evaluation Studies as Topic; D019317:Evidence-Based Medicine; D006801:Humans; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D016896:Treatment Outcome
D000894:Anti-Inflammatory Agents, Non-Steroidal; D018501:Antirheumatic Agents