Friday, 16 Feb 2018

You are here

ACR Clinical Guidelines Flawed by Low Evidence

JAMA Internal Medicine has reported that recommendations and clinical practice guidelines (CPGs) from the American College of Rheumatology (ACR) are often based on expert opinion, but lack rigorous (grade A) evidence to support many of their recommendations. (Citation source: https://buff.ly/2AlfUPK)

Researchers compiled eight published rheumatology CPGs endorsed by the ACR and studied the the level of evidence and strength of the recommendations.  

Specifically this included clinical practice guidelines covering glucocorticoid-induced osteoporosis (GIOP), juvenile idiopathic arthritis (JIA), gout, lupus nephritis, osteoarthritis (OA), ankylosing spondylitis (SpA), polymyalgia rheumatica (PMR), and rheumatoid arthritis (RA). 

These 8 guidelines included 403 recommendations, with more than half (58%) based on level C evidence (meaning on expert opinion, case studies, or standard of care).

Importantly, only 23% of these recommendations were based on level A evidence (based on multiple randomized clinical trials or meta-analyses); and one-fifth were level B (single RCT or nonrandomized studies).

The proportion of recommendations supported by A-level evidence ranged from 2% for juvenile idiopathic arthritis and 10% for polymyalgia rheumatica to 35% for glucocorticoid-induced osteoporosis and 58% for osteoarthritis.

Obviously, societal guidelines carry significant weight with patients, payors, and agencies dedicated to cost-efficient and effective care for the population. With an aging society, there is a belief that guidelines for arthritis management will be pivotal. Yet the authors question the utility of guidelines largely based on no evidence, weak evidence and expert opinion. 

The most commonly observed support was the combination of C-level evidence and class II strength (benefit greater than or equal to harm); this was seen in roughly 30% of the guidelines  and in 50% of the RA recommendations.

The quality of ACR guidelines is similar to that seen with other subspecialty guidelines, including cardiology, infectious diseases, nephrology, etc.

The authors point out that some guideline recommendations do have high levels of evidence and strength and that such guidelines merit greater adherence and implementation.

The authors conclude that the evidence supporting ACR recommendations is limited, with more than 50% of  recommendations classified as level C.  While the ACR has adopted the GRADE system of evidence evaluation to control for some of these deficits, the redefinition of level A evidence and the inclusion of real world evidence may improve the certainty, if not applicability, of future guidelines.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

The RheumNow Week in Review - 16 February 2018

Dr. Jack Cush reviews highlights, news and recent research published this week on RheumNow.com. This week's report includes news on social media, new rituximab indications, steroid complications, DECT in Gout, T2T in gout, Dementia and rheumatology numbers.

RWCS Day 4 Podcast

Listen in on the proceedings from the 2018 RWCS meeting in Maui, with excerpts from leading teachers in rheumatology. This podcast features presentations from Drs. Leslie Biello, Alvin Wells, Anne Stevens, Rachel Tate, Anna Postolova, Artie Kavanaugh, Bevra Hahn, Eric Ruderman, Mark Genovese, Uma Mahadevan, Bernie Rubin, Umber Ahmad. Listen here or on Stitcher, iTune, iPhone, Soundcloud or Google play. 

RWCS Day 3 Podcast

Listen in on the proceedings from the 2018 RWCS meeting in Maui with excerpts from leading teachers in rheumatology. This podcast features topics in dermatology, the fellowship program lead by Dr. Bernie Rubin and videos by the fellows.  Featured are Drs. Rachel Tate, Sheetal Patel, Bernie Rubin, Natasha Zohuri, Laura Howe, Kyle Maier, Jeff Chwa, George Martin, and Elaine Alexander.

The RWCS - RheumNow Week in Review - 9 February 2018

Dr. Jack Cush reviews highlights, news and recent research published this week on RheumNow.com. This week's report includes news and education from the RWCS meeting in Maui. Also featured are uricase treatments for gout, exercise in RA, CVD in lupus, NFC predicting mortality in systemic sclerosis, Uveitis predicting AS and future manpower shortages in rheumatology.

RWCS Day 2 Podcast

Listen in on the proceedings from the 2018 RWCS meeting in Maui with excerpts from leading teachers in rheumatology. This podcast features Drs. Martin Bergman, Jack Cush, Rachel Tate, Phil Aleksiejuk, Shubha Kollampare, Orrin Troum, and Alvin Wells. Listen here or on Stitcher, iTune, iPhone, Soundcloud or Google play.