Showing papers by "American College of Rheumatology published in 2017"

2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis

Abstract: Objective To develop recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP). Methods We conducted a systematic review to synthesize the evidence for the benefits and harms of GIOP prevention and treatment options. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence. We used a group consensus process to determine the final recommendations and grade their strength. The guideline addresses initial assessment and reassessment in patients beginning or continuing long-term (≥3 months) glucocorticoid (GC) treatment, as well as the relative benefits and harms of lifestyle modification and of calcium, vitamin D, bisphosphonate, raloxifene, teriparatide, and denosumab treatment in the general adult population receiving long-term GC treatment, as well as in special populations of long-term GC users. Results Because of limited evidence regarding the benefits and harms of interventions in GC users, most recommendations in this guideline are conditional (uncertain balance between benefits and harms). Recommendations include treating only with calcium and vitamin D in adults at low fracture risk, treating with calcium and vitamin D plus an additional osteoporosis medication (oral bisphosphonate preferred) in adults at moderate-to-high fracture risk, continuing calcium plus vitamin D but switching from an oral bisphosphonate to another antifracture medication in adults in whom oral bisphosphonate treatment is not appropriate, and continuing oral bisphosphonate treatment or switching to another antifracture medication in adults who complete a planned oral bisphosphonate regimen but continue to receive GC treatment. Recommendations for special populations, including children, people with organ transplants, women of childbearing potential, and people receiving very high-dose GC treatment, are also made. Conclusion This guideline provides direction for clinicians and patients making treatment decisions. Clinicians and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis: ACR GUIDELINE FOR GLUCOCORTICOID-INDUCED OSTEOPOROSIS PREVENTION AND TREATMENT

Abstract: To develop recommendations for prevention and treatment of glucocorticoid‐induced osteoporosis (GIOP).

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Abstract: Objective This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). Methods A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. Results The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. Conclusion This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty: ACR/AAHKS GUIDELINE FOR PERIOPERATIVE MANAGEMENT

Abstract: This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence‐based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA).

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Abstract: Objective This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). Methods A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. Results The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. Conclusion This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density

Abstract: Osteoporosis is a considerable public health risk, with 50% of women and 20% of men >50 years of age experiencing fracture, with mortality rates of 20% within the first year. Dual x-ray absorptiometry (DXA) is the primary diagnostic modality by which to screen women >65 years of age and men >70 years of age for osteoporosis. In postmenopausal women <65 years of age with additional risk factors for fracture, DXA is recommended. Some patients with bone mineral density above the threshold for treatment may qualify for treatment on the basis of vertebral body fractures detected through a vertebral fracture assessment scan, a lateral spine equivalent generated from a commercial DXA machine. Quantitative CT is useful in patients with advanced degenerative bony changes in their spines. New technologies such as trabecular bone score represent an emerging role for qualitative assessment of bone in clinical practice. It is critical that both radiologists and referring providers consider osteoporosis in their patients, thereby reducing substantial morbidity, mortality, and cost to the health care system. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Clinical Practice Guidelines: Incorporating Input From a Patient Panel

Abstract: Objective To describe the integral role of a Patient Panel in the development of the 2017 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) clinical practice guideline. Methods We convened a Panel of 11 patients with rheumatoid arthritis and juvenile idiopathic arthritis, all of whom had undergone 1 or more arthroplasties, to review the evidence and provide guidance on recommendations for the 2017 ACR/AAHKS guideline to address the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. The guideline used the Grading of Recommendations Assessment, Development, and Evaluation methodology that acknowledges the critical role of patient values and preferences when the quality of the evidence base is low or when there are important trade-offs between benefits and harms. The Patient Panel considered the relative importance of complications including perioperative infection versus rheumatic disease flare and voted on the recommendations. Before the Voting Panel's own discussion of the recommendations, they reviewed a summary of the Patient Panel's discussion, including their perioperative experience, the relative importance they placed on infections versus flares in the perioperative period, and their votes on the recommendations. Results The Patient Panel placed higher importance on avoiding an infection than a disease flare despite the far greater frequency of flares than infections. The decisions of the Voting Panel were concordant with those of the Patient Panel. For the 7 recommendations that both Panels voted on, the Panels agreed on the direction as well as the strength of recommendation (which was conditional for all recommendations). Conclusion The Voting Panel considered the importance that the patients placed on risk of infection. The Patient Panel's values informed the direction and strength of the recommendations in the final 2017 ACR/AAHKS guideline.

ACR Appropriateness Criteria ® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis.

Abstract: Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

New Roadmap for the Journey From Internist to Rheumatologist

Abstract: Objective Measurement is necessary to gauge improvement. US training programs have not previously used shared standards to assess trainees’ mastery of the knowledge, skills, and attitudes necessary to practice rheumatology competently. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System began requiring semiannual evaluation of all medicine subspecialty fellows on 23 internal medicine subspecialty reporting milestones. Since these reporting milestones are not subspecialty specific, rheumatology curricular milestones were needed to guide rheumatology fellowship training programs and fellows on the training journey from internist to rheumatologist. Methods Rheumatology curricular milestones were collaboratively composed by expanding the internal medicine reporting milestones to delineate the specific targets of rheumatology fellowship training within 6 ACGME core competencies. The 2006 American College of Rheumatology core curriculum for rheumatology training programs was updated. Results A total of 80 rheumatology curricular milestones were created, defining progressive learning through training; most focus on patient care and medical knowledge. The core curriculum update incorporates the new curricular milestones and rheumatology entrustable professional activities. Conclusion Rheumatology curricular milestones are now available for implementation by rheumatology fellowship training programs, providing a clear roadmap for specific training goals and a guide to track each fellow's achievement over a 2-year training period. The comprehensive core curriculum delineates the essential breadth of knowledge, skills, and attitudes that define rheumatology, and provides a guide for educational activities during fellowship training. These guiding documents are now used to train and assess fellows as they prepare for independent rheumatology practice as the next generation of rheumatologists.

OP0068 Practices participating in the ACR'S rheumatology informatics system for effectiveness (RISE) national registry show improvements in quality of care

Abstract: Background The ACR launched the RISE registry in 2014 to facilitate quality improvement on a national scale. The registry passively extracts electronic health record (EHR) data from rheumatology practices, aggregates and analyzes these data centrally, and feeds performance on quality measures back to clinicians using a web-based dashboard. Objectives We used data from RISE to 1) examine variation in performance on quality measures across practices, and 2) evaluate trends in measure performance over time. Methods RISE9s informatics platform continuously collects data from the EHRs of participating practices, allowing centralized aggregation and analysis of quality measures. We analyzed data collected between July 1, 2014-July 1, 2016 on all patients seen by 294 clinicians across 63 practices. Measures in the areas of rheumatoid arthritis, drug safety, preventive care and gout were examined. Performance on quality measures, defined as the percentage of eligible patients receiving recommended care, was examined at the practice level. To examine trends in performance over time, we took the subset of practices that continuously participated in RISE since its inception (n=44), and developed 1) control charts and 2) logistic regression models, in which the outcome was practice-level performance each month and the predictor was time. Results Data from 289,812 patients was examined. Mean (SD) age was 59 (16) years, 75% were female, 21% were racial/ethnic minorities, and 37% had public insurance. Most rheumatologists were in a group practice (73%); 25% were in solo practice and 2% part of a larger health system. Performance on measures varied significantly across practices (Table). The largest gaps were observed for gout and preventive care. For 4 of 5 measures for which the Medicare program has set national benchmarks, average performance of RISE practices exceeded targets. Of 11 measures, performance improved over time on 5 measures (p Conclusions We found significant variation in performance on quality measures across RISE practices, with the largest gaps seen in gout care and preventive care. Some practices have achieved a very high level of performance. Over time, RISE practices demonstrated improvement in over half of the measures examined. As rheumatologists aim to improve quality of care, RISE will, by design, allow participants to measure, benchmark, and continuously monitor performance improvement. Disclosure of Interest None declared