Abstract
Objectives
To identify recommendations on the diagnosis and management of rheumatoid arthritis (RA) supported by low recommendation grades, to study the causes of this low grading, and to propose solutions.
Methods
A group of six rheumatologists, with extensive experience in the development of systematic reviews, reviewed national and international RA recommendations and practice guidelines. They identified all recommendations with a low level of evidence or recommendation grade (levels equivalent to 4, 5, or grades C or D of the Oxford Levels of Evidence), classified them by areas (diagnosis, follow-up, treatment, others), and analyzed plausible causes of low graduation. A Delphi was used to select 10 recommendations where it was most important to obtain quality evidence to support them. Subsequently, actions were proposed to improve evidence and recommendation grading.
Results
Fourteen documents were analyzed, in which 192 recommendations with low evidence/grade of recommendation were identified, most of which were on treatment. The two most frequent causes of this low level are the absence of studies and the discrepancy between the wording of the recommendation and the evidence used. Finally, the proposed solution to the critical recommendations is a list of unanswered research questions and possible designs to answer them.
Conclusions
We propose to design and promote research that truly supports or rectifies clinical practice and, thus, bridges the gap between existing evidence and critical recommendations.
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Acknowledgments
Literature review and medical writing support was provided by Estibaliz Loza and Loreto Carmona from InMusc, Madrid, Spain.
Funding
This study was funded by Pfizer, S.L.U.
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Contributions
MM, MV and SG conceived the study and selected the panel, AMO, LSF, VV, MAA, JRM, and GC reviewed the evidence, voted priorities and analyzed all results, all authors discussed the solutions, and helped in the preparation of the manuscript. All authors revised the last version.
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Conflicts of interest
AMO, LSF, VV, MAA, JRM, GC and VV received a grant from Pfizer for the conduct of the study. In addition, AMO reports grants from Instituto de Salud Carlos III during the conduct of the study, and personal fees and non financial support from Lilly and Pfizer, non financial support from Novartis and Sanofi and personal fees from Abbvie outside the submitted work, and a patent (PCT/ES2015/070182); LSF reports personal fees from Lilly, and Sanofi and other from Abbvie, MSD, and Sandoz, outside the submitted work; and JRM a grant from Novartis, outside the submitted work. SG, MV and MM are Pfizer employees.
Ethical approval and patient and public involvement
The nature of the study, theoretical and with no inclusion of real patients’ data, does not make it necessary to undergo ethical review according to local regulations. For its technical difficulty and given that all decisions are physician based, patients or public were not involved in the project. Data are available upon request.
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Ortiz, A.M., Silva Fernández, L., Villaverde, V. et al. Gaps between research and recommendations in rheumatoid arthritis. Rheumatol Int 41, 57–66 (2021). https://doi.org/10.1007/s00296-020-04724-z
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DOI: https://doi.org/10.1007/s00296-020-04724-z