After the TFP meeting was complete, recommendations were derived from directly transcribing final clinical scenario ratings. Based on the ratings, scenario permutations were collapsed to yield the most parsimonious recommendations. For example, when ratings favored a drug indication for both moderate and high disease activity, one recommendation was given, specifying “moderate or high disease activity.” In most circumstances, the recommendations included only positive and not negative statements. For example, the recommendations focused on when to initiate specific therapies rather than when an alternate therapy should not be used. Most of the recommendations were formulated by drug category (DMARD, anti-TNF biologic, non-TNF biologic listed alphabetically within category), since in many instances, the ratings were similar for medications within a drug category. We specifically note instances where a particular medication was recommended but others in its group were not endorsed. Two additional community-based rheumatologists (Drs. Anthony Turkiewicz and Gary Feldman) independently reviewed the manuscript and provided comments. CEP and TFP members reviewed and approved all final recommendations.
For each final recommendation, the strength of evidence was assigned using the methods from the American College of Cardiology (11 (link)). Three levels of evidence are specified: 1) Level of Evidence A: data were derived from multiple randomized clinical trials (RCTs) ; 2) Level of Evidence B: data were derived from a single randomized trial or nonrandomized studies; 3) Level of Evidence C: data were derived from consensus opinion of experts, case studies, or standards of care. The evidence was rated by four panel experts (J.O. and J.K.; A.K. and L.M.—each rated half the evidence), and discrepancies were resolved by consensus.
Level C evidence often denoted a circumstance where medical literature addressed the general topic under discussion but it did not address the specific clinical situations or scenarios reviewed by the panel. Since several (but not all) recommendations had multiple components (in most cases multiple medication options), a range is sometimes provided for the level of evidence ; for others, the level of evidence is provided following each recommendation.
For each final recommendation, the strength of evidence was assigned using the methods from the American College of Cardiology (11 (link)). Three levels of evidence are specified: 1) Level of Evidence A: data were derived from multiple randomized clinical trials (RCTs) ; 2) Level of Evidence B: data were derived from a single randomized trial or nonrandomized studies; 3) Level of Evidence C: data were derived from consensus opinion of experts, case studies, or standards of care. The evidence was rated by four panel experts (J.O. and J.K.; A.K. and L.M.—each rated half the evidence), and discrepancies were resolved by consensus.
Level C evidence often denoted a circumstance where medical literature addressed the general topic under discussion but it did not address the specific clinical situations or scenarios reviewed by the panel. Since several (but not all) recommendations had multiple components (in most cases multiple medication options), a range is sometimes provided for the level of evidence ; for others, the level of evidence is provided following each recommendation.
