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The ACR publishes multiple types of documents to provide guidance for its members, but some potentially beneficial topics have not fit neatly into existing production pathways. To answer the need, the ACR has formed a Guidance Subcommittee to the Quality of Care (QOC) Committee. This will allow the ACR to adapt more nimbly, when appropriate, to the informational needs of the rheumatology community.
Previously Existing Publication Pathways
The ACR publishes different kinds of helpful written materials, such as those geared to patient education. The ACR also provides a variety of guidance documents, some of which give clinical information to help inform care. Until now, most ACR-endorsed guidance documents have fallen into one of three categories: clinical practice guidelines, position statements and white papers.
Clinical practice guidelines—with development overseen by the QOC Committee—are rigorously developed documents using codified processes, including systematic literature reviews, GRADE methodology, disclosure and conflict of interest evaluations and a formal peer review process. Guidelines typically require 18–24 months to complete.
The QOC Committee chair is Sindhu Johnson, MD, PhD, an associate professor in the Division of Rheumatology at the University of Toronto, Ontario, Canada. “Position papers are generally consensus driven, with some reference to published data. The intent of these papers is mainly advocacy, for example, to payers and government,” she explains. White papers frame issues and provide information about current data on a particular topic, but generally include few or no direct recommendations.
Dr. Johnson
“Over the last few years, members of the rheumatology community have made a number of requests to evaluate or develop products that really don’t fit into any of those aforementioned types of documents,” Dr. Johnson says. For example, a document providing clinical information and recommendations may need to be produced more quickly than a traditional clinical practice guideline, or a topic may be too narrow for this purpose, requiring review of a smaller body of medical literature than a standard clinical practice guideline.
In February 2020, the ACR Board of Directors created the new Guidance Subcommittee, overseen by the QOC, to play a role in the development and potential endorsement of alternative types of documents that may provide helpful clinical recommendations. For ultimate ACR endorsement, a given document will need to be approved by the Guidance Subcommittee, then by the QOC and, ultimately, by the ACR Board of Directors.
The specifics of this involvement will vary by the situation. For example, the Guidance Subcommittee will provide feedback to outside groups that want to consult with the ACR to maximize the chance of creating a document that will ultimately achieve ACR endorsement. Other times, it may play no role in document creation but may decide whether to approve a submitted document and send it on for approval by the QOC.
The Guidance Subcommittee is also tasked with identifying topics that may be suited to these alternative types of guidance documents. In all cases, the Guidance Subcommittee will decide whether a document can be sent on to the QOC for potential ACR endorsement.
Criteria for Document Approval
Dr. FitzGerald
The chair of the Guidance Subcommittee is John D. FitzGerald, MD, PhD, clinical chief of the Division of Rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles. He says, “Our group seeks to provide feedback to authors to ensure that appropriate methodology has been applied and clearly described. We try to guide authors through the approval process by the QOC, Board and ultimate review by the journals.”
To help accomplish this, the subcommittee is using specific criteria to help evaluate potential projects and their resulting guidance documents. Documents should address timely topics of high interest to the rheumatology community. Those ultimately approved by the Guidance Subcommittee must include a description of the evidence review and synthesis, and details on the expert-based consensus method used.
Dr. Johnson notes, “These [document] projects do not need to be as rigorous as the formal guideline process, but we expect a minimum standard of rigor to support the recommendation, and ideally, it should be a balance of published data, if available, and expert consensus.” She adds that a certain amount of flexibility is purposefully built into the process, for example in the types of methodologies that could be used, to help accommodate the specific needs of a given project.
For approval, documents must also outline how conflicts of interest would be or were disclosed and managed. Last, all approved guidance documents must be consistent with the overarching values of the ACR.
The Guidance Subcommittee can provide feedback to those creating the document, which hopefully allows it to move forward through the review and approval process. Although the ultimate goal is for most documents to achieve endorsement by the ACR and potential publication in a journal, the subcommittee will also provide input if a given project may be better suited to a different format.
Future Guidance Documents
The Guidance Subcommittee is currently evaluating proposed documents brought forward by ACR members and others that might ultimately achieve ACR endorsement, but it has not weighed in on any guidance documents that are now available.
However, Dr. FitzGerald notes the ACR has already released excellent examples of the type of document the subcommittee may approve or help create in the future: the guidance documents created on the management of adult and pediatric patients during the COVID‑19 pandemic. These were written by an ad hoc committee formed at about the same time as the subcommittee, which hadn’t yet established its procedures.
“The ACR was responding to providers’ and patients’ needs to hear more about COVID‑19,” Dr. FitzGerald says. “The COVID-19 clinical guidance papers were providing timely guidance on a new topic; they were important. They were not [clinical practice] guideline documents, but they do have clinical recommendations in there, so they are a good example of the kind of documents the Guidance Subcommittee would now do.” The first published guidance document managed by the subcommittee is expected to provide clinical recommendations related to COVID-19 vaccines.
More information about the Guidance Subcommittee can be found on the ACR website.
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.