The ACR-EULAR Collaboration: An Expert Interview With David A. Fox, MD
The ACR-EULAR Collaboration: An Expert Interview With David A. Fox, MD
Editor's Note:
The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) are key organizations on both sides of the Atlantic for rheumatologists and other healthcare professionals involved in the care of patients with rheumatic diseases. The work of these 2 organizations is complementary rather than contradictory. Accordingly, collaborative work on many initiatives will provide a high-level standardized approach to the optimal treatment of arthritis, nationally and internationally. Ferdinand Breedveld, MD, PhD, presented his perspective on the collaboration in an earlier interview with Medscape. In the interview that follows here, however, Helen Fosam, PhD, of Medscape Rheumatology, spoke with David A. Fox, MD, President of the ACR, for his perspective on this historic collaboration between the ACR and EULAR.
Medscape: The ACR-EULAR collaboration is a historic event. In your opinion, what is the significance and what are the key benefits of this collaboration, both for the ACR and for the care of patients with rheumatic diseases?
Dr. Fox: The ACR-EULAR collaboration will to lead to new criteria for classification of disease and for measuring response to treatment, as well as better standards for conducting clinical trials and measuring the efficacy of clinical trials. I think that the products that we come up with through these projects will be the best because we engage the best expertise possible from both sides of the Atlantic. This, in the long run, should advance research in rheumatic disease as well as advance patient care.
Medscape: Will the collaboration lead to a more unified treatment approach on both sides of the Atlantic?
Dr. Fox: Well, the goal is to avoid the confusion that can arise by using competing or different criteria for disease classification or for measuring clinical responses or responses to treatment. If you had differing criteria, then clinical studies would not be as comparable with each other as if you have uniform criteria; that has been a problem in the past. It has been a little difficult to interpret some of the clinical literature when nonuniform criteria have been used for disease classification or treatment response. The collaboration should bring more clarity to the field because some of the competing criteria are replaced with collaborative criteria.
I should mention, however, that we are not currently doing joint treatment algorithms, and there are specific reasons for that. Dr. Breedveld mentioned some of those in his interview. The projects that ACR and EULAR will work on together will primarily focus on criteria for classifying and diagnosing disease and approaches to measuring treatment response, in both the clinical and research settings.
Medscape: The ACR is a single entity e in which individual clinicians can become members, while EULAR is a collaborative membership of 44 European countries. Will this present challenges to working collaboratively?
Dr. Fox: There are some challenges, but they're not really due to the difference that you have mentioned -- that is, in terms of the ACR being made up of individual members and EULAR being made up of countries. The challenges come from other areas. For example, our budget cycles are on different calendars; EULAR's budget is on a calendar year, while ACR's budget is on a fiscal year that goes from July 1 to June 30.
So when we allocate funds (and, of course, these projects cost money), we have to coordinate our actions in the setting of having different budget years. It is something that we are aware of and can work around, but it does present some minor challenges.
I think another challenge is that the ACR has not only an Executive Committee but also a Board of Directors; our decision-making process is a little bit more lengthy compared with the decision-making process of EULAR, which is run by an Executive Committee. We are trying to get around that and be as efficient as possible, but at times EULAR has had to show some patience while waiting for ACR to go through its appropriate process to make decisions on projects and allocate funds.
Medscape: In his interview, Ferdinand Breedveld, MD, PhD, EULAR's president, summarized the objectives of the collaboration and the working logistics. In regard to joint projects, how are they initiated and taken forward?
Dr. Fox: Both EULAR and the ACR have standing committees composed of members who are responsible for, and have expertise in the development of criteria. On the ACR end, the committee is called the Quality of Care Committee, formerly known as the Quality Measures Committee, and is chaired by Daniel Solomon, MD. EULAR's committee has also recently been renamed: Previously it was the Standing Committee on Clinical Affairs, chaired by Professor Allen Tyndall; the new abbreviation is EULAR Standing Committee for Clinical Affairs (ESCAA).
The ideas for new projects typically arise from these committees and then are subject to approval by the Executive Committees of the organizations and, in the case of the ACR, by the ACR Board. The ACR Quality of Care Committee and the EULAR ESCAA maintain good communication with each other and they discuss possible projects with each other at least twice a year. So when a project idea is being considered, frequently the communication will quickly go back and forth to further develop and refine the idea.
Medscape: Are there project ideas that are developed but do not have a common interest between the ACR and EULAR?
Dr. Fox: We do some projects separately, because for any project there may be more interest in one organization than in another, and that is okay. When there is a coinciding interest, we hope to do all of those together. In some cases, this collaborative work comes together after projects have been initiated separately by each organization. For example, the revised classification criteria for rheumatoid arthritis (RA) is a project that the ACR was planning to work on. EULAR began to work on a similar type of project and invited some ACR members to be part of that project team. Because of the similarity in these project initiatives, EULAR was willing to collaborate and develop a joint ACR-EULAR project. I think that as long as communications are active and open, this is going to work very well. The experts in a field do talk to each other. They go to meetings. They have common interests in advancing knowledge and in improving patient care. They like to work together.
Medscape: Modification of the classification criteria for RA is the first of several upcoming joint publications between the ACR and EULAR. As a result of the collaborative input, how different do you imagine the updated version will be compared with the current ACR classification criteria for RA?
Dr. Fox: It would be a little presumptuous for me to guess at that, but let me do so anyway. I do not think that the modified criteria will be completely changed, but there are some changes in how we diagnose RA that will most likely be reflected in these new criteria.
For example, when the old ACR criteria were developed, we did not have the test for anti-citrullinated-peptide (anti-CCP) antibodies. We realize now that this is an important diagnostic test for RA because it is more specific than other autoantibody tests, and we do use this test in clinical practice a lot now.
I am quite confident that the results of anti-CCP testing will become part of one of the criteria in the revised criteria. It is also possible that given the advances in the use of ultrasound and magnetic resonance imaging as well as plain x-rays to monitor disease activity, that the portion of the criteria that relates to imaging could be revised to include definition of joint damage as imaged by either conventional x-rays or more sophisticated imaging techniques.
These are examples of 2 areas where new criteria would reflect current clinical practice. Beyond that, I am not sure that there are obvious areas where the criteria need to be revised, but this is a process that the expert group is going to look into. They may well come up with some changes that are hard to anticipate prior to execution of the project.
Medscape: In regard to the modification of classification criteria, would it reflect a process for identifying patients earlier on in their disease?
Dr. Fox: That is an important use for classification or diagnostic criteria: to facilitate early identification of important diseases such as RA so that treatment can be initiated before significant damage occurs. The criteria should be usable and understandable for primary care physicians and not just for specialists, because often these patients are presenting to the primary care physician with their complaints.
We certainly encourage early referral of patients with RA to rheumatologists. We feel strongly that all patients with RA need specialty rheumatology care as part of their medical treatment.
I think we have made a lot of progress in the United States in getting patients with RA referred earlier. My sense is that there may be some variation throughout our country in terms of how effective that is and that we still have some further progress that we need to make. I would also suspect that there are variations throughout Europe as well, from country to country, in terms of how effective is the early referral process.
Early referral, initiation of effective treatment, and prevention of joint damage are some of the things that we are interested in as common goals.
Medscape: As we understand it, there are no plans to "fuse" the 2 organizations. However, will the outcome of collaborative projects result in country-specific outcomes? For example, if treatment recommendations for RA are updated, due to differences in prescribing practices between Europe and the United States, should the clinical community expect the revision to contain country-specific recommendations?
Dr. Fox: Remember: We are not doing joint treatment guidelines. We are developing diagnostic and classification guidelines and guidelines on how to measure disease activity and whether a disease has improved sufficiently.
Treatment does differ from country to country for several reasons. First, medications approved for use may differ between the United States and Europe. Also, availability of medications, in terms of whether access is allowed to some of the more expensive treatments, can differ from country to country depending upon the resources available. Within Europe, I understand that there are significant differences -- for example, in access to biologic medications, which can be particularly expensive.
Because of the regulatory differences, the reimbursement differences, and the different structures in the health systems, at this point we are not doing combined treatment guidelines, and we expect that there will be some discrepancies in possible treatments in different parts of the world.
One could argue that this is undesirable and that there should be a uniform clinical standard of treatment worldwide. These disparities become even more striking if one compares, say, sub-Saharan Africa with either the United States or Europe. That is a very important question and it is a global health question. Currently, however, the barriers to doing combined treatment guidelines are significant enough that we are not planning to undertake those in the near future.
Medscape: I assume that the challenges of treating arthritis are the same for all physicians, both in the United States and Europe. In regard to managing RA, what are some of the most significant barriers to its optimal management?
Dr. Fox: The first barrier is to ascertain the cases -- in other words, to get correct diagnosis, or at least identification of possible cases, by primary care physicians and referral to rheumatologists promptly. The patients have to be able to get to a doctor. In some parts of the world, there is no medical care available for people with rheumatic diseases.
Once they get to the doctor, the physician has to recognize that RA, or whatever rheumatic disease one is talking about (lupus, vasculitis, spondyloarthropathy, and so forth), is a possibility. Then appropriate referral has to be made and the specialty care has to be accessible. There have to be enough rheumatologists and other allied health professionals to be able to see the patient expeditiously and to initiate treatment.
There are shortages of rheumatologists in many countries, including the United States, and we are concerned that the shortage is going to get worse. So access to rheumatology care is not uniform in this country and it is not always as prompt as we would like.
Once the specialty care has been accessed and correct diagnosis made, treatment needs to be initiated. In the United States, treatment often depends on the patient's insurance coverage. As you are aware, about 15% of the population has no health insurance, and there are many others with partial health insurance that may be inadequate if they have a serious chronic disease that requires expensive interventions. We are seeing, for example, increasing copays for medications in many insurance plans in the United States, which in some instances is forcing patients to discontinue medications that were controlling their RA.
So there are very significant barriers that exist at multiple levels. In the United States, we are concerned that over the last year or two, some of these barriers may be getting more problematic rather than improving.
Editor's Note:
The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) are key organizations on both sides of the Atlantic for rheumatologists and other healthcare professionals involved in the care of patients with rheumatic diseases. The work of these 2 organizations is complementary rather than contradictory. Accordingly, collaborative work on many initiatives will provide a high-level standardized approach to the optimal treatment of arthritis, nationally and internationally. Ferdinand Breedveld, MD, PhD, presented his perspective on the collaboration in an earlier interview with Medscape. In the interview that follows here, however, Helen Fosam, PhD, of Medscape Rheumatology, spoke with David A. Fox, MD, President of the ACR, for his perspective on this historic collaboration between the ACR and EULAR.
Medscape: The ACR-EULAR collaboration is a historic event. In your opinion, what is the significance and what are the key benefits of this collaboration, both for the ACR and for the care of patients with rheumatic diseases?
Dr. Fox: The ACR-EULAR collaboration will to lead to new criteria for classification of disease and for measuring response to treatment, as well as better standards for conducting clinical trials and measuring the efficacy of clinical trials. I think that the products that we come up with through these projects will be the best because we engage the best expertise possible from both sides of the Atlantic. This, in the long run, should advance research in rheumatic disease as well as advance patient care.
Medscape: Will the collaboration lead to a more unified treatment approach on both sides of the Atlantic?
Dr. Fox: Well, the goal is to avoid the confusion that can arise by using competing or different criteria for disease classification or for measuring clinical responses or responses to treatment. If you had differing criteria, then clinical studies would not be as comparable with each other as if you have uniform criteria; that has been a problem in the past. It has been a little difficult to interpret some of the clinical literature when nonuniform criteria have been used for disease classification or treatment response. The collaboration should bring more clarity to the field because some of the competing criteria are replaced with collaborative criteria.
I should mention, however, that we are not currently doing joint treatment algorithms, and there are specific reasons for that. Dr. Breedveld mentioned some of those in his interview. The projects that ACR and EULAR will work on together will primarily focus on criteria for classifying and diagnosing disease and approaches to measuring treatment response, in both the clinical and research settings.
Medscape: The ACR is a single entity e in which individual clinicians can become members, while EULAR is a collaborative membership of 44 European countries. Will this present challenges to working collaboratively?
Dr. Fox: There are some challenges, but they're not really due to the difference that you have mentioned -- that is, in terms of the ACR being made up of individual members and EULAR being made up of countries. The challenges come from other areas. For example, our budget cycles are on different calendars; EULAR's budget is on a calendar year, while ACR's budget is on a fiscal year that goes from July 1 to June 30.
So when we allocate funds (and, of course, these projects cost money), we have to coordinate our actions in the setting of having different budget years. It is something that we are aware of and can work around, but it does present some minor challenges.
I think another challenge is that the ACR has not only an Executive Committee but also a Board of Directors; our decision-making process is a little bit more lengthy compared with the decision-making process of EULAR, which is run by an Executive Committee. We are trying to get around that and be as efficient as possible, but at times EULAR has had to show some patience while waiting for ACR to go through its appropriate process to make decisions on projects and allocate funds.
Medscape: In his interview, Ferdinand Breedveld, MD, PhD, EULAR's president, summarized the objectives of the collaboration and the working logistics. In regard to joint projects, how are they initiated and taken forward?
Dr. Fox: Both EULAR and the ACR have standing committees composed of members who are responsible for, and have expertise in the development of criteria. On the ACR end, the committee is called the Quality of Care Committee, formerly known as the Quality Measures Committee, and is chaired by Daniel Solomon, MD. EULAR's committee has also recently been renamed: Previously it was the Standing Committee on Clinical Affairs, chaired by Professor Allen Tyndall; the new abbreviation is EULAR Standing Committee for Clinical Affairs (ESCAA).
The ideas for new projects typically arise from these committees and then are subject to approval by the Executive Committees of the organizations and, in the case of the ACR, by the ACR Board. The ACR Quality of Care Committee and the EULAR ESCAA maintain good communication with each other and they discuss possible projects with each other at least twice a year. So when a project idea is being considered, frequently the communication will quickly go back and forth to further develop and refine the idea.
Medscape: Are there project ideas that are developed but do not have a common interest between the ACR and EULAR?
Dr. Fox: We do some projects separately, because for any project there may be more interest in one organization than in another, and that is okay. When there is a coinciding interest, we hope to do all of those together. In some cases, this collaborative work comes together after projects have been initiated separately by each organization. For example, the revised classification criteria for rheumatoid arthritis (RA) is a project that the ACR was planning to work on. EULAR began to work on a similar type of project and invited some ACR members to be part of that project team. Because of the similarity in these project initiatives, EULAR was willing to collaborate and develop a joint ACR-EULAR project. I think that as long as communications are active and open, this is going to work very well. The experts in a field do talk to each other. They go to meetings. They have common interests in advancing knowledge and in improving patient care. They like to work together.
Medscape: Modification of the classification criteria for RA is the first of several upcoming joint publications between the ACR and EULAR. As a result of the collaborative input, how different do you imagine the updated version will be compared with the current ACR classification criteria for RA?
Dr. Fox: It would be a little presumptuous for me to guess at that, but let me do so anyway. I do not think that the modified criteria will be completely changed, but there are some changes in how we diagnose RA that will most likely be reflected in these new criteria.
For example, when the old ACR criteria were developed, we did not have the test for anti-citrullinated-peptide (anti-CCP) antibodies. We realize now that this is an important diagnostic test for RA because it is more specific than other autoantibody tests, and we do use this test in clinical practice a lot now.
I am quite confident that the results of anti-CCP testing will become part of one of the criteria in the revised criteria. It is also possible that given the advances in the use of ultrasound and magnetic resonance imaging as well as plain x-rays to monitor disease activity, that the portion of the criteria that relates to imaging could be revised to include definition of joint damage as imaged by either conventional x-rays or more sophisticated imaging techniques.
These are examples of 2 areas where new criteria would reflect current clinical practice. Beyond that, I am not sure that there are obvious areas where the criteria need to be revised, but this is a process that the expert group is going to look into. They may well come up with some changes that are hard to anticipate prior to execution of the project.
Medscape: In regard to the modification of classification criteria, would it reflect a process for identifying patients earlier on in their disease?
Dr. Fox: That is an important use for classification or diagnostic criteria: to facilitate early identification of important diseases such as RA so that treatment can be initiated before significant damage occurs. The criteria should be usable and understandable for primary care physicians and not just for specialists, because often these patients are presenting to the primary care physician with their complaints.
We certainly encourage early referral of patients with RA to rheumatologists. We feel strongly that all patients with RA need specialty rheumatology care as part of their medical treatment.
I think we have made a lot of progress in the United States in getting patients with RA referred earlier. My sense is that there may be some variation throughout our country in terms of how effective that is and that we still have some further progress that we need to make. I would also suspect that there are variations throughout Europe as well, from country to country, in terms of how effective is the early referral process.
Early referral, initiation of effective treatment, and prevention of joint damage are some of the things that we are interested in as common goals.
Medscape: As we understand it, there are no plans to "fuse" the 2 organizations. However, will the outcome of collaborative projects result in country-specific outcomes? For example, if treatment recommendations for RA are updated, due to differences in prescribing practices between Europe and the United States, should the clinical community expect the revision to contain country-specific recommendations?
Dr. Fox: Remember: We are not doing joint treatment guidelines. We are developing diagnostic and classification guidelines and guidelines on how to measure disease activity and whether a disease has improved sufficiently.
Treatment does differ from country to country for several reasons. First, medications approved for use may differ between the United States and Europe. Also, availability of medications, in terms of whether access is allowed to some of the more expensive treatments, can differ from country to country depending upon the resources available. Within Europe, I understand that there are significant differences -- for example, in access to biologic medications, which can be particularly expensive.
Because of the regulatory differences, the reimbursement differences, and the different structures in the health systems, at this point we are not doing combined treatment guidelines, and we expect that there will be some discrepancies in possible treatments in different parts of the world.
One could argue that this is undesirable and that there should be a uniform clinical standard of treatment worldwide. These disparities become even more striking if one compares, say, sub-Saharan Africa with either the United States or Europe. That is a very important question and it is a global health question. Currently, however, the barriers to doing combined treatment guidelines are significant enough that we are not planning to undertake those in the near future.
Medscape: I assume that the challenges of treating arthritis are the same for all physicians, both in the United States and Europe. In regard to managing RA, what are some of the most significant barriers to its optimal management?
Dr. Fox: The first barrier is to ascertain the cases -- in other words, to get correct diagnosis, or at least identification of possible cases, by primary care physicians and referral to rheumatologists promptly. The patients have to be able to get to a doctor. In some parts of the world, there is no medical care available for people with rheumatic diseases.
Once they get to the doctor, the physician has to recognize that RA, or whatever rheumatic disease one is talking about (lupus, vasculitis, spondyloarthropathy, and so forth), is a possibility. Then appropriate referral has to be made and the specialty care has to be accessible. There have to be enough rheumatologists and other allied health professionals to be able to see the patient expeditiously and to initiate treatment.
There are shortages of rheumatologists in many countries, including the United States, and we are concerned that the shortage is going to get worse. So access to rheumatology care is not uniform in this country and it is not always as prompt as we would like.
Once the specialty care has been accessed and correct diagnosis made, treatment needs to be initiated. In the United States, treatment often depends on the patient's insurance coverage. As you are aware, about 15% of the population has no health insurance, and there are many others with partial health insurance that may be inadequate if they have a serious chronic disease that requires expensive interventions. We are seeing, for example, increasing copays for medications in many insurance plans in the United States, which in some instances is forcing patients to discontinue medications that were controlling their RA.
So there are very significant barriers that exist at multiple levels. In the United States, we are concerned that over the last year or two, some of these barriers may be getting more problematic rather than improving.
