Implementation of evidence-based practice in rheumatology: the Egyptian guidelines for rheumatic diseases—an approach towards making better use of evidence to improve healthcare

Clinical guidelines, also called clinical practice guidelines, consensus statements, clinical standards, and care maps, as well as decision analyses, is an approach to optimize patients’ care in a given clinical scenario. Traditionally, medical practice and patients’ management was based on the healthcare professional own personal experience and knowledge. On another front, formal policies issued by the administration or governing bodies have outlined the absolute frame and boundaries of adequate clinical practice [1]. Clinical guidelines tackle the grey area in between these two, hence, its value for standard clinical practice.

The management of rheumatic diseases requires a holistic approach, and whilst control of disease activity is clearly the major goal, attention should also be given to general health and mental wellbeing as well as functional, educational, social, and economic status of the patients. Therefore, clinical guidelines are not only considered an educational tool but also a format for enhancing informed decision-making by the treating health care professionals. Over time, the clinical guidelines scope has got wider to target several goals: to guide and inform clinicians, particularly in a landscape of changing therapeutics; to define ‘best care’ through processing of the best available scientific evidence and broad consensus; also, to simultaneously point out where there is little information to guide treatment decisions; to reduce inappropriate variation in care and set standards for quality control; to promote efficient use of resources; and to highlight the research required to be done to inform future care [2]. In addition, the guidelines would be of value also for regulatory bodies, health-related organizations and interested patients’ groups/laypersons.

The vital value for clinical guidelines in rheumatology is the evidence of a broad pattern of practice in the day-to-day rheumatology services. In standard clinical care, variation of rheumatological therapeutic approaches has been reported even in common clinical setups, e.g. the use of disease modifying drug and biologic therapy in rheumatoid arthritis [3, 4] as well as management of other connective tissue diseases such as systemic lupus erythematosus and psoriatic arthritis patients [5]. Such variations in practice patterns have been attributed to several factors, including the concern of prescribing new therapies without preceding personal experience and the limited evidence to support a specific solitary intervention or economic factors linked to the request of diagnostic tests as well as financial reimbursement for the high-cost medications. These variations may carry both efficacy as well as cost implications. Physicians who prefer to prescribe the older, less efficacious medications may limit the clinical enhancement that their patients should experience. On the other hand, healthcare professionals who advocate new therapies for all their patients may drive up the cost the healthcare encounter without clear evidence for improved efficacy [6].

As Egypt has launched a nationwide universal health coverage in 2020, setting up guidelines for management of patients is vital to the process. So far, there are no published clinical guidelines for rheumatology practice in Egypt. The ‘Clinical, Evidence-based, Guidelines (CEG)’ initiative protocol was launched by the Egyptian Academy of Rheumatology and approved the local ethical committee. The overarching objective of was to develop an up-to-date consensus, evidence-based, clinical practice guidelines for treat-to-target management of variable rheumatic diseases. The main strengths of the developed guidelines are related to the diversity as well as the expertise of the participants and the high levels of consensus achieved, as well as the agreement with the most recently published treatment recommendations, in the meantime meeting the Egyptian standards being one of the low- and middle-income countries (LMIC). Also, the Patient/Population, Intervention, Comparison, Outcomes and Time (PICOT) approach was adopted to identify the key clinical questions and statements included in the guidelines. This would enhance the impact of the guidelines for both the patients as well as rheumatologists. By ensuring the optimum standards of care, all patients living with variable rheumatic diseases would have the right to equitable access to the highest quality of clinical care, based on current evidence and delivered by appropriately resourced and experienced multidisciplinary teams. These standards of care are designed to help and support both the patients and their families and the treating healthcare professional teams as well as the health authorities. Although framed for Egypt, it is hoped that these guidelines will be an addition and of valuable for rheumatology specialists across the globe.

This theme issue provides ‘gold standard’ clinical guidelines which support evidence-based rheumatology clinical practice in Egypt. The guidelines grow out of the collaborative efforts of several experienced rheumatologists. Adopting the treat-to-target approach in the 6 guidelines published in this issue as well as the consensus attained ensures that the guidelines are firmly embedded in standard clinical practice and cover areas where there is clinical uncertainty and where mortality or morbidity can be reduced. All guidelines are published under an ‘open access’ licence to help spreading the word and sharing the experience not only nationally but also at the international level, hoping that they also would be of help to rheumatologists and patients as well as health authorities across the globe.