10 Clinical guidelines for management

Guidelines provide explicit recommendations and seek to influence practice using a formal process to disseminate advice on most effective management in the light of scientific evidence. They provide a framework for the evaluation and treatment of common clinical problems, but are not intended to replace clinical judgement. There is considerable variation in rheumatology practice, fuelled by uncertainty about the optimal measurement of disease outcome. Guidelines can help identify and eliminate ineffective or unnecessary care as they are systematically developed statements to assist practitioners and patients' decisions about appropriate health care. There are North American guidelines for: the initial evaluation of adult patients with acute musculoskeletal symptoms, the management of rheumatoid arthritis and the management of osteoarthritis. These are discussed together with proposed guidelines for the management of early rheumatoid arthritis and areas of research into the value of guidelines. It is recommended that future work in this area should: (i) identify aspects of current guidelines which are directly related to outcome; (ii) educate clinicians in these aspects of care; (iii) ensure they are introduced into practice and the outcome of care subsequently improves; (iv) regularly update the guidelines to reflect current opinion. Present guidelines that give broadly similar recommendations from North American and UK perspectives. However, the available evidence all points to large variations between how clinicians practise and how they make their decisions and it may be unlikely that laying down exact recipes for practice will necessarily influence the clinician. Guidelines may appear relevant but they could prove to have very limited utility.