mutually exclusive proﬁles on a nine-point scale (reference val- ues: 1, inappropriate; 5, uncertain; 9, appropriate). Following the RAND/UCLA deﬁnition, a treatment had to be considered appropriate if the expected beneﬁts exceeded the potential neg- ative consequences by a sufﬁcient margin.12 Financial costs or other potential constraints had to be disregarded. Together with the rating program, the experts received a literature overview of which the scope and boundaries were determined during the ﬁrst meeting. This (electronic) document was rather an exten- sive data overview than a comprehensive synthesis of clinical evidence, and reﬂected the published English-language literature from 1998 to 2008, with a focus on reports with the highest level of evidence. The results of the ﬁrst round were discussed during a plenary meeting (June 2008), leading to a revision of the rating struc- ture and reﬁnement of some treatment options and deﬁnitions (see box 1). Thereafter a second individual rating round took place, including 144 different patient proﬁles and 10 treatment options. Based on the median score and the extent of agreement between the panellists, appropriateness statements (appropri- ate, inappropriate, uncertain) were calculated for all indications, according to common RAND/UCLA rules.13 Indications were deemed appropriate if the median panel score was between 7 and 9, and inappropriate if the median was between 1 and 3, both without disagreement between panellists. Disagreement was deﬁned as a situation in which at least six panellists scored in each of the sections 1–3 and 7–9. All indications not falling in the categories ‘appropriate’ and ‘inappropriate’ were labelled ‘uncertain’. A third panel meeting (November 2008) was organised to discuss the second round results and their applicability in daily clinical practice. The ﬁnal ratings were embedded in an elec- tronic tool that allows quick reference of the appropriateness statements for any of the patient proﬁles included. Concise report Statistical analysis A correlation matrix (using Spearman’s correlation coefﬁcient for ordinal variables) was applied to investigate the agreement between individual ratings, within and across the various speci- alities included. RESULTS Panel results Of all theoretical indications rated in this study, approximately one-third were deemed inappropriate, largely attributable to classic NSAID without proton pump inhibitors (PPI) (see sup- plementary ﬁgure 1, available online only). The percentage of appropriate indications was highest for naproxen plus PPI, fol- lowed by celecoxib alone and ibuprofen/diclofenac plus PPI. The outcomes were uncertain for more than half of the indications, of which approximately a quarter was caused by disagreement (strong opposite opinions), with highest values for naproxen plus PPI and celecoxib with or without PPI. Global ﬁgures show considerable variations in ratings over and within all specialties (supplementary ﬁgure 2, available online only). For the patient proﬁle without any unfavourable conditions, all NSAID without PPI (both classic and C2SI) were considered appropriate (supplementary ﬁgure 1, available online only). The presence of any gastrointestinal risk factors led to inappropri- ate outcomes of classic NSAID alone in the majority of cases. In patients with a low cardiovascular risk and a history of no or uncomplicated upper gastrointestinal events, celecoxib alone and classic NSAID plus PPI were generally favoured over the other options (ﬁgure 1). The combination of low cardiovascular risk and a history of complicated upper gastrointestinal events lowers the appropriateness of C2SI alone and naproxen plus PPI (uncertain). For patients with high cardiovascular risk, naproxen plus PPI showed the highest percentage of appropriate indica- tions (46%) (ﬁgure 1), whereas the other options scored between Box 1 Overview of treatment options, variables and deﬁnitions used in the second rating round ▶ Patient population ▶ Patients with a chronic rheumatic disease for whom treatment with a NSAID is considered ▶ Treatment options ▶ Ibuprofen, diclofenac, naproxen, celecoxib, etoricoxib, all without or with the addition of a PPI ▶ Clinical variables used for the construction of patient proﬁles ▶ Age (<65 years; ≥65 years) ▶ History of upper gastrointestinal events (none; uncomplicated; complicated) ▶ Uncomplicated: previous uncomplicated oesophageal, gastric or duodenal event (eg, signiﬁcant symptoms, ulcer discovered by a clinically indicated work-up); ▶ Complicated: previous complicated oesophageal, gastric or duodenal event (bleeding, obstruction or perforation) ▶ Cardiovascular risk (low; high) ▶ 10-Year risk of fatal cardiovascular disease (heart attack, stroke), based on the (country-speciﬁc) HeartScore of the European Society of Cardiology; low: <10%; high: ≥10% ▶ Use of low-dose aspirin (yes/no; only in patients with high cardiovascular risk)* ▶ Use of anticoagulants or other antiplatelet agents (yes/no) ▶ Anticoagulants: warfarin, acenocoumarol ▶ Antiplatelet agents: other than low-dose aspirin, for example clopidogrel (only in patients with high cardiovascular risk)* ▶ Use of systemic corticosteroids (yes/no) ▶ Treatment pattern (intermittent; continuous) ▶ Intermittent: short-term but repetitive ▶ Continuous: chronic use with standard doses *It is assumed that patients with low cardiovascular risk do not take low-dose aspirin or other antiplatelet agents. Ann Rheum Dis 2011;70:818–822. doi:10.1136/ard.2010.128660 819