colleagues, which he summarized for the committee at the workshop. They were unable to demonstrate significant differences between RA patients treated in fee-for-service (FFS) relationships and those treated in prepaid group practice health maintenance organizations (HMOs). All patients received some care from a specialist (rheumatologist). This finding is consistent with a larger body of data from studies of chronic diseases other than RA and SLE, although the data presented by Tarlov suggest that this may not hold true for certain vulnerable subsets of the chronically ill. The committee notes that lack of evidence for an effect does not constitute evidence for the absence of an effect, but the essentially negative answer to the first of the four questions in the charge would seem to rule out meaningful responses to questions 2 and 3, since they presuppose a positive answer to question 1. The rest of this chapter is therefore organized as a series of conclusions that the committee feels are justified by the current state of knowledge, and as recommendations for research that flow from these conclusions. The reader is referred to relevant portions of the workshop proceedings as appropriate. However, the committee was selected to bring a wide spectrum of experience and knowledge to bear on the task of answering these questions, and its conclusions and recommendations reflect the committee's own expertise as well as the data and opinions provided to it by the workshop's invited speakers and other participants. The committee alone bears full responsibility for the conclusions and recommendations.

Conclusion 1

Rheumatoid arthritis and systemic lupus erythematosus are very likely to be representative of a large number of chronic diseases that will increasingly come to dominate U.S health care. The study of systems of care for chronic diseases such as RA and SLE demands integrated research and longitudinal studies, despite the inherent limitations imposed by changing health care practices, physician and patient characteristics, population demographics, and limited funds.

Recommendation: The committee recommends that the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) seek additional funding to expand its research to include substantial support for high-quality studies that would allow a broad approach more closely linking scientific and technological advances to clinical trials, outcomes research, and health services research more generally. Although some of the required research is of the sort currently funded by the Agency for Health Care Policy and Research (AHCPR), there is much to be said for



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