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EARLY CONSULTATION WITH A RHEUMATOLOGIST LEADS TO BETTER OUTCOMES FOR PEOPLE WITH RHEUMATOID ARTHRITIS

CHICAGO - Early and appropriate treatment by a rheumatologist may decrease costly interventions —such as orthopedic surgery — in people with rheumatoid arthritis, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Chicago.

Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

Optimal care for RA includes the use of disease-modifying antirheumatic drugs (commonly called DMARDs) to prevent joint damage and decrease the need for future surgery. When used in the treatment of rheumatic diseases, DMARDs are best administered and monitored by rheumatologists, and researchers recently set out to determine if seeing a rheumatologist early in the course RA would prevent people from needing orthopedic surgery.

Led by Debbie Feldman, PhD; full professor, Faculty of Medicine, School of Rehabilitation, Université de Montréal, the research team studied 3,890 people in Quebec with RA from 1995 to 2007. Participants were considered “early consulters” if they were seen by a rheumatologist within three months of being diagnosed with RA by a referring physician. Conversely, participants were considered “late consulters” if they were seen more than three months after the initial diagnosis, and were considered “undetermined consulters” if they were first diagnosed with RA by a rheumatologist.

The majority of participants were women with an average age of 56 years. Most were considered undetermined consulters (73 percent); 13.7 percent were early consulters and 13.3 percent were late consulters.

The researchers used billing codes (codes submitted by physician offices to insurers to report what was done during a patient visit used for medical services reimbursement) to track the progress of each study participant to determine if and when they needed orthopedic surgery during a 12-year time period. Among all the participants, 15.3 percent needed orthopedic surgery during the study.

Participants who consulted a rheumatologist within three months of being first diagnosed by another doctor were almost 40 percent less likely to have had orthopedic surgery compared to those who consulted with a rheumatologist after three months from first diagnosis.

"Using more complex statistical models to account for other factors that may be associated with having surgery —such as age and severity of the disease at diagnosis — we showed that those who consulted later than three months were almost twice as likely to undergo orthopedic surgery as compared with those who consulted a rheumatologist earlier," explains Dr. Feldman.

These findings add more support to other research that shows early treatment with a rheumatologist helps people with rheumatic diseases lead longer, healthier lives and alleviates the need for costly medical treatment. "In addition to improving patient outcomes, this research shows appropriate medical treatment under the supervision of a rheumatologist may also decrease costly interventions such as orthopedic surgery. Our results add more credence to support early treatment guided by a rheumatologist in patients with rheumatoid arthritis," says Dr. Feldman.

The American College of Rheumatology is an international professional medical society that represents more than 8,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Scientific Meeting is the premier meeting in rheumatology. For more information about the meeting, visit www.rheumatology.org/education. Follow the meeting on Twitter by using the official hashtag: #ACR2011.

Editor’s Notes: Debbie Ehrmann Feldman, PhD will present this research during the ACR Annual Scientific Meeting at the McCormick Place Convention Center between 9:00 and 11:00 am on Monday, November 7 in Hall F2. Dr. Feldman will be available for media questions and briefing at 1:30 pm on Tuesday, November 8 in the on-site press conference room, W 175 C.

Learn more about living well with rheumatic disease as well as rheumatologists and the role they play in health care. Also, discover the ACR’s Simple Tasks campaign, which highlights the severity of rheumatic diseases and the importance of early and appropriate referral to a rheumatologist.


Presentation Number: 1546

Early Consultation with a Rheumatologist for Rheumatoid Arthritis: Does It Reduce Subsequent Use of Orthopaedic Surgery?

Debbie Ehrmann Feldman (Université de Montréal, Montréal, QC)
Sasha Bernatsky (McGill UHC/RVH, Montreal, QC)
Michelle Houde (Public Health Department of Montreal, Montreal, QC)
Marie-Eve Beauchamp (McGill UHC/RVH, Montreal, QC)
Michal Abrahamowicz (McGill UHC/RVH, Montreal, QC)

Background/Purpose: 
Optimal care in rheumatoid arthritis (RA) includes early use of disease-modifying anti-rheumatic drugs to prevent joint damage and hopefully decrease surgical interventions.  Our objective was to determine if persons with RA who saw a rheumatologist early in the disease course had a reduced rate of orthopaedic surgery.

Method: 
All persons with a diagnosis of RA confirmed by a rheumatologist and based on billing code data in the province of Quebec, in 1995 were followed until 2007.  Patients were classified as “early consulters” if they were seen by a rheumatologist within 3 months of being diagnosed with RA by their referring physician,  “late consulters” if they were seen by more than 3 months after the initial RA diagnosis, and “undetermined” if they were first diagnosed with RA by a rheumatologist.  Time to orthopaedic surgery, defined using ICD9 and ICD10 procedure codes, was compared with Cox’s proportional hazards regression. 

Result: 
There were 3,890 patients with a confirmed RA diagnosis: mean age at diagnosis was 56.3 years and 69.4% were female.   Most (73%) were “undetermined consulters”; 13.7% were “early” consulters and 13.3% “late” consulters.  Among all patients, 15.3% (610) had an orthopaedic surgery during the observation interval.  Patients in the early consultation group were less likely to undergo orthopaedic surgery over the 12 year follow-up period than those in the late consultation group (adjusted hazard  ratio: 0.63; 95% confidence interval: 0.46, 0.85). 

Conclusion:  Persons diagnosed with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual orthopaedic surgery.  In addition to improving patient outcomes, appropriate medical treatment under the supervision of a rheumatologist may also decrease costly interventions such as orthopaedic surgery.  Our results add more credence to support early treatment guided by a rheumatologist in patients with rheumatoid arthritis.

Disclosure: D. E. Feldman, None; S. Bernatsky, None; M. Houde, None; M. E. Beauchamp, None; M. Abrahamowicz, None.

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