Early Consultation With a Rheumatologist for RA
Objective. Optimal care in RA includes early use of DMARDs to prevent joint damage and hopefully decrease the need for costly surgical interventions. Our objective was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course.
Methods. We studied persons who had a diagnosis of RA based on billing code data in the province of Quebec in 1995, and for whom the initial date of RA diagnosis by a non-rheumatologist could be established before the confirmatory diagnosis by the rheumatologist. We followed these patients until 2007. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 3 months of being diagnosed with RA by their referring physician. The outcome, orthopaedic surgery, was defined using International Classification of Diseases (ICD) procedure codes ICD9 and ICD10. Multivariate Cox regression with time-dependent covariates estimated the effect of early consultation on the time to orthopaedic surgery.
Results. Our cohort consisted of 1051 persons; mean age at diagnosis was 55.7 years, 68.2% were female and 50.7% were early consulters. Among all patients, 20.5% (215) had an orthopaedic surgery during the observation interval. Early consulters were less likely to undergo orthopaedic surgery during the 12-year follow-up period (adjusted hazard ratio 0.60, 95% CI 0.44, 0.82).
Conclusion. Persons with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual requirement for orthopaedic surgery.
The importance of early referral of patients with RA to specialists is underscored by the evidence that early therapy with DMARDs (usually administered under the direction of a rheumatologist) is associated with improved outcomes in RA patients. Compared with specialists, family physicians are less likely to make correct or timely diagnoses of musculoskeletal diseases and are not as likely to manage them appropriately. Quality of care and health outcomes are better for RA patients who have contact with a relevant specialist such as a rheumatologist than for those who do not consult with one. However, there are problems regarding access and prompt treatment for RA.
Demonstration of long-term benefits of early consultation will generate awareness and highlight the necessity of finding solutions to the problems of access to rheumatologists for those with RA. Although early use of DMARDs is associated with less joint damage, long-term outcomes such as orthopaedic surgery have not been examined in the context of earlier consultation with a rheumatologist. Orthopaedic surgery, and in particular joint replacement, is costly and may be considered as an indicator of failure of medical treatment. Successful medical treatment of RA would target progression of joint destruction and ideally lead to a decrease in the need for orthopaedic surgery.
The objective of this study was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course compared with those who were seen later. Specifically, we hypothesized that early vs late rheumatology consultation may reduce the need for orthopaedic surgery in persons with newly diagnosed RA.
Abstract and Introduction
Abstract
Objective. Optimal care in RA includes early use of DMARDs to prevent joint damage and hopefully decrease the need for costly surgical interventions. Our objective was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course.
Methods. We studied persons who had a diagnosis of RA based on billing code data in the province of Quebec in 1995, and for whom the initial date of RA diagnosis by a non-rheumatologist could be established before the confirmatory diagnosis by the rheumatologist. We followed these patients until 2007. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 3 months of being diagnosed with RA by their referring physician. The outcome, orthopaedic surgery, was defined using International Classification of Diseases (ICD) procedure codes ICD9 and ICD10. Multivariate Cox regression with time-dependent covariates estimated the effect of early consultation on the time to orthopaedic surgery.
Results. Our cohort consisted of 1051 persons; mean age at diagnosis was 55.7 years, 68.2% were female and 50.7% were early consulters. Among all patients, 20.5% (215) had an orthopaedic surgery during the observation interval. Early consulters were less likely to undergo orthopaedic surgery during the 12-year follow-up period (adjusted hazard ratio 0.60, 95% CI 0.44, 0.82).
Conclusion. Persons with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual requirement for orthopaedic surgery.
Introduction
The importance of early referral of patients with RA to specialists is underscored by the evidence that early therapy with DMARDs (usually administered under the direction of a rheumatologist) is associated with improved outcomes in RA patients. Compared with specialists, family physicians are less likely to make correct or timely diagnoses of musculoskeletal diseases and are not as likely to manage them appropriately. Quality of care and health outcomes are better for RA patients who have contact with a relevant specialist such as a rheumatologist than for those who do not consult with one. However, there are problems regarding access and prompt treatment for RA.
Demonstration of long-term benefits of early consultation will generate awareness and highlight the necessity of finding solutions to the problems of access to rheumatologists for those with RA. Although early use of DMARDs is associated with less joint damage, long-term outcomes such as orthopaedic surgery have not been examined in the context of earlier consultation with a rheumatologist. Orthopaedic surgery, and in particular joint replacement, is costly and may be considered as an indicator of failure of medical treatment. Successful medical treatment of RA would target progression of joint destruction and ideally lead to a decrease in the need for orthopaedic surgery.
The objective of this study was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course compared with those who were seen later. Specifically, we hypothesized that early vs late rheumatology consultation may reduce the need for orthopaedic surgery in persons with newly diagnosed RA.