title: Early consultation with a rheumatologist for RA: does it reduce subsequent use of orthopaedic surgery?
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).
  
  
  CONCLUSIONS
  Persons with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual requirement for orthopaedic surgery.
authors.affiliation: CRIR, IRSPUM, Université de Montréal, Montréal, Québec H3C 3J7, Canada. debbie.feldman@umontreal.ca
authors.forename: Debbie Ehrmann
authors.initials: DE
authors.lastname: Feldman
authors.forename: Sasha
authors.initials: S
authors.lastname: Bernatsky
authors.forename: Michelle
authors.initials: M
authors.lastname: Houde
authors.forename: Marie-Eve
authors.initials: ME
authors.lastname: Beauchamp
authors.forename: Michal
authors.initials: M
authors.lastname: Abrahamowicz
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000601:surgery / Q000628:therapy*; D015331:Cohort Studies; D018450:Disease Progression; D061345:Early Medical Intervention / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D011792:Quebec; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012219:Rheumatology / Q000706:statistics & numerical data*; D013997:Time Factors