The effect of medical therapy on surgery for rheumatoid deformities of the upper extremity

Hypothesis: The medical management of rheumatoid arthritis has dramatically changed with the approval of biologic disease-modifying anti-rheumatic drugs (DMARDs). Today, early initiation of DMARDs is considered standard of care and a quality indicator by many professional societies. Among rheumatologists, surgical intervention is often considered a treatment failure. In contrast, surgeons fear that surgical referrals are delayed, potentially losing the opportunity to achieve a functional and aesthetically pleasing reconstruction for advanced deformities. This study examines the effect DMARDs (biologic and non-biologic) on the rates of RA-related procedures among older adults. We hypothesized that rates of surgery are lower among patients who receive biologic DMARDs. Methods: We examined all fee-for-service claims drawn from the Medicare Beneficiary Summary files between 2006 to 2012, including Part A, Part B, and Part D prescription drug events. We used National Drug Codes to identify the receipt of biologic and non-biologic DMARDs. We applied Current Procedural Terminology and ICD-9 codes to identify RA-related upper extremity procedures for the shoulder, elbow, wrist and hand. We used hierarchical logistic regression to examine the effect of patient-level factors, including the receipt of DMARDs and annual number of rheumatologist visits, and regional factors, including provider density, on rates of upper extremity reconstruction for RA (defined as number of RA patients who received the surgery per 10,000 RA patients per year). Results: In this cohort of 250,453 Medicare Beneficiaries with RA, 2.4% underwent upper extremity procedures, with wide variation across hospital referral regions (0.1% - 2.57%; national average rate=0.9%). (Figure 1) After controlling for other patient and regional-level factors, patients who received biologic DMARDs by infusion (OR=1.63; 95%CI: 1.39-1.93) or injection (OR=1.66; 95%CI: 1.51-1.83) were more likely to undergo upper extremity reconstruction compared with patients who received non-biologic DMARDs or no DMARD therapy (Table 1). Additionally, patients who visited rheumatologists more than 3 times per year were more likely and were maintained on biologics were twice as likely to undergo surgery compared with patients maintained on non-biologic DMARDs or without DMARDs and fewer rheumatologist visits (OR=2.12; 95%CI: 2.01-2.33). Summary Points: • Among older patients, biologic DMARDs do not reduce the need for upper extremity reconstruction. • Given the substantial cost and immunosuppression risk associated with biologicDMARDs, comparative evidence is needed to discernwhich patients will derive benefit frommedical or surgical intervention, and surgeons should continue to play an integral role in the multidisciplinary care of RA patients.