Nikiforou, E; (2013) Orthopaedic Intervention in Rheumatoid Arthritis: a retrospective analysis of incidence, prognostic markers and costs. Doctoral thesis , UCL (University College London).

Abstract

Background: Orthopaedic surgery in Rheumatoid Arthritis (RA) is an established intervention of long-term disease and a surrogate marker of joint destruction. Methods: This thesis examines orthopaedic data from the Early RA Study (1986-1999, 9 centres, n=1465) and the Early RA Network (2002-2012, 23 centres, n=1236) with linkage to national datasets (Hospital Episode Statistics, National Joint Registry and Office of National Statistics). Clinical and laboratory measures and hand and foot radiographs were standardised and performed yearly in both cohorts. Disease modifying, glucocorticosteroid and biologic therapies reflected conventional practice and guidelines of the time frames examined. Recruitment years were grouped into 6 periods, interventions classified into major, intermediate and minor categories. Cost analysis was based on the Norfolk Arthritis Register (1989-date, n>5000). Results: A total of 1602 surgical procedures were performed in 770 patients (29%). Declines in the rates of hand/foot surgery from 1986-2011 (p<0.001) coincided with secular changes in therapy. No secular variation was seen for large joint replacements. Low haemoglobin predicted shorter time to both major and intermediate surgery (p<0.001). There were declines in median length of stay over time for large, intermediate and minor procedures (8,3,1 days respectively). The mean annual direct health cost per RA patient was £3,430 (over 50% representing medications). The COI of RA in England was estimated at £1.46 billion. Conclusions: This study has compiled the largest, longest and most extensively linked RA- related orthopaedic surgery database in the UK. The declines in intermediate-type surgery during recruitment periods where early and intensive treatments were employed, suggests the impact of these treatments. The thesis demonstrates the predictive power of standard clinical measures in the first year of disease on orthopaedic surgery up to 25 years later. It demonstrates the high economic burden of RA and could be used as a basis for future cost- effectiveness and cost-benefit analyses.

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