1485 Loza, et al: Orthopedic surgery in Spain Personal non-commercial use only. The Journal of Rheumatology Copyright © 2007. All rights reserved. Variability in the Use of Orthopedic Surgery in Patients with Rheumatoid Arthritis in Spain ESTIBALIZ LOZA, LYDIAABÁSOLO, DANIEL CLEMENTE, RUTH LÓPEZ-GONZÁLEZ, LUIS RODRÍGUEZ, CRISTINAVADILLO, BENJAMIN FERNÁNDEZ-GUTIÉRREZ, PILAR MACARRÓN, JUANA. JOVER, and CÉSAR HERNÁNDEZ-GARCÍA ABSTRACT. Objective. To analyze sociodemographic and clinic-associated factors of patients with rheumatoid arthritis (RA) undergoing any orthopedic surgery (AOS) and total joint replacement (TJR) in Spain. Methods. A retrospective medical record review was performed in a probabilistic sample of 1379 RA patients from 46 centers distributed in 16 of 19 regions in Spain. Sociodemographic and clinical fea- tures, use of drugs, and arthritis-related joint surgeries were recorded following a standardized proto- col. Gross domestic product (GDP) data were obtained from the National Statistical Index. Results. Of 1379 patients, a total of 358 (26%) underwent one or more joint surgeries, and 194 (14%) had a TJR. The median time to first orthopedic procedure was 12.5 years from presentation of RA and the estimated rate was 5.6 surgeries per 100 person-years. The rate of AOS was increased in women, patients with RA with extraarticular complications, with longterm RA (> 10 yrs), with functional grade III-IV, and with persistent inflammatory disease. The risk factors for undergoing a TJR were longterm RA, functional grade III-IV, and extraarticular complications. Patients from regions with higher GDP per capita were more likely to undergo a procedure. Conclusion. Clinical variables reflecting disease activity and severity are predictors of orthopedic sur- gery, but geographic and socioeconomic variables were also independently associated with the rate of orthopedic surgery. (First Release June 1 2007; J Rheumatol 2007;34:1485–90) Key Indexing Terms: RHEUMATOIDARTHRITIS ORTHOPEDIC SURGERY VARIABILITY From the Servicio de Reumatología, Hospital Clínico San Carlos, Madrid, Spain. Supported in part by Novartis Pharmaceutics, Barcelona, Spain. E. Loza, MD; L. Abásolo, MD; D. Clemente, MD; R. López-González, MD; L. Rodríguez, MD; C. Vadillo, MD; B. Fernández-Gutiérrez, MD, PhD; P. Macarrón, MD; J.A. Jover, MD, PhD; C. Hernández-García, MD, PhD, Servicio de Reumatología. Address reprint requests to Dr. C. Hernández-García, Servicio de Reumatología, Hospital Clínico San Carlos, Calle Profesor Martín Lagos s/n, 28040 Madrid, Spain. E-mail: chernandez.hcsc@salud.madrid.org Accepted for publication March 6, 2007. Rheumatoid arthritis (RA) is a chronic inflammatory muscu- loskeletal disorder, with a high prevalence 1 and a great impact on patients in terms of pain, disability, and life expectancy 2,3 . It is currently assumed that early diagnosis and aggressive treatment improve RA outcomes. However, progressive joint destruction continues in some patients, who will require orthopedic surgery during their disease course 4 . The use of orthopedic interventions in RA, particularly large joint replacement, is considered a marker of disease severity 5 , and an indicator of medical management failure 6 . Therefore, patients undergoing an orthopedic surgery have a worse prog- nosis related to disability and quality of life; and as well cre- ate a high demand on healthcare resources and social servic- es, with great socioeconomic consequences 7-9 . As in other health conditions, the use of healthcare resources and indications of procedures would be mainly driv- en by patient- and disease-related characteristics. However, the medical service provided is often found to be strongly influenced by subjective factors related to the attitudes of indi- vidual physicians, institution organization, and/or healthcare service features. Use of orthopedic surgery for RA in Spain is not exten- sively documented, and only a few studies in rheumatology settings have been carried out 7 . There are no systematic records or hospital registries of orthopedic surgical procedures for RA, and general knowledge about them is low, even among health professionals. We investigated the rate of orthopedic surgical procedures in patients with RA in Spain, and examined sociodemograph- ic and clinic-related factors associated with the use of ortho- pedic procedures in this population. MATERIALS AND METHODS Study design, patient sample, and data acquisition. The emAR study (“Estudio Sobre El Manejo de la Artritis Reumatoide” or study on the man- agement of rheumatoid arthritis) was a cross-sectional study designed to assess variability in the management of RA in Spain 10 . It comprised a proba- bilistic sample of medical records of individuals aged ≥ 16 years diagnosed with RA who were followed at specialized healthcare units. Based on previ- ous reports of our group 7 , with accuracy of 5% and an error rate of 5%, we calculated a minimum sample requirement of 1085 medical records of patients that, assuming 15% losses and 15% incomplete records, entailed ran- domization of 1550 medical records. A proportion of one medical record per 25,000 inhabitants was taken (roughly 125 patients with RA according to prevalence rates for the Spanish population).