Delays in Rheumatology Referrals Examined in Study


Most patients wait an average of 74 days for a rheumatology referral in Canada, but some wait as long as three years.

For patients with rheumatic disease, catching and treating the disease early is necessary to control disease progression and ultimately, achieve remission.

But a new study, published in the April 25 issue of Arthritis Care & Research, shows that patients seeking first-time referrals to a rheumatologist, don’t always receive timely referrals from their primary care physicians.

Led by Jessica Widdifield, Ph.D., with the Institute for Clinical Evaluative Sciences in Toronto, researchers conducted a review of electronic medical records of patients seeking first-time rheumatology referrals between 2000 and 2013. The study was conducted in Ontario, Canada where, as a publicly-funded universal healthcare system, access to rheumatologists is dependent on referrals.

Researchers set out to characterize referrals from primary care physicians to rheumatologists, the early care management of patients with rheumatic diseases, and the timeliness of care and treatment among a large cohort of patients newly referred to a rheumatologist.  [[{"type":"media","view_mode":"media_crop","fid":"48953","attributes":{"alt":"©igor.stevanovic/","class":"media-image media-image-right","id":"media_crop_1053628482591","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5881","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©igor.stevanovic/","typeof":"foaf:Image"}}]]

The analysis included 2,430 patients whose principal diagnosis was osteoarthritis (32 percent), systemic inflammatory rheumatic disease (31 percent), a regional musculoskeletal condition (16 percent), a chronic pain condition (14 percent), osteoporosis (2 percent) or other (5 percent).

From primary care referral to rheumatologist consultation, most patients waited an average of 74 days (27-101) days or 66 days (18-84) for systemic inflammatory rheumatic diseases.

But in terms of symptom onset to a consult with a rheumatologist, the median time frame included:

- More than 1,000 days or three years for patients with crystal arthropathies, spondylitis, osteoarthritis and chronic pain conditions.

-360 days or more for patients with spondylitis, osteoarthritis and chronic pain conditions.

- More than 100 days for patients with systemic inflammatory rheumatic diseases (except for patients with vasculitis).

Delays in obtaining referrals led to delays in treatment, the study showed. For patients with rheumatoid arthritis, other inflammatory arthritis and psoriatic arthritis, the median time to DMARD treatment from the first rheumatology visit was 56, 152 and 214 days. Within the first year of a visit with the rheumatologist, 37 percent of patients were prescribed medication. Only 36 percent of rheumatoid arthritis patients were prescribed a DMARD within six months of symptom onset; and, 53 percent of rheumatoid arthritis patients were prescribed a DMARD within 12 months of symptom onset.

Prior to seeing a rheumatologist, 40 percent of patients were seen by another specialist for a rheumatic disease complaint (23 percent, allied health professional; 8 percent, orthopedic surgeon; 5 percent, neurologist; 3 percent internist; and, 4 percent were seen in the emergency room.

The systemic inflammatory rheumatic diseases included rheumatoid arthritis (16 percent); other forms of inflammatory arthritis (22 percent); other systemic autoimmune rheumatic diseases (18 percent); crystal arthropathies (16 percent); spondylitis (10 percent); psoriatic arthritis (6 percent); polymyalgia rheumatica (9 percent) and vasculitis (3 percent).

There were several limitations to the study, such as the possibility of differing dates of symptom onset, under-reported treatment in the first year and under-captured laboratory testing.

“Targeted efforts are urgently needed to promote timely rheumatology care for patients with systemic inflammatory rheumatic diseases,” the authors wrote.



Jessica Widdifield, Karen Tu, et al. “Patterns of care among first-time referrals to rheumatologists: Characteristics and timeliness of consultations and treatment in Ontario, Canada.” Arthritis Care & Research. 2016 DOI: 10.1002/acr.22910.



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