Although recent guidelines from the American College of Rheumatology (ACR) stress the need for timely diagnosis and treatment of rheumatoid arthritis (RA), one half of patients with early RA are not referred to rheumatologists in a timely manner. New research suggests that administrative issues, as well as the quality of interpersonal relationships between primary care physicians (PCPs) and rheumatologists, may play a role in referral delays. The new study, which appears in the April 15 issue of Arthritis & Rheumatism, highlights some simple solutions to help break down such barriers.¹

The researchers interviewed 19 Connecticut-based PCPs regarding their last patient who presented with symptoms suggestive of RA and asked them about the factors influencing referral and nonreferral. Transcripts were then coded and analyzed using the constant comparative method of qualitative data analysis. The study identified clinical characteristics such as prior alternative diagnosis, mild disease, slow disease progression, and improvement without treatment as factors that delay the decision to refer patients. In addition, the patient's reaction to a potential diagnosis of RA—eg, demanding a referral or, alternatively, refusing/failing to acknowledge the seriousness of the condition—could impact the PCP's decision to refer. Other factors that could delay the decision to refer a patient to a rheumatologist included busy phone lines; the lack of timely appointments with a specialist; and administrative leadership, within an office or practice, that did not prioritize quality and timeliness. Finally, a PCP's perception of the specialist's competence and relationships between doctors also affected the decision to refer a patient.

These domains interact in a manner that may jeopardize timely referral and quality of care. Moreover, previously underappreciated factors, such as the role of the PCP-specialist rapport, appeared to be critical in determining whether or not patients were promptly referred, the study results demonstrate.

"It was very clear, speaking with PCPs, that there are a range of things that can help, including prioritizing appointments," says lead researcher Lisa G. Suter, MD, a Veteran's Affairs/Robert Wood Johnson (VA/RWJ) special fellow at the VA Connecticut Healthcare System in West Haven, Connecticut, and the Yale University School of Medicine in New Haven, Connecticut. In this regard, picking up the phone is crucial, she says. "A phone call from the PCP to the rheumatologist raises this patient's status to [a] more urgent level." Moreover, it is also effective if the specialist calls the PCP afterward and says, "'I saw your patient today and these are the issues.' This type of communication goes a long way."

Interpersonal relationships and mutual respect can also help. "Making primary care physicians feel like part of the team as opposed to feeling like they are fighting for control of the patient or losing control of the care is helpful," Dr Suter tells CIAOMed. However, "clearly the barrier does not entirely rest on the shoulders of the rheumatologist. Everybody has a responsibility, including the patient, and a lot of the problems have to be addressed by all parties."

But access is not the only problem. "Our study illuminates [the fact] that the process of improving [timely access to specialists] is...very complex," says Dr. Suter. "It's important as rheumatologists to recognize that we are a part of a greater team, and [that] there is a need for cooperation [for an effective] team approach to [quality] care."

Reference

1. Suter LG, Fraenkel K, Holmboe ES. What factors account for referral delays for patients with suspected rheumatoid arthritis? Arthritis Rheum. 2006;55:300-305.