What factors account for referral delays for patients with suspected rheumatoid arthritis?
OBJECTIVE
Rheumatoid arthritis (RA) is a common, costly, and disabling disease. Early referral and treatment reduce long-term joint damage and improve functional outcomes. Despite efforts to improve referral, half of patients with RA are not referred in a timely manner. Our objective was to explore the factors influencing the decision of a primary care physician (PCP) to refer or not refer a patient with suspected RA, and to identify modifiable factors influencing timely referral.


METHODS
Using qualitative methods and in-depth, face-to-face interviews, we asked Connecticut PCPs to describe the last patient encounter where they suspected RA and the factors influencing referral and nonreferral. Participants represented a range of clinical experience, access to rheumatologists, and practice settings. Sample size was determined by thematic saturation. Transcripts were coded and analyzed using the constant comparative method of qualitative data analysis.


RESULTS
We interviewed 19 PCPs, 9 of whom were women. Our analysis identified clinical characteristics, patient preferences, access issues, clinical and administrative leadership, physician confidence and expectations, and interpersonal relationships as important domains influencing the referral decision. These domains interacted to impact timely referral and quality of care. Previously underappreciated factors, such as the magnitude of the effect of physician rapport, appeared to be critical in determining whether or not patients are promptly referred.


CONCLUSIONS
Issues such as physician rapport, as well as clinical and system issues, influence referral for suspected RA. To improve referral for RA, clinical guidelines, medical education, and quality improvement efforts should address all domains influencing the referral decision.
VA Connecticut Healthcare System, and Yale University School of Medicine, IE-61 SHM, c/o RWJ CSP, PO Box 208088, New Haven, CT 06520-8088, USA. lisa.suter@yale.edu
Lisa G
LG
Suter
Liana
L
Fraenkel
Eric S
ES
Holmboe
D001172:Arthritis, Rheumatoid / Q000628:therapy*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010820:Physicians; D011320:Primary Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013997:Time Factors