Patterns of Care Among Patients Referred to Rheumatologists in Ontario, Canada.
Our aim was to characterize referrals to rheumatologists, the early care management of patients with rheumatic diseases, and timeliness of care and treatment.



We conducted a retrospective observational study involving patients with first-time rheumatology referrals between 2000 and 2013 in the primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Referrals were characterized in terms of diagnoses, patient demographics, diagnostic tests, treatment initiated by family physicians and rheumatologists, and other specialists seen prior to rheumatology consultation. Timeliness of referrals, rheumatologist consultations, and treatment were determined overall and for each diagnostic category.



Among 2,430 patients referred to a rheumatologist, 69% were female, with an average age of 53 years. The principal diagnosis associated with the referral included osteoarthritis (32%), systemic inflammatory rheumatic diseases (31%), regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), and other/miscellaneous (5%). Family physicians most frequently prescribed nonsteroidal antiinflammatory drugs/cyclooxygenase 2 inhibitors (38%), and their pre-referral diagnostic testing practice varied considerably. The duration of time from symptom onset to rheumatology consultation varied by diagnoses, with the shortest being for patients with systemic rheumatic diseases; for rheumatoid arthritis (RA), the median time to consultation was 327 days. Most of the delay occurred prior to referral; 36% of RA patients initiated a disease-modifying antirheumatic drug within 6 months of symptom onset.



Approximately 1 in 3 referrals to rheumatologists were for a systemic inflammatory rheumatic disease. We observed substantial delays to rheumatology consultations and variations in patterns of care that could be amenable to quality improvement interventions.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, and McGill University, Montreal, Quebec, Canada.
Jessica
0000-0002-7464-0460
J
Widdifield
Institute for Clinical Evaluative Sciences, University of Toronto, and University Health Network, Toronto Western Hospital Family Health Team, Toronto, Ontario, Canada.
Karen
K
Tu
McGill University, Montreal, Quebec, Canada.
J
J
Carter Thorne
University of Toronto, Toronto, Ontario, Canada.
Claire
C
Bombardier
Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada, and McMaster University, Hamilton, Ontario, Canada.
J
J
Michael Paterson
Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada.
R
R
Liisa Jaakkimainen
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
Laura
L
Wing
University of Toronto and Scarborough Hospital, Toronto, Ontario, Canada.
Debra A
DA
Butt
Institute for Clinical Evaluative Sciences and Women's College Hospital, Toronto, Ontario, Canada.
Noah
N
Ivers
Patient Representative, Ontario, Canada.
Catherine
C
Hofstetter
Patient Representative, Ontario, Canada.
Anne
A
Lyddiatt
William Osler Health Centre, Brampton, Ontario, Canada.
Vandana
V
Ahluwalia
McGill University, Montreal, Quebec, Canada.
Sasha
S
Bernatsky
D000328:Adult; D000368:Aged; D057210:Delayed Diagnosis / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D012017:Referral and Consultation; D012189:Retrospective Studies; D012216:Rheumatic Diseases / Q000175:diagnosis* / Q000453:epidemiology*; D000072140:Rheumatologists; D012219:Rheumatology / Q000706:statistics & numerical data*