Background/Purpose: Recently, there has been an increase in referrals to Pediatric Rheumatology (PR) for non-specific symptoms and test results rather than clearcut inflammatory and/or autoimmune disease. This increases time spent on non-rheumatologic conditions by the already limited number of PRs. There are approximately 450 PR in the US; a 16% decrease in workforce by 2030 is predicted. This will not be an adequate number of PR to give sufficient care to the number of children referred. Referrals to PR often lack essential information, leading to delayed evaluations, unnecessary testing, and increased healthcare utilization. High quality referral documentation is crucial to expedite care and optimize outcomes. This study aims to evaluate quality and completeness of referrals to our PR center from 2021 to 2023. 

Methods: A retrospective chart review was conducted of all new patient referrals from 2021 to 2023. Referrals were assessed for completeness and quality of key elements and proposed diagnoses. Quality was assessed on five factors (clarity, appropriateness, clinical history, physical exam (PE), and testing) using descriptive criteria and qualitative scoring: good, fair, or poor. Associations between referral quality, provider specialty and training, and ultimate diagnoses were analyzed using descriptive statistics and Chi-square tests. IRB approval was obtained.

Results:
A total of 1345 charts were identified.  257 charts were excluded mainly due to duplications (7), no referral (154), internal referral (48), and previous diagnoses (39). Of the 1088 charts included, 52% scored “poor” in at least one domain; 18.38%, 23.71% and 28.95% scored “poor” in documentation of clinical history, PE, or inclusion of relevant test results, respectively.  

In the total population, compared to advanced practice providers (APP), physicians were statistically significantly more likely to have referral clarity rated ‘good’ (χ²= 6.8644, p< 0.05).  Among the two most common referring specialties, pediatrics (n=802) and family medicine (n=117), there were no significant differences in referral quality – nor between APPs and physicians within either specialty. However, of the pediatric and family medicine referrals, 53% and 48%, respectively, scored “poor” in at least one domain.  Rheumatologic diagnoses were ultimately made in 40% of all referrals.  These charts were more likely to be scored ‘good’ for appropriateness of the referral (χ²= 26.3724, p< 0.00001). 

Conclusion: Referral quality to PR is highly variable, with frequent omission of essential details and poor quality among key elements. Referrals leading to non-rheumatologic diagnoses take time away from evaluation of patients with rheumatic diagnoses from the limited number of PR.  Standardized referral templates and provider education, especially regarding clarity of diagnostic concerns, may improve the quality of referrals and streamline specialty care delivery.   

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/identification-of-challenges-in-the-quality-of-referrals-to-a-pediatric-rheumatology-center-a-retrospective-chart-review/