Background/Purpose: Early diagnosis and intervention are central premises in the management of patients with rheumatic diseases. Nevertheless, due to the shortage of rheumatologists, patients are often subject to significant delays before consultation with rheumatology can occur. A shortage of consultants and the large demand for consultations has forced us to review consult requests and determine reasonable time periods for new outpatient referrals. We reviewed new referrals to determine if information provided was sufficient to facilitate appointment allocation and timely consultation.

Methods: We reviewed the records of 300 consecutive referral requests, over 2 months, to our service. Due to a lack of capacity, patients were triaged as routine (3 months), semi-urgent (≤2 months), urgent (≤1 month), or declined. All determinations were reviewed by a second provider (RG) and adjusted as necessary. In our review, we looked for key clinical data defined as: a referral diagnosis, mention of duration and location of pain, a musculoskeletal examination (MSK) mentioning swelling and pain (MSK), laboratory results, specifically RF, CCP, and ANA, and pertinent imaging studies. For purposes of this analysis, we combined the urgent and semi-urgent groups. Logistic regression and multinomial logistic regression were used.

Results: The most common referral diagnosis was connective tissue disease (CTD), which included rheumatoid arthritis and systemic lupus erythematosus (43%), followed by nonspecific musculoskeletal pain (30%). Of the reviewed referrals, 58% were considered routine, 11% were either semi-urgent or urgent and 31% were declined. Information on location and/or duration of pain was provided for 55% of the referrals, examination findings of swelling and/or tenderness were provided for 38%, laboratory tests were provided for 39%, and imaging was provided for only 22%. 77% had data on at least one key clinical feature and this increased the odds of the referral being accepted (“Routine” or “Urgent”) 1.64 (95% CI: [0.93-2.87]) with “Decline” as the reference. In multivariate modeling, MSK, laboratory, imaging and pain data all increased the odds of being accepted. Having information on both MSK elements increased the odds of the referral being accepted (OR=3.58 (95% CI: [1.20, 10.67], p=0.02). Imaging information also improved the odds of the referral being accepted (OR= 2.77 (95% CI: [1.11, 6.92], p=0.02). 

Conclusion: We have found that referrals to our rheumatology practice often provide insufficient information to make the appropriate decisions regarding timely patient care. Targeted key information is critical and must be obtained from the referring health care providers. There is a need to improve communication with referring providers. Standardizing referral protocols can assist in facilitating timely scheduling of referrals, particularly patients with CTD.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/outpatient-consultation-requests-a-failure-to-communicate/