Delays in access to care in pediatric rheumatology (PR) are well known and may lead to significant morbidity. While barriers in accessing PR care are multifactorial, the literature suggests that incomplete referral letters may contribute to delays in subspecialist assessment. This study aims to describe the content of referral letters to PR at a tertiary care pediatric center, the impact of incomplete referral letters on time to PR assessment, and the proportion of referrals that resulted in a rheumatic diagnosis, all of which have yet to be described.

Methods:

All new referral letters to PR at our centre over an 8-month period were prospectively evaluated during weekly patient triage by 3 PR physicians. Using a validated referrals’ checklist, letters were reviewed for 8 components of a high-quality referral as outlined by hospital policy: rheumatic diagnosis of concern; patient symptoms; investigations; physical examination (mu­sculoskeletal and general); co-morbidities; current and past management; and medications. Referrals for patients >17 years old or previously followed by PR were excluded. Basic patient demographics and referring physician specialty were also collected.

Dates of triage decisions and resultant times to PR visits were recorded. Where incomplete referrals required additional information from referring physicians, we documented when this information was received and the resultant delay in triage time. Final diagnoses were recorded in retrospect.

Results:

Referrals (n=179, 63% female, median age 11.5 years) were received and analyzed from: family doctors (44%); pediatric providers, including subspecialists (43%); and others, e.g., pediatric ENT (13%). The frequency of specific components included in referral letters were: patient symptoms (94%); investigations (65%); diagnosis of concern (57%); medications (48%); musculoskeletal examination (46%); current and past management (41%); co-morbidities (34%); and general examination (27%).

Further information was requested from 33/179 (18%) referral letters regarding one or more of the following components: physical examination (91%); pertinent history (91%); diagnosis of concern (76%); and investigations (36%). Where missing information was requested, the median delay in time to triage was 1.3 weeks (IQR 0.1 – 2.3).

A final diagnosis was documented in 153 referrals, of which 53% had a confirmed rheumatic disease. The proportion of referrals resulting in a rheumatic diagnosis by provider was: 55% of those from pediatric providers; 51% from family doctors, and 52% from others. Referring physician specialty had no significant effect on the likelihood of a referral resulting in a rheumatic diagnosis.

Conclusion:

Pertinent history and physical examination were the most commonly omitted or inadequately described components of referral letters to PR. Requesting missing information resulted in delayed triage. Only about half of PR referrals from all referring physicians resulted in a rheumatic diagnosis. These findings can help guide medical education initiatives for referring physicians in their understanding of PR disease and facilitating access to timely PR care.