Background/Purpose: Optimal care for systemic inflammatory rheumatic diseases often hinges upon early referral from primary care physicians (PCP) to rheumatologists. Our aim was to quantify the time from symptom onset (T₀) to 1^st PCP visit related to the complaint (T₁) to PCP referral to rheumatologist (T₂) to 1^st rheumatologist visit (T₃), and to treatment (T₄).

Methods: We employed a novel approach to identify 1^st-time rheumatology referrals from the primary care Electronic Medical Record Administrative data Linked Database (EMRALD), representing comprehensive EMR data from 168 PCPs across Ontario, Canada (32 rural, 39 suburban and 97 urban physicians). Using a standardized data abstraction tool, PCP and rheumatology consultation records were reviewed to identify diagnoses and treatments associated with each referral. Administrative data were used to identify accurate dates of the 1^st rheumatologist visit subsequent to the date of referral identified in the EMR. The time in days from the date of each component of the care pathway was determined overall and for each diagnostic category.

Results: Among 2430 patients with 1^st-time referrals, we identified 745 patients with systemic inflammatory rheumatic diseases (31%): RA (16%), other inflammatory arthritis (22%), connective tissue diseases (18%), gout/crystal arthropathies (16%), spondyloarthropathies (10%), psoriatic arthritis (6%), polymyalgia rheumatica (9%), and vasculitis (3%). Overall, 21% and 70% of patients were seen by rheumatologists within 3 months of symptom onset and PCP referral, respectively. Wait-time measures varied by condition (table). Comparing to established Canadian wait-time measures (target being 100%), only 38% of RA patients were seen within 4 weeks from the date of referral, 63% of AS/SpA patients were seen within 3 months; and 34% of PsA patients were seen within 6 weeks. For RA patients, the median time to be seen by rheumatologists from symptom onset and referral was 327 and 66 days, respectively.  Within the 1^st year, 93% of RA patients had a documented treatment initiated by a rheumatologist, and of these, 95% were prescribed DMARDs, 26% oral steroid, 15% steroid injection, and 6% biologic. The average time to DMARD was 56 days from date of first rheumatology consultation.

Conclusion: Our representative sample of PCPs revealed longer wait-times than previous reports that sampled patients from urban rheumatology clinics and exceed current Canadian recommendations. Most of the delay occurs prior to referral, where targeted efforts are needed to optimize care for more timely consultations.