Patients with rheumatoid arthritis (RA) who have contact with a rheumatologist have better health outcomes than those who do not.1 We found that only 27% of newly suspected cases of RA consulted with a rheumatologist.2 However, this study was based on physician billing data; quality control of diagnostic coding and absence of severity indicators limit the conclusions. We pursued this issue further with patients who had a confirmed diagnosis and were in an early arthritis cohort. We hypothesised that this group would represent a “best case scenario” where the majority would have consulted a rheumatologist within the 3-month recommended window.3 We also explored factors that may be associated with referral, including patient characteristics such as laboratory results (C-reactive protein (CRP), rheumatoid factor),4 5 sociodemographic factors and disease severity,2 6 7 and referring physician characteristics.8

Data were collected from 252 patients in the McGill Early Inflammatory Arthritis Registry. Patients were eligible if they had inflammation in at least one joint for more than 6 weeks but less than 1 year (in the absence of any specific diagnosis other than RA or undifferentiated inflammatory arthritis), were older than 16 years, agreed to complete questionnaires and undergo periodic examinations.

The mean (SD) age of the patients was 56.3 (14.6) years and 173 (68.7%) were female. The mean (SD) time from first episode of symptom onset to consultation with a rheumatologist was 4.4 (2.8) months and the median time was 3.9 months (IQR 2.1–6.3) (fig 1). Only 101 patients (40.1%) were seen by the rheumatologist within 3 months. In bivariate analyses, patients seen by the rheumatologist within 3 months tended to have raised CRP (p = 0.02), not to have a regular family doctor (p = 0.04) and were referred by a specialist (p = 0.02). In the multivariable logistic regression model (table 1), only raised CRP was associated with earlier consultation with a rheumatologist (odds ratio 1.01, 95% confidence interval 1.01 to 1.03).

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Figure 1

Time between onset of arthritis symptoms and first visit to a rheumatologist.

Nearly 60% saw a rheumatologist more than 3 months after symptom onset, which is troubling in view of the nature of this cohort and also since benefits of early consultation have been publicised in the medical community. Those who had a regular family doctor were seen later in the rheumatology department. Specialists are more likely to refer when they recognise that the patient’s problem is not within their domain of expertise, whereas a general practitioner may order tests and continue observing the patient over time. Furthermore, patients who do not have a family doctor probably had contact with a doctor in a walk-in clinic or at the emergency department, who would refer the patient to the rheumatology department for assessment.

Our analyses leave out one important factor—the patient.9 10 There may be hesitation on the part of the patient to seek medical care with a specialist. Moreover, we did not document the wait time from referral to consultation,9 which is particularly relevant in the context of the manpower shortage of Canadian rheumatologists. Efforts to improve arthritis care will probably require multifaceted quality improvement initiatives, including attention to the education of family physicians and patients.9 10