Wednesday, September 28, 2016

Referral Patterns to Pediatric Rheumatology as a Needs Assessment for Curriculum Development

Kyla Driest
Nationwide Children's Hospital

Objective: There is a deficiency of pediatric rheumatologists in the United States.  Many pediatricians will not have easy access to rheumatology consults.  It is important that pediatric residents have a solid foundation in rheumatic and musculoskeletal conditions; however a standardized curriculum does not yet exist for residents on the inpatient rheumatology service at Nationwide Children’s Hospital.  An analysis of the referrals to pediatric rheumatology will be used as a needs assessment for resident curriculum development.

Methods: This mixed methods study involved the analysis of 486 patients referred to the pediatric rheumatology department with appointments from April 2015 to September 2015.  Grounded Theory was utilized as the framework for qualitative analysis.  Reason for referral, laboratory testing, and final diagnosis were all assessed.  For those diagnosed with rheumatologic diagnoses, time to referral was also analyzed.  Group comparisons were assessed using chi-squared and Fischer’s exact tests for categorical variables and Wilcoxon rank sum tests for continuous variables.  

Results: Of the 486 patients referred, mechanical was the most common diagnostic category with 32%.  Rheumatologic diagnoses accounted for 25%.  Of those with a rheumatologic diagnosis 48% had a diagnosis requiring prompt referral.  Only 15% of these patients were seen within 6 weeks of symptom-onset and 35% waited more than one year for referral.  Those with labs listed as a reason for referral had a shorter time to referral than those that did not.  216 patients had a positive ANA ordered by the referring physician with a PPV of only 0.20 for rheumatologic disease.

Conclusion: Significant delays in referral exist in patients with time-sensitive rheumatologic diagnoses.  There appears to be an over-reliance on the ANA and lab testing in general in determining the need for referral.