Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data

Jessica Widdifield; Sasha Bernatsky; J. Carter Thorne; Claire Bombardier; R. Liisa Jaakkimainen; Laura Wing; J. Michael Paterson; Noah Ivers; Debra Butt; Anne Lyddiatt; Catherine Hofstetter; Vandana Ahluwalia; Karen Tu

doi:10.9778/cmajo.20150116

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Table 1: Comparison of EMRALD study physicians and all primary care physicians in Ontario as of Mar. 31, 2014

Characteristic	No. (%) of physicians*
Characteristic	EMRALD physicians n = 168	All primary care physicians in Ontario† n = 8054
Sex
Female	94 (56.0)	3333 (41.4)
Male	74 (44.0)	4721 (58.6)
Age, yr
< 35	25 (14.9)	500 (6.2)
35-44	57 (33.9)	1643 (20.4)
45-54	36 (21.4)	2425 (30.1)
55-79	46 (27.4)	3471 (43.1)
Unknown	4 (2.4)	15 (0.2)
Medical training location
Canada	150 (89.3)	5967 (74.1)
Elsewhere/unknown	18 (10.7)	2087 (25.9)
Practice location
Rural	32 (19.0)	608 (7.5)
Suburban	39 (23.2)	1313 (16.3)
Urban	97 (57.7)	6133 (76.1)
Practice model
FHG or FHN	18 (10.7)	2795 (34.7)
FHO	136 (81.0)	3525 (43.8)
Other/unknown	14 (8.3)	1734 (21.5)
Age, yr, mean (range)	46.6 (28-69)	52.2 (27-79)
Years in practice, mean (range)	15.2 (1-36)	18.5 (0-45)
Years since graduation, mean (range)	19.9 (3-43)	26.3 (2-65)

Note: EMRALD = Electronic Medical Record Administrative data Linked Database, FHG = Family Health Group, FHN = Family Health Network, FHO = Family Health Organization.

*Unless stated otherwise.

†Primary care physicians whose practice was focused on primary care were defined as having a main specialty of general practice/family practice or community medicine/public health.

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Table 2: Patients' mean age and sex, by diagnosis at time of referral

Diagnosis	No. of patients	Age, yr, mean ± SD	Female, no. (%)
All patients	2430	53.0 ± 16.3	1682 (69.2)
Osteoarthritis	787	56.4 ± 15.6	554 (70.4)
Systemic inflammatory rheumatic disease	745	53.4 ± 17.0	427 (57.3)
Rheumatoid arthritis	120	55.4 ± 15.8	84 (70.0)
Inflammatory arthritis, other	167	50.9 ± 16.2	95 (56.9)
Crystal arthropathy	122	61.3 ± 15.3	33 (27.0)
Spondylitis/spondyloarthropathy	76	41.5 ± 15.2	31 (40.8)
Psoriatic arthritis	44	52.9 ± 12.6	26 (59.1)
Polymyalgia rheumatica	66	71.2 ± 9.2	41 (62.1)
Vasculitis	19	52.7 ± 23.5	10 (52.6)
Other systemic autoimmune rheumatic disease	131	45.3 ± 13.9	107 (81.7)
Regional musculoskeletal syndrome	395	52.2 ± 15.8	286 (72.4)
Chronic pain condition	346	46.5 ± 14.3	298 (86.1)
Osteoporosis	45	62.3 ± 15.2	38 (84.4)
Other	112	46.3 ± 16.3	79 (70.5)

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Table 3: Main reasons for declined referrals

Reason	No. (%) of patients n = 2430
Patient declined or missed consultation after first referral sent	68 (2.8)
Symptoms resolved	6 (8.8)
Patient choice	21 (30.9)
Patient unavailable/missed appointment	26 (38.2)
Rheumatologist declined consultation after first referral sent	87 (3.6)
Consulted only for certain conditions	23 (26.4)
Rheumatologist suggested alternative plan (e.g., pain clinic, another specialist)	21 (24.1)
No reason provided	19 (21.8)
Not accepting new patients	10 (11.5)

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Table 4: Wait time from date of referral to rheumatologist consultation

Diagnosis	No. of patients	No. (%) seen by rheumatologist within:						Wait time, d, median (IQR)	Wait time percentile, d*
Diagnosis	No. of patients	4 wk	6 wk	3 mo	6 mo	9 mo	12 mo	Wait time, d, median (IQR)	50th	90th
All patients	2430	579 (23.8)	846 (34.8)	1414 (58.2)	1839 (75.7)	1963 (80.8)	2015 (82.9)	74 (27-101)	57	170
Osteoarthritis	787	168 (21.3)	249 (31.6)	454 (57.7)	601 (76.4)	640 (81.3)	661 (84.0)	73 (30-103)	62	174
Systemic inflammatory rheumatic disease	745	242 (32.5)	333 (44.7)	496 (66.6)	597 (80.1)	629 (84.4)	643 (86.3)	66 (18-84)	43	155
Rheumatoid arthritis	120	46 (38.3)†	57 (47.5)	85 (70.8)	95 (79.2)	101 (84.2)	104 (86.7)	66 (15-81)	37	166
Inflammatory arthritis, other	167	59 (35.3)†	85 (50.9)	117 (70.1)	133 (79.6)	139 (83.2)	143 (85.6)	55 (17-71)	38	128
Crystal arthropathy	122	33 (27.0)	51 (41.8)	78 (63.9)	101 (82.8)	107 (87.7)	108 (88.5)	69 (24-93)	52	156
Spondylitis/ spondyloarthropathy	76	17 (22.4)	24 (31.6)	48 (63.2)†	63 (82.9)	65 (85.5)	65 (85.5)	62 (29-91)	58	146
Psoriatic arthritis	44	11 (25.0)	15 (34.1)†	26 (59.1)	38 (86.4)	42 (95.4)	43 (97.7)	88 (30-117)	56	189
Polymyalgia rheumatica	66	31 (47.0)	36 (54.5)	47 (71.2)	54 (81.8)	57 (86.4)	58 (87.9)	53 (11-64)	27	131
Vasculitis	19	10 (52.6)	12 (63.2)	14 (73.7)	14 (73.7)	15 (78.9)	15 (78.9)	28 (11-39)	16	71
Other systemic autoimmune rheumatic disease	131	35 (26.7)	53 (40.5)	81 (61.8)	99 (75.6)	103 (78.6)	107 (81.7)	62 (22-83)	46	137
Regional musculoskeletal syndrome	395	99 (25.1)	145 (36.7)	240 (60.8)	307 (77.7)	323 (81.8)	330 (83.5)	68 (26-94)	53	152
Chronic pain condition	346	51 (14.7)	88 (25.4)	161 (46.5)	236 (68.2)	263 (76.0)	271 (78.3)	90 (35-125)	72	204
Osteoporosis	45	NR‡	NR‡	9 (20.0)	24 (53.3)	28 (62.2)	28 (62.2)	82 (74-156)	118	183
Other	112	16 (14.3)	27 (24.1)	54 (48.2)	74 (66.1)	80 (71.4)	82 (73.2)	69 (40-110)	69	175

Note: IQR = interquartile range, NR = not reportable.

*The 50th percentile reflects that 50% of the patients had seen a rheumatologist within this time frame and 50% were still waiting; the 90th percentile reflects that 90% of patients had seen a rheumatologist within this time frame and 10% were still waiting.

†Benchmark target = 100%.

‡Suppressed to protect privacy.

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Table 5: Median wait time from symptom onset to rheumatologist consultation for systemic inflammatory rheumatic diseases*

Variable	Rheumatoid arthritis n = 101	Inflammatory arthritis, other n = 147	Crystal arthropathy n = 97	Spondylitis/ spondylo-arthropathy n = 56	Psoriatic arthritis n = 35	Polymyalgia rheumatica n = 60	Vasculitis n = 18	Other systemic autoimmune rheumatic disease n = 96
Median wait time (IQR), d
Symptom onset to primary care visit†	173 (16-189)	102 (10-112)	188 (4-192)	716 (14-730)	228 (17-245)	63 (14-77)	128 (3-131)	208 (14-222)
Primary care visit to referral‡	115 (14-128)	125 (11-136)	353 (20-373)	173 (7-181)	513 (15-528)	123 (15-138)	73 (7-80)	181 (7-188)
Symptom onset to referral	326 (49-375)	259 (41-300)	1326 (48-1374)	1342 (63-1405)	627 (90-7167)	238 (55-293)	293 (33-325)	855 (44-899)
Referral to rheumatologist consultation§	66 (15-81)	55 (17-71)	69 (24-93)	62 (29-91)	88 (30-117)	53 (11-64)	28 (11-39)	62 (22-83)
Symptom onset to rheumatologist consultation	327 (83-410)	260 (91-350)	1312 (111-1423)	1262 (112-1374)	680 (125-805)	240 (81-321)	608 (59-667)	940 (113-1053)
No. (%) of patients seen by rheumatologist within:
3 mo from symptom onset	24 (24)	31 (21)	15 (15)	8 (14)	NR¶	17 (28)	NR¶	16 (17)
6 mo from symptom onset	42 (42)	67 (46)	34 (35)	19 (34)	12 (34)	32 (53)	7 (39)	29 (30)
9 mo from symptom onset	50 (50)	86 (59)	44 (45)	22 (39)	15 (43)	38 (63)	8 (44)	40 (42)
12 mo from symptom onset	60 (59)	97 (66)	46 (47)	23 (41)	17 (49)	43 (72)	10 (56)	45 (47)

Note: IQR = interquartile range, NR = not reportable.

*Analyses confined to patients with date of symptom onset captured in their medical record.

†Defined as first documentation of the complaint within the primary care medical record.

‡Defined as the date the referral was sent to the rheumatologist.

§Defined as the first visit to the rheumatologist.

¶Suppressed to protect privacy.

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Table 6: Median wait time from referral to rheumatologist consultation, by patient's health service planning region (LHIN)

LHIN no.	LHIN	No. (%) of patients	Median wait time (IQR), d	No. of rheumatologists in 2009/10	No. of rheumatologists per 100 000
13	North East	190 (7.8)	55.0 (37.0-92.0)	< 6	0.2
3	Waterloo Wellington	405 (16.7)	77.5 (28.0-105.5)	< 6	0.5
1	Erie St. Clair	NR*	NR*	< 6	0.7
5	Central West	90 (3.7)	103.0 (41.0-144.0)	< 6	0.8
12	North Simcoe Muskoka	224 (9.2)	77.5 (25.5-103.0)	< 6	0.8
9	Central East	184 (7.6)	46.3 (32.0-78.3)	12	0.9
14	North West	NR*	NR*	< 6	1.0
2	South West	182 (7.5)	146.5 (34.3-180.8)	9	1.1
6	Mississauga Halton	29 (1.2)	65.0 (17.0-82.0)	11	1.2
8	Central	365 (15.0)	72.3 (27.0-99.3)	18	1.3
10	South East	13 (0.5)	125.2 (30.8-156.0)	6	1.4
4	Hamilton Niagara Haldimand Brant	67 (2.8)	71.2 (24.3-95.5)	19	1.6
11	Champlain	166 (6.8)	112.2 (49.8-162.0)	19	1.8
7	Toronto Central	509 (20.9)	59.0 (15.0-74.0)	50	5.2
-	All Ontario regions	2430 (100.0)	74.0 (27.0-101.0)	162	1.5