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Much emphasis has been placed on early diagnosis and treatment of rheumatoid arthritis (RA) in order to optimize outcomes for our patients. Numerous studies have identified the clinical and radiological benefits of early initiation of disease-modifying antirheumatic drugs (DMARD)1,2,3,4,5,6, and new American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA appear aimed at identifying RA earlier7. Unfortunately, the practicalities of achieving the goal of early treatment depend on optimal performance of the medical system. There are many hurdles to overcome before a patient with joint symptoms presents to a rheumatologist. First, the patient has to recognize that they have a medical problem that warrants mention to their primary healthcare provider (PCP) and obtain an appointment. We can call this patient delay. Next, the PCP has to recognize that the patient may have an inflammatory arthritis that may benefit from referral to a specialist and complete that referral (PCP delay). Then there may be significant wait time to see the rheumatologist, depending on whether there are early arthritis clinics available, or triage systems in place, to facilitate rapid assessment (rheumatologist delay).Shiff, et al 8 examined the time to referral of pediatric patients in a prospective multicenter Canadian juvenile idiopathic arthritis (JIA) cohort. They examined geographic barriers (distance to specialist), presenting clinical features, family history, ethnicity, and parental education. Fever, South Asian ethnicity, and parental education level were most predictive in their model. An accompanying editorial by Foster and Rapley9 categorized the barriers to referral as … Address correspondence to Dr. Homik; E-mail: joanne.homik{at}ualberta.ca

Who’s Holding Up the Queue? Delay in Treatment of Rheumatoid Arthritis