PC1002: Evaluation of Factors Influencing Successful Completion of a Pediatric Rheumatology Evaluation After Primary Referral

Background: Referral and access to a pediatric rheumatologist and initiation of treatment can improve disease outcomes and quality of life. According to a 2017 Institute for Healthcare Improvement report, breakdowns in the referral process can lead to delays in diagnosis and treatment, resulting in missed or delayed diagnosis with subsequent treatment delays. Factors associated with decreased likelihood of both scheduling and attendance of pediatric subspecialty appointments after referral include public insurance and lower median income by zip code. This analysis aims to identify gaps in clinical care specifically for pediatric rheumatology referrals by assessing demographic factors associated with scheduling and attendance of appointments.

Methods: We conducted a retrospective, cross-sectional chart review of all referrals meeting criteria over a six-month period from August 10, 2021 to February 10, 2022 at a large, urban academic medical center. All referrals for children and adolescents aged 0 to equal to or less than 21 years from urgent care sites, primary care sites, or the emergency department to pediatric rheumatologists within the health care system were considered. Descriptive statistics were used to describe patient and family characteristics for referred patients. The Fischer’s Exact, Chi Squared, and Mann Whitney U tests were used for bivariate analysis.

Results: We reviewed 192 referrals. 82.8% of appointments were scheduled and 91.8% of those were attended within 90 days. Overall, 146 (76%) patients who received a referral completed it. There were no significant associations observed between a scheduled referral and a completed referral and the patient’s age, race, ethnicity, zip code median income, sex, or preferred language. However, lack of insurance was associated with not initiating or completing a rheumatology referral (Table 1; p< 0.01). For those patients who scheduled a subspecialty visit, public insurance was associated with not showing up at the rheumatology visit (Table 2; p=0.02).

Conclusion: There is an association between the attendance of appointments and completion of referrals based on insurance category. Patients who do not have insurance are less likely to complete their referrals. For those patients that schedule their referral visit, patients with Medicaid are less likely to show up to the appointment. Having insurance increases access to pediatric rheumatologists. Additionally, this analysis suggests that practice managers need to focus on eliminating attendance barriers, particularly for their patients with Medicaid even once the appointment has been scheduled.