• Rheumatoid arthritis;
  • Specialty referral;
  • Physician communication;
  • Professionalism



Rheumatoid arthritis (RA) is a common, costly, and disabling disease. Early referral and treatment reduce long-term joint damage and improve functional outcomes. Despite efforts to improve referral, half of patients with RA are not referred in a timely manner. Our objective was to explore the factors influencing the decision of a primary care physician (PCP) to refer or not refer a patient with suspected RA, and to identify modifiable factors influencing timely referral.


Using qualitative methods and in-depth, face-to-face interviews, we asked Connecticut PCPs to describe the last patient encounter where they suspected RA and the factors influencing referral and nonreferral. Participants represented a range of clinical experience, access to rheumatologists, and practice settings. Sample size was determined by thematic saturation. Transcripts were coded and analyzed using the constant comparative method of qualitative data analysis.


We interviewed 19 PCPs, 9 of whom were women. Our analysis identified clinical characteristics, patient preferences, access issues, clinical and administrative leadership, physician confidence and expectations, and interpersonal relationships as important domains influencing the referral decision. These domains interacted to impact timely referral and quality of care. Previously underappreciated factors, such as the magnitude of the effect of physician rapport, appeared to be critical in determining whether or not patients are promptly referred.


Issues such as physician rapport, as well as clinical and system issues, influence referral for suspected RA. To improve referral for RA, clinical guidelines, medical education, and quality improvement efforts should address all domains influencing the referral decision.