Referral letters to pediatric rheumatology: referral content and impact on triage - an observational study

Referral letters to pediatric rheumatology: referral content and impact on triage - an observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Referral letters to pediatric rheumatology: referral content and impact on triage - an observational study Alexandra Rydz, Fangfang Fu, Zhe Lu, Mark Drew, Dax Rumsey, Yan Yuan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6378332/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Oct, 2025 Read the published version in Pediatric Rheumatology → Version 1 posted 12 You are reading this latest preprint version Abstract BACKGROUND Delays in access to care in rheumatology are well documented. Many factors contribute to these delays and studies in adult populations indicate that incomplete referral letters may play a role. This study aims to describe the content of referral letters to pediatric rheumatology and to investigate the impact of incomplete letters on time to triage and accessing care. FINDINGS Methods: We evaluated referrals to a tertiary care pediatric rheumatology centre for 8 components of comprehensive referral letters. In addition, we compared time-to-triage and percentage of patients receiving rheumatic diagnoses between letters with sufficient content for immediate triage versus incomplete letters requiring further information. Logistic regression models identified factors associated with delayed triage. Results: Further information was requested for 67/447 (15%) referrals, resulting in median delay in time-to-triage of 1.0 week. Delayed triage was associated with 4 factors: lack of musculoskeletal physical examination, referral from family physicians versus other specialty, missing information regarding management, and lack of rheumatic diagnosis of concern. Rheumatic diagnoses resulted from 42% of all referrals overall, specifically from 170/384 (44%) of immediately triaged referrals and 19/63 (30%) of referrals requiring further information. Rheumatic diagnoses resulted less commonly from family doctors’ referrals. CONCLUSIONS Missing important details in referrals to pediatric rheumatology contribute to delayed assessment. These findings can inform initiatives to educate physicians around relevant content of referral letters to facilitate timely access to care. referrals triage access to health care quality improvement Figures Figure 1 BACKGROUND Delays in accessing care in pediatric rheumatology (PR) are well documented ( 1 , 2 ) and multifactorial ( 3 ). Referral letters are one potential contributor to delayed access. Effective triage requires relevant medical history and physical examination, yet these details are often lacking ( 4 – 8 ). Adult rheumatology studies suggest an association between incomplete referral letters and increased wait times ( 9 , 10 ), but little is known about referral letters to PR. Identifying deficiencies in referrals can critically inform educational interventions for referring physicians to optimize patient outcomes. Our study describes the content of referral letters to PR at a tertiary care center and the impact of incomplete referral letters on time-to-triage for PR assessment. FINDINGS Methods New referral letters to PR at a Canadian tertiary care centre were evaluated weekly by pediatric rheumatologists over a 22-month period. Letters were benchmarked against a referrals’ checklist from an existing regional health authority resource ( 11 ), adapted for PR practice by adding musculoskeletal (MSK) examination and suspected rheumatic diagnosis as checklist items. Letters were reviewed for eight components of a high-quality referral: suspected rheumatic diagnosis; patient symptoms; investigations; general physical examination; MSK examination; co-morbidities; current and past management; and medications. Basic patient demographics and referring physician specialty were also collected. Exclusion criteria were age > 17 years at time of referral; previously diagnosed rheumatic disease; and referral description that was clearly non-rheumatic in nature (and thus declined). We calculated a sample size of 450 referrals to have 80% power to detect risk factors for delayed triage with an odds ratio of two. Date of referral receipt, triage decision, and resultant PR appointments were recorded. Time from referral receipt to PR appointment was calculated. Where incomplete referrals resulted in requesting additional information from referring physicians, the resultant delay in triage time was calculated. A multivariable logistic regression model identified factors contributing to delayed triage. Final diagnoses were abstracted from medical records. Three pediatric rheumatologists reviewed all diagnoses independently, then convened to achieve consensus (2/3 agreement) on rheumatic versus non-rheumatic diagnoses. Results Of 536 referrals received and evaluated, 89 were excluded (Figure 1. Flow diagram: referral screening and selection for analysis). The remaining 447 referrals were from family doctors (45%); pediatric specialists and subspecialists (42%); and others (13%), including surgical subspecialists. Almost all referrals (94%) described patient symptoms; 55% and 48% included rheumatologic diagnosis of concern and MSK examination (Table 1. Patient, provider and referral letter characteristics, including final diagnoses stratified by time-to-triage). Overall, 189/447 referrals (42%) resulted in rheumatic diagnoses: inflammatory arthritis (23% of all referrals), autoinflammatory disease (6%), connective tissue disease (3%), vasculitis (1.8%), and other rheumatic diagnoses (0.9%). Rheumatic diagnoses resulted from 49% of pediatrician referrals and 37% of family physician referrals ( p = 0.02). Sixty-seven letters required further information from referring doctors prior to triage and consistently contained fewer referral components than letters triaged immediately (median 2.9 versus 4.4 components, respectively). Additional information was requested regarding pertinent history (91%), musculoskeletal examination (91%), rheumatologic diagnosis of concern (70%), and investigations (46%). Additional information was received for 63/67 letters, resulting in a median delay in time-to-triage of 1.0 week (IQR 0.1 to 2.0, range 34 weeks). Information was received for four of these patients either the same or next day, facilitating immediate triage. Twelve of these 63 referrals (19%) resulted in a diagnosis of inflammatory arthritis. The median delay in time-to-triage for these 12 referrals was five days. The median time to first visit for patients diagnosed with inflammatory arthritis from the delayed triage group was 88 days (IQR 59-140), which was significantly longer compared to those diagnosed with inflammatory arthritis (n = 93) without delayed triage (median 46 days (IQR 26 – 75), p = 0.007). Logistic regression analysis identified four independent factors contributing to delayed triage: a lack of MSK examination (adj. OR = 5.8), referral from family physician versus other specialty (adj. OR = 3.9), missing past or current management information (adj. OR 3.4), and a lack of rheumatic diagnosis of concern (adj. OR 2.4) (Table 2. Influence of missing elements from referral letters and of referring physician type on delayed triage). Patient age and sex, symptoms, general physical examination, and current medications did not affect time-to-triage, after accounting for the four factors listed above. CONCLUSIONS Quality of referral letters to pediatric rheumatology Many referrals to PR lacked information necessary for effective triaging. Approximately 15% of referral letters in our study required further information, resembling the rate of incomplete referrals to pediatric specialists in other studies ( 12 ). Although most referrals described patient histories, MSK examination was only included in half of referrals and was frequently requested for triage in addition to more history. These findings mirror referrals to adult rheumatology, where symptom duration and pattern of joint involvement are commonly omitted ( 4 ). Complete referral letters are critical as they inform specialists’ decision-making for triage. In PR, inflammatory arthritis is a clinical diagnosis, based on history and physical examination. Several factors may contribute to the absence of pertinent histories and physical examinations. Educational gaps in rheumatic diseases may exist among the referring base of practitioners. In our study, referrals from family physicians were less likely to result in rheumatic diagnoses than those from pediatric providers and more often resulted in delayed triage. This likely reflects the decreased exposure family physicians have to pediatric rheumatic disease during their training compared to pediatric providers. Referring physicians who omit pertinent details on initial referral may also lack knowledge of rheumatic diseases to provide requested or relevant details that convey a sense of urgency even after prompting, leading to delayed triage and later appointment dates. A lack of confidence in performing MSK assessments among clinicians in general ( 13 , 14 ) is also recognized. Thus, referring physicians may opt to omit a physical examination rather than risk providing inaccurate examination findings. Finally, lack of details may simply reflect the reality of busy clinical practices. Impact of incomplete referral letters to pediatric rheumatology Requests for information can delay triage. While this study found a median delay of only one week, there is risk of more delayed triage if the referring physician cannot respond promptly. Some of our referrals were delayed much longer. Furthermore, requesting additional information poses a risk of loss to follow-up. In this study, four patients were not assessed because requested information was never submitted. Delayed assessment in patients with inflammatory arthritis contributes to accrual of joint damage and disability. Unlike rheumatic diseases that present with acute symptoms expediting triage (e.g., vasculitis), inflammatory arthritis often presents insidiously. Children may go for weeks, months, or even years before accessing appropriate care. Despite the Arthritis Alliance of Canada’s recommendation that all inflammatory arthritis be identified and treated within four weeks of seeing a health professional, the median time from symptom onset to PR assessment is an estimated 268 days ( 2 ). Patients diagnosed with inflammatory arthritis following an initial incomplete referral letter had longer times to first visit than would be expected based on delayed triage alone. Like other rheumatology centres, inflammatory arthritis accounted for approximately half of the rheumatic diagnoses in this study ( 15 ). This is the first study to our knowledge to examine the content and impact of referral letters on time-to-triage in PR. While some factors associated with delayed triage, e.g., patient demographics, geographic location, cannot be modified, medical trainees and practitioners can be educated on essential components of referral letters and the triage process. At our institution, we actively involve trainees in triaging referral letters, with the goal of informing their future referral writing practices. Vora et al. ( 16 ) recently developed a PR triage algorithm to educate referring doctors on information required to facilitate referral for effective triage. This study has strong internal validity, as it reflected local referral patterns, was adequately powered, and was conducted prospectively at weekly division triage meetings with a group of three physicians. Our findings may not be applicable to other centres due to inter-centre variability in triage processes and diagnoses considered appropriate for triage. Our study did not examine whether dates of initial visits after triage were first available appointments, or if delays were incurred by patient preference, difficulties communicating with referring physicians, or other. Furthermore, our study did not control for occasions where staff rheumatologists discussed referrals via phone call or e-mail, which may have allowed for immediate triage. Finally, our study only evaluated times to in-person appointments, recognizing that with the rise of telehealth during the COVID pandemic that some patients may have virtual consultations sooner now than if they had to be seen in-person only. Incomplete referral letters result in delayed triage in PR. Improving knowledge of pediatric rheumatic disease and MSK examination skills may improve clinical assessments and referral content. Learning to write and triage referrals appropriately, including critical information that informs triage, as an entrustable professional activity will be an invaluable skill for graduating medical trainees. Because family physicians are more likely to refer a patient who ultimately does not receive a rheumatic diagnosis, educational initiatives may be most effective if prioritized for family medicine practitioners. Abbreviations MSK musculoskeletal PR pediatric rheumatology Declarations Ethics approval: Ethics approval was obtained prior to study initiation from the research ethics board, University of Alberta (PRO-00059188). Consent for publication: Not applicable. Availability of data and materials: The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This project was supported by Canadian Rheumatology Association/Canadian Initiative for Outcomes for Rheumatology Care (CIORA) and Women and Children’s Health Research Institute, University of Alberta. Authors' contributions: MC and DR conceptualized and designed the study. AR collected data, trained MD in data collection and input, and drafted the initial manuscript. MD participated in data collection and input. FF and ZL conducted data analyses, under supervision of YY. All authors reviewed the manuscript and approved the final manuscript as submitted. Acknowledgements: The authors would like to acknowledge: Ms. Susan Byer for her administrative assistance with facilitating data collection over the course of this study; Dr. Janet Ellsworth for participating in data collection and assistance in classifying diagnoses as rheumatic; and, Dr. Lillian Lim for participating in data collection. References Foster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A. Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis. Arthritis Care Res. 2007;57:921–7. Shiff NJ, Abdwani R, Cabral DA, Houghton KM, Malleson PN, Petty RE, et al. Access to pediatric rheumatology subspecialty care in British Columbia, Canada. J Rheumatol. 2009;36:410–5. Shiff NJ, Tucker LB, Guzman J, Oen K, Yeung RSM, Duffy CM. Factors Associated with a Longer Time to Access Pediatric Rheumatologists in Canadian Children with Juvenile Idiopathic Arthritis. J Rheumatol. 2010;37:2415–21. Graydon SL, Thompson AE. Triage of referrals to an outpatient rheumatology clinic: Analysis of referral information and triage. J Rheumatol. 2008;35:1378–83. Jack C, Hazel E, Bernatsky S. Something's missing here: A look at the quality of rheumatology referral letters. Rheumatol Int. 2012;32:1083–5. Murphy CL, Sheane B, Durcan L, O'Shea FD, Doran M, Cunnane G. Benefits of pre-referral preparation for rheumatology clinics. Ir Med J. 2013;106:275–7. Murphy E, Mohammad A, Carey JJ, Coughlan RJ. The prevalence of missing data among patient referrals with suspected early inflammatory arthropathies. Ir J Med Sci. 2012;181:68–68. Ukachukwu V, Alam A, Baskar S, Price T, Venkatachalam S. How adequate are rheumatology referral letters? A prospective review of referrals to a secondary care rheumatology service. [abstract] Rheumatol. 2014;53:81–2. Cummins LL, Vangaveti V, Roberts LJ. Rheumatoid arthritis referrals and rheumatologist scarcity: A prioritization tool. Arthritis Care Res. 2015;67:326–31. Myklebust G, Brinkmann GH. First time referral to an out-patient clinic of rheumatology: Is the information of the patient history in the referral letter the main cause to prolonged waiting time in females? [abstract] Ann Rheum Dis. 2013;72:550. Quality Referral Pocket Checklist. [Internet. Accessed April 29, 2019]. Available from: https://www.albertahealthservices.ca/info/page13720.aspx MacGregor D, Parker S, MacMillan S, Blais I, Wong E, Robertson CJ, et al. Innovation in managing the referral process at a Canadian pediatric hospital. Healthc Q. 2009;12:72–9. Hergenroeder AC, Chorley JN, Laufman L, Fetterhoff AC. Pediatric residents' performance of ankle and knee examinations after an educational intervention. Pediatrics. 2001;107:E52. Jandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154:267–71. Feuchtenberger M, Nigg AP, Kraus MR, Schäfer A. Rate of proven rheumatic diseases in a large collective of referrals to an outpatient rheumatology clinic under routine conditions. Clin Med Insights Arthritis Musculoskelet Disord. 2016;9:181–7. Vora SS, Buitrago-Mogollon TL, Mabus SC. A Quality Improvement Approach to Ensuring Access to Specialty Care for Pediatric Patients. Pediatr Qual Saf. 2022;7(3):e566. Tables Table 1. Patient, provider and referral letter characteristics, including final diagnoses stratified by time-to-triage No Delay, n=384 Delay, n=63 P value Patient characteristics Age, mean (SD) 10.5 (4.6) 12.0 (4.1) 0.0153 Sex, n (% Male) 164 (42.7) 26 (41.3) 0.891 Referring physician specialities, n (%) Family medicine 155 (40.4) 47 (74.6) <0.001 Pediatrics 175 (45.6) 13 (20.6) Other 54 (14.1) 3 (4.8) Number of letter components, mean (SD) 4.4 (1.7) 2.9 (1.4) <0. 0001 Letter components, n (%) Rheumatic diagnosis of concern 226 (58.9) 18 (28.6) <0.001 Symptoms 364 (94.8) 56 (88.9) 0.084 Lab investigations 266 (69.3) 41 (65.1) 0.558 Physical examination - musculoskeletal 203 (52.9) 10 (15.9) <0.001 Physical examination – general 116 (30.2) 7 (11.1) 0.001 Current and past management 174 (45.3) 11 (17.5) <0.001 Co-morbidities 161 (41.9) 19 (30.2) 0.096 Current medications 172 (44.8) 20 (31.8) 0.056 Rheumatic diagnosis, n (%) 170 (44.3) 19 (30.2) 0.039 Inflammatory arthritis, n (%) 90 (23) 12 (19) 0.333 Number of further referral letter components requested, mean (SD) NA 2.97 (0.90) NA Further information requested, n (%) History NA 57 (90.5) NA Diagnosis of concern 44 (69.8) Physical examination 57 (90.5) Investigations 29 (46.0) SD: standard deviation NA: not applicable Table 2. Influence of missing elements from referral letters and of referring physician type on delayed triage Missing Elements from Referral Letter Adjusted Odds Ratio (95% CI) P-value Rheumatic diagnosis of concern 2.42 (1.28, 4.57) 0.007 Musculoskeletal physical examination 5.82 (2.79, 12.15) <0.001 Current/ past management 3.38 (1.64, 6.96) 0.001 Referring physician specialities, family physician versus other 3.88 (2.03, 7.43) <0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Oct, 2025 Read the published version in Pediatric Rheumatology → Version 1 posted Editorial decision: Revision requested 28 Jul, 2025 Reviews received at journal 25 Jul, 2025 Reviews received at journal 22 Jul, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviews received at journal 29 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers invited by journal 13 May, 2025 Editor assigned by journal 13 Apr, 2025 Submission checks completed at journal 13 Apr, 2025 First submitted to journal 04 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6378332","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":456108299,"identity":"1216217f-7075-4794-a69e-00b32582c845","order_by":0,"name":"Alexandra Rydz","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Rydz","suffix":""},{"id":456108300,"identity":"1f5d2ce4-ea92-4785-8da8-9c0616ef5088","order_by":1,"name":"Fangfang Fu","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Fangfang","middleName":"","lastName":"Fu","suffix":""},{"id":456108301,"identity":"f0ae6221-7766-4bcc-a3c9-41d92592c7e7","order_by":2,"name":"Zhe Lu","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Zhe","middleName":"","lastName":"Lu","suffix":""},{"id":456108302,"identity":"ee0fd567-8de3-4140-bd60-0d58d4f27a79","order_by":3,"name":"Mark Drew","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Drew","suffix":""},{"id":456108303,"identity":"94bc44da-93be-4dec-b944-f3a4c90968d0","order_by":4,"name":"Dax Rumsey","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Dax","middleName":"","lastName":"Rumsey","suffix":""},{"id":456108304,"identity":"ff2e0d13-de19-4038-b1e7-dc6056ebfecd","order_by":5,"name":"Yan Yuan","email":"","orcid":"","institution":"University of Alberta","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Yuan","suffix":""},{"id":456108306,"identity":"56a1e0a2-04a2-4d37-af1b-9b71c7adc9d7","order_by":6,"name":"Mercedes Chan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYBACg+NnQGSNHJBkI06L5ZkcIFlwzJh4LfY3dIDkB+bEBqK1mN3gPfi5wIAtvX9GAtuDHwx28kRo4UuWnmEgkzvjRgK7YQ9DsmEDYS08BtI8Bmy5G6QT2KQZGA4wEtRicIPH+DePAXO6AVSLPRFadMyAtjAnwLQkEtZyJsfMmsfgmOGM+w/bDXsMkpMJazl+xvg2z58aef6ew8ce/KiwsyWoBQmAPG5AgvpRMApGwSgYBbgBALMzN9m2C9QIAAAAAElFTkSuQmCC","orcid":"","institution":"University of British Columbia","correspondingAuthor":true,"prefix":"","firstName":"Mercedes","middleName":"","lastName":"Chan","suffix":""}],"badges":[],"createdAt":"2025-04-04 18:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6378332/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6378332/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12969-025-01150-y","type":"published","date":"2025-10-10T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82889516,"identity":"1e1c0856-3c91-41ee-a093-d450f5021322","added_by":"auto","created_at":"2025-05-16 12:06:23","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":439311,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram: referral screening and selection for analysis\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6378332/v1/d8fe7268af172501a433edac.jpeg"},{"id":93419451,"identity":"1577871f-685b-42f8-acc0-de9e253f90cd","added_by":"auto","created_at":"2025-10-13 16:00:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1408144,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6378332/v1/84c85de3-f2d2-4952-a436-2250c4464d27.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Referral letters to pediatric rheumatology: referral content and impact on triage - an observational study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDelays in accessing care in pediatric rheumatology (PR) are well documented (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and multifactorial (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Referral letters are one potential contributor to delayed access. Effective triage requires relevant medical history and physical examination, yet these details are often lacking (\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Adult rheumatology studies suggest an association between incomplete referral letters and increased wait times (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), but little is known about referral letters to PR. Identifying deficiencies in referrals can critically inform educational interventions for referring physicians to optimize patient outcomes. Our study describes the content of referral letters to PR at a tertiary care center and the impact of incomplete referral letters on time-to-triage for PR assessment.\u003c/p\u003e"},{"header":"FINDINGS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eNew referral letters to PR at a Canadian tertiary care centre were evaluated weekly by pediatric rheumatologists over a 22-month period. Letters were benchmarked against a referrals\u0026rsquo; checklist from an existing regional health authority resource (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), adapted for PR practice by adding musculoskeletal (MSK) examination and suspected rheumatic diagnosis as checklist items. Letters were reviewed for eight components of a high-quality referral: suspected rheumatic diagnosis; patient symptoms; investigations; general physical examination; MSK examination; co-morbidities; current and past management; and medications. Basic patient demographics and referring physician specialty were also collected. Exclusion criteria were age\u0026thinsp;\u0026gt;\u0026thinsp;17 years at time of referral; previously diagnosed rheumatic disease; and referral description that was clearly non-rheumatic in nature (and thus declined). We calculated a sample size of 450 referrals to have 80% power to detect risk factors for delayed triage with an odds ratio of two.\u003c/p\u003e \u003cp\u003eDate of referral receipt, triage decision, and resultant PR appointments were recorded. Time from referral receipt to PR appointment was calculated. Where incomplete referrals resulted in requesting additional information from referring physicians, the resultant delay in triage time was calculated. A multivariable logistic regression model identified factors contributing to delayed triage. Final diagnoses were abstracted from medical records. Three pediatric rheumatologists reviewed all diagnoses independently, then convened to achieve consensus (2/3 agreement) on rheumatic versus non-rheumatic diagnoses.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eOf 536 referrals received and evaluated, 89 were excluded (Figure 1. Flow diagram: referral screening and selection for analysis). The remaining 447 referrals were from family doctors (45%); pediatric specialists and subspecialists (42%); and others (13%), including surgical subspecialists. Almost all referrals (94%) described patient symptoms; 55% and 48% included rheumatologic diagnosis of concern and MSK examination (Table 1. Patient, provider and referral letter characteristics, including final diagnoses stratified by time-to-triage). Overall, 189/447 referrals (42%) resulted in rheumatic diagnoses: inflammatory arthritis (23% of all referrals), autoinflammatory disease (6%), connective tissue disease (3%), vasculitis (1.8%), and other rheumatic diagnoses (0.9%). Rheumatic diagnoses resulted from 49% of pediatrician referrals and 37% of family physician referrals (\u003cem\u003ep\u003c/em\u003e = 0.02). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixty-seven letters required further information from referring doctors prior to triage and consistently contained fewer referral components than letters triaged immediately (median 2.9 versus 4.4 components, respectively). Additional information was requested regarding pertinent history (91%), musculoskeletal examination (91%), rheumatologic diagnosis of concern (70%), and investigations (46%).\u003c/p\u003e\n\u003cp\u003eAdditional information was received for 63/67 letters, resulting in a median delay in time-to-triage of 1.0 week (IQR 0.1 to 2.0, range 34 weeks). \u0026nbsp;Information was received for four of these patients either the same or next day, facilitating immediate triage. Twelve of these 63 referrals (19%) resulted in a diagnosis of inflammatory arthritis. The median delay in time-to-triage for these 12 referrals was five days. The median time to first visit for patients diagnosed with inflammatory arthritis from the delayed triage group was 88 days (IQR 59-140), which was significantly longer compared to those diagnosed with inflammatory arthritis (n = 93) without delayed triage (median 46 days (IQR 26 \u0026ndash; 75), \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.007).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLogistic regression analysis identified four independent factors contributing to delayed triage: a lack of MSK examination (adj. OR = 5.8), referral from family physician versus other specialty (adj. OR = 3.9), missing past or current management information (adj. OR 3.4), and a lack of rheumatic diagnosis of concern (adj. OR 2.4) (Table 2. Influence of missing elements from referral letters and of referring physician type on delayed triage). Patient age and sex, symptoms, general physical examination, and current medications did not affect time-to-triage, after accounting for the four factors listed above.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQuality of referral letters to pediatric rheumatology\u003c/h2\u003e \u003cp\u003eMany referrals to PR lacked information necessary for effective triaging. Approximately 15% of referral letters in our study required further information, resembling the rate of incomplete referrals to pediatric specialists in other studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Although most referrals described patient histories, MSK examination was only included in half of referrals and was frequently requested for triage in addition to more history. These findings mirror referrals to adult rheumatology, where symptom duration and pattern of joint involvement are commonly omitted (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComplete referral letters are critical as they inform specialists\u0026rsquo; decision-making for triage. In PR, inflammatory arthritis is a clinical diagnosis, based on history and physical examination. Several factors may contribute to the absence of pertinent histories and physical examinations. Educational gaps in rheumatic diseases may exist among the referring base of practitioners. In our study, referrals from family physicians were less likely to result in rheumatic diagnoses than those from pediatric providers and more often resulted in delayed triage. This likely reflects the decreased exposure family physicians have to pediatric rheumatic disease during their training compared to pediatric providers. Referring physicians who omit pertinent details on initial referral may also lack knowledge of rheumatic diseases to provide requested or relevant details that convey a sense of urgency even after prompting, leading to delayed triage and later appointment dates. A lack of confidence in performing MSK assessments among clinicians in general (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) is also recognized. Thus, referring physicians may opt to omit a physical examination rather than risk providing inaccurate examination findings. Finally, lack of details may simply reflect the reality of busy clinical practices.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImpact of incomplete referral letters to pediatric rheumatology\u003c/h3\u003e\n\u003cp\u003eRequests for information can delay triage. While this study found a median delay of only one week, there is risk of more delayed triage if the referring physician cannot respond promptly. Some of our referrals were delayed much longer. Furthermore, requesting additional information poses a risk of loss to follow-up. In this study, four patients were not assessed because requested information was never submitted.\u003c/p\u003e \u003cp\u003eDelayed assessment in patients with inflammatory arthritis contributes to accrual of joint damage and disability. Unlike rheumatic diseases that present with acute symptoms expediting triage (e.g., vasculitis), inflammatory arthritis often presents insidiously. Children may go for weeks, months, or even years before accessing appropriate care. Despite the Arthritis Alliance of Canada\u0026rsquo;s recommendation that all inflammatory arthritis be identified and treated within four weeks of seeing a health professional, the median time from symptom onset to PR assessment is an estimated 268 days (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Patients diagnosed with inflammatory arthritis following an initial incomplete referral letter had longer times to first visit than would be expected based on delayed triage alone. Like other rheumatology centres, inflammatory arthritis accounted for approximately half of the rheumatic diagnoses in this study (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis is the first study to our knowledge to examine the content and impact of referral letters on time-to-triage in PR. While some factors associated with delayed triage, e.g., patient demographics, geographic location, cannot be modified, medical trainees and practitioners can be educated on essential components of referral letters and the triage process. At our institution, we actively involve trainees in triaging referral letters, with the goal of informing their future referral writing practices. Vora et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) recently developed a PR triage algorithm to educate referring doctors on information required to facilitate referral for effective triage.\u003c/p\u003e \u003cp\u003e This study has strong internal validity, as it reflected local referral patterns, was adequately powered, and was conducted prospectively at weekly division triage meetings with a group of three physicians. Our findings may not be applicable to other centres due to inter-centre variability in triage processes and diagnoses considered appropriate for triage. Our study did not examine whether dates of initial visits after triage were first available appointments, or if delays were incurred by patient preference, difficulties communicating with referring physicians, or other. Furthermore, our study did not control for occasions where staff rheumatologists discussed referrals via phone call or e-mail, which may have allowed for immediate triage. Finally, our study only evaluated times to in-person appointments, recognizing that with the rise of telehealth during the COVID pandemic that some patients may have virtual consultations sooner now than if they had to be seen in-person only.\u003c/p\u003e \u003cp\u003eIncomplete referral letters result in delayed triage in PR. Improving knowledge of pediatric rheumatic disease and MSK examination skills may improve clinical assessments and referral content. Learning to write and triage referrals appropriately, including critical information that informs triage, as an entrustable professional activity will be an invaluable skill for graduating medical trainees. Because family physicians are more likely to refer a patient who ultimately does \u003cem\u003enot\u003c/em\u003e receive a rheumatic diagnosis, educational initiatives may be most effective if prioritized for family medicine practitioners.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emusculoskeletal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epediatric rheumatology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained prior to study initiation from the research ethics board, University of Alberta (PRO-00059188).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported by Canadian Rheumatology Association/Canadian Initiative for Outcomes for Rheumatology Care (CIORA) and Women and Children\u0026rsquo;s Health Research Institute, University of Alberta.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMC and DR conceptualized and designed the study. AR collected data, trained MD in data collection and input, and drafted the initial manuscript. MD participated in data collection and input. FF and ZL conducted data analyses, under supervision of YY. All authors reviewed the manuscript and approved the final manuscript as submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge: Ms. Susan Byer for her administrative assistance with facilitating data collection over the course of this study; Dr. Janet Ellsworth for participating in data collection and assistance in classifying diagnoses as rheumatic; and, Dr. Lillian Lim for participating in data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFoster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A. Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis. Arthritis Care Res. 2007;57:921\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiff NJ, Abdwani R, Cabral DA, Houghton KM, Malleson PN, Petty RE, et al. Access to pediatric rheumatology subspecialty care in British Columbia, Canada. J Rheumatol. 2009;36:410\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiff NJ, Tucker LB, Guzman J, Oen K, Yeung RSM, Duffy CM. Factors Associated with a Longer Time to Access Pediatric Rheumatologists in Canadian Children with Juvenile Idiopathic Arthritis. J Rheumatol. 2010;37:2415\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraydon SL, Thompson AE. Triage of referrals to an outpatient rheumatology clinic: Analysis of referral information and triage. J Rheumatol. 2008;35:1378\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJack C, Hazel E, Bernatsky S. Something's missing here: A look at the quality of rheumatology referral letters. Rheumatol Int. 2012;32:1083\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy CL, Sheane B, Durcan L, O'Shea FD, Doran M, Cunnane G. Benefits of pre-referral preparation for rheumatology clinics. Ir Med J. 2013;106:275\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy E, Mohammad A, Carey JJ, Coughlan RJ. The prevalence of missing data among patient referrals with suspected early inflammatory arthropathies. Ir J Med Sci. 2012;181:68\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUkachukwu V, Alam A, Baskar S, Price T, Venkatachalam S. How adequate are rheumatology referral letters? A prospective review of referrals to a secondary care rheumatology service. [abstract] Rheumatol. 2014;53:81\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCummins LL, Vangaveti V, Roberts LJ. Rheumatoid arthritis referrals and rheumatologist scarcity: A prioritization tool. Arthritis Care Res. 2015;67:326\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyklebust G, Brinkmann GH. First time referral to an out-patient clinic of rheumatology: Is the information of the patient history in the referral letter the main cause to prolonged waiting time in females? [abstract] Ann Rheum Dis. 2013;72:550.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuality Referral Pocket Checklist. [Internet. Accessed April 29, 2019]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.albertahealthservices.ca/info/page13720.aspx\u003c/span\u003e\u003cspan address=\"https://www.albertahealthservices.ca/info/page13720.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacGregor D, Parker S, MacMillan S, Blais I, Wong E, Robertson CJ, et al. Innovation in managing the referral process at a Canadian pediatric hospital. Healthc Q. 2009;12:72\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHergenroeder AC, Chorley JN, Laufman L, Fetterhoff AC. Pediatric residents' performance of ankle and knee examinations after an educational intervention. Pediatrics. 2001;107:E52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154:267\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeuchtenberger M, Nigg AP, Kraus MR, Sch\u0026auml;fer A. Rate of proven rheumatic diseases in a large collective of referrals to an outpatient rheumatology clinic under routine conditions. Clin Med Insights Arthritis Musculoskelet Disord. 2016;9:181\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVora SS, Buitrago-Mogollon TL, Mabus SC. A Quality Improvement Approach to Ensuring Access to Specialty Care for Pediatric Patients. Pediatr Qual Saf. 2022;7(3):e566.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Table 1. Patient, provider and referral letter characteristics, including final diagnoses stratified by time-to-triage\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Delay, n=384\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelay, n=63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Age, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10.5 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e12.0 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.0153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Sex, n (% Male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e164 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e26 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferring physician specialities, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Family medicine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e155 (40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e47 (74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Pediatrics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e175 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e13 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Other\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e54 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of letter components, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4.4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.9 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0. 0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLetter components, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eRheumatic diagnosis of concern\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e226 (58.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e18 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eSymptoms\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e364 (94.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e56 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eLab investigations\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e266 (69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e41 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.558\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003ePhysical examination - musculoskeletal\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e203 (52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e10 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003ePhysical examination \u0026ndash; general\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e116 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e7 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"6\"\u003e\n \u003cli\u003e\u003cstrong\u003eCurrent and past management\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e174 (45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e11 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"7\"\u003e\n \u003cli\u003e\u003cstrong\u003eCo-morbidities\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e161 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e19 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003col start=\"8\"\u003e\n \u003cli\u003e\u003cstrong\u003eCurrent medications\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e172 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e20 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRheumatic diagnosis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e170 (44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e19 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Inflammatory arthritis, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e90 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e12 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of further referral letter components requested, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.97 (0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFurther information requested, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;History\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e57 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Diagnosis of concern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e44 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Physical examination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e57 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 292px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;Investigations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e29 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: standard deviation\u003c/p\u003e\n\u003cp\u003eNA: not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Table 2. Influence of missing elements from referral letters and of referring physician type on delayed triage\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing Elements from Referral Letter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Odds Ratio (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRheumatic diagnosis of concern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.42 (1.28, 4.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMusculoskeletal physical examination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5.82 (2.79, 12.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent/ past management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3.38 (1.64, 6.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferring physician specialities, family physician versus other\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3.88 (2.03, 7.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"referrals, triage, access to health care, quality improvement","lastPublishedDoi":"10.21203/rs.3.rs-6378332/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6378332/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDelays in access to care in rheumatology are well documented. Many factors contribute to these delays and studies in adult populations indicate that incomplete referral letters may play a role. This study aims to describe the content of referral letters to pediatric rheumatology and to investigate the impact of incomplete letters on time to triage and accessing care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFINDINGS\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eWe evaluated referrals to a tertiary care pediatric rheumatology centre for 8 components of comprehensive referral letters. In addition, we compared time-to-triage and percentage of patients receiving rheumatic diagnoses between letters with sufficient content for immediate triage versus incomplete letters requiring further information. Logistic regression models identified factors associated with delayed triage.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e Further information was requested for 67/447 (15%) referrals, resulting in median delay in time-to-triage of 1.0 week. Delayed triage was associated with 4 factors: lack of musculoskeletal physical examination, referral from family physicians versus other specialty, missing information regarding management, and lack of rheumatic diagnosis of concern. Rheumatic diagnoses resulted from 42% of all referrals overall, specifically from 170/384 (44%) of immediately triaged referrals and 19/63 (30%) of referrals requiring further information. Rheumatic diagnoses resulted less commonly from family doctors’ referrals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCONCLUSIONS\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMissing important details in referrals to pediatric rheumatology contribute to delayed assessment.\u003cstrong\u003e \u003c/strong\u003eThese findings can inform initiatives to educate physicians around relevant content of referral letters to facilitate timely access to care.\u003c/p\u003e","manuscriptTitle":"Referral letters to pediatric rheumatology: referral content and impact on triage - an observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 12:06:19","doi":"10.21203/rs.3.rs-6378332/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-28T12:00:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-25T19:58:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T12:02:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338771612776657609782519398464136785370","date":"2025-07-16T16:09:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47142047011490426676427884615478239917","date":"2025-07-15T10:34:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T19:51:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126868693039040063021728929402642196642","date":"2025-05-15T19:18:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3795800517846031108034689563576646277","date":"2025-05-13T16:56:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-13T13:31:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-14T01:02:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-14T01:00:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Rheumatology","date":"2025-04-04T18:36:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"541d39d5-875a-4e9e-86a7-1ea161a0feea","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T15:58:43+00:00","versionOfRecord":{"articleIdentity":"rs-6378332","link":"https://doi.org/10.1186/s12969-025-01150-y","journal":{"identity":"pediatric-rheumatology","isVorOnly":false,"title":"Pediatric Rheumatology"},"publishedOn":"2025-10-10 15:56:52","publishedOnDateReadable":"October 10th, 2025"},"versionCreatedAt":"2025-05-16 12:06:19","video":"","vorDoi":"10.1186/s12969-025-01150-y","vorDoiUrl":"https://doi.org/10.1186/s12969-025-01150-y","workflowStages":[]},"version":"v1","identity":"rs-6378332","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6378332","identity":"rs-6378332","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}