The Journal of Rheumatology 2003; 30:12 2700 From the Child Health Evaluation and Research (CHEAR) Unit, Ann Arbor, Michigan; and the Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. Supported by the Arthritis Foundation. G.L. Freed, MD, MPH; S. Jee, MD; L. Spera, MS; S.J. Clark, MPH, Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan; L. Stein, MD, Department of Pediatrics, University of North Carolina at Chapel Hill. Address reprint requests to Dr. G.L. Freed, Division of General Pediatrics, University of Michigan, 300 NIB 6E08, Ann Arbor, MI 48109-0456. E-mail: gfreed@med.umich.edu Submitted January 22, 2003; revision accepted May 13, 2003. Juvenile rheumatoid arthritis (JRA) is the most common rheumatic disease in children, with an incidence of 9–20 cases per 100,000 1-4 . Early diagnosis and appropriate treat- ment of JRA is critical to minimize deformity and to maxi- mize normal growth 5 . Patients with chronic diseases are usually first brought to medical attention in the offices of their primary care physi- cians, who often refer them to subspecialists for subsequent care 6-8 . We examined the patterns of referral among primary care pediatricians (PD) and family physicians (FP) for JRA. Prior studies have identified differences between PD and FP in terms of chronic disease management for conditions such as childhood depression 9,10 . These differences have been described with respect to medication use and treatment strategies for children with mental health issues 11,12 . The most common reason for PD to refer their patients to subspecialists is for advice on diagnosis and manage- ment 13,14 . While many studies have examined reasons for primary care physicians to refer to subspecialists 15-17 , few have delineated the similarities and differences between PD and FP regarding the referral process for their patients with specific chronic diseases, and none for JRA. Information in this area is important for determining the current and plan- ning the future physician workforce necessary to care for children with a variety of chronic conditions, including rheumatologic disorders. Much work has been done comparing PD and FP with respect to outpatient manage- ment of immunizations 18-21 , pediatric emergencies 22,23 , counseling 24-26 , antibiotic prescribing 27,28 , and the manage- Comparing the Self-Reported Referral and Management Preferences of Pediatricians and Family Physicians for Children with Juvenile Rheumatoid Arthritis GARY L. FREED, SANDRA JEE, LEONARD STEIN, LAURA SPERA, and SARAH J. CLARK ABSTRACT. Objective. The symptoms of juvenile rheumatoid arthritis (JRA) are often first recognized by primary care physicians. Little is known about the determinants of the initial management and referral patterns of these physicians for children with JRA. We compared the self-reported prefer- ences and practices of pediatricians (PD) and family physicians (FP) in the diagnosis and manage- ment of children with JRA. Methods. Surveys were mailed to a national random sample of 700 PD and 867 FP. Questions included prior experience with JRA, usual patterns in the diagnosis and management of JRA, percep- tion of the need for guidelines for referral and management of this condition, and physician demo- graphic information. Data analysis included univariate and bivariate analysis. Results. Response rates were 69% for PD and 49% for FP. Most respondents had seen very few JRA cases in the previous 5 years. Only 1% of respondents reported that they provided all diagnosis and management for patients with JRA. Forty-two percent of PD and 32% of FP refer all JRA diagnosis and management to subspecialists, while 46% of PD and 61% of FP refer only to confirm the diag- nosis and guide initial therapy (p = 0.011). More PD than FP (PD 92% vs FP 76%; p = 0.001) referred patients with JRA to pediatric rheumatologists, while more FP than PD referred to general rheumatologists (PD 17% vs FP 37%; p = 0.001). The majority of FP reported feeling more comfort- able managing rheumatologic disease in adults than children (82%). Few respondents felt that they were up to date on the latest advances in JRA treatment (PD 10% vs FP 4%; p = 0.024). Conclusion. Multiple factors may contribute to physicians’ referral practice, including a patient’s clinical status and the physician’s beliefs of inadequacy of training and inability to stay up to date. The pattern of care that children with JRA receive likely will be influenced by initial presentation to a PD or to a FP. (J Rheumatol 2003;30:2700–4) Key Indexing Terms: ARTHRITIS PEDIATRICIAN FAMILY PHYSICIAN TREATMENT Personal, non-commercial use only. The Journal of Rheumatology Copyright © 2003. All rights reserved. www.jrheum.org Downloaded on October 4, 2021 from