A retrospective study of pediatric rheumatology referrals reveals large discrepancies in referring providers’ musculoskeletal exams

Children with inflammatory arthritis face delayed access to care, partially because of a critical provider shortage. This may be further compounded by referrals for joint pain without associated joint swelling. This study aims to investigate referring providers’ chief concern (CC) and musculoskeletal (MSK) exams against pediatric rheumatologists’ final diagnoses (FDx) and MSK exams, hypothesizing that referrals for joint pain would be less likely to be juvenile idiopathic arthritis (JIA). A single-center retrospective study from January 2020 to December 2021 analyzed pediatric rheumatology referrals, examining CC, MSK exam findings by referring providers and pediatric rheumatologists, FDx, and referral visit costs. Primary assessments focused on descriptive statistics of referrals, concordance between MSK exams, and the relationships of CC and MSK exams to FDx. Secondary assessments included a cost analysis of MSK-related visits based on FDx. Of the 1000 referrals, 515 were for MSK concerns, of which, 72% were for joint pain and 28% were for joint swelling; 28% had a FDx of a non-rheumatic musculoskeletal concern (NR-MSK) and 20% had a final diagnosis of JIA. Of the 515 referrals, 33.4% did not have a documented referring provider MSK exam. Referrals for joint pain were more likely to have a FDx of NR-MSK, while referrals for joint swelling were more likely to be JIA (p = 0.0012). Concordance between the referring provider MSK exam and pediatric rheumatologist MSK exam were poor (Kappa = 0.1035). Referral visits with a FDx of NR-MSK incurred average costs of $2,144, while visits with a FDx of JIA incurred average costs of $3,298 (p < 0.001). Over half of pediatric rheumatology referrals were attributed to MSK concerns, and one-third of referrals lacked a documented MSK exam, a crucial step in identifying MSK abnormalities. Targeting educational strategies to improve the ability to distinguish between non-rheumatic causes of joint pain, such as MSK dysfunction, from rheumatic causes of joint pain or swelling, such as JIA, may reduce the number of avoidable pediatric rheumatology referrals. This holds promise in alleviating significant health burden and costs associated with unnecessary investigations and treatments.