Keele Research Repository

Objectives
National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This infrequently occurs. We aimed to identify modifiable barriers to early referral of suspected rheumatoid arthritis (RA) patients amongst English GPs.

Methods
National cross-sectional survey of 1,388 English GPs (RA-QUEST study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals, and secondary care access. Data were captured using 10-point visual analogue scales (VAS), 5-point Likert scales, yes/no questions, or free-text, and were analysed descriptively.

Results
Small joint swelling and pain were most influential in diagnosing RA (91% and 84% rated these of 4 or 5 importance on 5-point Likert scale, respectively); investigations including rheumatoid factor (RF; 61% rating 4 or 5) and anti-CCP (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organising further tests opted to test for RF.

Conclusion
For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations like RF.