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J R Soc Med. 2004 December; 97(12): 611.
PMCID: PMC1079692

Referral criteria in early rheumatoid arthritis

Dr Suresh (September 2004 JRSM1) highlights the importance of early referral in a patient with suspected rheumatoid arthritis or RA-like polyarthritis. As he indicates, the diagnosis is a clinical one and absence of rheumatoid factor (RF) is not informative. Unfortunately, there is reason to think some general practitioners delay referral when the serology is negative. Sinclair and Hull,2 looked at the reasons general practitioners request RF assays and the effect of the result on their subsequent action. The requests were generally backed by appropriate clinical signs of RA; however, 32% of responders believed that a negative RF excluded RA, even in a patient who fulfilled the American Rheumatism Association4 classification criteria. Referrals were made to a consultant rheumatologist in 52% of patients with a positive RF, but 66% of patients with a negative RF would not be referred. In only 1.2–2.5% of instances were patients referred for specialist review on clinical grounds alone. Seronegative RA should account for about 25% of total cases. With 60% of cases seronegative at presentation,5 the above data suggest that a sizeable number of RA patients are being missed. Should RF be removed from the decision-making process? If general practitioners relied wholly on clinical criteria and the RF test was restricted to rheumatologists only, we could expect a large increase in consultant referrals.


1. Suresh E. Diagnosis of early rheumatoid arthritis: what the non-specialist needs to know. J R Soc Med 2004;97: 421-6 [PMC free article] [PubMed]
2. Scott DL. Prognostic factors in early rheumatoid arthritis. Rheumatology 2000;39(suppl 1): 24-9 [PubMed]
3. Sinclair D, Hull RG. Why do general practitioners request rheumatoid factor? A study of symptoms, requesting patterns and patient outcome. Ann Clin Biochem 2003;40: 131-7 [PubMed]
4. Arnett FC, Edworth SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31: 315-24 [PubMed]
5. Emery P. The Dunlop-Dottridge Lecture: prognosis in inflammatory arthritis: the value of HLA genotyping and the oncological analogy. J Rheumatol 1997;24: 1436-42 [PubMed]

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