OBJECTIVE: To describe time to methotrexate (MTX) treatment among patients with a first-time diagnosis of rheumatoid arthritis (RA) in a hospital-based department of rheumatology. METHODS: Using prescription data, we conducted a large cohort study in the County of Aarhus, Denmark, including all patients with a first-time diagnosis of RA. We used Kaplan-Meier estimates to compute the cumulative probability of MTX treatment start with follow-up starting on the date of referral. We defined early treatment start as MTX initiation within 90 days after referral. RESULTS: Among 1516 RA patients, a total of 703 (46%) started MTX treatment during the study period. The overall median time to treatment start was 120 days [interquartile range (IQR) 19-557]. Patients included in 2000-2006 had an earlier MTX treatment start compared with patients included in 1996-1999 [adjusted incidence rate ratio (IRR) 1.83, 95% confidence interval (CI) 1.55-2.16]. Patients with a C-reactive protein (CRP) level>300 nmol/L had an earlier MTX treatment start compared with patients with a moderate CRP level (adjusted IRR 1.36, 95% CI 1.16-1.73). Only 21% of the patients started MTX within 90 days after referral and those were mainly patients included in later years and patients with a high CRP. CONCLUSIONS: The data suggest that reduction in the time to start MTX treatment after referral to hospital could be improved, especially among patients with less severe symptoms. However, our results show that treatment practice in recent years has changed towards an earlier MTX treatment start.