New research presented at ACR Convergence 2023, the annual meeting of the American College of Rheumatology (ACR), describes the expansion of a novel program to train primary care physicians (PCPs) in the diagnosis and management of rheumatoid arthritis (RA) in Native American communities. Little or no access to rheumatology care (abstract #2455).
Despite the high prevalence of RA and other rheumatologic diseases among Native Americans, many Native American communities lack adequate access to subspecialty care. As a result, the responsibility for treatment has shifted to primary care providers, who often do not feel confident prescribing RA medications or managing the disease. To help address the critical shortage of rheumatologists, the Rheumatology Access Expansion (RAE) Initiative launched RA ECHO (Extension for Community Healthcare Outcomes) in 2021, a 12-week training program to teach Navajo Nation PCPs how to diagnose and manage RA. The goal was to improve outcomes and reduce healthcare disparities. This year, the scheme has expanded to include tribes in 15 states.
We have successfully offered the RA ECHO curriculum on the Navajo Nation three times since 2021-2022. For our fourth cohort — spring 2023 — we greatly expanded our target audience, inviting participation from health care workers serving Native American communities across the country.”
Jennifer Mondal, MD, Assistant Professor at the University of California, San Francisco (UCSF) and Director of the RAE Initiative
Mandal said he and his team partnered with an organization called Indian Country ECHO to recruit participants into four teams.
“We knew Indian Country ECHO’s well-established lines of communication with tribes across the country would allow our RA ECHO program to reach a wider audience. And sure enough, when Indian Country ECHO put out a call for interested health care providers. “When we joined the program, the response was irresistible More than 100 providers responded that they wanted to participate, and once the final date and time were selected, 50 providers enrolled,” said Mondal.
Most participants were PCPs, but pharmacists, community health representatives, and providers from non-primary care settings such as emergency medicine, ophthalmology, and orthopedics were also enrolled.
The Spring 2023 program followed the same format as the first three: 12 weekly interactive classes were held virtually, including approximately 30 minutes of high-level didactic teaching on key aspects of RA diagnosis and management, followed by case-based discussions. Participants were encouraged to bring their own de-identified patient cases to class. In addition to weekly sessions, there were also bi-weekly virtual “office hours,” where participants could interact with a panel of rheumatologists.
To measure how successful the training actually was, the RAE Initiative team compiled data on PCP responses to tests and surveys. Before and after each of the four programs – cohort five is currently underway – participants completed an RA medical knowledge test as well as surveys on their confidence in diagnosing and managing RA on a five-point Likert scale. Beginning in cohort three, participants were also asked to rate changes in their own clinical behavior, such as how often they had joint screening tests or blood tests before starting immunosuppressive medications.
Pre- and post-intervention scores were available for more than one-third of participants. When data were pooled across cohorts, test scores increased by 26% and PCP confidence increased by more than one point on the Likert scale. About 80% of participants reported important clinical behaviors related to RA diagnosis and management “more frequently” or “very frequently” after taking the course.
While the results are encouraging, Mandal says one limitation is that they don’t directly look at patient outcomes.
“While the RAE Initiative team hopes to eventually quantify patient health data, it is important to recognize that, due to centuries of exploitation, there is widespread mistrust of requests for access to personal health records by the Navajo community. Focuses on long term construction. Long-standing trust before seeking personal health information, we strive to achieve our educational and empowerment goals while also aiming to prioritize the respectful and considerate management of sensitive information.”
Meanwhile, he listed other next steps, including:
- Developing culturally and linguistically appropriate RA patient education materials for the Navajo community
- Conducting in-person trainings for community health representatives across the Navajo Nation to spread awareness about joint health and various forms of arthritis.
- Creating online training resources for PCPs who want to learn more about common rheumatologic diseases
- Developing a new eco-training program in spondyloarthritis
Mondal hopes that the RA ECHO program can serve as a model for other communities with limited access to rheumatologists to create similar rheumatology training programs, saying, “We are eager to partner with others who are interested in joining this important mission to expand access to rheumatology care. . “
This work was funded by a grant from the Bristol Myers Squibb Foundation.