New training program expands access to rheumatology care for Native American communities

New research at ACR Convergence 2023, the annual meeting of the American College of Rheumatology (ACR), describes the expansion of a new program to train primary care physicians (PCPs) in the diagnosis and treatment of rheumatoid arthritis (RA) in Native American communities that 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 lack confidence in prescribing RA medications or managing the disease. To help offset 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 treat RA. The goal was to improve outcomes and reduce entrenched disparities in healthcare. This year, the project expanded to tribes in 15 states.

We successfully offered the RA ECHO curriculum three times on the Navajo Nation from 2021-2022. For our fourth cohort – Spring 2023 – we have dramatically expanded our target audience and invited healthcare professionals serving Native American communities across the country to participate.”

Jennifer Mandal, MD, assistant professor at the University of California, San Francisco (UCSF) and director of the RAE Initiative

Mandal says she and her team worked with an organization called Indian Country ECHO to recruit participants for cohort four.

“We knew that Indian Country ECHO’s established lines of communication with tribes across the country would allow us to reach a much broader audience for our RA ECHO program. And indeed, when Indian Country ECHO put out a call for interested health care providers the response was overwhelming in attending our program. Over 100 providers responded that they would like to participate, and after the final dates and times were selected, 50 providers registered,” says Mandal.

Most participants were PCPs, but pharmacists, community health care representatives, and providers from non-primary care settings such as emergency medicine, ophthalmology, and orthopedics also enrolled.

The Spring 2023 program followed the same format as the first three: 12 weekly interactive classes held virtually, with approximately 30 minutes of high-level didactics on key aspects of RA diagnosis and management, followed by case-based discussion. Participants were encouraged to bring their own anonymized patient cases to class. In addition to the weekly sessions, there were also biweekly virtual ‘office hours’, where participants could interact with a panel of rheumatologists.

To measure how successful the training actually was, the RAE Initiative team collected data on PCP responses to tests and surveys. Before and after each of the four programs (cohort five is currently underway), participants completed a medical knowledge test about RA and surveys about their confidence in the diagnosis and treatment of RA on a five-point Likert scale. Starting in cohort three, participants were also asked to rate changes in their own clinical behavior, such as how often they performed joint screening exams or blood tests before starting immunosuppressants.

Pre- and post-intervention scores were available for more than one-third of participants. When data across cohorts were pooled, test scores increased by 26% and PCP confidence increased by more than one point on the Likert scale. Nearly 80% of participants reported that they performed important clinical behaviors related to the diagnosis and treatment of RA “more often” or “much more often” after taking the course.

While the results are encouraging, Mandal says one limitation is that they did not look directly at patient outcomes.

“While the RAE Initiative team hopes to eventually measure patient health data, it is critical to recognize that, due to centuries of exploitation, there is widespread mistrust of requests for access to private medical records in the Navajo community. Before seeking out personal health information, we strive to prioritize respectful and considerate handling of sensitive information, while still striving to achieve our educational and empowerment goals.”

In the meantime, she lists other next steps, including:

• Creating educational materials for RA patients that are culturally and linguistically tailored to the Navajo community
• Organizing in-person training for community health representatives in Navajo Nation to increase awareness about joint health and different types of arthritis
• Creating online training resources for PCPs who want to learn more about common rheumatologic diseases
• Creating a new ECHO training program for spondyloarthritis

Mandal hopes that the RA ECHO program can serve as a model for creating similar rheumatology training programs for other communities with limited access to rheumatologists, saying, “We are eager to collaborate 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.