Rheumatology training program for Native American primary care physicians expands reach

New research at ACR Convergence 2023, the American College of Rheumatology's (ACR) annual meeting, 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 that have little or no access to rheumatology care.

Despite the high prevalence of RA and other rheumatologic diseases among Native Americans, many Native American communities lack adequate access to subspecialized care. As a result, responsibility for treatment has shifted to primary care providers, who often do not feel confident prescribing RA medications or managing the disease.

To help compensate for the critical shortage of rheumatologists, the Rheumatology Access Expansion (RAE) Initiative launched RA ECHO (Extension for Community Healthcare Outcomes) in 2021, which is a 12-week training program to teach Navajo Nation PCPs to diagnose and manage RA. The goal was to improve outcomes and reduce entrenched health care disparities. This year, the project expanded to include 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 greatly expanded our target audience, inviting health care workers serving Native American communities across the country to participate," says Jennifer Mandal, MD, an assistant professor at the University of California, San Francisco (UCSF) and director of the RAE Initiative.

Mandal says she and her team partnered with an organization called Indian Country ECHO to recruit participants for the fourth cohort.

"We knew that Indian Country ECHO's well-established lines of communication with tribes all over the country would allow us to reach a much broader audience for our RA ECHO program. And sure enough, when Indian Country ECHO put out a call for health care providers interested in attending our program, the response was overwhelming. Over 100 providers responded that they would like to participate, and once the final dates and times were selected, 50 providers enrolled," Mandal says.

Most participants were PCPs, but pharmacists, community health 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, which included about 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 de-identified patient cases to the class. In addition to the 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—the fifth cohort is currently underway—participants completed an RA medical knowledge test as well as surveys about their confidence in RA diagnosis and management on a five-point Likert scale. Beginning with the third cohort, participants were also asked to rate changes in their own clinical behavior, such how often they performed joint screening exams or ran blood tests before starting immunosuppressive drugs.

Pre- and post-intervention scores were available for more than one-third of participants. When data was pooled across cohorts, test scores increased by 26%, and PCP confidence went up more than a point on the Likert scale. Nearly 80% of participants reported performing important clinical behaviors related to RA diagnosis and management "more frequently" or "much more frequently" after taking the course.

Although the results are encouraging, Mandal says one limitation is that they didn't look directly at patient outcomes.

"While the RAE Initiative team hopes to measure patient health data eventually, it is crucial to acknowledge that due to centuries of exploitation, there is widespread mistrust of requests for access to private health records in the Navajo community. By focusing on building long-lasting trust before seeking personal health data, we aim 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 RA patient education materials that are culturally and linguistically tailored to the Navajo community
• Hosting in-person training for community health representatives across Navajo Nation to spread 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 in spondyloarthritis

Mandal hopes 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 partner with others who are interested in joining this important mission to expand access to rheumatology care."