Jennifer Mandal, MD
Implementation of a primary care provider training program could improve care for rheumatoid arthritis in underserved populations, according to new data from the Rheumatology Access Expansion (RAE) Initiative.
Presented at the American College of Rheumatology (ACR) Convergence 2022, results of the study demonstrate the development and implementation of the 12-week rheumatoid arthritis training program improved provider knowledge as well as self-confidence in diagnosis and management of rheumatoid arthritis among primary care providers caring for patients on Navajo Nation.
“The United States faces a critical shortage of rheumatology providers, and this deficit is expected to worsen dramatically over the next decade. In addition, racial and ethnic minorities, particularly Black, Latinx, and Indigenous people, often face longer delays in diagnosis and treatment and [have] less access to rheumatology care,” said lead investigator Jennifer Mandal, MD, an assistant professor at the University of California, San Francisco (UCSF) and director of the RAE Initiative, in a statement from the ACR.
Although most fields in medicine report a shortage of clinicians, the situation regarding the declining membership in the rheumatology workforce is among the direst. Few places are this more evident than on Navajo Nation, where a single rheumatologist serves 250,000 tribal members. As a result, primary care providers within Navajo Nation have been tasked with carrying a greater degree of the community’s rheumatoid arthritis burden than most communities. As a result of this predicament, investigators conducted a needs assessment of Navajo Area primary care providers to guide the building of an interdisciplinary team of rheumatologists, a pharmacist, and Navajo cultural interpreters to design a 12-week training program that came to be known as the RAE Initiative.
As part of the training program, investigators conducted weekly interactive webinars consisting of a didactic followed by a rheumatoid arthritis case discussion. Participating primary care providers completed surveys before and after the course, with questions within these surveys pertaining to the provider’s self-reported confidence in diagnosis and management as well as a rheumatoid arthritis medical knowledge test. Of note, the investigators’ questions related to confidence were group into 3 domains: rheumatoid arthritis diagnosis, rheumatoid arthritis management with conventional DMARDS, and management with biologics. Similarly, knowledge questions were grouped into 2 domains: rheumatoid arthritis diagnosis and rheumatoid arthritis management.
In total, 18 primary care providers participated within the program. Among this group were 15 physicians, 1 nurse practitioner, 1 physician associate, and 1 community worker. Of the study cohort, 10 primary care providers completed the pre- and post-training confidence ratings, 9 completed pre- and post-training knowledge tests, and 17 completed the satisfaction survey.
When assessing survey responses, Investigators found post-training confidence ratings were statistically significantly greater than the pre-training ratings in all 3 domains (P <.05). Further analysis demonstrated management with biologics saw the greatest improvements in confidence ratings, performance on the knowledge test increased by 22% (95% CI, 10-34; P=.001), and post-training performance was significantly greater than pre-training performance in both knowledge domains (P <.05). Investigators pointed out the mean session usefulness score across all 12 sessions 4.52 (SD, 0.77) out of 5.
“This model is cost-effective, logistically feasible, even in very rural communities, and easily scalable. We hope our work can serve as a blueprint for other rheumatology providers who may be interested in launching similar remote training programs in other underserved communities across the United States and beyond,” Mandal added. “By providing high-quality rheumatology training and mentoring to front-line primary care providers in vulnerable communities, this program could have a positive impact on many thousands of patients suffering from rheumatic diseases.”
This study, “The Rheumatology Access Expansion (RAE) Initiative: Improving Rheumatoid Arthritis Care on Navajo Nation Through Primary Care Provider Education,” was presented at ACR Convergence 2022.