Training Initiative for Management of Rheumatoid Arthritis Shows Promise in Native American Communities

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This new program was designed to be a scalable model for the formulation of similar initiatives in communities known to have limited access to specialized care for rheumatic conditions.

In new findings presented at the American College of Rheumatology 2023 Convergence, successful results were identified in a new initiative for primary care physician (PCP) training in specialized care for rheumatoid arthritis (RA) patients in Native American communities that may deal with limited care in specialized fields.1

In areas such as the Navajo Nation, there is a known shortage of providers in the rheumatology space due to a lack of specialist support. Many such areas often see the management of rheumatologic conditions being handled by PCPs without specialized rheumatology training.

The use of such training systems for frontline PCPs was viewed by the designers of this initiative as a necessary but underutilized way to help mitigate the workforce crisis in Native American communities. They addressed the needs of such communities by launching their Rheumatoid Arthritis Extension for Community Healthcare Outcomes (RA ECHO) initiative, a 12-week training program conducted remotely and made to help improve education of Navajo Area PCPs with regard to diagnosis of RA as well as management.

The curriculum for the team’s RA ECHO program was successfully implemented 3 times among those in the Navajo Nation between 2021 - 2022. As the investigators' fourth cohort took place in spring of 2023, their program substantially broadened its scope through the extension of invitations to healthcare professionals in Indigenous communities nationwide.

Their presentation at ACR of their data included results from the first 4 cohorts of the RA ECHO, and the team outlined the system’s effects on PCPs' awareness, confidence levels, and clinical behaviors related to RA diagnosis and RA management.

“We successfully offered the RA ECHO curriculum three times on the Navajo Nation from 2021-2022,” Jennifer Mandal, MD, assistant professor of the University of California, San Francisco (UCSF) and director of the RAE Initiative, said in a statement. “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.”2

Mandal and colleagues noted the high prevalence of RA and other types of rheumatologic conditions among different Native American communities, with many areas lacking the requisite access to specialized care as PCPs frequently do not feel equipped to prescribe RA medications or manage the condition usefully.

In response to the aforementioned critical shortage of rheumatologists, the Rheumatology Access Expansion (RAE) Initiative introduced RA ECHO was launched in 2021. In 2023, the program is planning an expansion to include tribes in 15 states.2

Though most of the study participants were noted as PCPs, the team’s initiative also involved community health representatives, pharmacists, and professionals found in non-primary care settings such as ophthalmology, emergency medicine, and orthopedics.

The spring 2023 program was designed to go along with the same structure as the first 3 initiative segments, with 12 weekly interactive virtual classes being used and each session involving around 30 minutes of high-level didactics regarding central aspects of diagnosis and management. The investigators followed by case-based meetings in which those participating were asked to share de-identified patient cases.

The RAE Initiative investigators sought to assess the program’s efficacy through the collected data on PCP responses to their tests and their surveys. The assessments were implemented before and after the program, including tests on RA medical information and confidence surveys on a five-point Likert scale.

Participants in cohort 3 and beyond additionally rated alterations in clinical behavior. These included joint screening exam frequency or blood tests prior to initiating immunosuppressive drugs. Over a third of those participating ended up with pre- and post-intervention ratings.

After aggregating across the different cohorts, scores in the tests implemented through the initiative were shown to have increased by 26%, with the investigators finding that PCP confidence increased by over a point on the Likert scale. Almost 80% of those participating noted that they had performed critical clinical behaviors regarding RA diagnosis and management "more frequently" or "much more frequently" following the end of the course.

The study’s investigators do acknowledge that their research did not directly assess patient outcomes.

Their next steps they plan to take involve developing culturally and linguistically-specialized RA patient materials for educational purposes in the Navajo community, as well as in-person classes for community health representatives over the Navajo Nation.

“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,” Mandal said in the same statement.

The research described here was funded through a grant from Bristol Myers Squibb Foundation.


  1. Mandal J, Izadi Z, Carroway T, Grant G, Margaretten M, Yazdany J. Addressing Native American Health Disparities in Rheumatoid Arthritis by Training Primary Care Providers: Expanding the Reach of the RAE Initiative [abstract]. Arthritis Rheumatol. 2023; 75 (suppl 9). Accessed November 10, 2023.
  2. Rheumatology Training Program for Native American Primary Care Physicians Expands Reach. American College of Rheumatology. November 7, 2023. Date accessed: November 10, 2023.