A Rheumatoid Arthritis Training Program for Primary Care Providers on the Navajo Nation

The Navajo Nation, the largest Native American reservation, faces a high prevalence of rheumatoid arthritis (RA) and a critical shortage of rheumatology providers. To address this gap, we developed an RA training program for primary care providers (PCPs) using the Project Extension for Community Healthcare Outcomes (ECHO) telementorship model. This study evaluates the impact of the RA ECHO curriculum on PCPs' knowledge, confidence, and self-reported clinical behaviors.

We designed a 12-week RA curriculum of weekly 60-minute Zoom sessions with expert-led didactics and case discussions. Content was informed by a needs assessment and input from Navajo cultural interpreters. PCPs completed precourse, postcourse, and one-year follow-up surveys assessing medical knowledge (multiple-choice test) and self-reported confidence (five-point Likert scale) in RA diagnosis and treatment. The one-year follow-up also assessed changes in self-reported clinical behaviors. Paired t-tests were used to assess score changes over time.

A total of 46 clinicians completed the program across three cohorts. Knowledge scores improved from 46% to 71% postcourse (+25%, 95% confidence interval [CI] 7%-43%, P = 0.009) and remained 69% after one year. Confidence scores increased from 2.9 ("neutral") to 3.9 ("somewhat comfortable"; +1.0, 95% CI 0.23-1.74, P = 0.01), sustained at one year. One year later, participants reported favorable changes in clinical behaviors including performing more detailed joint examinations and ordering preimmunosuppression laboratory tests and vaccines.

The RA ECHO curriculum improved PCPs' knowledge, confidence, and self-reported clinical behaviors in RA care in the Navajo Nation. This culturally grounded, disease-focused model demonstrates feasibility, acceptability, and scalability as a workforce expansion strategy in settings with limited rheumatology access.