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Program Disseminates Rheumatology Best Practices in Underserved Areas
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Project ECHO, a training and mentoring program that connects clinicians with specialists using videoconferencing, is effective in providing primary care clinicians in underserved areas with best-practice knowledge to better care for patients with rheumatic diseases, according to data published in Arthritis Care & Research.
“Primary care clinicians (PCCs), who usually provide first-line care to patients with arthritis, may not possess the knowledge or confidence to diagnose or initiate treatment for rheumatologic conditions, which further contributes to the delay of care,” Arthur Bankhurst, MD, of the University of New Mexico Health Sciences Center, and colleagues wrote. “With these barriers PCCs may be hesitant to administer referrals to rheumatologist or diagnose [rheumatoid arthritis] and manage it with [disease-modifying antirheumatic drugs].”
To address this, faculty members at the University of New Mexico Health Sciences Center developed the Extension for Community Healthcare Outcomes, or Project ECHO. Launched in 2003, the program uses videoconferencing to connect primary care clinicians in rural, typically underserved areas with specialist teams at academic medical centers.
Project members developed and launched ECHO Rheum in 2006, aiming to improve access to rheumatology care for hundreds of patients who were experiencing wait times of up to 1 year for an initial visit to the University of New Mexico Health Sciences Center. Each weekly, 90-minute teleconference session in the ECHO Rheum program included patient cases presented by participating primary care clinicians, an expert lecture and an opportunity for collaboration. In addition, primary care participants received access to scholarly articles and no-cost CME credits.
According to the project’s website, there are currently 419 ECHO programs in 46 states across the country.
“The ECHO model is not ‘telemedicine’ wherein care of the patient is transferred to the
specialist,” Bankhurst and colleagues wrote. “Rather, it enables PCCs to acquire specialized knowledge, and benefit from the shared experience of experts and peers to more effectively diagnose and care for patients in their local communities.”
To evaluate the effectiveness of ECHO Rheum in educating primary care clinicians in rheumatology best practices during its first 9 years, Bankhurst and colleagues studied attendee data for weekly sessions, lectures, grand rounds and mini-residency trainings from June 2006 to June 2014. They examined the total number of attendees, attendee type, the number of unique attendees and repeat attendees per year. In addition, the researchers reviewed participant feedback from January 2009, when the program was approved for CME credits, to December 2014.
The researchers also conducted a retrospective review of diagnoses associated with case presentations from June 2006 to June 2014, to categorize the types of cases presented. Data from these case presentations were provided by the presenting primary care clinician. Lastly, Bankhurst and colleagues formed a focus group of eight primary care clinicians in New Mexico who had continuously participated in ECHO Rheum for 1 year or longer. Of these participants, six participated in a face-to-face focus group in May 2013, while two were interviewed via telephone in June 2013.
According to the researchers, ECHO Rheum during its first 9 years educated 2,230 primary care providers, of whom 53% were physicians and 22% were nurse practitioners. In addition, 1,958 CME credits were awarded. The program saw 1,173 case presentations, 85% of which reflected the three most common diagnoses — rheumatoid arthritis, fibromyalgia and systemic lupus erythematosus. ECHO Rheum also facilitated 15 two-day mini-residencies, including 30 primary care clinicians, of which 21 completed the American College of Rheumatology online certification.
“ECHO Rheum and programs like it have the potential to positively impact the national shortage of rheumatologic care for underserved patients,” Bankhurst and colleagues wrote. “Empowering the health care workforce by disseminating knowledge of best-practice diagnosis and treatment has the potential to reduce suboptimal rheumatologic care and expand access for those suffering from rheumatologic conditions regardless of economic status or location.” – by Jason Laday
Disclosure: The authors report no relevant financial disclosures.
Perspective
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David A. McLain, MD, FACP, FACR
A major issue in rheumatology now is the shortage of rheumatologists, with more rheumatologists retiring than entering practice. On the other hand, rheumatology is one of the most sought-after fellowships now and there needs to be more fellowships offered. The American College of Rheumatology is addressing this issue, per a private conversation with the secretary of the ACR, Kenneth Saag, MD, MSc.
In their findings over a nine-year period with Project ECHO, Bankhurst and colleagues found that training community primary care physicians and nurse practitioners has had a significant impact on rheumatologic care. The program offered teleconferences and even mini-residencies, which resulted in primary care physicians completing ACR modules and certification.
The most common diagnoses covered in the case presentations (made by the PCPs via TeleECHO) were rheumatoid arthritis, fibromyalgia and lupus. After the case presentation, a subject matter expert would comment and instruct on the case. The researchers found that these contacts with primary care providers created a “community of practice” among clinicians in rural areas. The physicians’ de-identified data showed increased confidence in managing rheumatoid arthritis, fibromyalgia, and systemic lupus erythematosus.
The results from Project ECHO are impressive. Over nine years, the program has educated 2,230 clinicians and awarded 1,958 continuing medical education credits (at no charge). In this era of a rheumatology shortage, many rheumatologists in the community are hiring care extenders, mainly nurse practitioners and physician assistants. The ECHO model is another way to improve rural care of rheumatology patients by increasing the knowledge of their primary care physicians. This improved education in rheumatology would also help with referrals by eliminating many unnecessary referrals and focusing on those patients most in need.
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