From the Journals

ECHO Rheum widens rheumatology best practice care

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A model deserving further study

Although there is controversy regarding a potential physician shortage in the United States, the incontrovertible fact that the number of rheumatologists is declining and the daily experience of difficulty and delay in access to rheumatologists would argue that there surely is a problem. Moreover, the variability in distribution has resulted in many smaller regions of the country having no or few practicing adult rheumatologists. While addressing rheumatologist physician shortage and distribution may be important avenues to pursue, there are many barriers to overcoming the evident lack of access. Thus, changes in the delivery of rheumatologic care are urgently needed, and increasing our ability to use primary care physicians and midlevel practitioners is one immediate avenue to address this problem.

Dr. Calvin Brown

Dr. Calvin J. Brown Jr.

The authors of this study utilized Project ECHO (Extension for Community Healthcare Outcomes), an intervention model intended to increase the knowledge and capacity of clinicians working in rural communities in New Mexico. Participation took place via video or on telephone, connecting remotely from clinic sites throughout New Mexico. Members of the interdisciplinary specialist hub team included two rheumatology faculty members from the University of New Mexico, Albuquerque, a registered nurse, and a program coordinator. The results were measured as attendance and case presentations, thematic analyses of the focus group, individual interviews of participants, and completion of the American College of Rheumatology Advanced Rheumatology Course as well as CME credit and reporting. They were able to measure substantial participation, surveyed participants through focus groups, and CME evaluation. A total of 21 primary care physicians completed the ACR Advanced Rheumatology Course.

What remains to be done, as the authors themselves note, is measurement of patient and population-level outcomes. It is clear that the demand for rheumatologic services will continue to grow, and disparities in the regional distribution of rheumatologists in the United States will exacerbate the growing limits to access. The use of the ECHO model in this study to facilitate primary care practitioners and other providers in the management of common musculoskeletal conditions, especially in underserved areas, clearly deserves further study.

Calvin R. Brown Jr., MD, is a professor of medicine in the division of rheumatology at Northwestern University, Chicago. He is the director of the rheumatology training program there.


FROM Arthritis care & research

A telementoring and medical education program dubbed ECHO Rheum has helped to widen the provision of best practice rheumatology care to underserved areas in New Mexico, according to the results of a qualitative and quantitative study.

Dr. Arthur Bankhurst, medical director for the clinic and division chief of rheumatology at UNM.

Dr. Arthur Bankhurst

Over a 9-year period, ECHO (Extension for Community Healthcare Outcomes) Rheum educated 2,230 primary care clinicians, the majority of whom were physicians (53%) or nurse practitioners (22%), and helped increase the clinicians’ confidence in managing rheumatic conditions locally while still having access to specialist guidance.

Participants in ECHO Rheum accrued a total of 1,958 CME credits between them, and 21 of 30 (70%) clinicians who participated in 2-day miniresidencies obtained online certification from the American College of Rheumatology.

“ECHO Rheum and programs like it have the potential to positively impact the national shortage of rheumatologic care for underserved patients,” Arthur Bankhurst, MD, and his associates from the University of New Mexico, Albuquerque wrote in Arthritis Care & Research. “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.”

ECHO Rheum is part of the larger Project ECHO (Extension for Community Healthcare Outcomes), a program developed at UNM by gastroenterologist Sanjeev Arora, MD. Dr. Arora came up with the idea for the ECHO model in 2003 to try to improve access to best practice care for patients with hepatitis C. The potential of the model to translate across medical specialties was soon seen, however, and today, there are more than 40 teleECHO programs operating in New Mexico that also involve more than 400 community clinic sites. The ECHO model is also being used nationally, operating in more than 30 states, and globally in 31 countries.

According to information available via the Project ECHO website, “the ECHO model is not traditional ‘telemedicine’ where the specialist assumes care of the patient, but is instead telementoring, a guided practice model where the participating clinician retains responsibility for managing the patient.” The aim is to use medical education and care management to empower “clinicians everywhere to provide better care to more people, right where they live.”

The rheumatology arm of Project ECHO started in 2006 and follows the four main principles of the ECHO model: Using technology to leverage scarce resources, such as by facilitating regular educational sessions between central expert “hubs” at specialist centers and “spokes” at community practices; sharing best practice information to help reduce disparities in the quality of care; presenting and discussion around case histories; and evaluating and monitoring outcomes.

To demonstrate the effectiveness of ECHO Rheum, the team at UNM evaluated data on participants who had attended weekly teleconferencing sessions, lectures, grand rounds, and miniresidency training between June 2006 and June 2014.

The results demonstrated that “participation in ECHO Rheum provides clinicians in underresourced areas access to best practice knowledge and training in rheumatology,” Dr. Bankhurst and his coauthors observed.

Increased knowledge and confidence in managing rheumatic conditions among primary care physicians could help to reduce the ever-widening gap between the demand and supply of appropriate care. Indeed, while the projected population of adults with rheumatic disease is expected to grow to almost 67 million adults in the next 20 years, there is expected to be a shortfall of 4,700 full-time rheumatologists by 2030.

“Regular participation in teleECHO sessions creates a community of practice among rural clinicians,” the UNM team stated. Every week, participants were invited to attend a 90-minute virtual teleconference, either by video or telephone, that consisted of a brief evidence-based lecture by a subject matter expert and presentation of deidentified case histories submitted by the participants. Participants were able to obtain CME credits at no cost and learn how to use ACR-recommended disease activity measures, such as the Disease Activity Score in 28 joints.

Over the 9-year study period, 1,173 cases were presented, the majority of which (85%) reflected the three most common diagnoses seen in rheumatologic practice, namely RA (n = 715), fibromyalgia (n = 241), and systemic lupus erythematosus (n = 54). As might be expected, female cases were presented more often than male cases, as were cases involving patients aged 40-60 years, compared with other age groups.

“ECHO Rheum saw an increase in participation in 2010, when the ACR certification was offered at no cost, suggesting that ACR certification was an incentive for participation,” Dr. Bankhurst and his team observed.

In 2012, however, there was a drop-off in participation, which may have been caused by the end of funding for ACR certification or clinicians becoming “more confident in their abilities to diagnose and initiate treatment appropriately.” Clinical responsibilities may also have prevented clinicians from attending the weekly sessions.

“Although our formal collaboration with the ACR concluded when funds for this initiative came to an end, ECHO Rheum encourages clinicians to obtain certification in rheumatology and provides them with information about opportunities to offset the cost,” Dr. Bankhurst and his colleagues wrote.

Despite a decline in attendance at the weekly teleECHO sessions during the evaluation period, the UNM team believes that its continued use holds value for primary care practice. Since 2014, a further four clinicians have obtained ACR grant funding for certification and a number of the certified participants return to contribute to the weekly teleECHO sessions.

“This continued use of ECHO Rheum as a readily available resource for case presentations and acquisition of new learning about developments in treatment and medication demonstrates the long-term viability of the community of practice created by the program,” the team suggested.

“I think programs like this are going to be very important in addressing the physician shortage in rheumatology,” said Chad Deal, MD, in an interview.

Dr. Deal, who was not involved in the study, noted that such programs may work particularly well in underserved areas such as New Mexico, as shown in this study, as well as other states, such as in Alaska, North Dakota, and South Dakota. Essentially, “places where people are having to drive forever to get to a rheumatologist.”

“I like what they’ve done,” Dr. Deal said. It can make clinicians “feel much more comfortable with diagnosing and even treating inflammatory arthritis. I think that’s really important.”

It would be difficult to have harder outcomes measures, observed Dr. Deal, head of the Center for Osteoporosis and Metabolic Bone Disease and vice chair for quality and outcomes in the department of rheumatology at the Cleveland Clinic. “The goal is obviously early diagnosis and treatment of rheumatoid arthritis, let’s say, and improved outcomes, and that’s really difficult to show in any kind of program like this.”

Dr. Deal added that “maintaining any kind of program like this is difficult; physicians get busy, and like the authors note, sometimes clinicians get to a point where they are comfortable, and they don’t need it as much.”

Perhaps, these programs don’t need to run forever, he suggested. Perhaps a 1- or 2-year program may be sufficient for one group before moving on to focus on a different group of physicians.

Dr. Bankhurst and other authors of the study reported having no conflicts of interest. The work was funded by the Robert Wood Johnson Foundation, the New Mexico legislature, and the New Mexico Department of Health. Dr. Deal reported no conflicts of interest in relation to his comments.

SOURCE: Bankhurst A et al. Arthritis Care Res. 2019 Mar 30. doi: 10.1002/acr.23889.

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