Disproportionate burdens in delivering care for RA exist in AI/AN and rural populations. The Navajo Nation—the largest American Indian reservation, spanning 27,000 square miles across three states and home to 250,000 tribal members—faces a severe shortage of local rheumatology providers.8 Similarly, healthcare disparities are observed in systemic lupus erythematosus (SLE), particularly in its prevalence, disease activity, damage accrual, severity of disease manifestations (lupus nephritis) and disease outcomes (end-stage renal disease). These observed differences have led to the recognition that being a member of a minoritized or marginalized community may be an independent predictor of disease outcome in SLE.9
Telemedicine to Close Gaps
Although continued barriers exist to equitable care in rural areas and, in particular, for our American Indian/Alaska Native patients, the adoption of telemedicine has provided an opportunity to reach geographically distant populations. Concerns about the digital divide, as well as the inability to perform a complete physical examination, are ongoing barriers to the use of telemedicine in rheumatologic care.
A recent systematic review of the use of telemedicine in rheumatology demonstrates neutral effects of telemedicine on patient satisfaction, disease activity and quality of life, and a positive effect on medical costs.10 Clearly telerheumatology is, and will continue to be, an integral component of future care models; however, several practical and ethical considerations are necessary to maximize patient outcomes utilizing telemedicine.11,12 These include ensuring adequate establishment of the physician-patient relationship, maintaining respect for patient privacy, receiving adequate telemedicine training and understanding telemedicine legislation.10
Rural residents have been shown to access their providers through the internet less frequently than their urban counterparts.13 The Extension for Community Healthcare Outcomes (ECHO) program, an educational forum for in situ primary care providers, has proven valuable in expanding access to rheumatology care.14
Additional Interventions
Although telemedicine shows great promise for addressing care gaps in rural areas, it cannot stand alone, primarily due to issues of technology access. Additional approaches are needed to ensure adequate rheumatologic care.
1. Educate non-rheumatology clinicians.
Primary care physicians and advanced practice providers are generally at the forefront of care in rural areas. Programs to educate clinicians on rheumatologic care have been developed and will continue to be necessary to improve the early recognition and treatment of different rheumatic diseases. The Rheumatology Access Expansion (RAE) initiative has indicated that providing high-quality rheumatology training and mentoring to frontline primary care providers in vulnerable communities can have a positive impact on many patients suffering from rheumatic disease.8
