Nutrition services for alcohol/substance abuse clients. Indian Health Service's tribal survey provides insight.
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Alcoholism↗
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The Aberdeen Indian Health Service infant mortality study: design, methodology, and implementation.
Of all Indian Health Service areas, the Aberdeen Area has consistently had the highest infant mortality rate. Among some tribes in this area the rate has exceeded 30/ 1000 live birth and half the infant deaths have been attributed to Sudden Infant Death Syndrome,a rate four to five times higher than the national average. The Indian Health Service, Centers for Disease Control and Prevention, National Institute of Child Health and Human Development, and the Aberdeen Area Tribal Chairmen's Health Board collaborated to investigate these high rates with the goals of refining the ascertainment of the causes of death, improving cause-specific infant mortality rates and identifying factors contributing to the high rates. Ten of the 19 tribes or tribal communities, representing 66%of the area population, participated in a 4-year prospective case-control study of infants who died after discharge from the hospital. Infant care practices and socio-demographic, economic, medical, health care, and environmental factors were examined. The study included parental interviews, death scene investigations, autopsies, neuropathology studies, medical chart abstractions, blood cotinine assays, and a surveillance system for infant deaths. Controls were the previous and subsequent infants born on the case mother's reservation. From December 1,1992 until November 30,1996,72 infant deaths were investigated. This report describes the study methods and the model employed for involving the community and multiple agencies to study the problem of infant mortality among Northern Plains Indians. Data gathered during the investigations are being analyzed and will be published at a later date.
Case-Control Studies↗
Indian health services in Canada: a sociohistorical perspective.
The major trends and issues in the historical development of Indian health services in Canada since Confederation are discussed according to: (1) the legislative bases, including the BNA Act, the Indian Act, Indian Treaties, landmark court decisions and post-War national health legislations; (2) the policy statements of the federal government regarding services to Indians, culminating in the Indian Health Policy of 1979; (3) the changes in the organization and delivery of health services from the appointment of the first chief medical officer in 1904 to the multi-million operations of the Medical Services Branch in the 1980s; and (4) the reaction of Indian communities and political organizations to government-sponsored health care and the recent trend towards their increasing participation.
Canada↗
The impacts of alternative funding policies for ambulatory care services on hospitalization in the Indian Health Service Contract Health Care Program in Cordova, Alaska.
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Alaska↗
Improving American Indian Cancer Data in the Washington State Cancer Registry using linkages with the Indian Health Service and Tribal Records.
BACKGROUND: Previous reports have suggested that American Indians are sometimes classified as other races on cancer registries. Also, cancer registries typically do not include data on tribal affiliation. This study determined the extent of racial misclassification of American Indians in the Washington State Cancer Registry (WSCR) and obtained tribal-specific cancer data for Washington State. METHODS: A computer file including persons registered for services with the Portland Area Indian Health Service (IHS) or who were enrolled members of 19 tribes in Washington, Oregon, and Idaho (n = 127,375) was linked with WSCR records of incident cases for 1992 and 1993 (n = 49,420). Linkage was conducted with probabilistic methods using the AutoMatch software package. RESULTS: Of 180 persons recorded as American Indian in the WSCR, 130 (72.2%) were identified in the IHS/tribal roll file. Of 259 American Indians included in the IHS/tribal file who were identified in the WSCR, 130 (50.2%) were classified as American Indian. The estimated age-adjusted cancer incidence among American Indians in Washington State increased from 153.5 per 100,000 population before record linkage to 267.5 per 100,000 after linkage. Of the 259 persons who were linked to the WSCR, 17 were not registered with IHS and appeared solely in the tribal rolls. Only two tribes had more than five identified cancer cases during the 2-year study period. CONCLUSIONS: The number of IHS-enrolled American Indians or tribal members included in the WSCR would be underestimated by one third in the absence of record linkages, and the estimated cancer incidence of 43.6% would be lower before linkage. It is feasible to obtain tribal-specific cancer rates by linking tribal rolls to cancer registries, although the small number of cases in most tribes is a significant limitation. Further efforts to improve racial classification of American Indians in cancer registries should be undertaken.
Data Collection↗
Health service access, use, and insurance coverage among American Indians/Alaska Natives and Whites: what role does the Indian Health Service play?
OBJECTIVES: We compared access and utilization of health services among American Indians/Alaska Natives (AIANs) with that among non-Hispanic Whites. METHODS: We used data from the 1997 and 1999 National Survey of America's Families to estimate odds ratios for several measures of access and utilization and the effects of Indian Health Service (IHS) coverage. RESULTS: AIANs had less insurance coverage and worse access and utilization than Whites. Over half of low-income uninsured AIANs did not have access to the IHS. However, among the low-income population, AIANs with only IHS access fared better than uninsured AIANs and as well as insured Whites for key measures but received less preventive care. CONCLUSIONS: The IHS partially offsets lack of insurance for some uninsured AIANs, but important needs were potentially unmet.
Adolescent↗
Political and cultural factors in achieving continuity with a primary health care provider at an Indian Health Service hospital.
A primary care system was established at Zuni-Ramah Indian Health Service Hospital and clinic in New Mexico. Continuity and coordination of care were added to a health care system that was already accountable, accessible, and comprehensive. The new system offered each patient a personal health care provider who worked as a member of a multidisciplinary team. In changing the health care system, special attention was given to its cultural and political setting, the village of Zuni. After thorough discussion with community and staff, community members' concerns about patients' privacy and free choice were better understood, and special efforts were made to safeguard them. Ongoing evaluation is essential to maintain continuity. Eight months after the primary care system was begun, 64 percent of patients who came for care had established a personal relationship with a health care provider. For 59 percent of the visits during the 1-month evaluation period, patients saw their regular provider and, for 82 percent, patients saw their provider or one of his or her team colleagues. These percentages include night and walk-in visits. The system required no extra funding or staff. The political process of planning and consultation helped anticipate and alleviate the community's concerns, but resistance from physician's assistants and some physicians was unexpected. A flexible approach has led to a gradual acceptance of this voluntary system. This experience with the people of Zuni village shows that a primary care system can be started in a rural Indian Health Service facility with minimal outside help. Apparent improvements in quality of care make the continuity of primary care worthy of further consideration in the IHS and similar health services systems.
Continuity of Patient Care↗
Dental manpower planning in the Indian Health Service.
As a public health agency, the Indian Health Service (IHS) must plan for the needs of the entire American Indian and Alaskan Native (AI/AN) population and distribute resources as equitably as possible. To facilitate this process, the IHS has developed a manpower planning model to provide for the distribution of dental providers based upon the dental needs of the AI/AN population and within the limits of annual appropriations of funds. This paper briefly describes the original IHS Dental Program manpower planning model and the development of modifications over time. The need-based approach to manpower planning developed by the IHS Dental Program has exhibited utility and flexibility over time. It allows a determination of clinic size (number of operatories) and dental staffing requirements, and may be generalizable to other public health programs if an accurate assessment of utilization rate and treatment need can be made for the defined population. Nonetheless, the availability of resources in public programs is subject to the compromises inherent in the political process; thus, the use of a manpower planning model alone may not be sufficient to ensure the equitable distribution of dental resources and dental providers.
Dental Health Services↗
The cost-effectiveness of Indian Health Service Optometry.
BACKGROUND: In this time of federal government cutbacks, federal agencies are looking at the cost effectiveness of their programs. This pilot study is a first attempt at quantifying the cost effectiveness of Indian Health Service (IHS) optometry. METHODS: Using a super bill system and the Indian Health Service's own value figures per procedure, the cost of providing optometry services at one clinic was compared with the value of the care given in terms of dollars. RESULTS: The Indian Health Service receives about $2.44 in care for each dollar spent on optometric services at the clinic studied. CONCLUSIONS: If the results found are typical of all the IHS clinics, then the optometry program saves U.S. taxpayers more than $14 million per year. Further studies at multiple IHS sites should be performed to confirm these figures.
Cost-Benefit Analysis↗
Statement of organization, functions, and delegations of authority; Indian Health Service--PHS.
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Indians, North American↗
Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service.
We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.
Data Collection↗
Pine Ridge Indian Health Service Primary Care Resident Rotation: an update.
The Pine Ridge Indian Health Service Primary Care Resident Rotation has been in existence for 2 years. It was conceived in an effort to help address the problem of recruitment and retention of physicians at Pine Ridge in the long term, while offering a unique educational experience for primary care residents. Twenty-five residents from family practice, general internal medicine, and general pediatric residency programs across the country have participated in calendar years 1992 and 1993. Three of the original 12 residents have returned following completion of their residency programs to join the Pine Ridge medical staff.
Humans↗
Improving diabetes care in the primary health setting. The Indian Health Service experience.
PURPOSE: To identify key systems issues from the Indian Health Service (IHS) experience that must be addressed to improve metabolic control among patients with non-insulin-dependent diabetes mellitus (NIDDM) who were followed in primary care settings. DATA SOURCES: Records of diabetic patients seen in IHS facilities in specific geographic regions from 1987 to 1994. STUDY SELECTION: A representative sample of charts from each facility was reviewed yearly to measure key variables. The sampling frame was the number of diabetic patients currently active on the registry and the sample size calculated to measure a 10% change in selected practices at each facility. EXTRACTION: Regional diabetes coordinators reviewed charts or trained local providers to sample and extract data in a standard format. RESULTS: Regional data were examined to show trends in the performance of immunizations and foot examinations and in other variables such as hypertension and metabolic control. The percentage of diabetic patients who received a single dose of pneumococcal vaccine improved from 24% in 1987 to 1988 to 57% in 1994 (P < 0.01 for trend) among diabetic patients in Minnesota, Wisconsin, and Michigan. Rates of yearly comprehensive foot examination increased from 36% to 58% (P < 0.01 for trend) over the same period. In Montana and Wyoming, the percentage of diabetic patients with uncontrolled hypertension (defined as the mean of three systolic blood pressure measurements of > or = 140 mm Hg or diastolic pressure measurements > or = 90 mm Hg, or both, during the previous year) decreased from 36% in 1992 to 25% in 1993 after the regional diabetes coordinator emphasized hypertension control. In 1994, when less emphasis was placed on hypertension, 33% of the diabetic patients had uncontrolled hypertension. Estimates of metabolic control from records of diabetic patients in Washington, Oregon, and Idaho in 1994 showed that 29% of patients had excellent metabolic control (a hemoglobin A1c [HbA1c] level < or = 7.5% or mean blood glucose level < or = 9.2 mmol/L) within the past year; only 9% experienced poor control (a HbA1c level > 12% or mean blood glucose level > 18.9 mmol/L). CONCLUSIONS: The IHS experience shows that standard, ongoing monitoring of key variables allows facilities to improve diabetes care. Simple, reliable methods of defining metabolic control combined with a feedback system in the primary care setting are needed to improve metabolic control in patients with NIDDM.
Diabetes Mellitus, Type 2↗
Patients with diagnosed diabetes mellitus can be accurately identified in an Indian Health Service patient registration database.
OBJECTIVE: The computerized patient registration databases maintained by the Indian Health Service (IHS) represent a potentially important source of data about the epidemic of diabetes among American Indian and Alaskan Native people. The purpose of this study is to determine the accuracy of this data source, and to identify the optimal search criteria to identify patients with a diagnosis of diabetes in an IHS patient registration database. METHODS: The authors compared the results of a series of computerized searches to a "gold standard" sample of 465 manually reviewed charts from a large IHS facility. RESULTS: Among patients ages 15 years and older, the best criterion for identifying patients diagnosed with diabetes was the presence of at least one purpose of visit narrative identified by a 250.00 to 250.93 ICD-9 code. The presence of a single computerized code for diabetes identified patients with diagnosed diabetes with a sensitivity of 92% (95% confidence interval [CI] 81, 97), a specificity of 99% (95% CI 98, 99), and a calculated positive predictive value of 94% (95% CI 85, 99). In a separate chart review of 462 charts of patients who had at least one 250.00 to 250.93 ICD-9 code recorded in the database, 435 had a diagnosis of diabetes for an observed positive predictive value of 94%. Because the prevalence of diabetes varies by age of the patient, the positive predictive value of the ability to identify patients with diabetes also varies by age. CONCLUSION: A computerized search of an IHS patient database can identify patients with a diagnosis of diabetes with an accuracy that is similar to the reported accuracy from other health care system databases.
Abstracting and Indexing↗
Identification and clarification of drug therapy problems by Indian health service pharmacists.
OBJECTIVE: To describe drug therapy problem intervention activities of Indian Health Service (IHS) pharmacists and to characterize the types of drug therapy problems encountered. DESIGN: Longitudinal descriptive study of documented potential drug therapy problems detected by pharmacists during the conduct of routine dispensing activities during a 6-month period. SETTING: All 18 IHS hospitals and ambulatory care facilities in one geographic area. MAIN OUTCOME MEASURES: Potential drug therapy problem detection rates by pharmacists and problem detection rates per 100 dispensed prescriptions are reported. Problems are characterized as to type, nature of intervention activities undertaken, and results of interventions. Changes in problem detection rate across clinics and over time are reported. RESULTS: Pharmacists detected and reported problems at a rate of slightly less than one per 100 prescriptions dispensed; however, drug therapy changes occurred 78% of the time as a result of the interventions. The types of drug therapy problems occurring most frequently were incorrect information (40.7%), prescription clarification (39.6%), clinical problems (10.4%), and inappropriate drug (9.3%). Physician acceptance of pharmacist interventions varied by type of drug therapy problem. Drug therapy changes occurred 77.7% of the time as a result of the interventions. Pharmacists at several sites used records of the drug therapy problems to make changes in policy or procedures as a part of continuous quality improvement activities. As a result, the problem detection rate declined over time in several settings. CONCLUSIONS: In comparison with other settings where cognitive services have been reported, IHS pharmacists detected fewer problems, but their interventions resulted in a higher percentage of drug therapy changes.
Drug Prescriptions↗
A political history of the Indian Health Service.
One of the few bright spots to emerge from the history of relations between American Indians and the federal government is the remarkable record of the Indian Health Service (IHS). The IHS has raised the health status of Indians to approximate that of most other Americans, a striking achievement in the light of the poverty and stark living conditions experienced by this population. The gains occurred in spite of chronically low funding and can be attributed to the combination of vision, stubbornness, and political savvy of the agency's physician directors and the support of a handful of tribal leaders and powerful allies in the Congress and the White House. Despite the agency's imperfections and the sizeable health problems that still exist among American Indians and Alaskan Natives, the IHS is an example of one federal program that has worked.
Health Promotion↗
Implementation and use of an electronic health record within the Indian Health Service.
OBJECTIVES: There are limited data regarding implementing electronic health records (EHR) in underserved settings. We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans. DESIGN: We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005. METHODS: The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings. We fit a multivariable logistic regression model to identify correlates of increased utilization of the EHR. RESULTS: The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient-doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05-8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records. CONCLUSIONS: Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.
Attitude of Health Personnel↗
Preventing amputations from diabetes mellitus: the Indian Health Service experience.
With the heavy burden of diabetes mellitus among American Indians and Alaskan Natives, lower-extremity amputation (LEA) has become a common complication. Rates of diabetes-related LEA are 2-3 times those observed in other diabetic populations. During the past 12 years, the Indian Health Service (IHS) has made LEA prevention a public health priority. From 1988 to 1992 screening criteria based on simple examinations were developed and validated in primary care Settings. Prevention efforts have focused on targeting high-risk individuals for self-care foot education, provision of protective footwear, and routine podiatry care. Follow-up studies in Alaska and northern Minnesota saw 25-50% reductions in LEA rates associated with these interventions. In settings where these efforts were augmented with system changes, such as team coordination, patient-tracking systems, comprehensive footcare practice guidelines, flowsheets, and outreach programmes, LEA incidence was reduced by 50-75%. Efforts are currently underway to disseminate system-based approaches for comprehensive diabetic footcare and to expand the availability of foot care resources to tribal communities served by the IHS.
Alaska↗