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PubMed2001

Applying the diabetes quality improvement project indicators in the Indian Health Service primary care setting.

OBJECTIVE: With publication of the Diabetes Quality Improvement Project (DQIP) measures, the Indian Health Service National Diabetes Program applied the DQIP format to its IHS Diabetes Care and Outcomes Audit for comparison and benchmarks. RESEARCH DESIGN AND METHODS: Since 1986 the IHS Diabetes Care and Outcomes Audit has been conducted by medical record review in >75% of IHS and tribal facilities. Each year systematic random sample of charts is drawn from local diabetes registries. Chart reviews are conducted by, trained professionals according to standard definitions and instructions. Abstracted data are entered into a microcomputer-based epidemiologic software package. Local, regional, and national rates are constructed for each item. During the period 1995-1997, 150 facilities submitted data for compilation, representing participation from all 12 IHS administrative regions. The IHS Diabetes Care and Outcomes Audit collected virtually all of the DQIP measures, with the exception of LDL cholesterol (which was added to the record review in 1998). RESULTS: In 1995, 1996, and 1997, a total of 9,557, 9,985, and 9,626 individuals, respectively, were included in the total IHS audit sample. The reviews for 1995, 1996, and 1997 revealed that of all subjects: 55, 65, and 80%, respectively, had more than one HbA1c test during the year (P < 0.001); 42, 38, and 34%, respectively; had a high-risk HbA1c (>9.5%) (P < 0.001); 83, 81, and 84%, respectively, were tested for macroproteinuria (P < 0.11) and 16, 17, and 23%, respectively were tested for microproteinuria (P < 0.001); total cholesterol was assessed in 80, 81, and 85%, respectively (P < 0.001), and corresponding proportions of those with values <5.17 mmol/l were 48, 50, and 52%, respectively; triglyceride values were measured for 75,75, and 80%, respectively (P < 0.001), and the corresponding median triglyceride levels were 199, 198, and 193 mg/dl, respectively (P < 0.001); the proportion of clients with a blood pressure <140/90 mmHg was 64, 64, and 66%, respectively (P < 0.05); 55, 56, and 55%, respectively, had a dilated eye exam (P < 0.053); and the proportion of clients who had a comprehensive foot exam were 59, 59, and 61%, respectively (P < 0.05). CONCLUSIONS: The DQIP accountability and quality improvement measures could be easily applied to the IHS Diabetes Care and Outcomes Audit, and the process can prove to be practical. However, data alone are not sufficient to effect change. Use of the measures to ensure that the quality of care improves must also be stressed, because measuring alone will not guarantee such improvement.

Albuminuria↗
PubMed1978

Acceptance of the physician assistant by nonphysician health professionals in the Indian Health Service.

A survey of 55 licensed practical nurses, registered nurses and pharmacists in the Indian Health Service was conducted to determine attitudes about the use of physician assistants (PAs). The results tend to support findings of similar studies reported in the literature, but performed in other settings. Overall the PAs appear to have gained general acceptance among nonphysician health professionals. There are significant differences between the responses of LPNs and RNs, with the latter perceiving more conflict with PAs and being less supportive of the emergence of the role. Separation of the responses of LPNs and RNs, at least in this setting, appears to be an important distinction in the analysis and understanding of staff acceptance. Pharmacists were generally approving of the skill levels the PAs demonstrated in areas related to pharmacy, and tended to be intermediate in their response rates relative to LPNs and RNs in overall acceptance of the PA role.

Attitude of Health Personnel↗
PubMed2006

Biotech and biomaterials research to reduce the caries epidemic.

The goal of this workshop is to develop a consensus within the biomaterials/bioengineering community for a research agenda focused on creating technologies that will address the current dental caries pandemic. The workshop will bring together expertise from academia, industry, and the NIH institutes in the areas of oral biofilm microbiology and innovative biomaterials. The rationale for the workshop is that science and technology have not produced sufficient practical tools for public health practitioners and the private delivery system to address the pandemic in dental caries that exists for children and adults from families with low incomes and for numerous ethnic minority and racial groups. Moreover, it is unclear whether the barriers are remediable bioengineering and technical problems or fundamental science questions. Nevertheless, the obligation to address the gap between scientific research and practical application is especially relevant today. The U.S. and state governments bear the majority of the cost of trying to control this pandemic through Medicaid, the Public Health Service, Indian Health Service and other similar programs. These costs continue to escalate as continued applications of existing technology are unlikely to markedly reduce disparities. The mainstays of caries prevention, topical and systemic fluorides and pit and fissure sealants, are technologies developed in the 1950s and 1960s.

Journal Article↗
PubMed2000

Recruitment and retention in the Navajo Area Indian Health Service.

OBJECTIVE: To determine why physicians and midlevel providers join, leave, or stay in Navajo Area Indian Health Service (IHS). DESIGN: Cross-sectional analysis of data obtained from questionnaires. SETTING: Navajo Area IHS hospitals. SUBJECTS: Navajo Area health care physicians and midlevel health care providers. Main outcome measures The prevalence of physicians and midlevel providers who plan to leave the Navajo Area IHS, the demographic characteristics of these physicians and midlevel providers, and the most common reasons for staying or leaving. RESULTS: A total of 221 (64%) physicians and midlevel providers responded. Of these, 58% planned to leave eventually, and 47% of all physicians and midlevel providers planned to leave in the next 3 years. Physicians and midlevel providers planning to leave tended to be younger than those planning to stay (P: = 0.009). The most common reason to join the IHS was a desire to work in the Southwest, to stay was the quality of the medical staff, and to leave was lack of administrative support. CONCLUSIONS: A high turnover rate of physicians and midlevel providers may occur in the next 3 years. A combination of factors specific to the provider, the institution, and the environment attracts physicians to the Navajo IHS and encourages them to stay. Factors that push physicians and midlevel providers to leave tend to be specific to the institution and are potentially amenable.

Humans↗
PubMed2005

Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service?

BACKGROUND: Studying populations with low cesarean delivery rates can identify strategies for reducing unnecessary cesareans in other patient populations. Native American women have among the lowest cesarean delivery rates of all United States populations, yet few studies have focused on Native Americans. The study purpose was to determine the rate and risk factors for cesarean delivery in a Native American population. METHODS: We used a case-control design nested within a cohort of Native American live births, > or = 35 weeks of gestation (n = 789), occurring at an Indian Health Service hospital during 1996-1999. Data were abstracted from the labor and delivery logbook, the hospital's primary source of birth certificate data. Univariate and multivariate analyses examined demographic, prenatal, obstetric, intrapartum, and fetal factors associated with cesarean versus vaginal delivery. RESULTS: The total cesarean rate was 9.6 percent (95% CI 7.2-12.0). Nulliparity, a medical diagnosis, malpresentation, induction, labor length > 12.1 hours, arrested labor, fetal distress, meconium, and gestations < 37 weeks were each significantly associated with cesarean delivery in unadjusted analyses. The final multivariate model included a significant interaction between induction and arrested labor (p < 0.001); the effect of arrested labor was far greater among induced (OR 161.9) than noninduced (OR 6.0) labors. Other factors significantly associated with cesarean delivery in the final logistic model were an obstetrician labor attendant (OR 2.4; p = 0.02) and presence of meconium (OR 2.3; p = 0.03). CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.

Adolescent↗
PubMedDate not supplied

Community injury control programs of the Indian Health Service: an early assessment.

In response to the high rates of injury morbidity and mortality among Native Americans, the Indian Health Service initiated community injury control programs in 1982 mainly aimed at educating the populations served. Substantial declines in hospitalization rates per population for falls, motor vehicle injuries, and assaults were observed through 1984. Regression analyses of changes in hospitalization rates for particular types of injury in relation to rates of persons served in 54 service units suggests some favorable effect of certain activities and possible adverse effect of a few. Increased targeting of effort based on detailed surveillance of serious injuries is planned.

Accident Prevention↗
PubMed1992

HIV infection in American Indians and Alaska Natives: surveys in the Indian Health Service.

A network of surveys of HIV seroprevalence in American Indians and Alaska Natives (AI/AN) was begun in 1989. From July 1, 1989 through June 30, 1991, 37,681 serologic specimens were collected from prenatal and sexually transmitted disease patients in 58 facilities operated or funded by the Indian Health Service. Specimens from AI/AN women receiving initial prenatal care showed an overall HIV prevalence of 0.3/1,000, while specimens obtained during the third trimester of pregnancy showed an overall prevalence of 1.0/1,000. The rate for rural third trimester prenatal patients (0.9/1,000) was similar to that for urban patients (1.1/1,000). HIV rates among third trimester AI/AN patients in three western states were 4 to 8 times higher than rates observed in childbearing women of all races in those states. The overall HIV seroprevalence in AI/AN seeking care for sexually transmitted diseases was 4.5/1,000 for males (urban 10.8/1,000; rural 2.0/1,000) and 0.7/1,000 for females (urban 0.9/1,000; rural 0.6/1,000). Approximately 1,210 to 4,250 (midpoint of range = 2,730) AI/AN in the U.S. are projected from survey findings to be currently infected with HIV. The presence of HIV in multiple specimens from rural areas and the similarity of HIV infection rates for female patients from rural and urban locations provides evidence of diffusion of the HIV epidemic to rural AI/AN, and emphasizes the need for effective HIV prevention for this population.

Adolescent↗
PubMedDate not supplied

Infant mortality reviews in the Aberdeen Area of the Indian Health Service: strategies and outcomes.

OBJECTIVE: To determine cause and manner of death for consecutive infant deaths in the Aberdeen Area of the Indian Health Service (AAIHS) from 1998 to 2002 and to identify risk markers for infant mortality. METHODS: Infant deaths in the AAIHS were identified from four data sources: death certificates from the four states in the AAIHS, deaths reported by local IHS Service Units, from obituaries in local and regional newspapers, and deaths reported by area hospitals. Each infant death is then sent to the local IHS service unit for review, where data from the infant and mother's chart is extracted and recorded. Local community factors, birth and death certificates, and autopsy reports are collected. The case is then reviewed at the Perinatal Infant Mortality Review (PIMR) meeting and a cause and manner of death is assigned. Summary data for the cohort was examined and then compared by mortality category and three age-at-death groups. RESULTS: Sudden infant death syndrome accounted for 33% of all infant deaths in the AAIHS. Prematurity was the second most prevalent cause-specific mortality category, accounting for 22% of all infant deaths. The authors found that infant mortality was surprisingly recurrent, with 32% of mothers of this infant having had a previous infant death. CONCLUSIONS: The PIMR committee requires substantial resources to support a review committee with appropriate expertise and their travel. Participation of local IHS staff and tribal members provides an important cultural and community perspective for the review process. Quality improvement changes are currently being implemented. These include increasing data on substance use, mental health needs, and reviews of fetal deaths. The process of mortality review has been very helpful in public education in the AAIHS.

Cause of Death↗
PubMed2004

Chronic arthritis in children and adolescents in two Indian health service user populations.

BACKGROUND: High prevalence rates for rheumatoid arthritis, spondyloarthopathies, and systemic lupus erythematosus have been described in American Indian and Alaskan Native adults. The impact of these diseases on American Indian children has not been investigated. METHODS: We used International Classification of Diseases-9 (ICD-9) codes to search two Indian Health Service (IHS) patient registration databases over the years 1998-2000, searching for individuals 19 years of age or younger with specific ICD-9-specified diagnoses. Crude estimates for disease prevalence were made based on the number of individuals identified with these diagnoses within the database. RESULTS: Rheumatoid arthritis (RA) / juvenile rheumatoid arthritis (JRA) was the most frequent diagnosis given. The prevalence rate for JRA in the Oklahoma City Area was estimated as 53 per 100,000 individuals at risk, while in the Billings Area, the estimated prevalence was nearly twice that, at 115 per 100,000. These rates are considerably higher than those reported in the most recent European studies. CONCLUSION: Chronic arthritis in childhood represents an important, though unrecognized, chronic health challenge within the American Indian population living in the United States.

Adolescent↗
PubMedDate not supplied

IUD-related knowledge, attitudes and practices among Navajo Area Indian Health Service providers.

CONTEXT: The IUD once accounted for about half of contraceptive use among Navajo women but is now little used in this population, which has a high rate of unintended pregnancy. Identifying barriers to use--including those stemming from providers' IUD-related knowledge, attitudes and practices--could help expand use of the method. METHODS: In 2000, 107 Navajo Area Indian Health Service providers who offer contraceptive services completed a mailed survey. Responses of women's health providers and other types of providers were compared, using the Cochran-Mantel-Haenszel method. RESULTS: Overall, 69-78% of providers had good factual knowledge about the IUD and felt adequately prepared to insert a device or counsel women about it; considerably larger proportions of women's health providers than of others felt able to counsel about and insert IUDs. Sixty-five percent of providers (88% of women's health providers and 50% of others) currently inserted IUDs, and only 8% (none of them women's health providers) never recommended the method. The main reasons providers cited for not recommending the IUD were concerns about its safety and about side effects (mentioned by 69% and 44%, respectively); these concerns did not differ by provider type. CONCLUSIONS: Provider education and training should focus on insertion techniques and on the safety of available IUDs. Training should be targeted not only to women's health providers, but to family practice physicians, nurse practitioners and other providers who offer family planning counseling and services.

Clinical Competence↗
PubMed1995

Prevalence and correlates of depressive syndromes among adults visiting an Indian Health Service primary care clinic.

Depression is common among patients visiting primary care clinics. In order to describe the prevalence of depressive syndromes in an American Indian primary care clinic population and to help define the clinical correlates of depressive syndromes in this setting, a clinic-based research study of depression was undertaken by the Indian Health Service (IHS). One hundred and six patients from an IHS primary care clinic were systematically enlisted for participation in the study. Participants completed the Inventory for Diagnosing Depression (IDD). Twenty-two (20.7%) responded with answers scoring positive for a depressive syndrome. Nine of these 22 (8.9% of the 106 participants) met IDD criteria for a major depressive syndrome. A diagnosis of depression, a past history of depression, use of mental health facilities, unexplained pains, and antidepressant medication use were associated with the presence of a depressive syndrome.

Adult↗
PubMed1992

Cancer incidence and survival among American Indians registered for Indian health service care in Montana, 1982-1987.

BACKGROUND: Cancer incidence and cancer survival estimates in American Indians are quite limited. PURPOSE: Our purpose was to estimate cancer incidence and survival in American Indians who were registered for Indian Health Service (IHS) care in Montana. METHODS: We linked databases from the IHS and the Montana Central Tumor Registry (MCTR) to ascertain cases for the time period from January 1, 1982, through December 31, 1987. To calculate survival rates, we used a relative survival method that incorporated age-specific risks for noncancer deaths among American Indians. RESULTS: We identified 344 cases that were compatible with the National Cancer Institute (Surveillance, Epidemiology, and End Results Program) surveillance definition of cancer. Of these cases, 249 (72%) were listed in both the MCTR and the IHS databases; 56 (16%) and 39 (11%) were listed in only the MCTR or the IHS database, respectively. Compared with the overall cancer incidence in U.S. White men, the overall cancer incidence in Montana American Indian men was markedly lower, as was the incidence for colorectal and bladder cancers and for non-Hodgkin's lymphoma. The overall cancer incidence for Montana American Indian women differed less markedly, however, from the overall incidence in U.S. White women. Compared with the cancer incidence in U.S. White women, the incidence in Montana American Indian women was significantly higher for cervical cancer but was significantly lower for colorectal, breast, and uterine cancers. Survival rates from cancer were also examined for the first time in this population. For those sites examined, the survival rates were much lower in Montana American Indians than in U.S. Whites. CONCLUSIONS: We conclude that it is feasible to develop state-specific cancer incidence and survival estimates for American Indians in at least some states in different regions of the United States. Collaboration between the IHS and a state tumor registry is likely to improve the case ascertainment achieved by either agency alone.

Female↗