Denise A. Dillard

Metabolic syndrome: prevalence among American Indian and Alaska native people living in the southwestern United States and in Alaska.

BACKGROUND Metabolic syndrome occurs commonly in the United States. The purpose of this study was to measure the prevalence of metabolic syndrome among American Indian and Alaska Native people. METHODS We measured the prevalence rates of metabolic syndrome, as defined by the National Cholesterol Education Program, among four groups of American Indian and Alaska Native people aged 20 years and older. One group was from the southwestern United States (Navajo Nation), and three groups resided within Alaska. Prevalence rates were age-adjusted to the U.S. adult 2000 population and compared to rates for U.S. whites (National Health and Nutrition Examination Survey [NHANES] 1988-1994). RESULTS Among participants from the southwestern United States, metabolic syndrome was found among 43.2% of men and 47.3% of women. Among Alaska Native people, metabolic syndrome was found among 26.5% of men and 31.2% of women. In Alaska, the prevalence rate varied by region, ranging among men from 18.9% (western Alaska) to 35.1% (southeast), and among women from 22.0% (western Alaska) to 38.4 % (southeast). Compared to U.S. whites, American Indian/Alaska Native men and women from all regions except western Alaska were more likely to have metabolic syndrome; men in western Alaska were less likely to have metabolic syndrome than U.S. whites, and the prevalence among women in western Alaska was similar to that of U.S. whites. CONCLUSION The prevalence rate of metabolic syndrome varies widely among different American Indian and Alaska Native populations. Differences paralleled differences in the prevalence rates of diabetes.

Process and Outcomes of Patient-Centered Medical Care With Alaska Native People at Southcentral Foundation

PURPOSE This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition. METHODS We conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders. RESULTS Emergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation. CONCLUSIONS All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments.

Alaska native people's perceptions, understandings, and expectations for research involving biological specimens.

Objectives. Members of racially and ethnically diverse groups have been persistently underrepresented in biomedical research in general, possibly due to mistrust with the medical and research community. This article describes the perceptions, understandings, and expectations of Alaska Native people about research involving the collection and storage of biological specimens. Study design. Stratified focus groups. Methods. Twenty-nine focus groups with Alaska Native people (n = 178) were held in 14 locations using a semi-structured moderator guide. ATLAS.ti was used for thematic analysis through iterative readings and coding. Alaska Native peoples’ perceptions, understandings, and expectations of researcher beneficence, informed consent processes, and provision of research findings were elicited. Results and conclusions. Alaska Native people desired extensive disclosure of information beyond that typically provided in consent and results dissemination processes. Information germane to the motivation and intent of researchers and specifics of specimen storage and destruction were specifically requested. A clear and extensive process of informed consent and continued improvements in sharing results may enhance the transparency of research intent, conduct, and use of obtained results among Alaska Native people. Meeting expectations may improve relationships between researchers and the Alaska Native population which could result in increased research participation. Our findings offer a guide for researchers and communities when planning and implementing research with biological specimens.

Resources, roadblocks and turning points: a qualitative study of American Indian/Alaska Native adults with type 2 diabetes.

Type 2 diabetes is a worldwide health problem that has reached epidemic proportions in some communities. Alaska Native and American Indian (AN/AI) people are disproportionately diagnosed with type 2 diabetes and incidence is increasing in many Alaska communities. Developing effective interventions requires understanding the social and psychological factors that impact effective management of diabetes, yet little is known about these factors in AN/AI communities. The objective of this study was to explore perceived psychosocial needs and barriers to management of diabetes among AN/AI adults with type 2 diabetes receiving care at the Alaska Native Primary Care Center (ANPCC) to inform programmatic efforts and potential future research. We conducted three focus groups and five interviews with 13 AN/AI adults with type 2 diabetes. Interview and focus group questions elicited perceived factors that affect management of diabetes, with a focus on the psychological, social and spiritual impacts of diabetes. Data were transcribed, coded and analyzed using thematic analysis. Key themes that emerged from these data included resources and roadblocks, as well as turning points in the trajectory of diabetes. Resources are factors with a perceived positive impact on management of diabetes, including: (1) knowledge and education about diabetes, (2) social support from other people with diabetes, (3) spirituality, and (4) self-efficacy.Roadblocks are factors with a perceived negative impact on management of diabetes and include: (1) self-reportedlack of knowledge about nutrition and diet, (2) social difficulties caused by dietary restrictions, and (3) co-morbid medical conditions. Finally, turning points are experiences described by participants as having transformed roadblocks in resources and thus facilitating improvement in the management of diabetes. Future programmatic interventions to improve management of diabetes with this population should focus on improving dietary education and social support opportunities for newly-diagnosed individuals. Also, educational and support opportunities for family members and friends of individuals with diabetes should also be offered to facilitate understanding and support of their loved ones’ management of diabetes, especially with regard to dietary restrictions in social settings. Efforts should also focus on strengthening newly-diagnosed individuals’ self-efficacy and providing ongoing support as individuals progressively adjust to the illness over time and make behavioral changes. Future research with this population should explore the effects of family support groups and the possibility of Web-based or other alternative interventions for improving psychosocial health and management of diabetes efforts.

Tobacco use among Alaska Native people in the EARTH study

INTRODUCTION While aggregate rates of tobacco use for Alaska Native (AN) and American Indian people are high, use rates vary among populations and factors associated with use are not fully understood. For AN people living in three regions of Alaska, we present prevalence of tobacco use as well as factors associated with use. METHODS Using data from 3,828 participant questionnaires, associations with tobacco use are examined with chi-square tests and multivariate logistic regression. Covariates investigated include demographic factors, identification with tribal tradition, language spoken in the home, binge drinking, and depression screening results. RESULTS Current smoking was more prevalent among men. In multivariate analysis, higher likelihood of current smoking was found for participants with these characteristics: younger, unmarried, low income, and increased frequency of binge drinking. For women, additional characteristics included no high school diploma and positive depression screening. Participants from southeastern Alaska were less likely to be current smokers. Current smokeless tobacco use rates were similar across gender. Higher likelihood of current smokeless use was found in southwestern Alaska and among those with positive depression screening. Women with low income and who reported at least some identification with tribal tradition had increased odds of current smokeless use. More than 20% of smokeless tobacco users reported initiating by age 10. DISCUSSION Rates of tobacco use by AN people continue to be higher than other U.S. populations. Tobacco initiation prevention efforts targeting AN youth at an early age are recommended, given the early age of initiation demonstrated in this study.

Exploring Pathways to Trust: A Tribal Perspective on Data Sharing

The data-sharing policies of the National Institutes of Health aim to maximize public benefit derived from genetic studies by increasing research efficiency and use of a pooled data resource for future studies. Although broad access to data may lead to benefits for populations underrepresented in genetic studies, such as indigenous groups, tribes have ownership interest in their data. The Northwest-Alaska Pharmacogenetic Research Network, a partnership involving tribal organizations and universities conducting basic and translational pharmacogenetic research, convened a meeting to discuss the collection, management, and secondary use of research data, and of the processes surrounding access to data stored in federal repositories. This article reports the tribal perspectives that emerged from the dialogue and discusses the implications of tribal government sovereign status on research agreements and data-sharing negotiations. There is strong tribal support for efficient research processes that expedite the benefits from collaborative research, but there is also a need for data-sharing procedures that take into account tribal sovereignty and appropriate oversight of research—such as tribally based research review processes and review of draft manuscripts. We also note specific ways in which accountability could be encouraged by the National Institutes of Health as part of the research process.Genet Med 16 11, 820–826.

Variation in genes controlling warfarin disposition and response in American Indian and Alaska Native people: CYP2C9, VKORC1, CYP4F2, CYP4F11, GGCX.

Objectives Pharmacogenetic testing is projected to improve health outcomes and reduce the cost of care by increasing therapeutic efficacy and minimizing drug toxicity. American Indian and Alaska Native (AI/AN) people historically have been excluded from pharmacogenetic research and its potential benefits, a deficiency we sought to address. The vitamin K antagonist warfarin is prescribed for prevention of thromboembolic events, although its narrow therapeutic index and wide interindividual variability necessitate close monitoring of drug response. Therefore, we were interested in variation in CYP2C9, VKORC1, CYP4F2, CYP4F11, and GGCX, which encode enzymes important for the activity of warfarin and synthesis of vitamin K-dependent blood clotting factors. Methods We resequenced these genes in 188 AI/AN people in partnership with Southcentral Foundation in Anchorage, Alaska and 94 Yup’ik people living in the Yukon-Kuskokwim Delta of southwest Alaska to identify known or novel function-disrupting variation. We conducted genotyping for specific single nucleotide polymorphisms in larger cohorts of each study population (380 and 350, respectively). Results We identified high frequencies of the lower-warfarin dose VKORC1 haplotype (−1639G>A and 1173C>T) and the higher-warfarin dose CYP4F2*3 variant. We also identified two relatively common, novel, and potentially function-disrupting variants in CYP2C9 (M1L and N218I), which, along with CYP2C9*3, CYP2C9*2, and CYP2C9*29, predict that a significant proportion of AI/AN people will have decreased CYP2C9 activity. Conclusion Overall, we predict a lower average warfarin dose requirement in AI/AN populations in Alaska than that seen in non-AI/AN populations of the USA, a finding consistent with clinical experience in Alaska.

Engaging stakeholders to develop a depression management decision support tool in a tribal health system

AbstractPurpose Southcentral Foundation, an Alaska Native tribal health organization, has had a depression screening program in primary care since 2001. Program monitoring identified gaps in antidepressant refills and patients’ follow-up with behavioral health services. With extensive stakeholder participation, we developed an electronic, patient-centered, depression-management decision support tool (DM-DST). Quality of life and other outcomes are being assessed in a separate study; this case study reports on the multi-year stakeholder engagement process.MethodsData sources included interviews with patients and providers from integrated primary care teams, notes from research meetings, steering committee meetings, and consultations with tribal health system leadership, human subjects review committees, providers, and software designers, and a pilot test of the DS-DMT with patients and providers. We analyzed these sources using qualitative methods to assess the impact of stakeholder input on project processes and outcomes.ResultsOne comprehensive, iPad-based tool was originally planned to facilitate discussions about depression management. Stakeholder input emphasized the role of family and cultural context of depression and management and improving the usability of the DM-DST. Stakeholder direction led us to split the DM-DST into: (1) a brief iPad-based tool to facilitate conversations between patients and providers during clinic visits; and (2) a complementary Web site that provides detailed information and allows patients flexibility and time to learn more about depression and share information and preferences with family and friends.ConclusionsStakeholder input across the project substantially modified the DM-DST to ensure cultural applicability to patients and providers and facilitate integration into clinics.

Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use

Background Between 1995 and 1998, tribally owned Southcentral Foundation (SCF) incrementally assumed responsibility from the Indian Health Service (IHS) for primary care services on the Alaska Native Medical Center (ANMC) campus in Anchorage, Alaska. In 1999, SCF began implementing components of a Patient-Centered Medical Home (PCMH) model to improve access and continuity of care. Objective To evaluate hospitalisation trends before, during and after PCMH implementation. Design Time series analysis of aggregated medical record data. Methods Regression analysis with correlated errors was used to estimate trends over time for the percent of customer-owners hospitalised overall and for specific conditions during 4 time periods (March 1996–July 1999: SCF assumes responsibility for primary care; August 1999–July 2000: PCMH implementation starts; August 2000–April 2005: early post-PCMH implementation; May 2005–December 2009: later post-PCMH implementation). Analysis was restricted to individuals residing in Southcentral Alaska and receiving health care at ANMC. Results The percent of SCF customer-owners hospitalised per month for any reason was steady before and during PCMH implementation, declined steadily immediately following implementation and subsequently stabilised. The percent hospitalised per month for unintentional injury or poisoning also declined during and after the PCMH implementation. Among adult asthma patients, the percent hospitalised annually for asthma declined prior to and during implementation and remained lower thereafter. The percent of heart failure patients hospitalised annually for heart failure remained relatively constant throughout the study period while the percent of hypertension patients hospitalised for hypertension shifted higher between 1999 and 2002 compared to earlier and later years. Conclusion Implementation of PCMH at SCF was accompanied by decreases in the percent of customer-owners hospitalised monthly for any reason and for unintentional injury and in the percent of asthma patients hospitalised annually for asthma. Increased accessibility to empanelled care teams may have contributed to decreased need for hospitalisation.

Depression prevalence and associated factors among Alaska Native people: the Alaska education and research toward health (EARTH) study.

BACKGROUND Few studies have investigated depression among Alaska Native people (ANs). Depression prevalence and associated factors among EARTH Alaska study participants are described. METHODS The nine-item Patient Health Questionnaire (PHQ-9) assessed depression among 3771 ANs. Participants with PHQ-9 scores≥10 out of 27 were classified as positive for depression. Logistic regression analyses evaluated odds of scoring positive versus negative for depression by demographic, cultural, then health and lifestyle factors. RESULTS Twenty percent of women and 13% of men scored positive for depression. Univariate and multivariate models were fit separately for men and women. Among demographic factors, below median income was associated with positive depression scores for both genders. Among men, odds of depression were higher if unmarried and/or if highest educational level was less than high school. Women 34 to 59 years of age had increased odds of scoring positive. Little or no identification with tribal tradition was associated with increased odds of depression in women and decreased odds in men. For both genders, chronic physical conditions and poorer self-reported health were associated with positive depression scores then binge alcohol drinking and current tobacco use increased odds of depression among women only. LIMITATIONS Factors analyzed were self-reported without clinician follow-up in a non-random convenience sample of adults. CONCLUSIONS Depression is common among ANs with rates comparable to other indigenous cross-sectional investigations. Depression is associated with lower income and poorer physical health. Prevention and intervention efforts should consider gender as other associated factors varied between men and women.