Dorothy Gohdes

Identifying Diabetic Patients at High Risk for Lower-Extremity Amputation in a Primary Health Care Setting: A prospective evaluation of simple screening criteria

OBJECTIVE To evaluate prospectively a risk categorization scheme for lower-extremity problems that incorporates the Semmes-Weinstein 5.07 monofilament and a simple exam to stratify patients who were followed in a primary-care setting into risk groups for plantar ulceration and lower-extremity amputation. RESEARCH DESIGN AND METHODS Patients with diabetes in a well-defined American-Indian population were stratified into four risk categories based on sensation status to the 5.07 monofilament, the presence of foot deformity, and a history of lower-extremity events (amputation or ulceration): category 0, sensate; category 1, insensate; category 2, insensate with deformity; and category 3, history of lower extremity events. Patients were followed prospectively for lower extremity events and changes in sensation status. RESULTS We gave screening exams to 358 (88%) of 406 individuals with diabetes in the community. The distribution of patients for risk categories 0, 1, 2, and 3 was 74.3, 8.4, 4.5, and 13%, respectively. Over a 32-mo follow-up period, 41 patients developed ulcerations, and incidence rates correlated positively with increasing risk category (P < 0.00001). All 14 amputations occurred in risk groups 2 and 3. CONCLUSIONS These data suggest that the risk categorization described here may have a role in identifying patients at risk for lower extremity events who are followed in a primary-care setting.

Diabetes in Pregnancy in Zuni Indian Women: Prevalence and subsequent development of clinical diabetes after gestational diabetes

Objective— To determine the prevalence of gestational diabetes mellitus in Zuni Indian women and the subsequent rate of diabetes among Zuni women with GDM. Research Design and Methods— A retrospective analysis of 809 deliveries over a 4-yr period among Zuni Indian women was conducted to determine the prevalence of GDM and diabetes antedating pregnancy. A prospective case-control study of 47 full-blooded Zuni Indian women with GDM and 47 control subjects was performed to determine the progression to clinical diabetes in women with a first-time diagnosis of GDM. Cases with GDM delivered during a defined 8-yr period. The control group of Zuni women delivered during the same time period but had plasma glucose values <7.8 mM on the 1-h glucose screening test. Cases with GDM and control subjects were matched for age, body mass index, gravidity, and length of follow-up. All women were re-evaluated for diabetes up to 9 yr after the index pregnancy. Results— Between 1987–1990, 116 cases of GDM and 8 cases of pre-existing diabetes were identified, giving a prevalence of maternal diabetes in pregnancy of 15.3%. At the time of follow-up, 14 of 47 (30%) women with GDM had developed diabetes after a mean of 4.8 yr compared with only 3 of 47 (6%) from the control group with an average of 5.5 yr follow-up. Conclusions— GDM is prevalent among Zuni Indians and is associated with an increased risk of diabetes. Glucose tolerance after GDM may deteriorate at a greater rate in Native Americans than in other populations.

Assessment of Diabetes Care by Medical Record Review: The Indian Health Service Model

OBJECTIVE To evaluate the adherence to minimum standards for diabetes care in multiple primary-care facilities using a uniform system of medical record review. RESEARCH DESIGN AND METHODS In 1986, the Indian Health Service (IHS) developed diabetes care standards and an assessment process to evaluate adherence to those standards using medical record review. We review our assessment method and results for 1992. Charts were selected in a systematic random fashion from 138 participating facilities. Trained professional stai reviewed patient charts, using a uniform set of definitions. A weighted rate of adherence was constructed for each item. RESULTS Medical record reviews were conducted on 6,959 charts selected from 40,118 diabetic patients. High rates of adherence (>70%) were noted for blood pressureand weight measurements at each visit, blood sugar determinations at each visit, annual laboratory screening tests, electrocardiogram at baseline, and adult immunizations. Lower rates of adherence (≤50%) were noted for annual eye, foot, and dental examinations. CONCLUSIONS IHS rates of adherence are similar to rates obtained from medical record reviews and computerized billing data, but are less than rates obtained by provider self-report. Medical record review, using uniform definitions and inexpensive software for data entry and reports, can easily be implemented in multiple primary-care settings. Uniformity of data definition and collection facilitates the aggregation of the data and comparison over time and among facilities. This medical record review system, although labor intensive, can be easily adopted in a variety of primary-care settings for quality improvement activities, program planning, and evaluation.

Public Education Strategies to Increase Awareness of Stroke Warning Signs and the Need to Call 911

Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. We implemented a 20-week public education campaign to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older before and after the intervention to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up (67% to 83%). Awareness increased significantly among both men and women and younger and older respondents. There was no significant change in the proportion of respondents indicating that they would call 911 if they witnessed someone having a stroke (74% to 76%). However, after the campaign, an increased proportion of respondents indicated that they would call 911 if they experienced sudden speech problems (51% to 58%), numbness or loss of sensation (41% to 51%), or paralysis (46% to 59%) that would not go away. Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911.

Do Persons With Diabetes Know Their (AIC) Number

PURPOSE The objective of this study was to compare self-reported knowledge about Al C testing with information from the medical record. METHODS A telephone survey was conducted among patients with diabetes in a rural fee-for-service practice and a community health center. Self-reported information regarding Al C testing, the last Al C value, and perceived blood glucose control was compared with the most current Al C value documented in the medical record. RESULTS Seventy five percent of survey respondents reported having 1 or more Al C tests in the past year, which generally agreed with information from their medical records. However, only 24% of those who reported having a test remembered the actual value, and the self-reported values correlated weakly with the last Al C on the medical record. Among those with a documented Al C value, half described their blood glucose as very well controlled. The last Al C value, however, was <7.0% in only half of those respondents. CONCLUSIONS Persons with diabetes were aware of their previous Al C testing but did not interpret the values accurately in relation to their own glycemic control. If clinicians expect patient knowledge and understanding of glycemic control measures to improve outcomes of care, patient education will need to emphasize the meaning of these values.

Cardiovascular disease and risk factors in Montana American Indians and non-Indians

BACKGROUND Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. OBJECTIVE To compare CVD and risk factors in American Indian and non-Indian populations in Montana. METHODS Adult American Indians (n=1000) living on or near Montanas seven reservations and non-Indian (n=905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS Indians aged > or =45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18-44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged > or =45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged > or =45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). CONCLUSIONS Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

Epidemiology of Lower-Extremity Amputations in the Indian Health Service, 1982–1987

OBJECTIVE— To describe the LEA experience among IHS diabetic patients. RESEARCH DESIGN AND METHODS— A cross-sectional study of hospital discharges for nontraumatic LEAs from 1982 to 1987 in four IHS areas was conducted. RESULTS— Incidence rates of first LEA in the study period increased with increasing age. Compared with nondiabetic subjects, diabetic patients had increased risks in each age-group, with those between the ages of 15 and 44 yr having a 158-fold increased risk. The average annual age-adjusted incidence rates of all LEAs among diabetic subjects in the Tucson (240.8/10,000) and Phoenix (203.1/10,000) IHS areas were substantially higher than the rates for the U.S. (73.1/10,000), Navajo (74.0/10,000), and the Oklahoma (87.3/10,000) IHS areas. CONCLUSIONS— LEA rates varied in different IHS areas. Reasons for these findings need to be evaluated, but may include IHS area differences in preventive health-care practices or risk factors for LEA.

Diabetes in American Indians: An overview

Objective— To review the growth of diabetes as a major health problem for American Indians and Alaska Natives. Research Design and Methods— Pertinent studies of diabetes in Indians previously published are reviewed and compared with current data. Results— Although diabetes rates may vary among different Indian tribes, diabetes has become a widespread health problem. Conclusions— Our understanding of the natural history of diabetes among Indians has improved, but better strategies to prevent complications and ultimately to prevent diabetes are urgently needed in Indian communities.

Three-year prevalence and incidence of diabetes among American Indian youth in Montana and Wyoming, 1999 to 2001.

OBJECTIVES To estimate the prevalence and incidence of type 2 diabetes among American Indian youth. STUDY DESIGN Medical records were reviewed annually for all patients with diabetes who were <20 years of age at 6 Indian Health Service facilities in Montana and Wyoming. All cases < or =5 years of age or weight per age < or =10th percentile at diagnosis or with islet cell antibodies were considered as probable type 1. Among the remaining cases, probable type 2 diabetes was defined when a child had one or more of the following characteristics: weight per age > or =95th percentile or acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history of type 2 diabetes; treatment with oral agents with or without insulin or no hypoglycemic therapy after 1 year of follow-up. RESULTS From 1999 to 2001, 53% of prevalent cases and 70% of incident cases were categorized as probable type 2 diabetes. The average annual prevalence of probable type 1 and type 2 diabetes was 0.7 and 1.3 per 1000. The average annual incidence rates for probable type 1, and type 2 diabetes were 5.8, 23.3 per 100,000. CONCLUSIONS The incidence of probable type 2 diabetes was approximately 4 times higher than type 1 diabetes among American Indian youth in Montana and Wyoming

Smoking cessation and prevention: An urgent public health priority for American Indians in the Northern Plains

Objective. The purpose of this study was to compare the prevalence of cigarette smoking and smoking cessation among American Indians living on or near Montanas seven reservations to those of non-Indians living in the same geographic region. Methods. Data for Montana Behavioral Risk Factor Surveillance System (BRFSS) respondents (n = 1,722) were compared to data from a BRFSS survey of American Indians living on or near Montanas seven reservations in 1999 (n = 1,000). Respondents were asked about smoking and smoking cessation as well as cardiovascular disease (CVD) and selected risk factors. Quit ratios were calculated for both groups. Results. American Indians were more likely to report current smoking (38%) than non-Indians (19%; p<0.001). Thirty-seven percent of Indian respondents with CVD risk factors reported current smoking, compared with 17% of non-Indians with CVD risk factors. However, there was no significant difference in reported smoking rates between Indians (21%) and non-Indians (27%) with a history of CVD. Indian smokers were more likely to report quitting for one or more days in the past year (67%), compared with non-Indians (43%). Quit ratios were significantly lower among Indians (43%) than among non-Indians (65%). Conclusions. High smoking rates in Indians, particularly among those with other CVD risk factors, demonstrate an urgent need for culturally sensitive smoking cessation interventions among Northern Plains Indians and highlight the need for the Surgeon Generals focus on smoking in minority populations.