Ellen Provost

Geographic Variation in Colorectal Cancer Incidence and Mortality, Age of Onset, and Stage at Diagnosis Among American Indian and Alaska Native People, 1990–2009

OBJECTIVES We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

BACKGROUND The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. OBJECTIVE We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. DESIGN Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. SETTING Alaska Tribal Health System. PATIENTS AN population. INTERVENTIONS Itinerant endoscopy, patient navigation. MAIN OUTCOME MEASUREMENTS AN patients screened for CRC, colonoscopy quality measures. RESULTS As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. LIMITATIONS Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. CONCLUSIONS The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up.

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.

Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska

Objective To determine if video otoscope still images of the tympanic membrane taken in remote clinics are comparable to an in-person microscopic examination for follow-up care. Design Comparative concordance, diagnostic reliability. Methods Community health aide/practitioners in remote Alaska imaged 70 ears following tympanostomy tube placement. The patients were then examined in person by two otolaryngologists. Images were later reviewed at 8 and 14 weeks. Results Intraprovider concordance for physical examination findings was: “Tube in,” 94 percent-97 percent (κ = 0.89-0.94); “Tube patent,” 94 percent −97 percent (κ = 0.89-0.94); “Drainage,” 90 percent-96 percent (κ = –0.04-0.38); “Perforation,” 90 percent −96 percent (κ = 0.61-0.82); “Granulation,” 97 percent −100 percent (κ = 0.49-1.0); “Middle ear fluid,” 88 percent −96 percent (κ = 0.28-0.71); “Retracted,” 83 percent-91 percent (κ = 0.26-0.58). These agreement rates are similar to interprovider concordance when two otolaryngologists examine the same patient in person. Intraprovider concordance for diagnoses was 76 percent −80 percent (κ = 0.64-0.71) and 77 percent −88 percent (κ = 0.66-0.81) when poor images were excluded. Interprovider diagnostic concordance for the in-person exam was 89 percent (κ = 0.83). Conclusion Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.

Stroke Mortality Among Alaska Native People

OBJECTIVES We aimed to describe the epidemiology of stroke among Alaska Natives, which is essential for designing effective stroke prevention and intervention efforts for this population. METHODS We conducted an analysis of death certificate data for the state of Alaska for the period 1984 to 2003, comparing age-standardized stroke mortality rates among Alaska Natives residing in Alaska vs US Whites by age category, gender, stroke type, and time. RESULTS Compared with US Whites, Alaska Natives had significantly elevated stroke mortality from 1994 to 2003 but not from 1984 to 1993. Alaska Native women of all age groups and Alaska Native men younger than 45 years of age had the highest risk, although the rates for those younger than 65 years were statistically imprecise. Over the 20-year study period, the stroke mortality rate was stable for Alaska Natives but declined for US Whites. CONCLUSIONS Stroke mortality is higher among Alaska Natives, especially women, than among US Whites. Over the past 20 years, there has not been a significant decline in stroke mortality among Alaska Natives.

Alaska Native parental attitudes on cervical cancer, HPV and the HPV vaccine.

Objectives. To describe Alaska Native parents’ knowledge of and attitudes towards cervical cancer, the human papillomavirus (HPV) and the HPV vaccine. Study design. This was a qualitative study composed of 11 focus groups (n=80) that were held in 1 small village, 2 towns and 1 large urban centre in Alaska. Methods A convenience sample of Alaska Native parents/guardians was recruited in each community to participate in focus groups and to fill out a quantitative survey. Results While many parents had heard about HPV, most were unaware of its link with cervical cancer. The majority wanted to vaccinate their daughters because they had health and safety concerns; believed that vaccines work; had personal experiences with cancer; or believed that their daughters were susceptible to HPV. Reasons for refusal included general concerns about vaccines; a need for more information; a fear of side effects; wanting more vaccine research; and a fear of being in an experimental trial. Conclusions The majority of parents were interested in having their daughters vaccinated. Acceptance of the vaccine was primarily based on a parent’s desire to protect her/his child from cancer; while reasons for refusal revolved around trust issues and fear of unknown negative consequences of the vaccine.

Comprehensive cancer control programs and coalitions: partnering to launch successful colorectal cancer screening initiatives

Colorectal cancer control has long been a focus area for Comprehensive Cancer Control programs and their coalitions, given the high burden of disease and the availability of effective screening interventions. Colorectal cancer control has been a growing priority at the national, state, territorial, tribal, and local level. This paper summarizes several national initiatives and features several Comprehensive Cancer Control Program colorectal cancer control successes.

Alaska Native Mortality Rates and Trends

Objectives. This article compared mortality data (1999–2003) for Alaska Natives (AN), U.S. white residents (USW), and Alaska white residents (AKW), and examined changes in mortality rates from 1979 to 2003. Methods. We used SEERStat* software from the National Cancer Institute to calculate age-adjusted mortality rates. Results. The AN all-cause mortality rate was 40% higher (rate ratio [RR]=1.4) than the rate for both the USW and AKW populations. Based on comparisons with USW, the largest disparities in AN mortality were found for unintentional injuries (RR=3.0), suicide (RR=3.1), and homicide (RR=4.4). Disparities were also found for eight of the 10 leading causes of death, including cancer (AN/USW RR=1.3), cerebrovascular disease (RR=1.3), chronic obstructive pulmonary disease (RR=1.4), pneumonia/influenza (RR=1.6), and chronic liver disease (RR=2.0). In contrast, the mortality rate for heart disease among AN was significantly lower (RR=0.9) than for USW, and lower—though not significantly lower—for diabetes. Findings were quite similar when rates for AN were compared with AKW. AKW also had high rates of unintentional injury mortality and suicide compared with USW, but the magnitude of the difference was much less for AKW. From 1979 to 2003, mortality rates among AN declined 16% for all causes, similar to the USW decline of 15%. Conclusions. Monitoring mortality rates and their trends is essential not only to understand the health status of a population but also to target areas for prevention and evaluate the impact of policy change or the effect of interventions over time.

Reduction of amputation rates among Alaska Natives with diabetes following the development of a high-risk foot program

Objective. The prevalence of diabetes is increasing rapidly among Alaska’s Indian, Eskimo and Aleut populations. Approximately half the Native people with diabetes have no road access to hospitals or physicians, presenting a challenge in the attempt to prevent lower extremity amputation as a complication. In late 1998 funding became available for diabetes prevention and treatment among Native Americans. The tribal health corporations in Alaska decided to use a portion of this funding to implement a high-risk foot program to decrease the amputation rate. Program Design. The program initially involved a surgical podiatrist who provided training to local staff and performed preventive and reconstructive surgery on several patients with impending amputations. The program then provided training for a physical therapist to become a certified pedorthist. This individual established the long-term maintenance phase of the program by conducting diabetic foot clinics routinely at the Alaska Native Medical Center, a referral center in Anchorage. He also travels to other regions of the state to provide training for village and hospital-based health care providers and to conduct field clinics. A system was established in a common database management program to track the patients’ foot conditions. Patient education is emphasized. Results. The overall amputation incidence among all Alaska Native patients with diabetes decreased from 7.6/1,000 in the pre-program period (1996 to 1998) to 2.7/1,000 in the post-program period (1999–2001)(p<.001). The rate among Aleuts, who previously had the highest amputation incidence, decreased from 17.4/1,000 to 3.1/1,000 over the same time periods (p<.001). Among people who had had diabetes at least 10 years, the overall amputation incidence decreased from 16.4/1,000 to 6.8/1,000 (p=.021); among Aleuts the rate fell from 24.5/1,000 to 2.6/1,000 (p=.01). Conclusions. Though longer follow-up is needed, these data suggest that even in populations living in isolated regions, diabetic amputations can be prevented by a coordinated system to identify high-risk feet and provide preventive treatment and education in the context of a comprehensive diabetes management program in an integrated health system.

Innovative primary care delivery in rural Alaska: a review of patient encounters seen by community health aides

Background. For more than 50 years, Community Health Aides and Community Health Practitioners (CHA/Ps) have resided in and provided care for the residents of their villages. Objectives. This study is a systematic description of the clinical practice of primary care health workers in rural Alaska communities. This is the first evaluation of the scope of health problems seen by these lay health workers in their remote communities. Study design. Retrospective observational review of administrative records for outpatient visits seen by CHA/Ps in 150 rural Alaska villages (approximate population 47,370). Methods. Analysis of electronic records for outpatient visits to CHA/Ps in village clinics from October 2004 through September 2006. Data included all outpatient visits from the Indian Health Service National Patient Information Reporting System. Descriptive analysis included comparisons by region, age, sex, clinical assessment and treatment. Results. In total 272,242 visits were reviewed. CHA/Ps provided care for acute, chronic, preventive, and emergency problems at 176,957 (65%) visits. The remaining 95,285 (35%) of records did not include a diagnostic code, most of which were for administrative or medication-related encounters. The most common diagnostic codes were: pharyngitis (11%), respiratory infections (10%), otitis media (8%), hypertension (6%), skin infections (4%), and chronic lung disease (4%). Respiratory distress and chest pain accounted for 75% (n=10,552) of all emergency visits. Conclusions. CHA/Ps provide a broad range of primary care in remote Alaskan communities whose residents would otherwise be without consistent medical care. Alaskas CHA/P program could serve as a health-care delivery model for other remote communities with health care access challenges. To access the supplementary material to this article: ‘NPIRS Categorical Hierarchy’ please see the Supplementary files under Article Tools online