Julia J. Smith

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.

Differences in cigarette and smokeless tobacco use among American Indian and Alaska Native people living in Alaska and the Southwest United States.

INTRODUCTION This study analyzed self-reported tobacco use among American Indian and Alaska Native (AI/AN) people enrolled in the Education and Research Towards Health Study in Alaska (n = 3,821) and the Southwest United States (n = 7,505) from 2004 to 2006. METHODS Participants (7,060 women and 4,266 men) completed a computer-assisted self-administered questionnaire on cigarette and smokeless tobacco (ST) use. RESULTS Current use of cigarettes was considerably higher in Alaska than in the Southwest United States (32% vs. 8%). Current ST use was also more common in Alaska than in the Southwest United States (18% vs. 8%). Additionally, smoking was more common among men, younger age, those who were not married, and who only spoke English at home, while ST use was more common among men, those with lower educational attainment and those who spoke an AI/AN language at home (p < .01). Compared with the U.S. general population, AI/AN people living in Alaska were more likely and those living in the Southwest United States were less likely to be current smokers. Rates of ST use, including homemade ST, in both regions were much higher than the U.S. general population. DISCUSSION Tobacco use among AI/AN people in the Southwest United States, who have a tradition of ceremonial tobacco use, was far lower than among Alaska Native people, who do not have a tribal tradition. Tobacco use is a key risk factor for multiple diseases. Reduction of tobacco use is a critical prevention measure to improve the health of AI/AN people.

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.

The Effect of Regular Primary Care Utilization on Long-Term Glycemic and Blood Pressure Control in Adults With Diabetes

Purpose: Complications of diabetes mellitus (DM) can be reduced with regular preventive care and guidance on self-management. We investigated whether regular primary care utilization could improve glycemic control and blood pressure control among American Indian/Alaska Native people with DM. Methods: Patient characteristics, risk factors, and health outcomes were identified from electronic health records of a cohort of 2138 adults with DM who received care between 1995 and 2010 from Southcentral Foundation, a tribal provider. Bivariate probit regression models estimated the probability of glycemic control and blood pressure control as functions of regular primary care, risk factors, and access factors, while taking into account potential bias arising from voluntarily choosing to seek primary care services. Results: Regular primary care was associated with an 89% increased likelihood of blood pressure control (95% confidence interval [CI], 59–118%) and 177% increased likelihood of glycemic control (95% CI, 123–222%). Increasing the distance by 10 miles to primary care services reduced the likelihood of regular primary care by 3.7% (95% CI, −2.9% to −4.6%). Conclusions: Regular primary care utilization over 16 years was associated with higher rates of blood pressure control and glycemic control for adults with DM. People living closer to primary care services had a better chance of improved outcomes.

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.

Medical home implementation and trends in diabetes quality measures for AN/AI primary care patients

AIMS Patient-centered medical home (PCMH) principles including provider continuity, coordination of care, and advanced access align with healthcare needs of patients with Type II diabetes mellitus (DM-II). We investigate changes in trend for DM-II quality indicators after PCMH implementation at Southcentral Foundation, a tribal health organization in Alaska. METHODS Monthly rates of DM-II incidence, hemoglobin A1c (HbA1c) measurements, and service utilization were calculated from electronic health records from 1996 to 2009. We performed interrupted time series analysis to estimate changes in trend. RESULTS Rates of new DM-II diagnoses were stable prior to (p=0.349) and increased after implementation (p<0.001). DM-II rates of HbA1c screening increased, though not significantly, before (p=0.058) and remained stable after implementation (p=0.969). There was non-significant increasing trend in both periods for percent with average HbA1c less than 7% (53 mmol/mol; p=0.154 and p=0.687, respectively). Number of emergency visits increased before (p<0.001) and decreased after implementation (p<0.001). Number of inpatient days decreased in both periods, but not significantly (p=0.058 and p=0.101, respectively). CONCLUSIONS We found positive changes in DM-II quality trends following PCMH implementation of varying strength and onset of change, as well as duration of sustained trend.

The Impact of Patient and Provider Factors on Depression Screening of American Indian and Alaska Native People in Primary Care

Introduction: The US Preventive Services Task Force recommends routine depression screening in primary care, yet regular screening does not occur in most health systems serving Alaska Native and American Indian people. The authors examined factors associated with administration of depression screening among Alaska Native and American Indian people in a large urban clinic. Methods: Medical records of 18 625 Alaska Native and American Indian adults were examined 1 year after implementation of a depression screening initiative. Multilevel logistic regression models examined associations between patient and provider factors and administration of the Patient Health Questionnaire–9. Results: Forty-seven percent of patients were screened. Women were more likely than men to be screened (50% vs 43%, P < .001). Increased screening odds were associated with older age, increased service use, and chronic disease (P < .001) but not with substance abuse disorders or prior antidepressant dispensation. Women previously diagnosed with depression had higher odds of screening (P = .002). Men seen by male providers had higher odds of screening than did men seen by female providers (P = .040). Screening rates peaked among providers with 2 to 5 years of employment with the clinic. Limitations: Cross-sectional analysis of medical record data was of unknown reliability; there were limited sociodemographic data. Conclusions: Even with significant organizational support for annual depression screening, primary care providers systematically missed men and patients with infrequent primary care visits. Outreach to male patients and additional supports for primary care providers, especially in the first years of practice, may improve screening and treatment for depression among Alaska Native and American Indian people.

Prenatal alcohol exposure among Alaska Native/American Indian infants.

Background Recent reports indicate a decline in rates of Fetal Alcohol Syndrome (FAS) among Alaska Native and American Indian (AN/AI) infants. Nevertheless, AN/AI infants remain disproportionately impacted by the effects of prenatal alcohol exposure. Methods AN/AI pregnant women in their 3rd trimester completed a questionnaire on demographic data and the amount and frequency of their alcohol consumption in the month prior to conception and during pregnancy. Differences across demographics and trimesters were tested with the Chi-square, Fishers exact or McNemars test as appropriate. Results Of the 125 participants, 56% (n=71) reported no alcohol consumption in the 1st through 3rd trimesters of pregnancy; 30% (n=38) of the 125 participants also reported no alcohol consumption in the month before pregnancy. Of the 43% (n=54) who reported consuming alcohol during pregnancy (1st, 2nd and/or 3rd trimester), most (35%) reported alcohol use only in the 1st trimester. Binge drinking in the 1st or 2nd trimester was reported amongst 20% (n=25) of participants with an additional 18% (n=29) reporting binge drinking in the month prior to pregnancy. Women who reported pre-conception binge drinking were significantly more likely to report binge drinking during their 1st trimester (p<0.0001) and 2nd trimester (p<0.0001). A history of tobacco use (p=0.0403) and cigarette smoking during pregnancy (p<0.0001) were also associated with binge drinking during pregnancy. Conclusion Among study participants, reported use of alcohol was primarily limited to pre-conception and the 1st trimester, with a dramatic decrease in the 2nd and 3rd trimesters. Prevention programmes, such as the Alaska FAS Prevention Project, may have contributed to observed decreases in the 2nd and 3rd trimesters. Additional study and focus on pre-conception, the 1st trimester and binge drinking, as well as tobacco use might augment Fetal Alcohol Spectrum Disorder prevention efforts.

Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people: Text Messages for Colorectal Cancer Screening

Alaska Native and American Indian people (AN/AIs) have a high incidence of colorectal cancer (CRC) and CRC‐related mortality. Screening can prevent death from CRC, but screening rates are low in racially and ethnically diverse populations. The authors conducted a randomized controlled trial using text messaging to increase CRC screening among unscreened AN/AIs in a tribal health care system in Anchorage, Alaska.