Kelly J. Acton

Trends in Diabetes Prevalence Among American Indian and Alaska Native Children, Adolescents, and Young Adults

OBJECTIVES This study determined trends in diabetes prevalence among young American Indians and Alaska Natives. METHODS American Indian and Alaska Native children (< 15 years), adolescents (15-19 years), and young adults (20-34 years) with diabetes were identified from the Indian Health Service (IHS) outpatient database. The population living within IHS contract health service delivery areas was determined from census data. RESULTS From 1990 to 1998, the total number of young American Indians and Alaska Natives with diagnosed diabetes increased by 71% (4534 to 7736); prevalence increased by 46% (6.4 per 1000 to 9.3 per 1000 population). Increases in prevalence were greater among adolescents and among young men. CONCLUSIONS Diabetes should be considered a major public health problem among young American Indians and Alaska Natives.

Translating the Diabetes Prevention Program Into American Indian and Alaska Native Communities Results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project

OBJECTIVE The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities. RESEARCH DESIGN AND METHODS The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated. RESULTS The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure. CONCLUSIONS Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.

Racial Disparities in Health Status: A comparison of the morbidity among American Indian and U.S. adults with diabetes

OBJECTIVE American Indians and Alaska Natives are 2.3 times more likely to have diabetes than are individuals in the U.S. general population. The objective of this study was to compare morbidity among American Indian and U.S. adults with diabetes. RESEARCH DESIGN AND METHODS We extracted demographic and health service utilization data for an adult American Indian population aged 18–64 years (n = 30,121) served by the Phoenix Service Unit from the Indian Health Service clinical reporting system. Similar data for a U.S. population (n = 1,500,002) with commercial health insurance, matched by age and sex to the American Indian population, were drawn from the MartketScan Research Database. We used Diagnostic Cost Groups to identify medical conditions for which each individual was treated and to assign a risk score to quantify his or her morbidity burden. We compared the prevalence of comorbidities and morbidity burden of American Indian and U.S. adults with diabetes. RESULTS American Indians with diabetes had significantly higher rates of hypertension, cerebrovascular disease, renal failure, lower-extremity amputations, and liver disease than commercially insured U.S. adults with diabetes (P < 0.05). The American Indian prevalence rates were 61.2, 6.9, 3.9, 1.8, and 7.1%, respectively. The morbidity burden among the American Indian with diabetes exceeded that of the insured U.S. adults with diabetes by 50%. CONCLUSIONS The morbidity burden associated with diabetes among American Indians seen at the Phoenix Service Unit far exceeded that of commercially insured U.S. adults. These findings point to the urgency of enhancing diabetes prevention and treatment services for American Indians/Alaska Natives to reduce diabetes-related disparities.

Diabetes outcomes in the indian health system during the era of the special diabetes program for indians and the government performance and results act

OBJECTIVES We reviewed changes in blood glucose, blood pressure, and cholesterol levels among American Indians and Alaska Natives between 1995 and 2001 to estimate the quality of diabetes care in the Indian Health Service (IHS) health care delivery system. METHODS We conducted a cross-sectional analysis of data from the Indian Health Service Diabetes Care and Outcomes Audit. RESULTS Adjusted mean Hemoglobin A1c (HbA1c) levels (7.9% vs 8.9%) and mean diastolic blood pressure levels (76 vs 79 mm Hg) were lower in 2001 than in 1995, respectively. A similar pattern was observed for mean total cholesterol (193 vs 208 mg/dL) and triglyceride (235 vs 257 mg/dL) levels in 2001 and 1995, respectively. CONCLUSIONS We identified changes in intermediate clinical outcomes over the period from 1995 to 2001 that may reflect the global impact of increased resource allocation and improvements in processes on the quality of diabetes care, and we describe the results that may be achieved when community, health program, and congressional initiatives focus on common goals.

Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska Natives.

OBJECTIVE Research suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c). METHODS Analyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project (N=2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework. RESULTS Model 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c. CONCLUSION Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes. PRACTICE IMPLICATIONS Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.

Improving diabetes care in the primary health setting : The Indian health service experience

American Indians and Alaskan Natives, like many indigenous peoples, are experiencing an epidemic of noninsulin-dependent diabetes mellitus (NIDDM) [1-3]. To improve the long-term outcomes of diabetic patients, Indian Health Service (IHS) primary care physicians acting as regional diabetes coordinators identified preventive practices that could be incorporated into the care of diabetic patients who were followed in primary care facilities, along with key surrogate variables that could be measured to evaluate care and intermediate patient outcomes. Since 1986, 12 regional coordinators have promoted these variables as minimum standards of care and have revised them periodically to reflect clinically significant scientific advances. Efforts to encourage the 176 IHS, tribal, and urban facilities to incorporate these practices into their settings were collaborative and collegial and were not done as closely monitored research studies. Timely, affordable, and accurate measures of the implementation of these standards were essential to ensure that facilities in this geographically widespread, culturally diverse, and largely rural primary health system could assess their own practices and identify opportunities for improvement. Methods The actual strategy for measuring implementation of these standards and providing ongoing, appropriate feedback has evolved over several years, as discussed in detail in previous publications [4, 5]. Briefly, staff at each facility were encouraged to maintain a registry of active patients with diabetes who were living in the community; written guidance was provided for the definition of active patients. Selected clinical interventions and patient variables were measured yearly in a sample of charts drawn in a systematic, random fashion from the registry. The sample size was sufficient to yield estimates within approximately 10% of the true rate for that facility with a confidence of 90% or greater using a threshold estimate of 70% for most variables. Chart review was done by the regional diabetes coordinators and other professional staff trained by the coordinators; a uniform set of definitions was used throughout the United States. The abstracted data were entered into a general-purpose microcomputer-based software program [6]. Summary reports were generated immediately to be available to the facilitys staff for quality improvement activities and program planning. The data from participating sites were then combined regionally and finally aggregated to determine national rates. This comprehensive, ongoing surveillance program provides timely, affordable, and accurate measures to identify and evaluate quality improvement strategies at the local, regional, and national levels. Selected trends from several geographic areas for recent years are reported here to document the utility of a simple feedback system and highlight challenges that must be addressed to improve care provided to diabetic patients in primary care settings. Results and Discussion Administering pneumococcal vaccine to protect diabetic patients from pneumococcal pneumonia is a standard recommendation from several national advisory bodies on immunization; it is particularly important to Native American communities, which have high death rates from pneumonia and a particular susceptibility to pneumococcal infection [7-10]. Table 1 shows a consistent increase from 1987 to 1994 in the percentage of diabetic patients in Minnesota, Wisconsin, and Michigan who received pneumococcal vaccination. After immunizations were promoted and immunization status was monitored over several years, the overall percentage of diabetic patients who had received the vaccine once increased from 24% to 59% (P < 0.001 for trend). Table 1. Documentation of Pneumovax Vaccination Status in Records of Diabetic Patients from Indian Health Services Facilities in Minnesota, Wisconsin, and Michigan* Over the same period, rates of yearly comprehensive foot examinations increased less consistently, as shown in Table 2. Accurate measures using monofilaments and clinical examinations to quantify the risk for lower-extremity problems were promoted as a preventive practice because many IHS primary care settings had a shortage of foot care resources and providers needed to identify patients who could benefit most from specialized intervention [11-14]. In a large study in 1993, targeting diabetic patients at high risk for foot problems was shown to reduce clinical abnormalities [15]. In Alaska, identifying high-risk patients and targeting services to these patients decreased rates of lower-extremity amputation [16]. From 1987 to 1994, primary care providers gradually became familiar with the techniques of neurologic examination with monofilaments and examining feet for peripheral pulses and deformities. However, primary care physicians often delegated the examination to other providers who were not consistently available, and the increase in examination rates was not sustained as consistently as the increase in immunization practices. Table 2. Documentation of Annual Foot Examination in Records of Diabetic Patients from Indian Health Services Facilities in Minnesota, Wisconsin, and Michigan* Surveillance of diabetes care can also measure other important, related parameters such as blood pressure. Hypertension control in diabetic patients has received widespread emphasis in recent years because of the substantial and growing evidence of the adverse effect of hypertension on many diabetic complications and the availability of effective, well-tolerated antihypertensive agents [17]. Because blood pressure is monitored regularly in most facilities, regional diabetes coordinators have been able to collect the last three blood pressure measurements recorded in the past year [5]. Mean systolic and mean diastolic pressures were calculated separately. Table 3 shows categories of blood pressure measurements taken in 1992, 1993, and 1994 in 10 IHS facilities in Montana and Wyoming. Uncontrolled hypertensiondefined as a mean systolic pressure of 140 mm Hg or more or a mean diastolic pressure of 90 mm Hg or more, or bothwas found in 36% of the patient charts in 1992. As a result of the data, quality improvement efforts were initiated. The regional diabetes coordinator visited each of the 10 facilities, reviewed the data with the providers to give feedback, and re-emphasized the importance of hypertension control. Despite staff turnover and the necessity for patients to return monthly for medication refills, the rate of uncontrolled hypertension decreased substantially to 25% during 1993, as shown in Table 3. During 1994, however, less emphasis was placed on hypertension, and the rate of uncontrolled hypertension increased to 33%. Staff members at each facility were quickly informed of the higher rate, which prompted redoubled efforts and new strategies to reduce it. Ongoing monitoring will permit an evaluation of these efforts. In summary, hypertension control in diabetic patients can be defined, measured, and monitored to create an evaluation system for interventions that should decrease morbidity from diabetic complications adversely influenced by hypertension [17]. Table 3. Recorded Blood Pressures by Categories in Indian Health Services Facilities in Montana and Wyoming In contrast to hypertension control, levels of metabolic control are relatively difficult to measure, and no widely accepted classification of levels exists. A preliminary categorization scheme for monitoring glycemia, using 1994 data from charts of diabetic patients in Washington, Oregon, and Idaho, is shown in Table 4. In a sample of 568 charts taken from 1647 diabetic patient records, 29 charts contained insufficient data to categorize glycemia; 384 charts recorded HbA1c values from five laboratories using two commercial assays; and 155 charts recorded no HbA1c values but contained fasting or postprandial blood glucose levels, or both, from which the mean of the three most recent values was calculated. The mean blood glucose levels were then used to stratify the patients into categories of glycemic control, which were roughly equivalent to the categories defined using HbA1c values. These blood glucose level categories were constructed by interpolating the range of blood glucose levels equivalent to the HbA1c values in the published graph comparing the HbA1c assay used in the Diabetes Control and Complications Trial with the mean blood glucose levels of study participants [18]. Thirty percent of patients were in the acceptable range (HbA1c less than equals 7.5% or a mean blood glucose level less than equals 9.2 mmol/L), and 9% were in the poorest category (HbA1c more than 12% or a mean blood glucose level more than 18.9 mmol/L). Obviously, there are inherent methodologic issues in the measurement of glycosylated hemoglobin within and between laboratories, and the estimates of equivalent mean blood glucose levels are not precise [19-24]. Efforts to improve and standardize glycosylated hemoglobin measurements are under way and should greatly enhance their utility for both clinical and surveillance purposes. Nevertheless, the classification system presented is a preliminary framework and provides a useful overview. Table 4. Glycemic Control by Category from Indian Health Services Facilities in Washington, Oregon, and Idaho in 1994 A simple, reproducible, and affordable system to measure and track levels of glycemia in diabetic patient populations is essential for providing feedback to primary care systems. In Japan, the introduction of a simple categorization system using HbA1c was associated with improved levels of control [25]. Widespread use of such a standard system in the United States would allow investigators to examine variations in metabolic outcomes and could provide important information about the resources needed to achieve improved glycemic control in the primary care setting. Because diabetes ed

Measuring the Quality of Diabetes Care for Older American Indians and Alaska Natives

OBJECTIVES This study evaluated the quality of diabetes care for older American Indians and Alaska Natives. METHODS We analyzed the Indian Health Service Diabetes Care and Outcomes Audit to determine whether completion of indicators of diabetes care differed as a function of age and whether additional patient and program factors were also associated with completion of the majority of the indicators. RESULTS Completion rates varied by age group, with significantly lower rates seen among the youngest and oldest. Patient diabetes education and duration of diabetes were most strongly associated with the completion of the majority of these indicators. CONCLUSIONS Further studies are needed to determine effective interventions, including diabetes education, to improve the quality of diabetes care in the youngest and oldest age groups.

Comparing self-reported measures of diabetes care with similar measures from a chart audit in a well-defined population.

The objective of this study was to compare self-reported measures of diabetes care with measures derived from medical records in a well-defined population. Diabetes measures were collected through a 1997 Behavioral Risk Factor Surveillance System telephone survey of American Indians living on or near 7 Montana reservations (N = 398) and were compared with data collected from charts of a systematic sample of American Indians with diabetes seen in 1997 at Indian Health Service (IHS) facilities. Survey respondents were more likely to report a duration of diabetes >10 years (44 vs 31%), annual dilated retinal exam (75 vs 59o), and an influenza immunization in the past year (73 vs 57%) compared with estimates from the chart audit. Estimates of pneumococcal immunization (88 vs 42%), annual cholesterol screening (86 vs 69o), and overweight, based on body mass index (67 vs 50%), were significantly higher from the chart audit. No significant differences were found between the survey respondents and the chart audit data for annual foot exams (65 vs 61%), annual blood pressure checks (98 vs 93%), high cholesterol (35 vs 41%), and high blood pressure (54 vs 64%). These findings suggest that self-reported data may over and underestimate specific measures of diabetes care.

The Costs of Treating American Indian Adults With Diabetes Within the Indian Health Service

OBJECTIVES We examined the costs of treating American Indian adults with diabetes within the Indian Health Service (IHS). METHODS We extracted demographic and health service utilization data from the IHS electronic medical reporting system for 32 052 American Indian adults in central Arizona in 2004 and 2005. We derived treatment cost estimates from an IHS facility-specific cost report. We examined chronic condition prevalence, medical service utilization, and treatment costs for American Indians with and without diabetes. RESULTS IHS treatment costs for the 10.9% of American Indian adults with diabetes accounted for 37.0% of all adult treatment costs. Persons with diabetes accounted for nearly half of all hospital days (excluding days for obstetrical care). Hospital inpatient service costs for those with diabetes accounted for 32.2% of all costs. CONCLUSIONS In this first study of treatment costs within the IHS, costs for American Indians with diabetes were found to consume a significant proportion of IHS resources. The findings give federal agencies and tribes critical information for resource allocation and policy formulation to reduce and eventually eliminate diabetes-related disparities between American Indians and Alaska Natives and other racial/ethnic populations.

Special Diabetes Program for Indians: Retention in Cardiovascular Risk Reduction

PURPOSE This study examined the associations between participant and site characteristics and retention in a multisite cardiovascular disease risk reduction project. DESIGN AND METHODS Data were derived from the Special Diabetes Program for Indians Healthy Heart Demonstration Project, an intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. In 2006, a total of 1,072 participants from 30 participating sites completed baseline questionnaires measuring demographics and sociobehavioral factors. They also underwent a medical examination at baseline and were reassessed annually after baseline. A Provider Annual Questionnaire was administered to staff members of each grantee site at the end of each year to assess site characteristics. Generalized estimating equation models were used to evaluate the relationships between participant and site characteristics and retention 1 year after baseline. RESULTS Among enrolled participants, 792 (74%) completed their first annual assessment. Participants who completed the first annual assessment tended to be older and had, at baseline, higher body mass index and higher level of physical activity. Site characteristics associated with retention included average age of staff, proportion of female staff members, and percentage of staff members having completed graduate or professional school. IMPLICATIONS Understanding successful retention must reach beyond individual characteristics of participants to include features of the settings that house the interventions.