Article

Trends in Quality of Care and Barriers to Improvement in the Indian Health Service

Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 12/2010; 26(5):480-6. DOI: 10.1007/s11606-010-1594-4
Source: PubMed

ABSTRACT Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.
To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).
Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.
Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.
Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.
Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.
Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

Full-text

Available from: Shimon Aaron Shaykevich, Apr 07, 2014
0 Followers
 · 
140 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: American Indian and Alaska Native (AIAN) women have relatively high breast cancer mortality rates despite the availability of free or low-cost screening. This qualitative study explored issues that influence the participation of older AIAN women in mammography screening through tribally directed National Breast and Cervical Cancer Early Detection Programs (NBCCEDPs). We interviewed staff (n = 12) representing five tribal NBCCEDPs and conducted four focus groups with AIAN women ages 50 to 80 years (n = 33). Our analysis identified four main areas of factors that predispose, enable, or reinforce decisions around mammography: financial issues and personal investments, program characteristics including direct services and education, access issues such as transportation, and comfort zone topics that include cultural or community-wide norms regarding cancer prevention. This study has implications for nurse education and training on delivering effective mammography services and preventive cancer outreach and education programs in AIAN communities.
    Journal of Transcultural Nursing 03/2014; 26(2). DOI:10.1177/1043659614523994 · 0.83 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To examine patient characteristics, treatment modalities, and human papillomavirus (HPV) prevalence to identify potential mediators of disparities that may lead to differences in outcomes for American Indians with head and neck squamous cell carcinoma (HNSCC). Historical cohort study. Community cancer centers. We reviewed all patients older than 18 years with a new diagnosis of HNSCC in South Dakota from 1999 to 2009. We assessed tissue samples from cases of oropharyngeal cancer for the presence of HPV DNA. In total, 474 white patients were compared with 32 American Indians. American Indians experienced significantly worse survival compared with whites (hazard ratio [HR], 0.59; P = .05), even after controlling for other factors such as age, sex, distance, Charlson comorbidity index, alcohol abuse, smoking, insurance, and disease stage. American Indians had a greater risk of alcohol abuse (68% vs 42%; P = .008), current smoking (67% vs 49%; P = .03), living more than 1 hour from a cancer center (81% vs 30%; P < .001), lacking private insurance (24% vs 68%; P < .001), and late-stage disease presentation (stages III and IV) (74% vs 55%; P = .04). There were no detected differences in age, sex, medical comorbidities, tumor site, tumor grade, HPV status, time to treatment, or type of treatment received. American Indians in South Dakota with HNSCC have poorer survival compared with white patients. Once presented to a cancer center, American Indians received nearly identical treatment to white patients. Disparities in outcomes arise primarily due to sociodemographic factors and later stage at presentation.
    Otolaryngology Head and Neck Surgery 04/2014; 151(2). DOI:10.1177/0194599814533083 · 1.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives. We assessed diabetes-related mortality for American Indians and Alaska Natives (AI/ANs) and Whites. Methods. Study populations were non-Hispanic AI/AN and White persons in Indian Health Service (IHS) Contract Health Service Delivery Area counties; Hispanics were excluded. We used 1990 to 2009 death certificate data linked to IHS patient registration records to identify AI/AN decedents aged 20 years or older. We examined disparities and trends in mortality related to diabetes as an underlying cause of death (COD) and as a multiple COD. Results. After increasing between 1990 and 1999, rates of diabetes as an underlying COD and a multiple COD subsequently decreased in both groups. However, between 2000 and 2009, age-adjusted rates of diabetes as an underlying COD and a multiple COD remained 2.5 to 3.5 times higher among AI/AN persons than among Whites for all age groups (20-44, 45-54, 55-64, 65-74, and ≥ 75 years), both sexes, and every IHS region except Alaska. Conclusions. Declining trends in diabetes-related mortality in both AI/AN and White populations are consistent with recent improvements in their health status. Reducing persistent disparities in diabetes mortality will require developing effective approaches to not only control but also prevent diabetes among AI/AN populations. (Am J Public Health. Published online ahead of print April 22, 2014: e1-e8. doi:10.2105/AJPH.2014.301968).
    American Journal of Public Health 04/2014; DOI:10.2105/AJPH.2014.301968 · 4.23 Impact Factor