Improving Diabetes Care in the Primary Health Setting: The Indian Health Service Experience

1 January 1996 | Volume 124 Issue 1 Part 2 | Pages 149-152

Purpose: To identify key systems issues from the Indian Health Service (IHS) experience that must be addressed to improve metabolic control among patients with noninsulin-dependent diabetes mellitus (NIDDM) who were followed in primary care settings.

Data Sources: Records of diabetic patients seen in IHS facilities in specific geographic regions from 1987 to 1994.

Study Selection: A representative sample of charts from each facility was reviewed yearly to measure key variables. The sampling frame was the number of diabetic patients currently active on the registry and the sample size calculated to measure a 10% change in selected practices at each facility.

Extraction: Regional diabetes coordinators reviewed charts or trained local providers to sample and extract data in a standard format.

Results: Regional data were examined to show trends in the performance of immunizations and foot examinations and in other variables such as hypertension and metabolic control. The percentage of diabetic patients who received a single dose of pneumococcal vaccine improved from 24% in 1987 to 1988 to 57% in 1994 (P < 0.01 for trend) among diabetic patients in Minnesota, Wisconsin, and Michigan. Rates of yearly comprehensive foot examination increased from 36% to 58% (P < 0.01 for trend) over the same period. In Montana and Wyoming, the percentage of diabetic patients with uncontrolled hypertension (defined as the mean of three systolic blood pressure measurements of more than equals 140 mm Hg or diastolic pressure measurements more than equals 90 mm Hg, or both, during the previous year) decreased from 36% in 1992 to 25% in 1993 after the regional diabetes coordinator emphasized hypertension control. In 1994, when less emphasis was placed on hypertension, 33% of the diabetic patients had uncontrolled hypertension. Estimates of metabolic control from records of diabetic patients in Washington, Oregon, and Idaho in 1994 showed that 29% of patients had excellent metabolic control (a hemoglobin A_1c [HbA_1c] level less than equals 7.5% or mean blood glucose level less than equals 9.2 mmol/L) within the past year; only 9% experienced poor control (a HbA_1c level more than 12% or mean blood glucose level more than 18.9 mmol/L).

Conclusions: The IHS experience shows that standard, ongoing monitoring of key variables allows facilities to improve diabetes care. Simple, reliable methods of defining metabolic control combined with a feedback system in the primary care setting are needed to improve metabolic control in patients with NIDDM.

Author and Article Information

From the Indian Health Service Diabetes Program, Albuquerque, New Mexico; the Bemidji Area Indian Health Service, Bemidji, Minnesota; the Billings Area Diabetes Program, Tribal Health and Human Services, St. Ignatius, Montana; and the Portland Area Diabetes Program, Bellingham, Washington.
Note: This article is one of a series of articles comprising an Annals of Internal Medicine supplement entitled "Risks and Benefits of Intensive Management in Non-Insulin-dependent Diabetes Mellitus: The Fifth Regenstrief Conference." To view a complete list of the articles included in this supplement, please view its Table of Contents.
Disclaimer: The opinions expressed here are those of the authors and do not necessarily reflect the views of the Indian Health Service.
Acknowledgments: The authors thank the many dedicated Indian Health Services and tribal health providers who have contributed to this effort and Dr. Betty Skipper for her guidance.
Requests for Reprints: Dorothy Gohdes, MD, Indian Health Service Diabetes Program, 5300 Homestead Road, NE, Albuquerque, NM 87110.
Current Author Addresses: Dr. Gohdes: Indian Health Service Diabetes Program, 5300 Homestead Road, NE, Albuquerque, NM 87110.