This study evaluated the utility of a model diabetes demonstration program created by the Indian Health Service (IHS) in 1979. Through analysis of 634 medical records, focus groups, and interviews, the model program was found to improve patients' blood sugar control and to reduce their hospitalizations. A critical element of the model program was a team of health professionals who augmented primary care by providing a combination of education, outreach, service delivery, and referrals. Recommendations were made to patients, providers, administrators, and policymakers that would refine and expand this demonstration program.
The purpose of this study was to evaluate a model diabetes demonstration program at two of the five sites at which the program was launched by IHS in 1979. The hallmark of the program is a team of three to five midlevel health professionals, including a physician's assistant or nurse practitioner, nurse, and dietitian/nutritionist. The team educated patients in preventive care, referred patients to specialists when needed, coordinated services, performed community screening, and maintained patient registries. The study measured two key patient outcomes--blood sugar control and hospitalizations--in relation to a control group of patients who received usual IHS diabetes services.
The Indian Health Care Improvement Act (Public Law 94-437) of 1992 mandated an evaluation of a model diabetes demonstration program established by IHS in 1979. Since its inception, this model program of intensive primary and preventive care has been extended to at least one site within each of the 12 regional areas of IHS. The impetus for the formation of the model program was to improve patient management and to reduce hospitalizations for a costly condition that disproportionately affects American Indians.
The prevalence of diabetes in this population (6.9 percent) is almost three times higher than that in the U.S. population as a whole (2.4 percent). American Indians also suffer from disproportionately higher rates of diabetic complications. Complications include loss of vision or blindness, lower extremity amputations, and end-stage renal disease. Mortality rates among diabetic American Indians also are higher compared with those of other ethnic groups. Moreover, diabetics are intensive consumers of medical services, and the costs per patient are among the highest of any medical condition.
The underlying philosophy behind the creation of the model program was that a team of primary care professionals could effectively deliver patient education, outreach, and treatment. Patient education was designed to address diet, exercise, foot care, administration of medications, and monitoring of blood sugar. Equipped with more knowledge and skills, patients were thought to be in a better position to control their blood sugar levels. Achieving better control over blood sugar levels was expected to lower the rate of diabetic complications and other conditions that lead to hospitalization.
The study methodology consisted of quantitative and qualitative components. Abstracted medical records from a total of 634 patients who entered treatment between 1983 and 1992 were analyzed. Information from medical records was supplemented by data on inpatient and outpatient contacts from IHS health services utilization databases. Additional analyses were conducted to determine the generalizability of findings to other IHS sites. Using 1993 IHS audit data, patient demographics, severity of illness, and extent of services at model sites were compared with similar data at other model sites. The analyses also compared the control site with other IHS sites that provided usual treatment.
Focus groups with patients and interviews with IHS and tribal staff supplemented quantitative analyses. During four focus group meetings--two at model sites and two at control sites--patients were asked about problems they encountered in complying with medical recommendations and their views of the services they received. Interviews with medical personnel yielded information about the content and the perceived quality of diabetes services.
The study found the model program to be successful at controlling patients' blood sugar levels and at reducing their hospitalizations. Fewer patients (11-35 percent) at model versus control sites experienced poor blood sugar control, as defined by fasting levels of more than 220 milligrams per deciliter of blood or by random levels of more than 250 milligrams per deciliter of blood. Patients at model sites were at lower risk of being hospitalized, operationally defined as the time from diagnosis to the first diabetes-related hospitalization.
The study identified several elements of the program that were associated with good blood sugar control: consultations with a dietitian and a podiatrist in the first year after diagnosis and receipt of a hemoglobin A1c test one or more times in 2 years. This test for blood sugar levels is more reliable than others because it reflects average levels over the previous 3- to 4-month period. Similar programmatic elements helped prevent hospitalizations. As to the generalizability of all study findings to other IHS sites, the analysis of audit data could not provide a definitive answer because of undersampling at the control site.
Observations from patients and providers at focus groups and interviews, respectively, offered important insights about the model program. Patients and providers both claimed changes in diet to be the most difficult for patients to implement. Patients stressed the importance of good communication with their providers, and those receiving the usual care reported more communication problems. This finding was considered noteworthy because earlier published research revealed that the quality of the patient-physician relationship is predictive of diabetic patients' compliance with lifestyle changes and medication dosing.
Use of Results
The study offered a battery of recommendations to refine the model program and to enhance care at IHS sites that do not have the program. The study is being prepared for publication. Knowledgeable clinical staff who are current with diabetes management were considered vital to the delivery of primary care to diabetes patients. Those IHS sites that do not have the model program can greatly benefit from creating one new staff position that is devoted to diabetes education, coordination, and outreach.
The finding that patient education in the first year after diagnosis had important and long-lasting impacts led to a recommendation for early patient education that focused on difficult lifestyle changes, particularly dietary changes. Blood sugar evaluation by both standard tests and by the hemoglobin A1c test were requirements for good clinical management and were correlated with better sugar control and lower hospitalizations. Only a small percentage of patients at model sites, and even fewer at the control site, received both tests once a year.
The study recommended more time for direct patient contact with providers even in lieu of some educational services. A strong bond between patients and providers was viewed as essential for improving patient compliance. Finally, the study recommended training for providers in counseling patients who are especially stressed by the diagnosis of diabetes.
Office of Planning, Evaluation, and Legislation
Frank E. Marion
PIC ID: 6005
Native American Consultants, Inc., Washington, DC