Comprehensive diabetes surveillance (including total and age-specific prevalence In FY 2002, over 5500 diabetes education materials were sent to over 300 I/T/U …
ACTIVITY/MECHANISMS BUDGET SUMMARY
Department of Health and Human Services
Indian Health Service - 75-0390-0-1-551
DIABETES
Program Authorization
Program authorized by 111 STAT 574, 1997 Balanced Budget Act PL 105-33
and HR 4577, Consolidated Appropriation Act 2001 PL 106-554 and
Interior Appropriation Indian Health Service National Diabetes Program
| | |2003 | | |
| |2002 |Presidents |2004 |Increase |
| |Actual |Budget |Estimate |or Decrease |
|BA |100,000,000 |100,000,000 |150,000,000 |50,000,000 |
|FTE |1 |2 |6 |4 |
The Balanced Budget Act of 1997 PL 105-33 provided that 30 million per
year appropriated to the Childrens Health Insurance Program CHIP be
transferred to Indian Health Service for diabetes prevention and treatment
for five years ending in FY 2002 called the Special Diabetes Program for
Indians grant program An additional 70,000,000/year was provided under
the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act
of 2000 for FY 2001 and FY 2002, and 100,000,000 was provided for FY 2003
These funds support the Secretarys initiative to prevent diabetes and
obesity, as well as a focus on healthier youth Total Indian Health
Service IHS diabetes funding also includes the IHS National Diabetes
Program NDP with 12 Area Diabetes Consultants and 19 model diabetes sites
77 million per year and, starting in FY 1998, 3 million was added to
the diabetes grants
The Special Diabetes Program for Indians grant funds will expire in
FY 2003, under the current legislation The SDPI funding was reauthorized
in December 2002 at 150 million per year, a 50 million per year increase,
for five years 2004-2008
PURPOSE AND METHOD OF OPERATION
American Indian and Alaska Native AI/AN communities suffer a
disproportionately high rate of type 2 diabetes The mission of the IHS NDP
is to develop, document, and sustain a public health effort to prevent and
control diabetes in AI/ANs In FY 2002, with total funding for IHS
National Diabetes Program of 1107 million, the IHS NDP promoted
collaborative strategies for the prevention of diabetes and its
complications in the 12 IHS Service Areas regions through
coordination of
a network of 19 Model Diabetes Programs and 13 Area Diabetes Consultants
They in turn provided resource distribution, program monitoring and
evaluation activities, and technical support to 84 Service Units local
level, whether federal or tribal, in the delivery of comprehensive health
care to over 15 million American Indians and Alaska Natives The NDP
continues to develop and operate the Special Diabetes Program for Indians
grant program with 318 grantees in 35 states
PROGRAM MISSION AND RESPONSIBILITIES:
The National Diabetes Program provides
Comprehensive diabetes surveillance including total and age-specific
prevalence rates of diabetes and diabetic complications across Indian
country at the local, regional and national levels through
collaboration with CDC epidemiologists and use of contract
epidemiologists and statisticians
Research translation through training and technical assistance
provided via our extensive network
Promotion of quality assurance / improvement activities in clinical
and community programs through updated Standards of Care for Diabetes,
the annual Diabetes Care Outcomes Audit, and
the Integrated Diabetes
Care and Education Recognition Program
Technical support to I/T/U sites nationwide through bulletins, updates
and comprehensive website information
Resource information on a full complement of training opportunities
including specialized training related to primary outpatient treatment
models of diabetes management
Health care provider/ consumer education resources and best
practices information to IHS, tribal and urban health programs
Development, field testing and distribution of Native American-
specific diabetes education printed and audio-visual materials to IHS
tribal health centers In FY 2002, over 5500 diabetes education
materials were sent to over 300 I/T/U programs nationwide
In addition, the NDP serves as the key IHS contact and source of
information for outside organizations and agencies working on issues of
diabetes and disparities related to diabetes
The Burden of Type 2 diabetes in AI/AN communities
Diabetes was the most frequently identified health problem in the IHS Area
I/T/U budget formulation workshops for FY 2001
Type 2 diabetes occurs at dramatically higher rates
among AI/AN adults who
are over 3 times as likely to have diabetes than the general US
population
A recent alarming trend is the increase in prevalence of type 2 diabetes
in young AI/AN Over an eleven-year period, from 1990-2001, the prevalence
of diabetes rose 25 percent in children and 106 percent in AI/AN
adolescents
Complications of diabetes lead to much higher incidence rates of blindness,
vascular insufficiency leading to amputation, and End Stage Renal Disease
ESRD than in the general US population Most recent data show that
diabetes mortality is 43 times higher in the AI/AN population than in the
US population
Special Diabetes Program for Indians
The Balanced Budget Act BBA of 1997 provided 30 million per year for
5 years through the Special Diabetes Program for Indians On December 15,
2000, Congress passed PL 106-568, the Consolidated Appropriations Act of
2001, which included a provision for supplemental funding of the Special
Diabetes Program for Indians PL 106-568 authorized an additional 70
million in FY 2001, 70 million in FY 2002 and 100 million in 2003 In
December 2002, the President signed PL 107-360 authorizing 150 million per
year from 2004 - 2008 for
grants to eligible tribes and organizations Key
aspects of the Special Diabetes Program for Indians include:
Tribal Consultation A Tribal Leaders Diabetes Workgroup was established
in 1998 to review the Area tribal input and make recommendations on the
administration and distribution of the diabetes funds Based on their
recommendations, funds were awarded through non-competitive grants for a
five-year project term The Workgroup recommended that IHS distribute
the funding by IHS Area according to a formula based primarily on disease
burden and user population with an adjustment to increase funding for
very small tribes They also recommended that 15 million be set aside
for the urban programs who were to be exempt from the distribution
formula process In addition, 5 percent of the overall funds were
reserved for improved data collection to enhance the evaluation process
An Area-wide consultation process determined distribution of the grant
funds within each Area to local IHS and tribal programs An evaluation
process was created for national and regional levels
Grant Program Evaluation There were 286 grants representing 333
separate sites awarded each year The CDCs Framework for Public Health
Evaluation, using a mixed methods approach both qualitative and
quantitative methods, has been implemented Tribal programs determined
at the local level how their funding was to be used
Prevention Efforts Sixty-six percent of programs have chosen to focus
on primary prevention, such as offering exercise and nutrition programs
to prevent the onset of diabetes Sixty-five percent of programs are also
devoting some of their grant funds toward secondary prevention efforts
managing diabetes to prevent complications such as kidney failure,
amputations, heart disease and blindness and 33 percent of programs
decided to implement tertiary prevention efforts to reduce morbidity and
disability in those who have complications from diabetes
CDC/National Diabetes Prevention Center 1 million of the BBA funds were
allocated to CDC Division of Diabetes for the development of a National
Diabetes Prevention Center NDPC in Gallup, NM The NDPC agreement was
originally awarded to the University of New Mexico UNM In 2001, UNM
redefined the NDPCs area of impact from that of a national
perspective
to a southwest regional focus UNM will continue to work primarily with
the Zuni Pueblo and Navajo Nation as originally legislated and will keep
a solely southwest focus The IHS NDP and the CDC Division of Diabetes
are working collaboratively to expand the national focus of the NDPC
through the dissemination of diabetes technical assistance resources and
other diabetes data The Tribal Leaders Diabetes Committee, established
as a result of the BBA funds to advise IHS on diabetes-related issues,
advises the IHS and CDC on these national expansion efforts
Tribal Management of Local Grant Programs The number of tribally
managed programs continues to grow steadily 81 percent of the SDPI
grant recipients are tribal programs To responsibly manage a health
program requires data that supports an assessment of the health needs of
the population To meet this need, tribal programs were well represented
in the IHS 2002 Diabetes Care and Outcomes Audit of AI/AN with diagnosed
diabetes and will have the opportunity to participate in the 2003 survey
Data gathered by these surveys provides tribes information from which to
make
rational decisions regarding their diabetes programs
The IHS National Diabetes Program has a long and distinguished history of
serving as a benchmark of diabetes clinical and public health excellence
including:
Development of the IHS Standards of Care for Diabetes in 1985, prior to
those published by the American Diabetes Association in 1986, that are
updated every 2 years based on the latest diabetes science
Leader in developing a diabetes care surveillance system, the Annual
Diabetes Care and Outcomes Audit, carried out voluntarily in Indian
health facilities, to track clinical performance This audit:
measures 87 quality improvement indicators / outcomes yearly, and
allows IHS to assess trends in these outcomes over time,
monitors use of standards and outcomes of diabetes care, including
blood sugar and blood pressure control, screening for complications,
and preventive health services and
in FY 2002 reviewed over 17,000 charts representing care to almost
90,000 patients with diagnosed diabetes at 190 IHS / tribal health
facilities in the 12 IHS Areas
This diabetes care surveillance system has been instrumental in
the
improvement of diabetes care practices in many Indian health settings For
example, in a special program in Alaska and in northern Minnesota from 1989-
2002, lower extremity amputation rates were reduced by 60 percent in people
with diabetes who received complete foot screening and protective footwear
This same system enabled IHS to measure significant improvements in blood
sugar control nationwide and in blood pressure control in Montana after an
intensive intervention
FINDINGS INFLUENCING THE FY 2004 REQUEST
The 1997 BBA Special Diabetes Program for Indians SDPI provided IHS 30
million per year for 5 years for the prevention and treatment of diabetes
The amendment to the 1997 BBA SDPI through HR 4577, the Consolidated
Appropriations Act, 2001 provided additional funding for FY 2001, 2002 and
2003 On Dec 17, 2002 a second amendment, through HR5738, was signed
into law, which provides 15 billion for the Special Diabetes Program for
Indians over the next five years 150 million each year for FY 2004 - FY
2008
SDPI funds originally provided seed money to 318 new programs to begin or
enhance diabetes prevention programs in Indian communities as well as to
address diabetes
treatment The result has been the creation of
innovative, culturally appropriate strategies that address diabetes The
SDPI funds have significantly enhanced diabetes care and education in AI/AN
communities, as well as built desperately needed infrastructure for
diabetes programs
The IHS distributed SDPI funding for FY 2003 to eligible I/T/U grantees
utilizing a formula determined with input from tribes through an extensive
Area tribal consultation process Funds were distributed to each Area based
on a formula using the following components:
disease burden defined as 75 diabetes prevalence, 25 diabetes
mortality,
user population defined through HIS data collection efforts and
a tribal size adjustment
Each IHS Area had the flexibility to further define distribution to tribes
and IHS grant programs locally Urban Indian health programs,
administrative and data improvement support costs were also funded through
a set-aside determined by the IHS Director
In order to support grant programs in planning for use of the supplemental
grant funds in FY 2001 - FY 2003, the application process included a
community assessment tool and 14 suggested Best Practice
approaches
Grantees were given the option to strengthen clinical diabetes and
complications prevention and/or to develop and strengthen primary diabetes
prevention programs
The IHS used administrative funding to strengthen diabetes infrastructure
at the Headquarters and Area office levels to maintain and improve diabetes
surveillance, technical assistance, provider networks, clinical monitoring
and grant evaluation activities Support for the Area Diabetes
consultants, who serve a crucial role in coordinating these functions at
the Area level, was also strengthened Funding for the past 5 years has
served to provide much needed infrastructure within IHS and tribal
administrations that will enable continued development of diabetes programs
to address treatment and prevention of diabetes
Tribes have had to make choices about how to best use their local SDPI
funding because, while it is a significant increase in funding, it is not
enough to address the entire problem of diabetes in AI/AN communities
Managed care studies have estimated that it costs 5000-9000 per year to
care for one person with diabetes Based on current IHS figures, a
conservative estimate is that it costs the
agency 425 million per year to
care for those who are diagnosed today These figures do not include those
with undiagnosed diabetes or those in whom we could prevent the disease
The Indian health care system recognized from the start of this program
that we would have to make careful choices about where to best invest these
funds And we knew these choices would best be made locally
Tribes have had to make decisions about whether to focus on:
treatment such as supporting pharmacy budgets, hiring eye or foot
specialists, hiring nurse educators and nutritionists, etc,
prevention such as creating physical activity programs for youth,
community cooking classes, weight management programs, etc, or
divide the funding between both treatment and prevention
The SDPI has brought tribes together over these past 5 years, working
toward a common purpose and sharing information lessons learned along the
way The IHS has shown through its public health evaluation activities
that these programs have been very successful in improving diabetes care
and outcomes, as well as the start of primary prevention efforts, on
reservations and in urban clinics The FY 2001 GPRA
performance for the
diabetes indicators showed improved clinical outcomes for the four diabetes
outcome indicators In addition, through innovative collaboration and
sound public health techniques, there were significant accomplishments
reached in eye exam rates and reductions in lower extremity amputations for
some programs
Eye Disease: The IHS has partnered with the Joslin Diabetes Center to
implement the Joslin Vision Network JVN, a tele-ophthalomolgy state of
the art technology in several IHS clinics This allows for an eye exam to
be done through equipment operated on site in the clinic and then evaluated
by an eye care specialist in another facility IHS has been evaluating this
technology and comparing it to its other sites with regular eye care
Eye exams are a very important part of the care for the person with
diabetes as diabetic eye disease is usually silent until its late stages,
but if discovered early through regular eye exams, can be readily treated
and blindness prevented
Data shows eye exam rate outcomes following implementation of the JVN in
one IHS site compared to a site with no JVN Eye exam rates improved in one
year from 48 percent to 79 percent of all people
with diabetes at the JVN
site while in the site with no JVN the eye exam rates remained unchanged
Several studies have suggested that 75 percent of lower extremity
amputations LEA due to diabetes can be prevented through the use of
public health techniques and low-tech strategies to categorize patients by
risk Programmatic changes were used in the Bemidji and Alaska Area to
implement foot care practice guidelines through a process called Staged
Diabetes Management SDM in partnership with the International Diabetes
Center SDM uses a local consensus process to customize the guidelines to
promote acceptance by providers and the community SDM also stresses the
importance of system changes The IHS continues to partner with IDC, and to
date, the SDM process for improving overall diabetes care has been
implemented in over 50 facilities IHS-wide
Amputation prevention: Data shows that following implementation of SDM,
amputation rates were reduced by half, compared with the baseline period
As part of an effort to build on this program, vascular surgery and
pedorthic specialty preventive shoes outreach
services were added, and
the LEA rate was further reduced by half These latter efforts were made
possible through support from the Special Diabetes Program for Indians
grant program
Blood sugar control: IHS has been able to demonstrate significant
improvements in blood glucose control over time, greater than 1 percentage
point drop for each age group, as measured by A1C
Large clinical trials have shown that a 1 percentage point drop in A1C in
people with diabetes should result in:
14 decrease in total mortality 21 decrease in diabetes-
related deaths
14 decrease in heart attacks 12 decrease in strokes
43 decrease in amputations 24 decrease in kidney
failure
800 reduction per person in annual health care costs
Continued funding beyond FY 2003 will provide for continuation of all
current diabetes programs in AI/AN communities and provide resources needed
to establish more primary prevention activities in AI/AN communities based
on proven lifestyle programs and pharmaceutical interventions, as well as
address the rise in cardiovascular disease The IHS, in collaboration with
the CDC
NDPC, will disseminate the new promising practices learned from
these grant programs to other tribal communities for adaptation and
implementation A compendium of grant program descriptions is being
compiled for dissemination nationwide An in-depth analysis and interim
evaluation of grant program activities will provide a compilation of best
practices developed and outcomes of these activities which will provide a
basis for planning and future direction
ACCOMPLISHMENTS
Primary Prevention of Diabetes
Two thirds of the 318 Special Diabetes Program for Indians grant programs
are focused on primary prevention projects Analysis of our most recent
survey results, done in March 2002, showed that compared with before the
grants were awarded:
More diabetes prevention efforts now focus on elders86, adults89,
young adults73, adolescents65, school age55, and preschool
children 39,
More diabetes prevention activities now focus on screening85,
nutrition84 and physical activity69
Programs now report that they focus more on clients with newly diagnosed
diabetes 87, family members of people with diabetes 74 and on
pregnant women 48 as a result of the grant funds
More
emphasis is now placed on addressing preventive measures in adults
who are overweight 73, people with high blood pressure 63, children
and youth who are overweight 67, and on tobacco users 40 than
before they received their grant funds
Some important impacts now focused on are diabetes prevention efforts
92, increase in healthy behaviors of individuals 95, and increase I
healthy behaviors of the community 88
70 percent of grantees report being able to develop or greatly improve
nutrition counseling for people with diabetes
As a result of the SDPI grant funds, programs have both enhanced existing
diabetes activities and developed new activities Many of these activities
have been shown in studies to improve diabetes care For example:
83 percent of programs now track their diabetic patients through diabetes
registries,
81 percent have diabetes teams in place to provide better care,
66 percent of programs report that basic diabetes care is now available
for people with diabetes in their communities,
87 percent of programs now have diabetes education services available
Many grant programs are using traditional approaches in their new
diabetes
activities, including:
story-telling 34,
talking circles 35,
use of traditional herbs or medicines 28
Traditional approaches can help support and influence positive diabetes
self-management behaviors within communities
The diabetes grant funds have afforded tribes the opportunity to address
diabetes prevention where it needs to be addressed - at the tribal
community level
89 percent of programs now solicit and receive feedback from their
local communities on what their diabetes goals and priorities are, and
then use this information to design their diabetes care programs
53 percent have developed community walking programs
42 percent have created diabetes awareness programs for high-risk
family members of people with diabetes
Translation of the Diabetes Prevention Program DPP The study results
published in the Feb 7, 2002 issue of the New England Journal of Medicine
which included 171 AI participants showed conclusively that type 2
diabetes could actually be prevented or delayed through lifestyle changes
58 percent reduction or use of the medication metformin 31 percent
reduction
The DPP has provided a road map for diabetes
prevention that was not
available to us before Many of our SDPI grant programs were working on
diabetes prevention interventions prior to the publication of this study
Thus, these SDPI funds have allowed us a much more advantaged position,
with a much stronger diabetes infrastructure and good ideas about what
works and what doesnt work, to launch diabetes prevention activities in
AI/AN communities to translate the exciting news Since February 2002 the
NDP has organized a workgroup to adapt the DPP materials for use in the
field by IHS and tribal sites American Indian DPP participants have been
interviewed and a special issue of our magazine Health for Native Life
focusing on their accomplishments was published in December 2002
Diabetes and Obesity Prevention Initiative This partnership between the
Head Start Bureau and the IHS, initiated in 1997, has provided an
opportunity to address the increasing trend of obesity and diabetes in
children and youth The goal is to promote healthy lifestyle development
and change among Head Start children, families, staff, and their
communities and to develop / sustain local community partnerships Five
Tribal Head Start pilot sites, in
collaboration with their respective
community health partners, have developed local obesity and diabetes
prevention interventions Each Head Start site community action plan
includes multifaceted program activities and milestones focusing on healthy
eating, physical activity, healthy behavior and community
partnerships These efforts are the foundation of the success of the
initiative and the development of new resources for the Head Start
community
Other Accomplishments
IHS Diabetes Education Recognition Program approved by CMS and
announced in the March 22, 2002 issue of the Federal Register as a
National Accreditation Organization for diabetes self-management
education programs The IHS NDP joins the American Diabetes
Association as the only other agency with this authority, allowing
certified AI/AN programs to bill Medicare for diabetes education
services
Developed a tool to assess use of 14 Identified Best Practices by the
grant programs Results available in July
Completed Tribal consultation for FY03 SDPI funding
Collaborated with the NDPC in Gallup, NM to develop 8 diabetes-related
monographs on grant
activities and GIS mapping of diabetes
complications for dissemination later in the year
Program Director serves as a Steering Committee member on the National
Diabetes Education Program and attended a Steering Committee meeting
in May 2002 and a NDEP Evaluation Committee meeting in April to
determine a national evaluation plan for the NDEP Other staff serves
on the NDEP American Indian and the DPP Lifestyle Tools Workgroups
The IHS diabetes prevalence and complications surveillance system has
been automated through the assignment of a CDC Epidemiologist to the
program The 1999 - 2001 diabetes prevalence data were calculated and
adjusted in May 2002 and have been disseminated to the Tribal Leaders
Diabetes Workgroup, Area Directors, Area Diabetes Consultants, and
others The data are now available by region on our website
Workgroup established with CDC, IHS, the American Academy of
Pediatrics and the American Diabetes Association to address the
growing concern about type 2 diabetes in AI/AN children IHS staff
are leading the effort The committee recently published draft
screening
protocols, standards of care and treatment recommendations
for these children which were distributed to the field in January
2002
The IHS NDP has begun a collaborative effort to provide I/T/Us with
information on the CMS reimbursement process for Medical Nutrition
Therapy for diabetes / kidney disease through area trainings An
article published in the IHS Provider
The IHS NDP published an article in the December 2002 issue of the
professional journal Diabetes Care on its successful lowering of A1C
levels indicating better blood sugar control in the past decade
Following are the funding levels for the last 5 fiscal years: without
accrued
|Year |Funding |FTE |
|1999 |30,000,000 |0 |
|2000 |30,000,000 |0 |
|2001 |100,000,000 |0 |
|2002 |100,000,000 |1 |
|2003 |100,000,000 |2 |
PERFORMANCE MEASURES
Indicator 1: During FY 2004, continue tracking ie, data collection and
analyses
Area age-specific diabetes prevalence rates to identify trends in the age-
specific prevalence of diabetes as a surrogate marker for diabetes
incidence for the AI/AN population
Indicator 2: During FY 2004, increase
the proportion of I/T/U clients with
diagnosed diabetes that have demonstated improved glycemic control by 2
percent over the FY 2003 level
Indicator 3: During FY 2004, increase the proportion of I/T/U clients with
diagnosed diabetes who have achieved blood pressure control standards by 2
percent over the FY 2003 level
Indicator 4: During FY 2004, increase the proportion of I/T/U clients with
diagnosed diabetes assessed for dyslipidemia i e, LDL cholesterol by 2
percent over the FY 2003 level
Indicator 5: During FY 2004, increase the proportion of I/T/U clients with
diagnosed diabetes assessed for nephropathy by 2 percent over the FY 2003
level
Indicator 6: During FY 2004, increase the proportion of American
Indian/Alaska Native diabetics who receive an annual diabetic retinal
examination at designated sites by 3 percent over the FY 2003 rate
In addition, the IHS NDP has developed a set of short-term, intermediate
and long-term outcome measures for evaluation of the Special Diabetes
Program for Indians, using the CDCs Framework for Public Health Evaluation
methodology The 2003 Interim Report on the SDPI will provide data on IHS
accomplishments thus far on the short-term
and intermediate outcomes, and
provide a description of the baseline long-term outcomes that will be
measured over the next decade
RATIONALE FOR BUDGET REQUEST
TOTAL REQUEST — The request of 150,000,000 is a net increase of
50,000,000 over the FY 2003 Presidents Budget request of 100,000,000
Program Increase: 50,000,000
In consultation with the tribes, the IHS proposes to let these grants out
as a combination of competitive and non-competitive RFAs to I/T/Us with
emphasis in the following areas:
assure continuation of all current diabetes grant programs in AI/AN
communities;
provide additional resources to establish more focused diabetes primary
prevention activities in AI/AN communities both proven lifestyle
programs as well as pharmaceutical interventions based on findings
from the Diabetes Prevention Program DPP model For example, these
communities would be able to hire additional physical activity
specialists, registered dieticians, nurses and psychologists;
add/improve Wellness facilities for physical activity and prevention
activity; and purchase the medication metformin GlucophageR for
pharmaceutical prevention of
type 2 diabetes;
address the rising tide of cardiovascular disease in AI/AN with
diabetes through translation of established risk factor reduction
practices; and
devoted additional resources to provide adequate infrastructure,
administrative oversight, monitoring, data improvement, educational
resources and program evaluation activities related to these grants as
well as to disseminate comprehensive diabetes-related information to
the field in a timely way
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