- Diabetes Treatments

Indian Health Service 2005 Executive Summary
Improving the Quality of Health Care Measuring Successes and Challenges

Government Performance and Results Act March 1,2006

Table ofOF CONTENTS TABLE Contents
Preface
Acknowledgements Introduction

03
4-6

2005 Results
Diabetes: Poor Glycemic Control Diabetes: Ideal Glycemic Control Diabetes: Blood Pressure Control Diabetes: Dyslipidemia LDL Assessment Diabetes: Nephropathy Assessment Diabetes: Retinopathy Assessment Pap Screening Mammography Screening Alcohol Screening FAS Prevention Dental Access Dental Sealants Dental Access: Patients with Diabetes Domestic Violence/Intimate Partner Violence Public Health Nursing Childhood Immunizations Influenza Immunizations Pnemococcal Immunizations Cholesterol Screening CVD Prevention Obesity Assessment BMI Measurement Tobacco Screening Prenatal HIV screening

07
08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

26 27

Appendix A
Key Findings GPRA Measures Mortality Disparities Table Bibliography

28-29 30 31-33

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

Acknowledgements PREFACE

Data collected by: IHS and Tribal Health Program staff IHS Area
GPRA Coordinators IHS Area Information Technology staff IHS Headquarters GPRA leads

Area GPRA Coordinators:

Aberdeen Alaska Albuquerque Bemidji Billings California Nashville Navajo Oklahoma Phoenix Portland Tucson

Carol Smith Bonnie Boedeker Regina Robertson Mary Fairbanks Diane Jeanotte Elaine Brinn Michelle Ruslavage Jenny Notah Marjorie Rogers Jody Sekerak Cheryl Bittle John Kittredge

605 226-7244 907 729-3665 505 248-4773 218 444-0487 406 247-7125 916 930-3927 615 467-1507 928 871-5836 405 951-6020 602 364-5190 503 326-3288 520 295-2406

CarolSmith@ihsgov BBoedeker@akanmcihsgov ReginaRobertson@ihsgov MaryFairbanks@ihsgov DianeJeanotte@ihsgov ElaineBrinn@ihsgov MichelleRuslavage@ihsgov GenevieveNotah@ihsgov MarjorieRogers@ihsgov JodySekerak@ihsgov CherylBittle@ihsgov JohnKittredge@ihsgov

Special Thanks for data analysis, data format presentation, and report preparation to: Elaine Brinn, Theresa Cullen, Carol Goodin, Amy Patterson, and Janae Price IHS Contacts: Theresa Cullen, MD Phone: 520 670-4803 TheresaCullen@ihsgov Francis Frazier, NP Phone: 301 443-4700 FrancisFrazier@ihsgov

2005 Government PerformanceHealth Assessment Tippecanoe County and Results
Act

Introduction PREFACE
The Indian Health Service IHS is an agency within the Department of Health and Human Services that carries out the federal governments trust responsibility to provide health care services to eligible American Indian and Alaska Native AI/AN people IHS provides these health services through a network of hospitals, emergency clinics, health stations, school-based clinics, and numerous Alaskan village clinics In Fiscal Year FY 2005, these facilities provided direct health care services to over 14 million AI/AN people Since 1975, many Tribes have assumed the administrative and program direction roles that were previously carried out by the Federal government Through Self-Determination contracts or Self-Governance compacts, Tribes administer over one-half of IHS resources The IHS administers the remaining resources and manages those facilities where Tribes have elected not to contract or compact their health programs IHS also contracts with 34 urban Indian organizations to provide services to eligible AI/AN people who reside in large metropolitan areas Together, these sources of care are known as the IHS/Tribal/Urban I/T/U network When the capability to
provide a particular service is not available through this network, the IHS Contract Health Services CHS appropriation covers the cost of referring patients to hospitals and specialists However, most health programs funds are depleted before the end of the year due to continually increasing healthcare costs Historically, the Indian Health Service has succeeded in substantially improving the health status of the AI/AN population, primarily by focusing on preventive and primary care services and developing a community-based public health system Examples can be seen in the dramatic decreases in mortality rates for certain health problems between 1972-74 and 2000-2002:

Gastrointestinal disease mortality reduced 91 percent 93 to 08 per 100,000; Tuberculosis mortality reduced 80 percent 107 to 21 per 100,000; Cervical cancer mortality reduced 76 percent 190 to 45 per 100,000; Infant mortality reduced 66 percent 250 to 85 per 1,000; Unintentional injuries mortality reduced 60 percent 2231 to 901 per 100,000; and Maternal mortality reduced 64 percent 348 to 125 per 100,000; 4 The average death rate from all causes for the AI/AN population dropped a significant 28 percent between 1972-1974
and 2000-2002

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

Introduction PREFACE
Population growth and economic factors continue to create pressures on AI/AN communities, and the IHS system From 1990 to 2000, the AI/AN population grew at a rate of 26 percent, while the total US population grew by only 13 percent Poverty and low educational attainment remain as critical external factors affecting the health status of AI/AN people The AI/AN population also suffers disproportionately from a number of health problems For example, the 2000-2002 death rate from alcohol abuse was more than 45 times higher among AI/ANs than the rates for all races in 2001, and the cervical cancer death rate was 38 times higher The Government Performance Results Act GPRA requires performance-based budgeting and performance measures to demonstrate the agencys effectiveness in meeting its mission GPRA results are now part of performance appraisal criteria at all levels of the Indian Health Service Clinical GPRA measures are tracked through Clinical Reporting System CRS software In 2005, IHS met and/or exceeded 83 of its GPRA performance measure targets In FY 2005, there
were a total of 35 GPRA measures, including 20 clinical and 15 nonclinical measures This report provides a summary of results for clinical and non-clinical GPRA measures, and includes detailed results for all FY 2005 clinical measures Detailed results for another clinical measure, influenza vaccination, are also included in this report However, this measure was placed on hold due to national shortages and was not a GPRA measure for 2005 The results for clinical measures are based on the aggregated performance of the 12 IHS Areas, as measured by CRS Of these, eighteen clinical measures met their pre-determined targets; twelve measures not only met but exceeded their target Only two clinical measures, BMI Assessment and Diabetic Retinopathy Screening, did not meet their targets Of the 15 non-clinical GPRA measures for FY 2005, only three did not meet their targets Results for one non-clinical measure, Unintentional Injury Rates, will not be reported until 2009 Overall, the agency met 29 of 35 GPRA performance measure targets 83, compared to 74 in FY 2004 In accordance with the One HHS 10 Department-wide Management Objectives, the Indian Health Service committed to implementing
results-oriented management by achieving a 10 percent relative increase in program performance from FY 2004 levels by FY 2007 in four measures: Pneumovax Immunization, Domestic Violence/Intimate Partner Violence Screening, Alcohol Screening Fetal Alcohol Syndrome Prevention, and LDL Screening in patients with diabetes The FY 2005 results show a significant increase in rates for two of these measures Between 2004 and 2005, Domestic Violence/Intimate Partner Violence Screening rates showed a 9 absolute percentile point increase overall, while Alcohol Screening FAS prevention rates showed a 4 absolute percentile point increase overall, exceeding the FY 2007 targets substantially However, LDL Screening and Pneumovax Immunization rates were unchanged from 2004 to 2005; 5 the Agency will put particular emphasis on these measures to achieve the 10 relative increase by FY 2007

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

Introduction PREFACE
Additionally, in FY 2005 the agency made significant progress on almost all of its diabetic measures The overall prevalence of diabetes among the IHS direct and Tribal population as measured by CRS increased from
10 in 2004 to 11 in 2005 Despite this increase, screening rates for virtually every diabetic measure improved IHS also continued to improve its rate of A1C screening In FY 2005, 78 of patients with diabetes received A1C blood glucose screening, compared to 67 in 2000 and 77 in 2004 This rate substantially exceeds the Healthy People 2010 goal of 50 Although A1C screening rates are not a GPRA measure, the agency tracks them through CRS to help measure the overall quality of preventative care for patients with diabetes GPRA diabetes measures are the Agencys assessment of quality of care for the following areas: Glycemic Control, Blood Pressure Control, as well as LDL, Nephropathy, and Retinopathy assessments On a national level, significant progress was made on both poor and ideal glycemic control The number of patients in poor control declined by 2 overall, while the number of patients in ideal control increased by 3 overall The percentage of patients diagnosed with diabetes with controlled blood pressure 130/80 increased by 2 Diabetic Nephropathy assessment rates also exceeded the 2004 average by 5 Although there was not an overall increase in LDL assessment rates, this measure met
the 2005 target to maintain the 2004 level Only one diabetic measure, Retinopathy screening, did not meet the 2005 target to maintain screening rates at designated sites However, CRS collects data from all sites, and the average rate for retinopathy screening at all sites actually increased from 47 to 50 This data indicates that diabetes control continues to be a top priority both on the national and Area levels The progress made on diabetic measures is all the more significant given the continuing epidemic of diabetes among the AI/AN populations Diabetes continues to increase in prevalence among AI/AN communities and across all age groups In fact, American Indians and Alaska Natives have the highest published prevalence of diabetes in the world The diabetes epidemic is also occurring in an increasingly younger population AI/ANs ages 25-34 years experienced a 132 increase in diabetes prevalence between 1990 and 2002; AI/ANs ages 20-24 experienced a 69 increase, and AI/ANs ages 15-19 experienced a 106 increase In 2002, AI/AN people were 22 times more likely to have diagnosed diabetes than non-Hispanic whites, and the death rate from diabetes in the AI/AN community has increased by
55 percent between 1972-1974 and 2000-2002 In the period between 2000-2002, the death rate for AI/AN people with diabetes was 33 times that for non-Hispanic whites in 2001 Diabetes is accompanied by an array of disabling and life-threatening complications However, studies show that adequate control of glucose levels and blood pressure, preventive measures that are tracked through GPRA, can minimize associated complications such as retinopathy, nephropathy, and heart disease IHS continues to increase the quality of care for all users of our healthcare system Significant strides have been made not only to improve the current standards of care but also to increase access to care throughout Indian country In the long term, our mission is to decrease unnecessary health inequities among American Indians/Alaska Natives 6 both within their own communities and in comparison to other racial and ethnic groups

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

2005 Results 2005 Results Diabetes: Poor Glycemic Control
Measure Proportion of patients with diagnosed diabetes that have poor glycemic control Importance Reducing the number of patients with poor
glycemic control will reduce the prevalence of diabetes complications Some clinical studies have shown that a 1 decrease in the absolute A1C level translates into a: 14 decrease in total mortality, 21 decrease in diabetes-related deaths, 14 decrease in myocardial infarction, 40 decrease in eye disease, 12 decrease in strokes, 43 decrease in amputations, and a 24 decrease in kidney failure Reducing A1C levels can also save 800 in annual health care costs 2005 Target Assure that the proportion of patients with diabetes that have poor glycemic control does not increase above the 2004 level of 17

Poor Glycemic Control:
AI/AN patients with diabetes in poor A1c control 95 during the past year
25

20 18 17 15

Percent

2010 Goal 10

0 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met and exceeded the target for this measure, reducing the percent of patients with poor glycemic control by 2 overall, from 17 FY 2004 to 15 FY 2005 The Hemoglobin A1C test measures average blood sugar over the last 1-2 months Decreasing the7 rate of patients with poor control is a significant accomplishment, considering that the
prevalence of diabetes within the active user population increased from 10 to 11 between 2004 and 2005

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

2005 Results 2005 Results Diabetes: Ideal Glycemic Control
Measure Proportion of patients with diagnosed diabetes with ideal glycemic control A1C70 Importance Keeping blood sugar levels below 7 can slow or prevent the onset and progression of eye, kidney, and nerve disease caused by diabetes Good blood sugar control also lowers the risk of heart attack and stroke 2005 Target Maintain the proportion of patients with diabetes that have demonstrated ideal glycemic control at the 2004 level of 27

Ideal Glycemic Control:
AI/AN patients with diabetes who have maintained Ideal A1c control 7 during the past year
50

45 2010 Goal 40 40 36 34 30 25 GPRA Diabetes Audit 31 28 27 30

P ercen t

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of patients with ideal glycemic control by 3 overall, from 27 FY 2004 to 30 FY 2005 as measured by
the Hemoglobin A1C test that measures average blood sugar over the last 1-2 months This improvement came despite a significant increase in the number of patients with diabetes in the same 8 time period These results reflect meaningful agency accomplishments in dealing with a significant increase in the number of patients with diabetes while reducing complications associated with uncontrolled blood sugar

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

2005 Results 2005 Results Diabetes: Blood Pressure Control
Measure Proportion of patients with diagnosed diabetes that have achieved blood pressure control BP 130/80 Importance This measure is directed at reducing complications of diabetes A National Heart, Lung, and Blood Institute report indicates that the risk of heart disease and stroke doubles for every increase of 20 mm in systolic or 10 mm in diastolic pressure Lower blood pressure levels in people with diabetes reduce the risk of heart disease and stroke by 33-50 Blood pressure control also reduces the risk of eye, kidney, and nerve disease by one third 2005 Target Maintain the proportion of patients with diagnosed diabetes that have
achieved blood pressure control at the 2004 level of 35

Blood Pressure Control:
AI/AN patients with diabetes who have maintained Ideal BP control 130/80 during the past year

2010 Goal 50

40 36

37 35

36
GPRA Diabetes Audit

Percent

32 30

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the percent of patients with ideal blood pressure control by 2 overall, from 35 FY 2004 to 37 FY 2005 By meeting and exceeding the target for this measure, the agency helped reduce the potential complications of high blood 9 pressure among diabetics

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

2005 Results 2005 Results Diabetes: Dyslipidemia LDL Assessed
Measure Proportion of patients with diagnosed diabetes assessed for dyslipidemia Importance Dyslipidemia refers to disorders in the lipoprotein metabolism, including hypercholesterolemia high LDL cholesterol, and low HDL cholesterol Low cholesterol levels help to protect diabetic patients from developing heart disease Improved control of cholesterol
levels reduces the risk of cardiovascular complications by 2050 National standards recommend that people with diabetes keep their cholesterol levels below 200 mg/dl, and their LDL cholesterol levels below 130 mg/dl and ideally below 100 mg/dl Diabetic patients are especially prone to develop heart disease and therefore identification and treatment of elevated lipids in diabetic patients is extremely important 2005 Target Maintain the proportion of patients with diagnosed diabetes assessed for dyslipidemia at the 2004 level of 53

LDL Assessed:
AI/AN patients with diabetes who have been assessed for dyslipidemia LDL within the past year
80 2010 Goal 70 70 64 60 53 53 65 69 70

Percent

50 44

48 GPRA

Diabetes Audit

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met the target for this measure, maintaining the percentage of patients assessed for 10 dyslipidemia at 53 in FY 2005 The agency met this target despite a significant increase in the overall population of patients diagnosed with diabetes

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2005
Results 2005 Results Diabetes: Nephropathy Assessment
Measure Proportion of patients with diagnosed diabetes assessed for nephropathy Importance Diabetes can cause kidney disease by damaging the parts of the kidneys that filter out wastes Diabetic nephropathy, or kidney disease, can eventually lead to kidney failure Diabetes is the leading cause of end stage renal disease ESRD, which is a significant and growing problem in American Indian communities Early identification of at risk patients may help prevent or delay the need for costly care such as dialysis or renal transplant Microalbuminuria or proteinuria is measured in the urine with a urinalysis test Microalbumin in the urine is an early sign of diabetic kidney disease Proteinuria is also an independent predictor of cardiovascular disease, which is the number one killer of American Indian and Alaska Native adults 2005 Target Maintain the proportion of patients with diagnosed diabetes assessed for nephropathy at the FY 2004 level of 42
Nephropathy Assessed:
AI/AN patients with diabetes who have been assessed for nephropathy within the past year
80 2010 Goal 70 70 63 60 56
53

61
55

Percent

50 42 40 35 30 38

47 GPRA
Diabetes Audit

0 2002 2003 2004 2005
In 2005, diabetes audit logic w as changed to conform to GPRA logic for this measure Therefore audit results 2003 and 2004 w ere recalculated and are displayed below the previous results

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the number of diabetic patients 11 assessed for nephropathy by 5 overall, from 42 FY 2004 to 47 FY 2005 The agency met and exceeded this target despite a significant increase in the overall population of patients diagnosed with diabetes

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2005 Results 2005 Results Diabetes: Retinopathy Assessment
Measure Proportion of patients with diagnosed diabetes who receive an annual diabetic retinal examination Importance Diabetes can affect sight by damaging the blood vessels inside the eye, a condition known as diabetic retinopathy Diabetic eye disease is a leading cause of blindness in the United States Early detection of diabetic retinopathy DR is a fundamental part of the effort to reduce visual disability in diabetic
patients Clinical trials demonstrated that effective laser photocoagulation treatment of DR could reduce vision loss by 90 These studies also underscore the need for early identification of DR at a time when laser photocoagulation is most effective 2005 Target Maintain the proportion of patients with diagnosed diabetes who receive an annual diabetic retinal examination at designated sites at the 2004 level of 55
Retinopathy Assessed:
AI/AN patients with diabetes who have been assessed for retinopathy within the past year
80 2010 Goal 75 70

58 55 55

50
50
GPRA All sites GPRA Pilot sites

Percent

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS did not meet the target for this measure The proportion of diabetic patients who received an annual diabetic retinal exam declined from 55 FY 2004 to 50 FY 2005 at designated sites However, at all sites, the exam rate was also 50, an increase from the 2004 rate of 47There are many barriers that exist that have prevented significant improvement in the diabetic eye screening rates over the past few years Prominent among them is a
substantial and sustained increase in the prevalence of diabetes Because of this growth in the number of individuals with diabetes, the small observed decrease in surveillance rate still represents a real increase in the number of retinopathy 12 examinations Since controlled studies indicate great advantages from the technology used at pilot sites, its use will be broadened in FY 2006 in the effort to increase the DR examination rate to meet or exceed target goals In FY 2006, rates for diabetic retinal exams at all sites will be reported

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2005 Results 2005 Results PAP Screening
Measure Proportion of eligible women patients who have had a Pap screen within the previous three years Importance In 2002, American Indian women had a cervical cancer mortality rate of 30 that exceeded the rate of 25 for US all races More than any other racial or ethnic group, American Indian women report having never had a Pap screen Regular screening with a pap smear lowers the risk of developing invasive cervical cancer by detecting pre-cancerous cervical lesions that can be treated If cervical cancer is detected
early, the likelihood of survival is almost 100 percent with appropriate treatment and follow- up Cervical cancer was once the leading cause of cancer death among women, but it has dropped to thirteenth among US All Races, thanks to the use of Pap screens 2005 Target Maintain the proportion of female patients aged 21-64 who have had a Pap screen within the previous three years at the 2004 level of 58

Pap Screening:
100

AI/AN female patients age 21-64 who have received a Pap screen within the previous three years
2010 Goal 90

70 62 61 58 60

Percent

GPRA

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 263,576 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of women who have 13 had a Pap screen by 2 overall, from 58 FY 2004 to 60 FY 2005 In 2005 the Pap smear rate was 60, an increase of two percent from the 58 rate reported in 2004

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2005 Results 2005 Results Mammography Screening
Measure

Proportion of eligible women who have had mammography screening within the previous
two years

Importance Biennial screening of women between the ages of 50 and 69 has been shown to be a cost effective way to decrease the breast cancer mortality rate Breast cancer is the second leading cause of cancer death among US women lung cancer is first Although there has been overall improvement in breast cancer mortality rates since 1990, AI/AN women have not shared these gains Between 1992 and 2002, breast cancer mortality rates declined for all racial and ethnic groups except American Indian/Alaska Native women, who experienced no decline in mortality rates Regular mammography screening can reduce breast cancer mortality by 20-25 AI/AN women diagnosed with breast cancer have lower 5-year survival rates in comparison to whites, mainly because their cancers are less likely to be found in earlier stages It is because of this disparity that breast cancer screening remains one of the Agencys highest priorities 2005 Target

Maintain the proportion of female patients aged 50-64 who have had mammography screening within the previous two years at the 2004 level of 40
Mammography Screening:
AI/AN female patients age 52-64 who have received mammography screening within the
previous two years
80

2010 Goal 70

Percent

50 42 40 40 40 41 GPRA

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 48,320 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of eligible patients who have had a mammography screening by 1 overall, from 40 FY 2004 to 41 FY 2005 Because many tribal and urban facilities lack the equipment to perform mammograms on site, this 14 rate is one of the more difficult measures to increase Sites that do not have equipment must pay for mammograms with Contract Health Services funds However, these funds are frequently depleted to pay for acute problems such as heart attacks and cancer treatments

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

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2005 Results 2005 Results Alcohol Screening Fetal Alcohol Syndrome Prevention
Measure

Alcohol use screening to prevent Fetal Alcohol Syndrome in appropriate female patients

Importance Heavy drinking during pregnancy can cause significant birth defects, including Fetal Alcohol Syndrome FAS FAS is the leading known, and preventable, cause of mental retardation
Rates of FAS are higher among American Indians and Alaska Natives than the general population FAS cases have been reported at a rate of 98 per 1000 live births among southwestern Plains Indians living on reservations, 56 per 1000 in Alaska, and 25 per 1000 in Arizona, well above that of any other race or ethnicity Studies have found alcohol consumption rates among AI/AN women of childbearing age to be higher than average The US Preventative Services Task Force recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings Screening with intervention has been shown to be effective in reducing alcohol misuse in pregnancy and to reduce the incidence of FAS 2005 Target

Increase the screening rate for alcohol use in female patients ages 15-44 over the 2004 level of 7
Alcohol Screening FAS Prevention:
AI/AN female patients age 15-44 who have been screened for alcohol use within the past year
30

2010 Goal 25

Percent

GPRA 15

11 10 7 5

0 2004
Baseline established in 2004

2005

Data Source CRS 51 electronic examination of 246,941 patient records Results and Analysis IHS met the target
for this measure, increasing the proportion of eligible patients screened for alcohol use by 4 overall, from 7 FY 2004 to 11 FY 2005 This measure is included in the One HHS 10 Department-wide Management Objectives to achieve a relative increase 10 increase by FY 2007 The agency has already met and exceeded that targeted increase The targeted increase for 15 FY 2006 has been revised to 13, and the FY 2007 target has been revised to 14 as a result of the dramatic improvement in screening rates from FY 2004 to FY 2005

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2005 Results 2005 Results Dental Access
Measure Proportion of patients who obtain access to dental services Importance This measure is directed at improving the oral health status of the American Indian and Alaska Native population A recent study showed that American Indians and Alaska Natives reported greater unmet dental health needs compared to Non-Hispanic Whites However, according to Trends in Indian Health, the number of direct and contract dental service provided by Indian Health Service IHS, Tribal, and Urban Programs has increased 272 percent since FY 1970 and in FY 2001,
over 27 million dental services were provided Untreated tooth decay can cause abscesses and infections, pain, dysfunction and weight loss Dental problems result in the loss of almost 25 million workdays each year Access to dental care improves oral health as well as the overall health of AI/AN people 2005 Target Maintain the proportion of patients that obtain access to dental services at the 2004 level of 24

General Dental Access:
AI/AN patients who have received dental care within the past year

GPRA

Percent

50 2010 Goal 40 40

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 1,324,303 patient records Results and Analysis IHS met the target for this measure, maintaining the proportion of patients who obtained access to dental services at 24 The key national factor contributing to maintaining as opposed to exceeding 16 this measure is the continued high vacancy rate in the dental program, which remains around 23 In recent years, access to care seems closely tied to vacancy rates

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

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2005 Results 2005 Results Dental Sealants
Measure
Number of sealants placed per year in American Indian and Alaska Native patients Importance Surveys of American Indian and Alaska Native children have consistently identified them as having significantly higher dental decay rates than the general US population Dental sealants, a recognized standard in preventive dental care, are an effective measure for reducing dental decay rates and can be effectively applied by dental auxiliaries at relatively low cost Sealants reduce both the ravages and costs of treating dental decay 2005 Target Maintain the number of sealants placed in American Indian and Alaska Native patients at the 2004 level of 230,295 sealants
Dental Sealants:
Number of dental sealants placed in AI/AN patients within the past year
300000

287,158
249,882 250000 230,295

243,499
227,945 200000

Percent

150000

GPRA NPIRS

100000

50000

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 249,882 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the number of sealants placed in AI/AN patients by 8 overall 19,587 more sealants placed in FY 2005 compared to FY 2004 The intent of this measure is to reduce
dental decay by increasing both the number of patients with dental sealants and the number of sealants per patient The number of sealants in FY 2004 as measured by CRS was 230,295 and this number was used to set the target for this measure Prior to FY 2005, the number of sealants was collected through NPIRS

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

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2005 Results 2005 Results Dental Access: Patients with Diabetes
Measure Proportion of patients diagnosed with diabetes who obtain access to dental services Importance The purpose of this measure is to improve both oral health status and diabetic control for American Indian and Alaska Native diabetics All diabetic patients should receive a complete dental exam on an annual basis Diabetics are at increased risk for destructive periodontal disease and subsequent tooth loss In addition, untreated periodontitis in diabetics may complicate glycemic control Access to both primary and secondary treatment and preventive services for diabetics can lessen periodontal disease progression and the subsequent effects on diabetes and overall health Regular visits provide opportunities for prevention,
early detection, and treatment 2005 Target Maintain the proportion of patients with diagnosed diabetes who obtain access to dental services at the 2004 level of 37
Diabetic Dental Access:
AI/AN patients with diabetes who have received dental care during the past year
80 2010 Goal 70 70

Percent

50 Data not available 40

36
35

36
36

37
38

GPRA Diabetes Audit

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 89,757 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of patients with diagnosed diabetes that obtained access to dental services by 2 overall, from 37 FY 2004 to 39 FY 2005 In FY 2006, diabetic dental access will no longer be tracked as a GPRA measure 18 The National Oral Health Council recommended eliminating this measure, as it determined that the measure Dental Access, which includes diabetic patients, is an adequate measure of access The agency will strive to increase dental access for all of its users, including patients with diabetes

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

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2005 Results 2005 Results Domestic
Violence/Intimate Partner Violence Screening
Measure Proportion of women who are screened for domestic violence at health care facilities Importance This measure is designed to help ascertain, evaluate and reduce the prevalence of family violence, abuse and neglect in American Indian and Alaska Native communities Thirty percent of women in the United States experience domestic violence at some time in their lives AI/AN women experience domestic violence at rates similar to or higher than the national average A survey of Navajo women seeking routine care at an IHS facility revealed that 14 had experienced physical abuse in the past year, and 42 had experienced physical abuse from a male partner at least once in their lives The health consequences of intimate partner violence are numerous Women who experience domestic violence are more often victims of nonconsensual sex, have higher levels of smoking, chronic pain syndromes, depression, generalized anxiety, substance abuse, and Post-Traumatic Stress Disorder 2005 Target Maintain the proportion of women aged 15-40 screened for domestic and intimate partner violence at the 2004 level of 4
Intimate Partner Violence/Domestic
Violence:
AI/AN female patients age 15-40 who were screened for domestic violence within the past year
30

2010 Goal 25 25

Percent

GPRA 13

0 2004 2005

Data Source CRS 51 electronic examination of 217,838 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of eligible patients who have had Intimate Partner/Domestic Violence screening by 9 overall, from 4 FY 2004 to 13 FY 2005 This measure is included in the One HHS 10 Department-wide Management Objectives to attain a 10 relative increase by FY 2007 IHS has already reached and exceeded the target for 19 the DV/IPV measure The targeted increase for FY 2006 has been revised to 14, and the FY 2007 target has been revised to 15 as a result of the dramatic improvement in screening rates from FY 2004 to FY 2005

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2005 Results 2005 Results Public Health Nursing
Measure Number of public health nursing services primary and secondary treatment and preventive services provided by public health nursing Importance Public health nursing is a method of delivering services to
outside of the I/T/U setting Public health nurses treat very young children, medically under-served pregnant women, patients with chronic or acute diseases, and the elderly Public health nurses provide health assessment, health promotion, disease prevention, and infectious disease management The public health nurse has intimate knowledge of the local community and family structures; this knowledge is essential in improving health status Direct service helps reduce health care costs through early detection and prevention of health problems 2005 Target Maintain the total number of public health nursing services provided to individuals in all settings, including the home, at the 2004 workload levels
Public Health Nursing:
Number of visits by PHNs in any setting, including home
500,000

450,000

438,376 423,379

400,000

359,089
350,000

343,844

300,000

250,000 GPRA 200,000

150,000

100,000

50,000

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 438,376 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the number of public health nursing services by 4 overall, from 423,379 FY 2004 to 438,376 FY 2005 In FY 2006,
this measure will no longer track the number of PHN visits, and will become a non-clinical measure The goal for FY 20 2006 will be to implement a data system capable of recording the time spent and nature of public health activities other than one-on-one patient care, with an emphasis on activities that serve groups or the entire community

2005 Government PerformanceHealth Assessment Tippecanoe County and Results Act

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2005 Results 2005 Results Childhood Immunizations
Measure Immunization rates for AI/AN patients aged 19-35 months Importance Routine immunizations vaccines represent a cost-effective public health measure that significantly improves the health of children The Healthy People 2010 goal is 90 coverage for all routine immunizations for children aged 19-35 months and 80 coverage for the combined 4:3:1:3:3 series of vaccinations The combined series includes coverage with 4 doses of DTaP, 3 doses of IPV, 1 dose of MMR, 3 doses of Hep B and 3 doses of Hib 2005 Target Maintain rates for the combined series of recommended immunizations for American Indian and Alaska Native children aged 19-35 months at the 2004 level of 72

Childhood Immunizations:
100

AI/AN
patients age 19-35 months who have received the combined childhood vaccination series 4:3:1:3:3

90 80 80 72 70 81
2010 Goal 80

Percent

Imm Report

0 2002 2004 2005 2002 and 2003 data represent children 3-27 months old2003 In 2004, the GPRA definition of this measure changed from 3-27 month olds to 19-35 month olds; numbers for 2004 and 2005 are for children 19-35 months old

Data Source Annual 2- year old immunization report based on IHS patient care records and public health nursing records of children who receive immunizations at an IHS facility CRS data will be used in future years Results and Analysis IHS met and exceeded the target for this measure, increasing the percentage of children ages 19-35 21 months receiving recommended vaccines to 75, up 3 from the FY 2004 baseline of 72 Continued success in increasing vaccination rates each year will help IHS to reach the HP 2010 goal of an 80 immunization rate for the combined series of childhood immunizations

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2005 Results 2005 Results Influenza Immunizations
Measure Influenza vaccination rates among adult
patients age 65 years and older Importance Influenza is a highly contagious respiratory disease that can cause potentially life-threatening secondary infections Elders who get influenza are also at increased risk of hospitalization and death from heart disease and stroke, and vaccination reduces that risk In one observational study comparing vaccinated to nonvaccinated persons aged 65 and older in a managed care setting over two influenza seasons, researchers found a 19 and 16-23 reduction in hospitalization for cardiovascular and cerebrovascular events, respectively In addition they found a 29-32 reduction in hospitalization for influenza or pneumonia and a 4850 reduction in risk of death from all causes 2005 Target Maintain the rate for influenza vaccination at the 2004 level of 54 Placed on hold due to vaccine shortages

Influenza Vaccination:
AI/AN patients age 65 who have received the influenza vaccine within the past year
100 2010 Goal 90

Percent

60 54 51 51

GPRA

0 2002 2003 2004 2005 Measure on hold in FY 2005 due to influenza vaccine shortage, 2005 data shown above for context purposes only

Data Source CRS 51 electronic examination of 57,359
patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of eligible patients receiving an influenza vaccination by 5 overall, from 54 FY 2004 to 59 FY 2005 However, due to vaccine shortages, this measure was placed on hold for FY 2005 Therefore, the results for this measure are not included in the evaluation of the Agencys GPRA performance in 2005; these results are presented for informational purposes The improvement and maintenance of influenza vaccination rates is important because studies have shown that AI/AN people are at high risk for this 22 disease; the 1999-2001 AI/AN death rate from influenza and pneumonia was 42 percent greater than the 2000 US all-races death rate Continued success in increasing vaccination rates each year will help IHS to reach the HP 2010 goal of a 90 immunization rate

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2005 Results 2005 Results Pnumoccocal Immunizations
Measure Pneumococcal vaccination rates among adult patients aged 65 years and older Importance The purpose of this measure is to reduce morbidity and mortality due to pneumococcal disease
among older adults Elder health is an increasingly important issue as more and more of the population survives beyond the age of 65 Pneumococcal disease includes pneumonia, bacteremia, and meningitis Pneumococcal disease has the highest death toll from a vaccine-preventable bacterial disease and patients over the age of 65 account for more than 51 of the deaths In 1998, over 3400 patients over the age of 65 died from pneumonia Vaccination of the elderly against pneumococcal disease is one of the few medical interventions found to improve health and save on medical costs 2005 Target Maintain the rate for pneumococcal vaccination at 2004 level of 69

Pneumococcal Vaccination:
AI/AN patients age 65 who have ever received the pneumococcal vaccination
100 2010 Goal 90

69 64 65

Percent

GPRA

0 2002 2003 2004 2005

Data Source CRS 51 electronic examination of 57,359 patient records Results and Analysis IHS met the target for this measure, maintaining a 69 pneumococcal vaccination rate for FY 2005 This measure is included in the One HHS 10 Department-wide Management Objectives to attain a 23 10 relative increase by FY 2007 Although the number of patients over age
65 who have received pneumococcal vaccinations kept pace with the overall increase in the number of patients, the agency will need to refocus its efforts to attain the required percentage increase by 2007

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Conclusions and Recommendations CONCLUSIONS RECOMMENDATIONS Cholesterol Screening - CVD Prevention
Measure Proportion of patients ages 23 and older who receive blood cholesterol screening Importance Death rates from cardiovascular disease are higher among AI/AN people than other groups In the late 1990s, heart disease death rates were 20 higher among AI/AN people than the total US population, and stroke death rates were 14 higher Cardiovascular disease represents the leading cause of death for American Indian and Alaska Native people above 45 years of age Unlike other racial and ethnic groups, American Indians appear to have an increasing incidence of cardiovascular disease, likely due to the high prevalence of diabetes Elevated LDL cholesterol is associated with increased risk of cardiovascular disease, heart attacks, and strokes However, a 10 decrease in total blood cholesterol levels may
reduce the incidence of heart disease by as much as 30 2005 Target Establish the proportion of patients ages 23 and older that receive blood cholesterol screening

Cholesterol Screening CVD prevention:
AI/AN patients ages 23 and older who receive blood cholesterol screening

216,800
CVD patients who received cholesterol screening within the past year CVD patients not screened for cholesterol

43
284,362

2006 Target: 44 Prior to FY 2005 measure was: Number of community-directed pilot cardiovascular disease prevention programs In FY 2007 measure changes to CVD Comprehensive Assessment: Proportion of at risk patients who have a comprehensive assessment for all CVD-related risk factors

Data Source CRS 51 electronic examination of 501,162 patient records Results and Analysis IHS met the target for this measure, establishing a baseline of 43 In FY 2006 the target is to increase the rate to 44 Increasing screening rates will allow the agency to identify patients at risk for developing cardiovascular disease Studies have shown that over a third of AI/AN people have high or borderline-high cholesterol levels In FY 2007, this measure will focus on comprehensive 24 cardiovascular disease
assessment, focusing on the proportion of at-risk patients who have a comprehensive assessment for all cardiovascular disease-related risk factors; cholesterol screening will be part of this comprehensive assessment

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2005 Results 2005 Results Obesity Assessment BMI Measurement
Measure Proportion of patients for whom BMI data can be measured Importance Body Mass Index BMI is a simple measure of weight in relation to height and is used to determine whether patients are overweight or obese Rates of obesity and overweight among American Indian and Alaska Native populations exceed the national averages Obesity is a risk factor for high blood pressure, asthma, arthritis, coronary heart disease, stroke, colon cancer, post-menopausal breast cancer, endometrial cancer, gall bladder disease, and sleep apnea Obesity is also a major risk factor for type 2 diabetes particularly among American Indians This measure is part of a comprehensive long-term effort to identify effective interventions to prevent and reduce obesity in American Indian and Alaska Native people 2005 Target Increase the proportion of
patients for whom BMI can be calculated by 5 over the 2004 baseline level of 60
BMI Assessment:
AI/AN patients ages 2-74 who have ever had a BMI calculated
100 2010 Goal 90

Percent

64
GPRA

0 2004 2005

Data Source CRS 51 electronic examination of 872,233 patient records Results and Analysis IHS did not meet the target for this measure The target for this measure was an ambitious 5 increase over FY 2005 Although the agency was unable to achieve a 5 overall increase in one 25 year, it did achieve a significant rate increase BMI measurement increased from the 2004 level by 4 overall In FY 2006, this measure will focus on obesity and overweight rates in children ages 2-5, in order to address the growing problem of childhood obesity

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2005 Results 2005 Results Tobacco Screening
Measure Proportion of patients ages 5 and above who are screened for tobacco use Importance The use of tobacco represents the second largest cause of preventable deaths for American Indian and Alaska Native people Smoking rates in many communities are almost twice the national average Tobacco use
contributes to the leading causes of mortality among American Indians and Alaska Natives Lung cancer is the leading cause of cancer death among AI/AN people Cardiovascular disease is the leading cause of death among AI/ANs, and tobacco use is an important risk factor for this disease 2005 Target Maintain the proportion of patients screened for tobacco use at the 2004 level of 27
Tobacco Use Assessment:
AI/AN patients age 5 screened for tobacco use within the past year
80 2010 Goal 75

Percent

GPRA

34 27
20

0 2004 2005

Data Source CRS 51 electronic examination of 829,166 patient records Results and Analysis IHS met and exceeded the target for this measure, increasing the proportion of eligible patients who have had tobacco screening by 7 overall, from 27 FY 2004 to 34 FY 2005 Screening for tobacco use is essential to identifying patients at risk for complications of tobacco abuse In FY 2006, this measure changes to measuring rates of tobacco cessation intervention, aimed at reducing 26 tobacco usage in AI/AN communities Because tobacco has a unique status among many American Indian and Alaska Native tribes as a sacred plant, any plan for control activities must have
significant input from American Indian and Alaska Native community leaders

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2005 Results 2005 Results Prenatal HIV Screening
Measure Support screening for HIV infections in appropriate population groups Importance The HIV/AIDS epidemic represents a growing threat to American women of childbearing age From 1999 through 2003, the estimated number of AIDS cases increased 15 among women and 1 among men In 1992, women made up 14 of adults and adolescents living with AIDS; by the end of 2003, they made up 22 In 2001, HIV infection was the 6th leading cause of death among women aged 25-34 years, and the 4th leading cause of death among women aged 35-44 HIV infections in newborn children are one potential consequence of higher HIV infection rates among women of childbearing age In 2003, the CDC reported that 92 of HIV and AIDS cases in children and virtually all new HIV infections in children in the United States were the result of perinatal transmission of HIV The CDC estimates that over 8,700 children have contracted HIV through perinatal transmission cumulatively through the year 2003 Studies have
shown transmission rates of less than 2 among HIV infected mothers who started antiretroviral treatment during pregnancy; those who did not begin treatment until labor or after birth had transmission rates of 12-13, and those who received no treatment had rates of 25 Routine prenatal HIV testing of all pregnant women is the best way to avoid transmission of HIV from mother to infant

2005 Target Establish the baseline number of women screened for HIV in pregnancy
Prenatal HIV Testing:
AI/AN pregnant patients screened for HIV within the past year

12,379
Patients not screened for HIV

54
Patients who received HIV screening within the past year

14,759

2006 Target: 55

Prior to 2005, measure was screened for HIV infections in high risk groups at designated sites

Data Source CRS 51 electronic examination of 27,138 patient records Results and Analysis IHS met the target for this measure by establishing a baseline screening rate of 54 The goal of this measure is to eliminate HIV infections in newborn children The Indian Health Service has issued guidance recommending universal prenatal HIV testing using the opt-out approach In opt-out testing, HIV tests are included in the standard
battery of prenatal tests and women are informed that 27 an HIV test is being conducted and that they have a right to refuse it Information regarding HIV is included as part of a patients prenatal education As more practitioners adopt opt-out testing, prenatal HIV screening rates should increase

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Appendix A

Summary of of KEY FINDINGS SUMMARY Key Findings
Summary Table of GPRA Measures: Clinical Measure
2005 Target 2005 Rate 2004 Rate Measure Status

Diabetes: Poor Glycemic Control Diabetes: Ideal Glycemic Control Diabetes: Blood Pressure Control Diabetes: Dyslipidemia Assessed Diabetes: Nephropathy Assessment Diabetes: Retinopathy Assessment Pap Screening Mammography Screening Alcohol Screening FAS Prevention Dental Access Dental Sealants Dental Access-Patients with Diabetes Domestic Violence Screening Public Health Nursing Childhood Immunizations Adult Immunizations: Influenza Adults Immunizations: Pnumococcal Cholesterol Screening CVD Prevention Obesity Assessment Tobacco Use Assessment Prenatal HIV Screening
Reporting System changed to CRS in GY05 Data collected from Immunization Report

17
27 35 53 42 55 58 40 7 24 230,295 37 4 423379 72 54 69 Baseline 65 27 Baseline

15 30 37 53 47 50 60 41 11 24 No data 39 13 No data 75 59 69 43 64 34 54

17 27 35 53 42 55 58 40 7 24 No data 37 4 No data 72 54 69 No data 60 27 No data

Met Met Met Met Met Not Met Met Met Met Met Met Met Met Met Met Met Met Met Not Met Met Met 29

On hold 2004, National Vaccine Shortage

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Summary of of KEY FINDINGS SUMMARY Key Findings
Summary Table of GPRA Measures: Non-Clinical Measure
2005 Target 100 N/A N/A N/A N/A 2005 Rate 100 No data No data No data No data 2004 Rate N/A 70 100 100 100 Measure Status

RTC Accreditation
Youths who completed Substance Abuse Treatment Youths who developed after care plan Youth who have communicated after care plan Youth programs that have a family week

Met

Measure changed in FY05 to indicate of YRTCs
accredited

Data Quality Improvement
Implemented training in all 12 areas, 2 new measures

2 new measures Increase
Implement CG language

4 new measures 4
CG language no implemented

7
Minimum data set language developed

Met Met Not Met Met Met Met Not Met Met Met Met Not Met
Not Met 30 Met

Behavioral Health BH
Percent increase from previous year

Urban IS Improvement Accreditation Medication Error Improvement Injury Intervention Unintentional Injury Rates Suicide Surveillance Environmental Surveillance
Represents percent increase from previous year

100
NCCMERP use by all direct care facilities

100
All areas using NCCMERP

100
Baseline 6 areas

37 projects GY04 rate

37 projects
Results available 12/2009 BHS integrated

37 projects
Results available 12/2008 National plan implemented

Integrate BHS reporting tool

12 programs WebEHRS 20,000 21 sites 3 offices 22

12 programs 24,072 Partial No resources 30

15 24,928 12 sites 41 20

Sanitation Improvement homes Facility Construction
See specific FC report of status

Public Health Infrastructure
additional areas assessed from previous year

Provider Retention/Scholarships

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Indian Health Service Mortality Disparities Table SUMMARY of KEY FINDINGS
American Indian and Alaska Natives AI/AN in the IHS Service Area 2000-2002, US All Races 2001

Rate
AI/AN 2000-2002 ALL CAUSES 10399

Rate
US All Races 2001
8545

Ratio:
AI/AN: US All Races 12

ALCOHOL INDUCED BREAST CANCER CEREBROVASCULAR DISEASE CERVICAL CANCER DIABETES DISEASES OF THE HEART HIV INFECTION HOMICIDE assault INFANT DEATHS per 1,000 live births MALIGNANT NEOPLASMS ALL MATERNAL DEATHS1/per 100,000 live births MOTOR VEHICLE CRASHES PNEUMONIA INFLUENZA SUICIDE Intentional self-harm TUBERCULOSIS UNINTENTIONAL INJURIES

421 165 599 45 732 2362 29 114 85 1835 125 504 311 173 21 901

69 260 579 14 253 2478 50 71 68 1960 99 153 220 107 03 357

61 06 10 32 29 10 06 16 13 09 13 33 14 16 70 25

Rate per 100,000 live births Rate does not meet the standards of reliability due to small numbers The break in comparability for 31 maternal mortality has not been quantified by NCHS Source: Unpublished data: OPHS/Division of Program Statistics 2000-2002 AI/AN rates based on 2000 census with bridged-race categories Date: January 2006

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Bibliography BIBLIOGRAPHY
Bernard, V B, NC Lee, M Piper, L Richardson 2001 Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection
Program, 1991-1998 United States Cancer Causes and Control, 12: 61-68 Centers for Disease Control and Prevention 2003 National Diabetes Fact Sheet: National estimates and general information on diabetes in the United States Atlanta, GA http://wwwcdcgov/diabetes/pubs/estimateshtm Centers for Disease Control and Prevention 2003 The National Breast and Cervical Cancer Early Detection Program http://wwwcdcgov/cancer Centers for Disease Control and Prevention 2004 CDC Fact Sheet: HIV/AIDS Among US Women: Minority and Young Women at Continuing Risk http://wwwcdcgov/hiv/pubs/facts/womenhtm Early Treatment Diabetic Retinopathy Study Research Group Early photocoagulation for Diabetic Retinopathy ETDRS Report 9 Ophthalmology 1991;98:766-785 Abstract Espey, D, RE Paisano, and N Cobb 2003 Cervical Cancer Mortality Data for AI/AN Females, 1994-98 http://wwwihsgov/MedicalPrograms/MCH/W/WHcancerasp Fairchild D, Fairchild M, Stoner S Prevalence of adult domestic violence among women seeking routine care in a Native American health care facility American Journal of Public Health 1998;88:1515-7 Fetal alcohol syndrome: Alaska, Arizona, Colorado, and New York, 1995-1997: MMWR Morbidity and Mortality
Weekly Report 2002 May 24;5120 433-5 Flanders, S 2003 Pneumococcal vaccination prior to hospital discharge Making Health Care Safer 12 pp http://wwwahrqgov/clinic/ptsafety/chap36htm Flegal KM, Carroll MD, Ogden CL, Johnson CL Prevalence and trends in obesity among US adults, 1999-2000 Journal of the American Medical Association 2002 Oct 9;28814:1723-7 Ganley A, Warshaw C, eds Improving the Health Care Response to Domestic Violence: A resource manual for health care providers Family Violence Prevention Fund 1995 Hamby S, Skupien M Domestic violence on the San Carlos Apache reservation: Rates, associated psychological symptoms, and current beliefs IHS Provider 1998, August Hankin, JR Fetal Alcohol Syndrome Prevention Research Alcohol research health : the journal of the National Institute on Alcohol Abuse and Alcoholism 32 2002;261:58-65

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Bibliography BIBLIOGRAPHY
Lieu TA, Cochi SL, Black SB, Halloran ME, Shinefield HR, Holmes SJ, Wharton M, Washington AE Cost-effectiveness of a routine varicella vaccination program for US children Journal of the American Medical Association; 1994 Feb
2;2715:375-81 May PA, Hymbaugh KJ, Aase JM, Samet JM Epidemiology of fetal alcohol syndrome among American Indians of the Southwest Social Biology 1983 Winter;304:37487 McFarlane J, Gondolf EPreventing abuse during pregnancy: a clinical protocol MCN American Journal of Maternal Child Nursing 1998 Jan-Feb;231:22-6 National Immunization Survey 2003 tables National Institute of Diabetes and Digestive and Kidney Diseases 1995 The Pima Indians: Pathfinders for Health NIH Publication No 95-3821 Washington, DC: US Government Printing Office National Institutes of Health 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Pub No 03-5233 National, State, and Urban Area Vaccination Coverage Among Children Aged 19-35 Months–United States, 2003 MMWR: Morbidity and Mortality Weekly Report 2004;July 30;5329:658-661 Photocoagulation treatment of proliferative diabetic retinopathy: The Second Report of Diabetic Retinopathy Study Findings Ophthalmology 1978; 85: 82-106 Abstract Prevalence and characteristics of alcohol consumption and fetal alcohol syndrome awareness–Alaska, 1991 and 1993 MMWR Morbidity and Mortality
Weekly Report 1994 Jan 14;431:3-6 Saslow, D, CD Runowicz, D Solomon, A Moscicki, R A Smith, H J Eyre, C Cohen 2002 American Cancer Society Guideline for the early detection of cervical neoplasia and cancer CA, A Cancer Journal for Clinicians, 52: 342-362 Sisk, J E 2000 The best and worst of times: Use of adult immunizations American Journal of Preventive Medicine, 19: 26-27 Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP, Foster RS, Hendrik E, Eyre HJ, and Sener S 2003 American Cancer Society Guidelines for breast cancer screening: Update 2004 CA, A Cancer Journal for Clinicians, 53:131169 Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B The epidemic of obesity in American Indian communities and the need for childhood obesityprevention programs American Journal of Clinical Nutrition 1999 Apr;694 Suppl: 33

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Bibliography BIBLIOGRAPHY
US Department of Health and Human Services 1998 Tobacco Use Among US Racial/Ethnic Minority Groups –African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon
General Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention US Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women MMWR: Recommendations and Reports 1995 Jul 7;44RR-7:1-15 Wagner, E H, C Davis, C Homer, S Hagedorn, B Austin, A Kaplan 2002 Curing the system: Stories of change in chronic illness care Accelerating Change Today: 9 http://wwwqualityhealthcareorg/QHC/Topics/ChronicConditions/Diabetes/Literature /CuringthesystemStoriesofchangeinchronicillnesscarehtm

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Source:health.state.mn.us

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