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AHRQ Research and Other Activities Relevant to American Indians and Alaska Natives

Program Brief

This program brief summarizes a number of ongoing and recently completed research pursuits sponsored by the Agency for Healthcare Research and Quality, in which information technology, educational programs, cooperative partnerships, and analyses of care are being used to improve health outcomes in United States indigenous populations.

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Contents

Introduction
Enhancing Knowledge To Improve Health and Health Care
Developing Data and Research Capacity
Building Relationships and Fostering Collaborative Activities
For More Information
References

Introduction

The Agency for Healthcare Research and Quality (AHRQ) is committed to improving the quality, safety, effectiveness, and efficiency of health care for all Americans. With its focus on transforming sound research into practice to improve outcomes, AHRQ continues to enhance the health services research knowledge base; develop tools and talent that foster the health services research infrastructure; and build relationships with tribal and other American Indian/Alaska Native (AI/AN) organizations, the Indian Health Service (IHS), and other Federal agencies to advance excellence in health care. Recently completed and ongoing AHRQ activities of particular importance and relevance to the AI/AN population are summarized in this Program Brief.

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Enhancing Knowledge To Improve Health and Health Care

Rheumatoid Arthritis Quality of Care in Alaska Natives. Rheumatoid arthritis, a major cause of disability among the general U.S. population, has a higher prevalence among some AI/AN subgroups. This new pilot study aims to assess the level of adherence to 27 quality indicators among an Alaska Native subpopulation living in the Anchorage Service Unit. The study team will gather data on patient and provider characteristics that influence quality of care and use this information to generate hypotheses for further investigation.

Long-term goals include identifying deficiencies in arthritis care and developing quality initiatives for implementation statewide to improve care for Alaska Natives with rheumatoid arthritis. (Principal Investigator: Elizabeth Ferucci, Alaska Native Tribal Health Consortium; Grant HS15625, 9/30/05-9/29/07)

IT Systems for Rural Indian Clinic Health Care. Beginning September 2004, the California Rural Indian Health Board is partnering with three of its rural tribal health programs which have implemented electronic health records with clinical decision support systems in a coordinated effort to reduce hospitalizations that may be preventable through improving quality of care and reducing medical errors.

The information technology (IT) systems that result will be used in conjunction with local hospitals to support the review of all hospitalizations for their preventability and to detect and track the programs' medical and medication errors as well as their clinical care performance according to standardized performance guidelines. (Principal Investigator: Susan Dahl, California Rural Indian Health Board; Grant HS15339, 9/20/04-8/31/07)

Understanding and Reducing Native Elder Health Disparities.1-9 At one of AHRQ's Excellence Centers to Eliminate Ethnic/racial Disparities, a team headed by an American Indian researcher is examining health care of elderly AI/ANs for diabetes, heart disease, cancer, and respiratory diseases such as influenza, tuberculosis and pneumonia—chronic conditions for which the AI/AN population is at an increased risk.

Individual projects address improving the quality of diabetic care, increasing participation in clinical preventive services such as immunization and cancer detection/management, and smoking cessation, as well as identifying both the barriers and facilitators to improved health status and functioning of older Al/ANs. (Principal Investigator: Spero Manson, University of Colorado; Grant HS10854, 9/30/00-9/29/06)

Quality Care and Error Reduction in Rural Hospitals.10,11 This project examined organizational factors directly influencing the rural health care provider; the delivery of patient care in rural settings; and the identification, discussion, and disclosure of medical errors and adverse events. The investigators used a Web-based intervention in the form of a curriculum accessible to health care providers in rural hospitals and designed to raise awareness, encourage error reporting, and build skills to address adverse events across 30 hospital settings in a nine-State area of the rural West.

The grant also included a supplement to add minority investigators and include key contacts from 26 American Indian reservations in Idaho, Montana, North and South Dakota, and Wyoming. (Principal Investigator: Ann Cook, University of Montana; Grant HS11930, 9/30/01-9/29/04)

Effect of Navajo Interpreters on Diabetes Outcomes.12-14 Investigators led by an American Indian physician evaluated how formally trained Navajo-speaking medical interpreters affect diabetes outcomes and health care use patterns compared with the usual-care interpretation with no formal medical interpreter or diabetes knowledge training.

By probing linguistic, cultural, and regional language issues, including a possible lack of word-for-word translatability from English into Navajo, the researchers have been able to articulate approaches that can be used in explaining diabetes management in an appropriate cultural context. (Principal Investigator: Melvina McCabe, University of New Mexico; Grant HS10637, 9/30/00-9/29/05)

Multimethod Assessment of Medicaid Managed Care in New Mexico.15-21 Researchers received a grant supplement to study the impact of Medicaid managed care (MMC) on American Indians in tribal, IHS, and urban health care systems in New Mexico; the supplement was in addition to the main study's purpose to assess how MMC affected individual, organizational/community, and population levels of health care, including immunization rates and mental health care. (Principal Investigator: Howard Waitzkin, University of New Mexico; Grant HS09703, 9/30/98-3/31/02)

Effectiveness of Prenatal Diabetes Education Among Pima Indians.22-24 This evaluation focused on Pima Indians, who continue to have high rates of diabetes, in a project designed to develop a culturally informed understanding of diabetes in American Indian communities and to translate this understanding into more effective diabetes prevention programs.

An emphasis on women and mothers was used in recognition of the importance of mothers' behaviors (e.g., prenatal diabetes control, breast-feeding) as factors in their children's diabetes status. (Principal Investigator: Carolyn Smith, University of Arizona; Grant HS10802, 9/30/00-2/28/02)

Cultural Variation in Data Privacy and Bioethical Views. This qualitative study examined the effects of ethnicity and rurality on patient/consumer perspectives about health data privacy and confidentiality using 18 focus groups which comprised members of American Indian (Navajo, Pueblo) and Latino (both native and immigrant) communities. (Principal Investigator: Robert Williams, University of New Mexico; Grant HS13208, 7/1/02-12/30/03)

Government Coverage of Traditional Indigenous Medicine (TIM). AHRQ has supported conference discussions on TIM in three settings over a 5-year period:

  • The first discussion formed part of a larger international ethics conference in London in 2000; the second, held in Arizona in 2001, specifically focused on the importance of traditional practices to Native American communities. Attendees at the 2001 meeting addressed issues surrounding the need for support of traditional practitioners and the role of indigenous medicine, both in Tribes' economic self-sufficiency and in government-supported health systems. The final project report is available from the National Technical Information Service and can be ordered by referencing NTIS Accession No. PB2005-102221. (Principal Investigator: J. Kristin Olson-Garewa, University of Arizona; Grant HS10930, 8/15/00-2/14/2002)
  • The most recent conference was planned and coordinated by the National Center for Complementary and Alternative Medicine at the National Institutes of Health with additional support from AHRQ and the Indian Health Service. The meeting, held in August 2005, focused on research in traditional indigenous medicine.

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Developing Data and Research Capacity

Building Research Capacity at the California Rural Indian Health Board's Native American Research Center for Health (NARCH). In addition to building the NARCH's research capacity, this multiyear project aims to identify which health care characteristics of tribal health program service systems are associated with preventable hospitalizations. AHRQ became a partner in the NARCH program in 2005.

This program—which aims to develop opportunities for conducting research and research training that respond to the needs of AI/AN communities—is predominantly funded by the National Institutes of Health and managed by the Indian Health Service. The Centers are working partnerships between AI/AN organizations and research-intensive institutions. Further information on the 2005 NARCH grants can be found at http://www.ihs.gov/MedicalPrograms/Research/.

Infrastructure Development and Research in Montana and Wyoming.25 In addition to support for the Montana/Wyoming Tribal Leaders Council, Black Hill State University, and the Black Hills Center for American Indian Health to develop a sustainable research infrastructure, this project provides funding for two studies. The first is identifying factors that affect breast and cervical cancer screening and followup of abnormal findings; investigators are developing a pilot program to increase the proportion of American Indian women who receive screening tests.

The second study aims to design, implement, and evaluate the effectiveness of a structured process in which tribal members and IHS providers are jointly developing strategies for performance improvement based on priority issues that are identified through a consumer survey. Investigators are developing a targeted research agenda that addresses tribally identified priority issues, such as hepatitis C, West Nile virus, and methamphetamine use. (Principal Investigator: Gordon Belcourt, Montana/Wyoming Tribal Leaders Council; Grant HS14034, 9/30/03-9/29/06)

Implementation of Health Improvement Collaboration in Cherokee County, Oklahoma. This project includes a collaborative partnership among 12 agencies, including a rural acute care hospital, a large American Indian tribal entity, an IHS hospital, a community health center, a health department, and a community consortium. The total patient population is 250,000 in 14 counties in rural northeastern Oklahoma.

The project includes three components for improving quality of care. The first, Healthfinder, is an electronic and telephone resource for consumers to assist in locating health providers and social services; it also assists providers in meeting community needs. The second component implements an integrated community health information exchange network to facilitate provider coordination and transfer of critical patient information. The last component explores areas for the most cost effective prevention strategies and adopts common objectives for prevention interventions and outcome measurement.

This project builds on an earlier 1-year planning grant (HS15364) by the same investigator. (Principal Investigator: Mark Jones, Tahlequah City Hospital; Grant HS16131, 9/30/05-9/29/08)

Development and Implementation of a Point-of-Care Electronic Health Record. AHRQ is supporting a collaborative, multi-million-dollar effort by the Indian Health Service and Department of Veterans Affairs to develop and deploy an electronic health record and disease management system and to investigate the effect of the system on the quality and safety of health care delivery in IHS facilities. AHRQ support is facilitating IHS' ability to evaluate its current electronic health information system model, develop clinical requirements for a cardiovascular disease case management system, and provide better coordination and documentation.

Enhancing Data Collection Systems in Primary Care Practice-Based Research Networks (PBRNs). Two AHRQ-supported PBRN projects were designed to develop electronic data system capacity in networks serving large numbers of AI/AN patients:

  • The Oklahoma PBRN increased training in and utilization of personal digital assistants (PDAs) to ensure that all member practices were able to collect and transmit research data electronically and better utilize the PDA's Web-based Preventive Services Reminder System to collect routine practice data and increase the delivery and documentation of preventive services. At the conclusion of the study period, 13 practices and 20 clinicians were using the reminder system to report on service delivery and patient sociodemographic information. Four Native American clinics participated in network projects. (Principal Investigator: James Mold, University of Oklahoma; Grant HS13557, 9/30/02-9/29/05)
  • The Research Involving Outpatient Settings Network (RIOS Net) is composed of clinicians in IHS facilities, community health centers, and university-supported practices which serve culturally diverse, medically underserved, and low-income communities in New Mexico. Among the objectives of this completed study was a pilot project to learn more about the process of primary prevention and risk factor reduction. Data were gathered through various methods to explore provider decisionmaking on obesity counseling during the patient encounter. Investigators found the decision on whether to counsel was influenced less by clinical guidelines than by patient factors and external considerations. (Principal Investigator: Robert Williams, University of New Mexico; Grant HS11229, 9/30/00-9/29/02)

Increasing Career Opportunities for American Indian Researchers. A major AHRQ goal is to enhance opportunities for AI/AN investigators in health services research. For example:

  • AHRQ is an active supporter of the Tribal College and University (TCU) Initiative of the Department of Health and Human Services (HHS). AHRQ has employed TCU and other American Indian students for summer internships since 1999, as well as during additional academic terms in 2001, 2002, and 2006. AHRQ will continue to foster interest in the health services research field among tribal college students through its summer internship program.
  • In response to a stated need on the part of the American Indian Higher Education Consortium, an umbrella organization for tribal colleges, AHRQ offered statistical support for a research study by the group on public health issues and tribal colleges. Also, in November 2003, Dr. Carolyn Clancy, AHRQ Director, sent a letter to all tribal college presidents reintroducing them to the Agency and its work (previous letters had been sent in 2000 and 1998) and encouraging them to contact AHRQ to discuss possibilities for joint efforts.
  • AHRQ contributed to the 2002 meeting of the National Alaska Native American Indian Nurses Association. In addition to financial support, AHRQ staff conducted a session on funding opportunities, the grants process, and review procedures for nurse researchers.

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Building Relationships and Fostering Collaborative Activities

Identifying and Disseminating Tribal Health Research Priorities. HHS has formed a new tribal advisory group of elected tribal leaders from around the country to advise departmental operating and staff divisions on Tribes' health research needs and priorities. In addition to its advisory objectives, the group will work to further coordination and cooperation among member operating and staff divisions as well as to inform Tribes about departmental health-related research activities and the results of previous research.

The advisory group held its first meeting in May 2006. AHRQ, along with others, played a key role in the planning and development of this effort.

Assessing AI/AN Patient Experiences With Care. AHRQ has completed the development and testing of a survey to assess the AI/AN perspective on ambulatory care quality. The survey instrument, part of the CAHPS® family of surveys, was developed in cooperation with the Choctaw Nation Health Service Authority. Major domains of the instrument include wait time, after hours care, communication, office staff courtesy, and overall rating of primary care doctor or nurse.

The instrument serves as the basis for a survey of AI/AN patients' assessments of their quality of care. Details on CAHPS® can be found at http://www.cahps.ahrq.gov/default.asp.

Reducing Health Care Disparities Among AI/AN Populations. AHRQ is supporting efforts to identify and address disparities in health and health care among AI/ANs:

  • AHRQ was a participating cosponsor of the HHS Office of Minority Health National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health held in January 2006. A list of presentations relevant to minority communities, including AI/AN subpopulations, can be found on the Summit Web site at http://www.omhsummit2006.org/PresentationsCommunity.htm.
  • AHRQ participated in a 1-day meeting of HHS officials and TCU presidents in 2003 to identify ways in which the TCUs can contribute to the national efforts to address health care disparities and how HHS components can help them in these and other efforts to support and promote the development of TCUs.
  • AHRQ provided support to the HHS Office of Minority Health for a 2002 national forum for tribal leaders, public/private organizations, Federal and State policymakers, and other health officials to examine ways to ameliorate health disparities among American Indians and Alaska Natives. In addition, AHRQ sponsored two sessions and a monograph on performing research in AI/AN communities by the Native Research Network.
  • AHRQ sponsored a 3-day workshop entitled “Addressing Critical Concerns of Health Care Systems Serving American Indians/Alaska Natives” in 2000. Presenters and participants included tribal council members and legislators as well as representatives of tribal health authorities/departments, clinics and health centers, urban Indian programs, Indian health boards, IHS facilities, and Federal and State agencies. A summary of the workshop is available on the AHRQ Web site at http://www.ahrq.gov/news/ulp/tribal/ulptribal.htm.

Addressing Long-term Care Needs of Rural AI/ANs. In 2003 AHRQ held a workshop for tribal and State health officials in the Denver Region, which includes Colorado, Montana, North and South Dakota, Utah, and Wyoming. The 3-day workshop was designed to help tribal and State policymakers better understand and assess American Indian long-term care needs and develop policies, resources, and programs that meet those needs. The role of IHS, tribal governments, and State programs in delivering care and the special problem of lack of infrastructure, particularly in the very rural areas of the Region's reservations, were among the topics addressed. A summary of the workshop is available on the AHRQ Web site at http://www.ahrq.gov/news/ulp/amindltc/ulpailtc.htm.

Assisting in Implementation of a Clinical Prevention Pilot Program. Following technical assistance training in 2003, the Alaska Department of Health and Social Services implemented AHRQ's Put Prevention Into Practice (PPIP) program at a pilot site at Iliuliuk Clinic in Unalaska. The purpose of PPIP is to increase the appropriate use of clinical preventive services, such as screening tests, immunizations, and counseling, based on U.S. Preventive Services Task Force recommendations.

Eleven of Alaska's community health center sites that receive funding as federally qualified health centers are operated by tribal health organizations. All Alaska centers serve members of the AI/AN community. Five sites have expressed interest in potential participation in the Alaska PPIP project.

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For More Information

For further details about AI/AN projects and other activities at AHRQ, contact:

Wendy Perry
AHRQ Senior Program Analyst for AI/AN Health
540 Gaither Road
Rockville, MD 20850
E-mail: Wendy.Perry@ahrq.hhs.gov

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References

  1. Beals J, Welty TK, Mitchell CM, et al. Different factor loadings for SF36: the Strong Heart Study and the National Survey of Functional Health Status. J Clin Epidemiol 2006 Feb;59(2):208-15.
  2. Buchwald D, Goldberg J, Noonan C, et al. Relationship between post-traumatic stress disorder and pain in two American Indian tribes.Pain Med 2005 Jan-Feb;6(1):72-9.
  3. Bryant A Jr, Goins RT, Bell R, et al. Health differences among Lumbee Indians using public and private sources of care. J Rural Health 2004 Summer;20(3):231-6.
  4. Manson SM, Beals J, Klein SA, et al. Social epidemiology of trauma among 2 American Indian reservation populations. Am J Public Health 2005 May;95(5):851-9.
  5. Manson SM, Garroutte E, Goins RT, Henderson PN. Access, relevance, and control in the research process: lessons from Indian country. J Aging Health 2004 Nov;16(5 Suppl):58S-77S.
  6. Nez Henderson P, Jacobsen C, Beals J; AISUPERPFP Team. Correlates of cigarette smoking among selected Southwest and Northern plains tribal groups: the AISUPERPFP Study. Am J Public Health 2005 May;95(5):867-72.
  7. Rhoades DA, Manson SM, Noonan C, Buchwald D. Characteristics associated with reservation travel among urban Native American outpatients. J Health Care Poor Underserved 2005 Aug;16(3):464-74.
  8. Sawchuk CN, Roy-Byrne P, Goldberg J, et al. The relationship between post-traumatic stress disorder, depression and cardiovascular disease in an American Indian tribe. Psychol Med 2005 Dec;35(12):1785-94.
  9. Shore JH, Manson SM. A developmental model for rural telepsychiatry. Psychiatr Serv 2005 Aug;56(8):976-80.
  10. Cook AF, Hoas H, Guttmannova K. Not by technology alone....Project seeks to assess and aid patient safety in rural areas. Biomed Instrum Technol 2003 Mar-Apr;37(2):128-30.
  11. Cook AF, Hoas H, Guttmannova K, Joyner JC. An error by any other name. Am J Nurs 2004 Jun;104(6):32-43; quiz 44.
  12. McCabe M, Morgan F, Smith M, et al. Lessons learned: challenges in interpreting diabetes concepts in the Navajo language. Diabetes Care 2003 June;26(6):1913-4.
  13. McCabe M, Gohdes D, Morgan F, et al. Herbal therapies and diabetes among Navajo Indians. Diabetes Care 2005 Jun;28(6):1534-5.
  14. McCabe M, Morgan F, Curley H, et al. The informed consent process in a cross-cultural setting: is the process achieving the intended result? Ethn Dis 2005 Spring;15(2):300-4.
  15. Nelson NL. Ideologies of aid, practices of power: lessons for Medicaid managed care. Med Anthropol Q 2005 Mar;19(1):103-22.
  16. Schillaci MA, Waitzkin H, Carson EA, et al. Immunization coverage and Medicaid managed care in New Mexico: a multimethod assessment. Ann Fam Med 2004 Jan-Feb;2(1):13-21.
  17. Stocker K, Waitzkin H, Iriart C. The exportation of managed care to Latin America. N Engl J Med 1999 Apr 8;340(14):1131-6.
  18. Waitzkin H, Williams RL, Bock JA, et al. Safety-net institutions buffer the impact of Medicaid managed care: a multi-method assessment in a rural state. Am J Public Health 2002 Apr;92(4):598-610.
  19. Willging CE. Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico. Med Anthropol Q 2005 Mar;19(1):84-102.
  20. Willging CE, Semansky RM, Waitzkin H. State Mental Health Policy: New Mexico's Medicaid managed care waiver: organizing input from mental health consumers and advocates. Psychiatr Serv 2003 Mar;54(3):289-91.
  21. Willging C, Waitzkin H, Wagner W. Medicaid managed care for mental health services in a rural state. J Health Care Poor Underserved 2005 Aug;16(3):497-514.
  22. Smith-Morris C. Diagnostic controversy: gestational diabetes and the meaning of risk for Pima Indian women. Med Anthropol 2005 Apr-Jun;24(2):145-77.
  23. Smith-Morris C. Prenatal mysteries of symptomless diabetes in the Gila River Indian community. In: Ferreira ML, Lang GC, editors. Indigenous Peoples and Diabetes. Durham, NC: Carolina Academic Press; 2006. p. 187-202.
  24. Smith-Morris C. Reducing diabetes in Indian country: lessons from the three domains influencing Pima diabetes. Human Organization 2004 Spring;63(1):34-46.
  25. Andersen SR, Belcourt GM, Langwell KM. Building healthy tribal nations in Montana and Wyoming through collaborative research and development. Government, Politics, and Law 2005 May;95(5):784-9.

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Current as of May 2006
AHRQ Publication No. 06-P021
Replaces AHRQ Pub. No. 05-P001

Internet Citation:

AHRQ Research and Other Activities Relevant to American Indians and Alaska Natives. Program Brief. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ Publication No. 06-P021, May 2006. http://www.ahrq.gov/research/amindbrf.htm

 
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