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

Program Brief

American Indian/Alaska Native (AI/AN) people have long experienced lower life expectancy and disproportionate disease burden when compared with other Americans. This program brief provides a summary, by topic, of ongoing and recently completed AHRQ activities that specifically address the health of the AI/AN people.

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Contents

Introduction
Arthritis
Asthma
Cardiovascular Disease
Children's Health
Diabetes
Disparities
Long-Term Care
Managed Care for Medicaid
Mental Health
Perceptions of Care
Preventive Care
Quality of Care
Research Considerations
Research Infrastructure Development
Technology (Health Information Technology, Telehealth)
Tobacco Use
Traditional Medicine
Trauma
Women's Health
Glossary
For More Information

Introduction

American Indian/Alaska Native (AI/AN) people have long experienced lower life expectancy and disproportionate disease burden when compared with other Americans. AI/ANs die at higher rates than other Americans from tuberculosis (500 percent higher), alcoholism (550 percent higher), diabetes (200 percent higher), unintentional injuries (150 percent higher), homicide (100 percent higher), and suicide (60 percent higher).

The Agency for Healthcare Research and Quality (AHRQ) is committed to improving the quality, safety, effectiveness, and efficiency of health care for all Americans. In the past three years alone, AHRQ has provided more than $8.3 million in grants 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 AI/AN organizations, the Indian Health Service (IHS), and other Federal agencies to advance excellence in health care for AI/ANs.

This program brief provides a summary, by topic, of ongoing and recently completed AHRQ activities that specifically address the health of the AI/AN people.

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Arthritis

Rheumatoid arthritis, a major cause of disability among the general U.S. population, has a higher prevalence among some AI/AN subgroups.

  • Study examines rheumatoid arthritis quality of care in Alaska Natives

    This pilot study assessed the level of adherence to 27 quality indicators among an Alaska Native subpopulation living in the Anchorage Service Unit. The study team gathered 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)

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Asthma

Asthma is a chronic lung disease that affects 14 to 15 million people in the United States. People with asthma have almost half a million hospitalizations annually, and 5,000 die each year of the disease.When only race is considered, AI/ANs and black people have a 25 percent higher prevalence than white people.

  • Asthma education conference held for tribal health officers

    The main goal of this October 2006 regional conference on asthma was to inform Northern Plains tribal health agencies about the current state of knowledge, research, and treatment of asthma, its potential environmental health triggers, prevention strategies, and environmental improvement measures. Topics covered included exposures to everyday types of indoor and outdoor contaminants, such as environmental tobacco smoke, allergens, endotoxins, molds, insects, dust mites, pesticides, formaldehyde, exhaust from wood-burning stoves, motor vehicle exhaust, and other biological and chemical contaminants. Conference participants included tribal health representatives and directors, IHS staff, emergency medical workers, nurses, and pediatricians working with 18 tribes in a four-State region served by the Northern Plains Tribal Epidemiology Center. (Principal Investigator: David Osterberg, University of Iowa; Grant HS16435, 06/01/06-05/31/07)

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Cardiovascular Disease

Although mortality rates from cardiovascular disease (CVD) in the United States continue to decrease, rates are rising among AI/AN people and are now likely exceed those of the general population. Also, CVD is the leading cause of death in American Indians beginning at age 45 compared with age 65 for the general U.S. population. AI/ANs are 1.2 times as likely as white adults to have heart disease, are 1.6 times as likely as white adults to be obese, and 1.3 times as likely as white adults to have high blood pressure.

  • Risk factors for developing cardiovascular disease increase as older American Indians age

    As older American Indians age, more of them than the general population develop hypertension, diabetes, and low levels of high density lipoprotein cholesterol (HDL-C), all risk factors for developing CVD, according to this study. Researchers examined the development of major CVD risk factors among a rural group of 4,549 American Indians aged 45 to 74 during initial examination in 1989 to 1991 and 8 years later. This aging group had decreased prevalence of smoking and no consistent changes in adverse HDL-C and low-density lipoprotein-cholesterol profiles. However, the group had substantial increases in the prevalence of hypertension and diabetes, two of the most important CVD risk factors.

    Source: Rhoades DA, Welty TK, Wang W, et al. Aging and the prevalence of CVD risk factors in older American Indians: The strong heart study. J Am Geriatric Society 2007 Jan;55:87-94. (Grant HS10854)

  • Posttraumatic stress disorder linked to cardiovascular disease

    Researchers interviewed 1,414 Northern Plains American Indians aged 18–57 years to examine the association with lifetime posttraumatic stress disorder (PTSD) and lifetime major depression on CVD among Northern Plains American Indians. Fifteen percent of respondents had PTSD, and 8 percent had major depression. CVD was more commonly reported by participants with PTSD than by those without PTSD (12 percent vs. 5 percent). More participants with major depression reported having CVD than their nondepressed counterparts (14 percent vs. 6 percent). The authors suggest rising CVD rates in this population may be better understood if PTSD is considered along with other traditional risk factors.

    Source: Sawchuk CN, Roy-Byrne P, Goldberg J, et al. The relationship between posttraumatic stress disorder, depression, and CVD in an American Indian tribe. Psychol Med 2005 Dec;35(12):1785-94. (Grant HS10854)

  • Cardiovascular disease death rates higher among AI/ANs than other U.S. groups

    National vital events data published by the IHS prior to the early 1990s suggested that CVD mortality rates (for example, for heart attack and stroke) were lower for AI/ANs than the U.S. general population. Given that American Indians have for years had some of the Nation's highest rates of major CVD risk factors, such as smoking, diabetes, and obesity, the author adjusted for racial misclassification in the IHS data and concluded the opposite—she found that AI/ANs have higher CVD mortality rates than the rest of the U.S. population, and these rates may have been higher for more than a decade. Further, CVD mortality is increasing among AI/ANs but decreasing in the general population, widening a previously unrecognized disparity. After adjusting for age and racial misclassification, by 1996-1998 the number of CVD deaths per 100,000 among AI/ANs was 195.9 compared with 166.1 and 159.1 for all races and whites, respectively. The most striking and widening disparities were found for middle-aged AI/ANs; CVD mortality among elderly AI/ANs was lower than in the other groups.

    Source: Rhoades, DA. Racial misclassification and disparities in CVD among American Indians and Alaska Natives. Circulation 2005 March 15;111:1250-6. (Grant HS10854)

  • Better diagnosis, management, and monitoring of hypertension is needed for older AI/ANs

    The authors studied the medical records of 524 AI/ANs aged 50 and older who were seen at an urban health clinic in the Pacific Northwest between 1994 and 1995. The researchers examined the frequency of diagnosed hypertension, undiagnosed hypertension, and coexisting conditions, as well as hypertension treatment, control, and quality of care. More than one-third (38 percent) of AI/ANs seen at the clinic had diagnosed hypertension. However, because 23 percent of those without a diagnosis of hypertension had two or more elevated blood pressure measurements during clinic visits, the prevalence of total possible hypertension may have been as high as 52 percent. Eighty-one percent of diagnosed patients were treated with medication. Although treatment rates were high, blood pressure control was suboptimal. Blood pressure was well controlled in only 37 percent of patients, with men being less well controlled than women. This first and largest study of hypertension among older AI/ANs living in urban areas underscores the need for better diagnosis, management, and monitoring of hypertension and its complications (for example, kidney disease).

    Source: Rhoades DA, Buchwald D. Hypertension in older urban Native American primary care patients. J Am Geriatric Society 2003 June;(51):774-81. (Grant HS10854)

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Children's Health

AI/AN children face serious health issues. American Indian and Alaska Native infants die at a rate of nearly 10 per every 1,000 live births, as compared to 7 per 1,000 for the U.S. all races population (2001-2003 rates). The prevalence of overweight and obesity among AI/AN children has increased dramatically in the last 30 years, and type 2 diabetes is increasingly prevalent. On a positive note, the vaccination rates for AI/AN children increased to 83 percent as of 2001.

  • International meeting held on indigenous child health

    This collaborative conference, held in Montreal on April 20-22, 2007, focused on innovative clinical care models and community-based public health approaches for children and youth in First Nations, Inuit, Metis, American Indian, and Alaska Native communities. The conference was planned and jointly sponsored by a number of U.S. and Canadian organizations and agencies. While the health care systems in the U.S. and Canada differ, there are many similarities in terms of providing culturally effective care to indigenous children and youth. This conference brought exposure to successful models of care and unique research implemented at the community level, and offered opportunities for providers to gain valuable skills in areas of health disparities among indigenous children. Additional information is available at www.aap.org/nach/2InternationalMeeting.htm. (Principal Investigator: Sunnah Kim, American Academy of Pediatrics; Grant HS16753, 12/01/06-11/30/07)

  • Immunizations declined with Medicaid reform in New Mexico

    An expected consequence of New Mexico's adopting Medicaid managed care was increased immunization coverage for children receiving the 4:3:1 series (four doses of diphtheria, tetanus, and acellular pertussis vaccines; three doses of poliovirus vaccine; and one dose of measles-containing vaccine). However, immunizations decreased from 80 percent in 1996 to 73 percent in 2001. Additionally, the State dropped in rank among States from 30th for this vaccination series in 1996 to 50th in 2001. The authors suggest that decreased funding at public health clinics, difficulty in getting appointments with Medicaid managed care providers, increased referrals to community health centers and State-run public health clinics, and increased workloads and delays at community health centers may have contributed to the decline in immunizations.

    Source: 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. (Grant HS09703)

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Diabetes

AI/ANs have the highest rates of type 2 diabetes in the United States. Diabetes is traditionally a disease of older people, but diabetes is being diagnosed at young ages in American Indian communities. About 15.1 percent of AI/ANs aged 20 years and older and receiving care from the IHS have diabetes. Diabetes is least common among Alaska Natives (8.1 percent) and most common among American Indians in the southern U.S. and southern Arizona (26.7 percent and 27.6 percent respectively). The Pima Indians of Arizona have one of the highest diabetes rates in the world.

  • Robeson County Primary Care Research Network studies prevalence of diabetes in local American Indians

    This project brings together 54 providers, 21 of which are American Indian, with the goal of creating a research network of primary care providers who largely serve American Indian patients in Robeson County, North Carolina, a rural county that is home to most of the state's more than 50,000 members of the Lumbee Tribe. In addition to creating the network of primary care practices where disease- and tribe-specific data can be collected, researchers will estimate diabetes prevalence in adults and children as well as pilot data collection on the care processes for diabetes. The creation of the network, measurement of prevalence, and results of the pilot study will be used to direct further work for improving the identification and care for diabetes in the community. (Principal Investigator: Bonnie Yankaskas, University of North Carolina at Chapel Hill; Grant HS15989, 08/01/06-07/31/08)

  • AI/AN patients in urban areas more likely than rural patients to receive diabetes education

    The authors of this study reviewed medical record data as part of the IHS Diabetes Care and Outcomes Audit in 2002. They compared Indian health facilities' adherence to diabetes care guidelines when treating all 710 AI/AN patients at 17 urban Indian health clinics and a random sample of 1,420 AI/AN patients from 225 rural Indian health facilities. Urban patients were more likely than rural patients to have received formal diabetes education in the past 12 months (76 vs. 62 percent). After adjusting for other factors affecting outcomes, blood glucose levels, blood pressure, and cholesterol levels were similar for urban and rural patients. Overall, rates of adherence to nationally recommended care guidelines for AI/AN health programs were comparable to or surpassed rates described for the general population.

    Source: Moore K, Roubideaux Y, Noonan C, et al. Measuring the quality of diabetes care in urban and rural Indian health programs. Ethnicity & Disease 2006 Autumn;16:772-7. (Grant HS10854)

  • Structural change is needed to stem diabetes crisis

    Native American communities in the United States have experienced an upswing of community participation in health programming, especially for diabetes. The author suggests that because knowledge of the disease, its risk factors, and the behavioral elements that assist in its spread and prevalence are known, a structural change is needed in tribal health care. A holistic approach is required that recognizes how genetic, cultural, environmental, and political-economic factors work simultaneously to produce the current crisis in diabetes.

    Source: Smith-Morris, CM. Community participation in tribal diabetes programs. Am Indian Culture and Research J 2006;30(2):85–110. (Grant HS10802)

  • Pregnancy may be best time to curb diabetes in the Pima

    The author delves into the spectrum of causes, perspectives, and conditions that underlie the occurrence of diabetes in the Pima community. Using narratives of pregnant Pima women and nearly 10 years of research in this community, the volume provides the Pimas' perspective of type 2 and gestational diabetes and their experience, including their core values of motherhood, foodways, ethnic identity, exercise, attitude toward health care, and willingness to seek care. The author asserts that the prenatal period may offer the most hope for curbing the epidemic.

    Source: Smith-Morris, CM. Diabetes among the Pima: Stories of survival. Tucson: University of Arizona Press. 2006. (Grant HS10802)

  • Pima women place high value on own and others' experiences with gestational diabetes

    Because it is mostly symptomless, gestational diabetes can be a mysterious disease. Medical information that contradicts family and friends' information on diabetes can contribute to Pima women's not undergoing testing during pregnancy. Though Pima women do listen to health professionals, they also rely on their family and friends as sources of medical information.

    Source: Smith-Morris C. Prenatal mysteries of symptomless diabetes in the Gila River Indian community. In: Ferreira ML, Lang GC, Eds. Indigenous peoples and diabetes. Durham: Carolina Academic Press, 2006:187-202. (Grant HS10802)

  • Investigators examine the effect of Navajo interpreters on diabetes outcomes

    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)

  • Providers and patients have similar concerns about preventing diabetes

    When pregnant women develop gestational diabetes, they and their children are at risk for developing type 2 diabetes. Pima women have been targeted for diabetes prevention because of the disease's prevalence in the community. Both health care professionals and the Pima raise the same set of questions about diabetes prevention and surveillance during pregnancy.

    Source: 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. (Grant HS10802)

  • Tribal acceptance key to diabetes prevention

    Diabetes programs for the Pima Indians tend to center on disease-causing behaviors or translating medical instructions into locally understood metaphors. Less often stressed are economic and genetic factors, which can lead some to believe the disease is inevitable. Because of strong community and cultural values, the author suggests tribes are best positioned to take on the problem of diabetes on the reservation. To accomplish this, tribes need to see structural changes in health care, political-economic changes to sustain communitywide change, and a stable financial foundation for diabetes programs.

    Source: Smith-Morris C. Reducing diabetes in Indian country: Lessons from the three domains influencing Pima diabetes. Human Organization 2004 Spring;63(1):34-46. (Grant HS10802)

  • Study examines the effectiveness of prenatal diabetes education among Pima Indians

    More than half of all Pima Indians over age 35 have diabetes. This project was 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)

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Disparities

AHRQ is supporting efforts to identify and address disparities in health and health care among AI/ANs:

  • AHRQ has undertaken a project aimed at understanding health care disparities for AI/AN populations with a focus on comparing rural with urban AI/AN populations and reservation with non-reservation populations. Using Medical Expenditure Panel Survey and U.S. Census data, researchers are examining the extent to which AI/ANs experience barriers to obtaining medical care and mental health services.
  • AHRQ was a participating co-sponsor 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.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1616m.
  • AHRQ participated in a 1-day meeting of U.S. Department of Health and Human Services (HHS) officials and Tribal College and University presidents in 2003 to identify ways in which the colleges and universities 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 Tribal College and Universities.
  • 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.

  • Researcher examines native elder health disparities

    At one of AHRQ's Excellence Centers to Eliminate Ethnic/Racial Disparities, a team headed by an American Indian researcher examined the 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 included improving the quality of diabetic care; increasing participation in clinical preventive services, such as immunization and cancer detection/management; 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)

  • Survey measures disparities between American Indians and U.S. population

    The authors looked at the usefulness of a 36-item health survey for comparing the health of American Indians to an age- and gender-matched sample of the U.S. general population. The survey's scales include physical functioning, pain, general health, vitality, social functioning, mental health, and physical and emotional roles. They found that the 36-Item Short Form Health Survey is an important tool for studying cultural equivalence and health disparities increases.

    Source: 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. (Grant HS10854)

  • Several projects address health disparities in Montana and Wyoming

    The authors report on the progress of studies undertaken as part of a collaborative consortium formed to address health disparities (for example, lower life expectancy) affecting Montana and Wyoming tribal nations. Funded until 2011, six studies address topics such as seatbelt use, eye disease, suicide prevention, emergency medical services, and physical and mental health care access improvement. One of the six studies entails developing and testing a CAHPS® instrument for IHS users to gain information on user experience with providers, processes, and care access.

    Source: (Andersen SR, Belcourt GM, Langwell KM. Building healthy tribal nations in Montana and Wyoming through collaborative research and development. Am J Public Health 2005 May;95(5):784-9. (Grant HS14034)

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Long-Term Care

The average life expectancy of AI/ANs has increased by 10 years since 1955, leading to a rapid increase in the number of elders and an increasing need for facilities to care for them. However, perceptions of long-term care, both facilities and access to home and other assistance, is not always favorable. Consequently, many Indian elders resist going to a long-term care facility. Further, those receiving home health care feel they do not receive the help they deserve.

  • Workshop addresses 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.

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Managed Care for Medicaid

Managed care has brought many changes to health care delivery and financing in the United States. While this has created many benefits, it has also complicated the health care industry. When New Mexico introduced Medicaid managed care for physical and mental health services in 1997, it spawned many unintended consequences.

  • Researchers examine New Mexico's managed care program for Medicaid

    Researchers received a grant supplement to study the impact of Medicaid managed care 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 Medicaid managed care 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)

  • Managed care for Medicaid may not be beneficial in rural areas

    New Mexico's Medicaid managed care program led to administrative burdens, payment problems, and high turnover among providers. The restrictions the program instituted on inpatient and residential treatment aggravated access issues for Medicaid recipients and caused the Federal Government to terminate the State's program, though it later reversed that decision. The authors suggest that the advantages of managed care for cost control, access, and quality assurance may be diminished in rural, medically underserved states.

    Source: 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. (Grant HS09703)

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Mental Health

For AI/ANs, alcoholism rates are over seven times the national average, suicide rates are almost double, and homicide rates are one-and-a-half times the national average for all races. Although some AI/ANs have access to care through IHS, barriers such as access to care and questionable quality and comprehensiveness of care may impede those who need help.

  • Childhood experiences influence war-related PTSD

    The authors looked at the relationship between childhood conduct disorders, levels of war zone stress, and war-related PTSD symptoms in 591 male participants from the American Indian Vietnam Veterans Project. Childhood conduct disorder, which involves risk taking, was associated with war-related PTSD symptoms, independent of how much stress was encountered in the war zone. Symptoms of conduct disorder may be important for care providers to consider when they treat American Indian Vietnam veterans with PTSD and may be important for the military in assessing American Indians for combat readiness.

    Source: Dillard D, Jacobsen C, Ramsey S, and Manson S. Conduct disorder, war zone stress, and war-related posttraumatic stress disorder symptoms in American Indian Vietnam veterans. J Traumatic Stress 2007 Feb;20(1):53-62. (Grant HS10854)

  • Posttraumatic Stress Disorder linked to pain in Plains Indians study

    The authors examined the relationship between PTSD and pain in 3,084 American Indians from the Northern and Southwestern Plains areas. Nineteen percent of women and 10 percent of men experienced lifetime PTSD, and women in both areas were nearly twice as likely as men to have lifetime PTSD. The authors found a strong association of PTSD and physical pain and suggest that more research is needed among American Indians and other minorities to examine if and how the pain experience varies by tribe or culture.

    Source: 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. (Grant HS10854)

  • Managed care Medicaid not best solution in rural areas

    When New Mexico turned to managed care for health services, it led to access difficulties for patients because inpatient and residential treatments for mental health care were restricted. The authors suggest that the advantages managed care offers in cost, quality, and access to many locales may not translate to rural, medically underserved states.

    Source: 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. (Grant HS09703)

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Perceptions of Care

To gauge AI/ANs satisfaction with the quality of their health care, researchers use surveys, focus groups, and other assessment tools.

  • Survey probes AI/AN patient experiences with care

    In collaboration with the Choctaw Nation Health Service Authority, AHRQ and the RAND Corporation developed an 81-question survey instrument to assess patients'; experiences with Choctaw Nation health care facilities. The instrument will not only help establish benchmarks to track patients' experiences with care, but it will also support the facilities in their efforts to evaluate the need for internal quality improvements. The survey is available for download at https://www.cahps.ahrq.gov/content/products/AI/PROD_AI_AIIntro.asp.

  • Older American Indians often have a poorer view of their health than their doctors

    Investigators surveyed 115 patients 50 years and older who sought care at a Cherokee Nation clinic and their seven health care providers. In 40 percent of medical visits, providers and patients rated the patient's health differently. In 68 percent of the cases, providers rated patients healthier than the patients rated themselves. Differing perceptions between providers and patients about the patient's health are associated with inadequate and unnecessary treatment, poor adherence to treatment advice, dissatisfaction with care, diminished symptom resolution, and mismatching of care services to needs. Misaligned perceptions of health status pose special concerns for chronically ill patients, who must carefully follow providers' advice to maintain their health, and for older patients, who are often unassertive with providers and unlikely to challenge their perceptions.

    Source: Garroutte EM, Sarkisian N, Arguelles L, et al. Cultural identities and perceptions of health among health care providers and older American Indians. J General Internal Med 2006 Feb;21:111-6. (Grant HS10854)

  • AI/ANs most likely to report discrimination in health care

    This study found that the AI/AN racial group was most likely to report discrimination in health care. AI/ANs who identified as both AI/AN and white were twice as likely to perceive discrimination as whites. A telephone survey of adults in the 2001 California Health Interview Survey found that 7.1 percent of the AI/AN group, 8.8 percent of the AI/AN plus white group, 5.6 percent of blacks, 4.3 percent of whites, and 2.6 percent of Asian Americans felt discriminated against at some point during the past year of care. More than 20 percent of AI/AN, black, and Asian American respondents reporting discrimination cited race as the sole reason compared with less than 10 percent of AI/AN plus white and white respondents.

    Source: Johansson P, Jacobsen C, and Buchwald D. Perceived discrimination in health care among American Indians/Alaska Natives. Ethnicity & Disease 2006 Autumn;16:766-71. (Grant HS10854)

  • Survey of patients' experiences completed

    Researchers completed standardized surveys of patients' experiences with the Billings Area Office of the IHS in 2003 to develop new performance initiatives and learn why eligible patients with other insurance coverage choose non-IHS providers. Gaining this information is particularly important because the IHS can receive reimbursement from public and private insurers when services are provided to covered patients. The research team used AHRQ's CAHPS® program, a multiyear initiative of AHRQ that assesses the patient-centeredness of care, compares and reports on performance, and improves the quality of care. Researchers, through a cooperative agreement, used survey results to develop a performance improvement plan in spring 2007 that identified cost-effective, feasible strategies for improving care. Follow-on work will include deploying interventions at one hospital and three ambulatory clinics to give researchers an opportunity to refine tools and interventions for use in culturally diverse populations served by underfunded health care providers. (Grant HS14034)

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