American Indian and Alaska Native(AI/AN) people continue to havedisproportionately higher rates of illnessand higher mortality rates whencompared with other Americans.AI/ANs die at higher rates than otherAmericans from tuberculosis (500percent higher), alcoholism (550percent higher), diabetes (200 percenthigher), unintentional injuries (150percent higher), homicide (100 percenthigher), and suicide (70 percent higher).This group is also burdened with highinfant mortality rates and high rates ofobesity and diabetes among children.

The Agency for Healthcare Researchand Quality (AHRQ) is committed toimproving the quality, safety,effectiveness, and efficiency of healthcare for all Americans. AHRQ providesgrants to enhance the health servicesresearch knowledge base; develops toolsand talent that foster the health servicesresearch infrastructure; and builds

relationships with tribal and otherAI/AN organizations, the Indian HealthService (IHS), and other Federalagencies to advance excellence in healthcare for AI/ANs.

This program brief provides a summary,arranged by topic, of ongoing andrecently completed AHRQ activitiesthat specifically address the health of theAI/AN people.

AHRQ Research andOther Activities Relevantto American Indians andAlaska Natives

P R O G R A M B R I E F

Agency for Healthcare Research and Quality

AHRQ’s mission is to improve the quality,safety, efficiency, and effectiveness of healthcare by:

• Using evidence to improve health care.

• Improving health care outcomes throughresearch.

• Transforming research into practice.

Advancing Excellence in Health Care • www.ahrq.govAgency for Healthcare Research and Quality

ContentsArthritis ..........................................2

Diabetes ..........................................2

Disparities........................................3

Perceptions of Care..........................3

Preventive Care................................4

Quality of Care................................5

Research Infrastructure Development ................................7

Tobacco Use ....................................9

ArthritisRheumatoid arthritis (RA), a majorcause of disability among the generalU.S. population, has a higher prevalenceamong some AI/AN subgroups.

• Quality of arthritis care for AlaskaNatives varies significantly byquality measure

This study provides an initial evaluationof quality of care for RA in an AlaskaNative population receiving care in anintegrated health care system. Theresearchers assessed the providers' levelof adherence to eight quality-of-careindicators among 106 Alaska Nativesliving in the Anchorage Service Unit.The highest performance scores were forfolic acid prescription while onmethotrexate (93.6 percent) and disease-modifying antirheumatic drugprescription (90.6 percent). The areas inneed of greatest improvement wererelated to radiographs of both handsand feet and laboratory measures tomonitor RA. Having at least one visit toa rheumatologist increased thelikelihood of high performance onmany, but not all, quality indicators.Ferucci ED, Donnithorne KJ, KollerKR, et al. Performance on rheumatoidarthritis quality indicators in an AlaskaNative healthcare system. Qual SafHealth Care. 2010 Oct; 19(5):387-391.(Grant HS15625).

DiabetesAI/ANs have the highest rates of type 2diabetes in the United States. Diabetes istraditionally a disease of older people,but diabetes is being diagnosed at youngages in American Indian communities.American Indian youths (15-19 yearsold) have the highest prevalence (4.5 per1,000) of type 2 diabetes among allethnic groups. Of AI/ANs aged 18 yearsand older, about 17.2 percent have

diabetes. Diabetes is least commonamong Alaska Natives (8.1 percent) andmost common among AmericanIndians in the southern United Statesand southern Arizona (26.7 percent and27.6 percent respectively). The PimaIndians of Arizona have one of thehighest diabetes rates in the world.

• More comprehensive diabeteseducation programs are linked tobetter diabetes care.

Researchers found that few diabeteseducation programs for AI/ANs metnational standards in 2001. They alsofound that more comprehensiveprograms were associated with betterquality diabetes care. All 88 IHS-fundeddiabetes care programs in 2001completed a checklist of criteria fromthe IHS Integrated Diabetes EducationRecognition Program (IDERP) on howwell programs implemented each of the10 national standards for diabetes self-management education. Programs werethen categorized as Level 1(developmental), Level 2 (educational),or Level 3 (integrated). Patientsreceiving care from Level 2 and Level 3programs had higher completion ratesof all 15 diabetes quality-of-careindicators compared with those inprograms at or below Level 1. Yet, only9 of the 86 programs had fulfilledenough criteria to qualify for at leastLevel 2 IDERP recognition. Theremaining 77 programs qualified atLevel 1 or less. Programs were oftenunderstaffed and unable to complete theextensive documentation processrequired by the IDERP, according to theauthors. Roubideaux Y, Noonan C,Goldberg JH, et al. Relation betweenthe level of American Indian and AlaskaNative diabetes education programservices and quality-of-care indicators.Am J of Pub Health. 2008 Nov;98(11):2079-84. (Grant HS10854).

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• Robeson County Primary CareResearch Network studiesprevalence of diabetes in localAmerican Indians

This project brings together 54providers, 21 of which are AmericanIndian, with the goal of creating aresearch network of primary careproviders who largely serve AmericanIndian patients in Robeson County,North Carolina, a rural county that ishome to most of the State's more than50,000 members of the Lumbee Tribe.In addition to creating the network ofprimary care practices where disease-and tribe-specific data can be collected,researchers will estimate diabetesprevalence in adults and children as wellas collect pilot data on the care processesfor diabetes. The creation of thenetwork, measurement of diabetesprevalence, and results of the pilot studywill be used to direct further work forimproving the identification and carefor diabetes in the community.(Principal Investigator: BonnieYankaskas, University of North Carolinaat Chapel Hill; Grant HS15989,8/01/06-7/31/09).

DisparitiesImprovements in preventive services,care for chronic conditions, and accessto care have led to a reduction and insome cases elimination of disparities inaccess to and receipt of care for AI/ANpopulations. However, disparities in carecontinue to be a problem for someconditions.

• Higher education amongAmerican Indian elders increasestheir likelihood of engaging inphysical activity

AI/ANs report lower levels of leisure-time physical activity than the majoritypopulation. This lack of exercise putsthem at risk for obesity, hypertension,type 2 diabetes, and cardiovascular

disease, which are becoming moreprevalent in many AI/AN communities.However, as with many other groups,more educated AI/AN elders havehigher levels of physical activity thantheir less educated counterparts.Researchers correlated education withphysical activity level among 107AI/AN elders (age 50 to 74 years) whoself-identified as not having beenphysically active in the 6 monthspreceding the study. After receivinginformation about the benefits ofexercise and the types of exercise theymight engage in, they participated in a6-week trial comparing two approachesto physical activity monitoring. Bothapproaches required participants to fillout weekly activity monitoring sheetsbut the second approach also requiredthe use of a pedometer. After controllingfor relevant demographic and healthfactors, they found that groups atdifferent educational levels (less thanhigh school, completed high school,General Education Degree or somevocational education, and collegeeducation) did differ significantly incaloric expenditure due to moderate tovigorous exercise, with the differencesincreasing significantly with higherlevels of educational attainment.Sawchuk C, Bogart A, Charles S, et al.Education is associated with physicalactivity among American Indian elders.American Indian Alaska Native MentalHealth Research. 2008; 15(1):1-17.(Grant HS10854).

• Distance to cancer care facilitieshinders access for AmericanIndians

For specialized services such as cancercare that are not widely distributedgeographically, access may befundamentally limited by distance,which can be measured in travel time.Using census data, researchers estimatedtravel times to National Cancer Institute

(NCI)-designated Cancer Centers,academic medical centers, andoncologists by various demographiccharacteristics, including race/ethnicityand region. AI/ANs, non-urbandwellers, and residents in the South hadthe longest travel times to a NCICancer Center. Travel burdens alsopersisted for AI/ANs and non-urbanpopulations for cancer treatment byacademic medical centers andoncologists. These disparities in accessmerit further examination if correctivepolicies are to be designed andimplemented. Onega T, Duell EJ, ShiX, et al. Geographic access to cancercare in the U.S. Cancer. 2008; 112:909-918. (Grant T32 HS00070).

Perceptions of CareTo gauge AI/ANs satisfaction with thequality of their health care, researchersuse surveys, focus groups, and otherassessment tools.

• Collaboration between ChoctawNation, AHRQ, and IHS yieldsthe American Indian Survey, anadaptation of CAHPS®

The Consumer Assessment ofHealthcare Providers and Systems(CAHPS®) surveys measure patients'experiences with ambulatory andfacility-level care. Since these surveys arenot adapted for ethnic and linguisticminority populations, the ChoctawNation Health Service (CNHS)Program and AHRQ agreed to exploredeveloping a survey to collect patientexperience-of-care data to evaluate carereceived by patients at different CNHSclinics. AHRQ and the CAHPSconsortium, together with the IHS,worked with CNHS to develop aCAHPS American Indian Survey. Theyconducted a mail survey of the Choctawpopulation that yielded 696 surveys (a58 percent response rate). Thiscollaboration and community-based

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participatory research helped to producea useful survey tool that can be used byother American Indian tribes and by theIHS. Weidmer-Ocampo B, Johansson P,Dalpoas, D, et al. Adapting CAHPS foran American Indian population. JHealth Care for the Poor Underserved.2009; 20:695-712. (Grant HS16980).

• Survey of patients' experiencescompleted

Researchers completed standardizedsurveys of patients' experiences with theBillings Area Office of the IHS in 2003to develop new performance initiativesand learn why eligible patients withother insurance coverage choose non-IHS providers. Gaining this informationis particularly important because theIHS can receive reimbursement frompublic and private insurers whenservices are provided to covered patients.The research team used AHRQ'sCAHPS program, a multiyear initiativeof AHRQ that assesses the patient-centeredness of care and compares andreports on performance in an effort toimprove the quality of care. Researchers,through a cooperative agreement, usedsurvey results to develop a performanceimprovement plan in spring 2007 thatidentified cost-effective, feasiblestrategies for improving care. Follow-onwork will include deployinginterventions at one hospital and threeambulatory clinics to give researchers anopportunity to refine tools andinterventions for use in culturallydiverse populations served byunderfunded health care providers.(Principal Investigator: GordonBelcourt, Montana/Wyoming TribalLeaders Council; Grant HS14034,9/30/03-3/31/12).

Preventive CareThe main health challenges currentlyfaced by AI/AN people are the healthconditions and chronic diseases relatedto lifestyle issues such as obesity,

physical inactivity, poor diet, substanceabuse, and injuries. Preventive healthinitiatives for AI/AN populations havebeen undertaken to create healthiercommunities, improve quality of life,decrease health care use, controldisability, and improve productivity.Initiatives include developing,coordinating, implementing, anddisseminating effective healthpromotion and chronic diseaseprevention programs throughcollaboration with key stakeholders andby building on individual, family, andcommunity strengths and assets.

• Project focuses on healthy weightand cancer outcomes for women

This continuation grant builds upon itsearlier capacity-building success duringwhich the Montana-Wyoming TribalLeaders Council developed a shared dataresource and research infrastructure forparticipatory research among a majorityof the 10 tribes it serves. Thecontinuation project will further buildcapacity for health care research on thepriority health issues identified by thetribes and continue to support culturallyappropriate health programs. Three newresearch studies are planned: evaluationof interventions to promote healthyweight among women, examination offactors that contribute to breast andcervical cancer outcomes, and designand implementation of a "healthyreservations" model program forsystemwide health improvement onreservations. (Principal Investigator:Gordon Belcourt, Montana-WyomingTribal Leaders Council; GrantHS14034, 9/30/03-3/31/12).

• Study delineates low rates of breastand cervical cancer screeningsamong American Indian women

The researchers investigated factorsassociated with primary and secondarybreast and cervical cancer screeningamong American Indian women

receiving care from the IHS in Montanaand Wyoming. Primary screening isscreening for those women who havehad no previous abnormal mammogramor Pap screening results while secondaryscreening is followup screening forwomen with prior abnormal screeningresults. They found that 3-yearmammography prevalence rates amongAmerican Indian women age 45 andolder were 37.7 percent for primary and58.7 percent for secondary screening.Among women age 18 and older, 3-yearPap test prevalence rates were 37.8percent for primary and 53.2 percentfor secondary screening. Primarymammography screening was positivelyassociated with number of visits andreceiving care at an IHS hospital.Primary Pap test screening was inverselyassociated with age and positivelyassociated with the number of patientvisits. Secondary mammographyscreening was inversely associated withdriving distance to an IHS facility.These results are consistent with othersurveys among American Indianwomen, which report that HealthyPeople 2010 goals for breast (90percent) and cervical (70 percent)cancer screening have not been met.Wilson RT, Giroux J, Kasicky KR, et al.Breast and cervical cancer screeningpatterns among American Indianwomen at IHS clinics in Montana andWyoming. Public Health Rep. 2011Nov-Dec; 126(6):806-15. (GrantHS14034).

• Use of a tribal language not abarrier to colorectal cancerscreening among AmericanIndians

American Indians have one of thelowest colorectal cancer (CRC)screening rates for any racial/ethnicgroup in the U.S., yet reasons for theirlow screening participation are poorlyunderstood. The researchers examinedwhether tribal language use is associated

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with knowledge and use of CRCscreening in a community-based sampleof American Indians. They found thatparticipants speaking primarily Englishwere no more aware of CRC screeningtests than those speaking primarily atribal language. Participants who spokeonly a tribal language at home and thosewho spoke both a tribal language andEnglish also showed a comparablelikelihood of receipt of CRC screening.Study findings failed to support theconcept that use of a tribal language is abarrier to CRC screening amongAmerican Indians. Gonzales AA,Garroutte E, Ton TG, et al. Effect oftribal language use on colorectal cancerscreening among American Indians. JImmigr Minor Health. 2012 Dec;14(6):975-982. (Grant HS10854).

• Improving preventive servicesrecommendations and reminders

To improve the quality of preventiveservices recommendations andreminders, in 2009 AHRQcommissioned a gap analysis to compareits recommendations in the electronicPreventive Services Selector (ePSS) tool,to the preventive health reminderscurrently in use in the IHS's Resourceand Patient Management System(RPMS). The analysis found that themajority of the recommendations in theePSS tool are not currently contained inthe RPMS, and the ones that are haveslightly different logic definitions.However, the RPMS does containsufficient data elements so that theAHRQ recommendations can easily bebuilt into the Best Practice and HealthMaintenance sections of the existingRPMS Health Summary. (AHRQContract No. 4290-2009-00014C).

Quality of CareA primary interest of AHRQ isimproving the quality of health care inthe United States. Improving quality ofcare for AI/ANs poses various

challenges. Overall, AI/ANs receiveworse care than whites for about 30percent of quality measures and worseaccess to care than whites for 62 percentof access measures, according toAHRQ's 2011 National HealthcareQuality Report. The Agency has fundedseveral studies aimed at improving carequality for AI/ANs.

• Results of Baseline AmericanIndian CAHPS® survey lead toimplementation of customerservice quality improvementinitiatives

The purpose of this project was todemonstrate the potential usefulness ofthe CAHPS® as a tool for identifyingopportunities for the IHS qualityimprovement (QI) and monitoringimprovements (seehttps://cahps.ahrq.gov/about.htm forinformation on AHRQ’s CAHPSprogram). The Baseline AmericanIndian CAHPS survey was administeredto 400 IHS patients in mid-2010 andthe results were used by the joint IHS-Tribal Working Group to developspecific quality improvement initiativesthat will be implemented in these IHSfacilities in 2011. The Wind RiverIHS/Tribal Working Group selectedcustomer service as the targeted area forimprovement. A QI strategy wasdeveloped to improve customer servicethat included presentations from threeexperts in customer service, monthlyincentives tied to specific customerservice indicators, and competitionbetween the two Wind River IHSclinics. The implementation of the QIstrategy began in March 2011 andcontinued through March 2012. InApril 2012, the followup CAHPSsurvey was conducted. Analysis of thefollowup survey data focused onassessing the impact of the QI strategyon the ratings of office staff courtesyand respect, office staff helpfulness, andon overall rating of the IHS. Results

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were positive and significant for all threemeasures. Results were disseminated tothe Wind River IHS Leadership Team,the Eastern Shoshone and NorthernArapaho Tribal Health Directors, and atan all-staff IHS meeting. The IHSLeadership Team plans to developadditional QI initiatives making use ofthe CAHPS approach. (PrincipalInvestigator: Paul D. Cleary, YaleUniversity; Grant HS16978, 09/01/07-09/29/17)

• Medical home model for AlaskaNatives to be assessed for impacton patient care delivery

The Southcentral Foundation (SCF), atribally owned organization,implemented a patient-centered medicalhome (PCMH) in 1999 and 2000 inAnchorage, Alaska. In this project, theUniversity of Alaska and the SCFpartnered to determine the impact ofthe PCMH transformation on thecharacteristics and quality of patient caredelivery, and to assess changes in healthcare delivery, such as quality and safetyefforts, efforts to bring evidence to thepoint of care, use of informationsystems, and costs. The study focusedon process and outcomes related tothree components of the PCMH model:patient-provider match (empanelment);integrated primary care teams(team-based care); and increased access(oftensame day). It also included a costassessment and a time series analyses ofprimary care sensitive patient outcomesand patient service utilization frommedical record data. The researchersfound that emergent care utilizationrates among all patients for anydiagnosis were increasing before thePCMH implementation, droppedduring the implementation, continuedto decrease steadily immediatelyfollowing the implementation, andsubsequently leveled off. Hospitalizationrates for any diagnosis were flat beforeand during the PCMH

implementation, decreased immediatelyafter the implementation, and thenflattened out again in the later postimplementation stage. Interviewparticipants observed improved access toprimary care services following thetransition to the PCMH tempered byincreased staff burnout. Additionalthemes of PCMH transformationincluded the building of patient-provider relationships and the role ofleadership in PCMH implementation.This PCMH model could have nationalimplications for improving the health ofthe AI/AN population and may also berelevant to other practices servingdiverse populations with multiple healthdisparities. (Principal Investigator:David L. Driscoll, University of Alaskaat Anchorage; Grant HS19154,7/01/10-6/30/12).

• Study links funding levels of tribalhealth programs to outcomes

Tribally Operated Health Programs(TOHPs) provide care nationally tomore than one-third of the 2 millionAI/ANs who obtain services from theIHS. Many unnecessary hospitalizationscan be prevented with access tocomprehensive, effective ambulatorycare. This study found that higher IHSfunding levels for TOHPs in Californiawere associated with lower rates ofhospitalization for ambulatory care-sensitive conditions (HASCs) by theAI/ANs who used them. On average,IHS funding pays for less than 49percent of the medical care provided byTOHPs in California. For TOHPs withfunding less than 60 percent of what theFederal Government pays for Federalemployee medical care (benchmark), theHASC rate dropped 12 percent forevery 10 percent increase in funding.Even when adjusted for confoundingcharacteristics, the funding effect wasbetween 9 and 11 percent. The authorsconcluded that additional funding oftribal program health care is likely to

improve outcomes of care for theAI/AN population. Korenbrot C, KaoC, Crouch JA. Funding of tribal healthprograms linked to lower rates ofhospitalization for conditions sensitiveto ambulatory care. Medical Care. 2009Jan; 47(1):88-96.

• Collaboration creates communityhealth information exchangenetwor

This project includes a collaborativepartnership among 12 agencies,including a rural acute care hospital, alarge American Indian tribal entity, anIHS hospital, a community healthcenter, a health department, and acommunity consortium. The totalpatient population is 250,000 in 14counties in rural northeasternOklahoma. The project includes threecomponents for improving quality ofcare. The first, Healthfinder, is anelectronic and telephone resource toassist consumers in locating healthproviders and social services. It alsoassists providers in meeting communityneeds. Healthfinder(www.okhealthfinder.com) includes aspecial section to assist AI/ANs infinding tribal and IHS resources. Thesecond component implements anintegrated community healthinformation exchange network tofacilitate provider coordination andtransfer of critical patient information.The network is using Hastings IndianMedical Center, an IHS facility, and theCherokee tribe, the second largest tribein the country, as initial connectionswith the goal of allowing all IHS andNative American tribes to connectquickly and inexpensively through thenetwork. The last component exploresareas for the most cost-effectiveprevention strategies and adoptscommon objectives for preventioninterventions and outcomemeasurement. This project builds on anearlier 1-year planning grant (HS15364)

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by the same investigator. (PrincipalInvestigator: Mark Jones, TahlequahCity Hospital; Grant HS16131,9/30/05-9/29/08).

• Study seeks strategies to improveperformance based on priorityissues

In addition to supporting thedevelopment of a sustainable researchinfrastructure for theMontana/Wyoming Tribal LeadersCouncil, Black Hill State University,and the Black Hills Center for AmericanIndian Health, this project funded astudy aimed at designing,implementing, and evaluating theeffectiveness of a structured process inwhich tribal members and IHSproviders jointly developed strategies toimprove performance based on priorityissues identified through a consumersurvey. Investigators developed atargeted research agenda that addressedtribally identified priority issues, such ashepatitis C, West Nile virus, andmethamphetamine use. (PrincipalInvestigator: Gordon Belcourt,Montana/Wyoming Tribal LeadersCouncil; Grant HS14034,9/30/03–3/31/12).

• Database developed to assist inhealth care planning

This grant enabled the development of ashared resource database for tribes to usein health care program planning andapplication development. It includesarea- and tribal-specific data, "bestpractices" papers, and links to resourceson health topics of interest to the tribes.It is currently being maintained by theRocky Mountain Tribal Epi-Center.(Principal Investigator: GordonBelcourt, Montana/Wyoming TribalLeaders Council; Grant HS14034,9/30/03–3/31/12).

Research InfrastructureDevelopmentA major AHRQ goal is to build researchinfrastructure and enhanceopportunities for AI/AN investigators inhealth services research.

• Project to improve race and healthstatus data for Pacific NorthwestStates

The Improving Data and EnhancingAccess-Northwest Project uses the mostcomplete roster of Northwest AI/ANs toconduct record linkages with an array ofhealth-related data systems in a three-state region (Oregon, Washington State,and Idaho). It seeks to more accuratelycharacterize health status and clinicaloutcomes data for Northwest tribalpeople, while working to minimize andeventually eliminate racialmisclassification errors in Statesurveillance data systems. Ultimately, itwill disseminate results and developconcrete methods by which other Statesand Tribal Epidemiology Centers mayimplement similar programs. Thus far,the grantee has disseminated AI/ANmortality data and information aboutlinkage methods at two recentconferences. AHRQ is providingsupport for this project through fundingreceived from the American Recoveryand Reinvestment Act of 2009.(Principal Investigator: Victoria Warren-Mears, Northwest Portland Area IndianHealth Board; Grant HS19972,9/30/10-9/29/13).

• Project to improve the reportingof race, ethnicity, and language inCalifornia

In order to identify, understand, andeliminate health care disparities, it iscritically important to make headway inthe way that hospitals and otherproviders and payers successfully collectconsistent and accurate data regardingrace, ethnicity, and language from their

patients. This project integrates andimproves upon methods for collection,auditing, and post-collection dataimputing of race, ethnicity, andlanguage data. The size of California, itsdiverse population, and large number ofhospitals make California an importanttest bed for the development anddissemination of approaches that canwork across a large spectrum of States.The grantee is working with AHRQ todevelop a Web site that will disseminateproducts to enhance race/ethnicity datareporting. In addition, the grantee iswriting a section on data auditing for ajoint manuscript with the other AHRQ-funded grantees in this program.AHRQ is providing support for thisproject through funding received fromthe American Recovery andReinvestment Act of 2009. (PrincipalInvestigator: David S. Zingmond,University of California, Los Angeles;Grant HS19963, 9/30/10-9/29/13).

• Project to improve the quality ofrace and ethnicity data in hospitaldischarge and emergencydepartment databases in NewMexico

New Mexico's Improving the Quality ofRace and Ethnicity Data Project willcontribute to reducing racial and ethnichealth and health care disparities byimproving the reliability of race,ethnicity, and tribal affiliation hospitaldata in the State. Guided by a Stateadvisory committee, between 5 and 10pilot hospitals will field test trainingmaterials that will be developed for theproject. These will include hospitalprocedure, data collection, patienteducation, and train-the-trainermaterials. Hospital discharge recordswill be linked with birth certificaterecords and IHS records to trackimprovements. New Mexico expects toestablish a model for the collection,reporting, and appropriatedissemination of tribal identifier data

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that will be informally disseminated toother States and through a publishedmanuscript. To date, the grantee hascompleted work on data linkages withother large datasets (Bureau of VitalStatistics) and incorporation ofemergency department data is ongoing.Moreover, the grantee continues to workwith the New Mexico HospitalAssociation and Health Insight NewMexico to coordinate trainings andeducation for all levels of hospital staff.A Community Advisory Committeemeeting was held on July 20, 2012 atthe New Mexico Hospital Associationoffices in Albuquerque. This Committeehas representatives from hospitals,academic institutions, communitygroups and the New MexicoDepartment of Health. AHRQ isproviding support for this projectthrough funding received from theAmerican Recovery and ReinvestmentAct of 2009. (Principal Investigator:Michael Landen, New Mexico StateDepartment of Health; GrantHS20033, 9/30/10-9/29/13).

• Coding problems inhibit ability tostudy American Indian acuteinpatient hospital data

Reliable coding of race and ethnicity byhospitals represents a critical step towardassessing and addressing racial andethnic disparities in acute inpatient care.The authors examined the reliability ofrace and ethnicity classifications bydifferent hospitals who admitted thesame patients in a large, diverse State.The rates of coding agreement forAmerican Indians were very low (19percent), compared with whites (91percent), and blacks (88 percent). Therewas a similar pattern for hospital dataand death certificates with agreement ofonly 27 percent for American Indians.The authors concluded that codingagreement is too low for AmericanIndians (as well as persons born in

American Indian and selected Hispanicsubgroups) for these groups to bestudied using this data. Fiscella K andMeldrum S. Race and ethnicity codingagreement between hospitals andbetween hospital and death data. MedSci Monit. 2008; 14(3):SR9-SR13.(Grant HS10910).

• Comparative effectiveness research(CER) to enhance the delivery ofservices within the Indian HealthService

The purpose of this project was toenhance CER research methodologywithin the IHS and develop a largedataset to allow IHS to conduct CERon IHS delivery models. In the fall of2010, AHRQ, in collaboration withIHS, awarded a competitive task ordercontract to develop the infrastructure tolink service data, pharmacy cost data,and health status measures to allow forCER to assist IHS in better serving itspopulations. The team successfullylinked data from four IHS data sourcesand built a CER dataset covering 4 fiscalyears (2007-2010) and including dataon approximately 440,000 AI/ANs. Thedataset was used to develop newmethods for IHS to calculate healthstatus scores for its clients and toidentify ambulatory-sensitive inpatientadmissions. Additional work createdalgorithms for estimating comprehensivetreatment costs using data from acrosspractice settings. After completing apilot CER study examining theassociation between the use of educationand case management services providedby a variety of health care providers andthe use of hospital emergencydepartment and inpatient services, theteam provided training to IHS andtribal researchers in the use of datasetsfor CER. The project successfullywrapped-up in the summer of 2012with all project materials, including theintegrated CER dataset, research

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method and dataset documentation,and study findings delivered to IHS.(AHRQ Contract No. 290-2006-00020, 9/27/10–9/26/12).

• Comparative effectiveness ofquality improvement effortsfocuses on chronically ill adultsamong American Indian/AlaskaNative communities

The overall purpose of this project wasto support the development of alongitudinal data infrastructure (LDI)for the IHS capable of building thecapacity for CER, a type of patient-centered outcomes research. Afterconducting a thorough evaluation of thetechnical functionality of IHS databasesystems and their data dictionaries(RPMS, C32 repository, NDW, andiCare), the project team successfullydeveloped and tested an LDI thatintegrates clinical and administrativedata for IHS clients across multiplesettings of care. The LDI resolves severalprevious gaps in data sources available toIHS for research and qualityimprovement activities, providing IHSwith coordination across data sources,well-documented data infrastructure,and significantly enhanced capacity forCER and patient-centered outcomessearch. The initial LDI contains dataderived from four IHS sites and isinclusive of events for over 300,000patients across multiple years. It wasused for two small feasibility studies thatdemonstrated the potential of the LDIfor CER. The LDI is capable of beingexpanded and continuously updated toallow IHS greater research power. Theproject successfully concluded inNovember 2012 with the delivery of theLDI and detailed technical manuals tostaff in IHS's Office of InformationTechnology. An important aspect of thedevelopment of the LDI was close work

with tribal entities including the UnitedSouth and Eastern Tribes EpidemiologyCenter to provide them with skillsdevelopment in utilizing the LDI andtheir own data sources to conduct CERresponsive to local needs. AHRQprovided staff support to IHS in thisproject with funding received from theAmerican Recovery and ReinvestmentAct of 2009. (AHRQ Contract No.290-2009-000231, 9/01/10–11/30/12).

• Research infrastructuredevelopment leads to researchstudies and disseminationactivities

AHRQ awarded a Minority ResearchInfrastructure Support Program (M-RISP) grant to the Montana-WyomingTribal Leaders Council (TLC). At thetime of the initial award, TLC had verylimited research infrastructure andcapacity, with four staff and tworesearch partners. Tribes in the regionhad little experience with research andwere skeptical. A structured approach toinfrastructure development wasimplemented, focusing on engagingTribes, expanding financial andadministrative capacity, and buildingstaff and partnerships. Several researchstudies were designed and implementedto increase both TLC and Tribalresearch experience. Over the durationof the M-RISP, the TLC engaged Tribesin research activities and created boththe Rocky Mountain TribalEpidemiology Center and the RockyMountain Tribal Institutional ReviewBoard to serve the Tribes in its region;increased its professional research staff tosustain and expand capacity; developedpartnerships with academic institutionsto augment substantive and technicalresearch capacity; obtained numerousgrants from a diverse set of Federalagencies and foundations, many of

which are multiyear and provide a solidfoundation for sustainability of TLCresearch; and engaged in disseminationactivities to contribute to knowledge ofAI/AN health research and methods forengaging Tribes in research. (Principalinvestigator: Gordon Belcourt,Montana-Wyoming Tribal LeadersCouncil; Grant HS14034, 9/30/03-3/31/12).

• Conceptual model of academicpersistence aids in training ofyoung AI/AN professionals

Various programs have emerged torecruit junior investigators to the social,behavioral, and health sciences.Drawing on Tinto's general theory ofacademic persistence focusing on theundergraduate education and IHSexperience with the Native InvestigatorDevelopment Program, the authorpresents a conceptual model that appliesto individuals early in the postdoctoralor postresidency experience. This modelis exemplified in the Native InvestigatorDevelopment Program at the Universityof Colorado, Denver. All trainees in thisprogram are either American Indian orAlaska Native. The author describesprogram and institutional characteristicsas well as trainee processes. Heconcludes by describing the variousbenefits of the model, such as providinga common language for discussingelements of the training process andserving as a guide for assessing traineeneeds. Manson SM. Professionaljourneys, professional paths: Persistencein navigating the crossroads of a researchcareer. Am J of Pub Health. 2009 Apr;99 suppl 1:S20-S25. (Grant HS10854).

Tobacco UseTraditional tobacco has a spiritual rolein Indian culture and varies from tribeto tribe. By some estimates, American

Indians have used the tobacco plantfor more than 18,000 years.Traditional tobacco is still used bymany tribes for prayer, ceremonies,offerings, gift-giving, or as a healingmedicine. Commercial tobacco use,however, is also significant amongAI/ANs. Approximately 32 percent ofAI/ANs are smokers. This is thehighest rate of tobacco use amongevery age, ethnic, and gender categoryin the United States. Between 1983and 2002, adult smoking rates fell inall racial and ethnic groups except forAI/ANs.

• Study delineates effects ofsmokeless tobacco on anxietyand depression among twoAmerican Indian tribes

Rates of nicotine use are high inAmerican Indians. Anxiety anddepression tend to be associated withcigarette use, but the association ofanxiety and depression withsmokeless tobacco (ST) is less clear.This study is the first to examinepsychiatric conditions and lifetimeST use in a large, geographicallydiverse American Indian communitysample. The researchers asked if panicdisorder, major depression, and

posttraumatic stress disorder (PTSD)are related to lifetime ST use in twoAmerican Indian tribes. The odds oflifetime ST use were 1.6 times higherin Northern Plains tribal memberswith a lifetime history of PTSD aftercontrolling for sociodemographicvariables and smoking. In theSouthwest, lifetime psychiatricdisorders were not associated withlifetime ST use status. Increasingpsychiatric comorbidity wassignificantly linked to increased oddsof ST use in both tribes. Althoughapproximately 30 percent of tribalmembers were lifetime users of ST,the association with lifetimepsychiatric disorders was not as strongas those observed with cigarettesmoking. Understanding sharedmechanisms between all forms oftobacco use with anxiety anddepressive disorders remains animportant area for investigation.Sawchuk, CN, Roy-Byrne P, NoonanC, et al. Smokeless tobacco use andits relation to panic disorder, majordepression, and post-traumatic stressdisorder in American Indians.Nicotine Tob Res. 2012 Sep;14(9):1048-1056. (Grant HS10854).

For More InformationFor further details about AI/ANprojects and other activities atAHRQ, contact:

Wendy PerryAHRQ Senior Program Analyst for AI/AN Health540 Gaither RoadRockville, MD 20850Email: Wendy.Perry@ahrq.hhs.gov

Photos courtesy of IHS

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Key AcronymsAHRQ Agency for Healthcare

Research and Quality

AI/AN American Indian/Alaska Native

CAHPS® Consumer Assessment of Healthcare Providers and Systems

HHS Department of Health and Human Services

IHS Indian Health Service

www.ahrq.gov

AHRQ Pub. No. 13-P005-EFReplaces AHRQ Pub. No. 10-P007

Revised April 2013