Understanding P-values and Confidence Intervals Thomas B. Newman, MD, MPH 20 Nov 08.
Introduction to the Indian Health Service Thomas Sequist, MD MPH.
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Transcript of Introduction to the Indian Health Service Thomas Sequist, MD MPH.
Introduction to theIndian Health Service
Thomas Sequist, MD MPH
Varying Population Estimates
0
1
2
3
4
5
6
AI/AN Combination AI/AN Alone IHS Users
Pop
ulat
ion
size
(m
illi
ons)
2010 US Census/ IHS Enrollment Files
Population Distribution
Office of Minority Health, 2010
60%
18%22%
UrbanRuralReservation
Health Status of AI/AN Population
4 year shorter life expectancy
71.4
76.5 76.9 77.5 77.7
63.6
70.672.3 72.5 73.6
55
60
65
70
75
80
1973 1997 2000 2003 2007
Yea
rs
White AI/AN
IHS, Indian Health Disparities, www.ihs.gov
Life Expectancy at Birth
Sequist et al, Health Affairs 2011
Major Contributors to Premature Death
US Census Bureau 2010
Health Insurance Coverage
The Indian Health Service
• 1.9 million people served• 850 federally employed physicians• 500 health centers• 45 hospitals
Indian Health Service
IHS Clinical Locations
Hospital
AmbulatoryCenter
Hospital
AmbulatoryCenter
Hospital
AmbulatoryCenter
Roubideaux, Y. N Engl J Med 2005Kaiser Family Foundation, 2013
IHS Budget Process
▫Annual appropriation through House and Senate
▫Extensive tribal consultation
▫Budget justification
▫House and Senate approval
Contract Health Services
▫Many services not available within IHS or tribal facilities
▫Hospital services, specialty services, pharmacy, imaging
▫Rationing of health services Prioritize funding of medical cases that
“threaten life or limb” Lack of priority on preventive services
Tribal Management of Funds
▫>50% of funds currently
▫Tribal sovereignty and local control
▫Ability to seek external grant funding
▫Ability to lobby on behalf of community
There are limited rigorous data evaluating the impact on health care and outcomes
Quality of Care
Challenges to Quality Improvement
Preventiveservices
Chronicdisease
The Burden of Diabetes
CDC 2010
0
5
10
15
20
1994 2002 2008
Dia
bete
s P
reva
lenc
e (%
)
US Population AI/AN
The Epidemic of Heart Disease
12
10
8
15
0
2
4
6
8
10
12
14
White Black Hispanic AI/AN
His
tory
of
Hea
rt D
isea
se, %
CDC 2010
Preventiveservices
Chronicdisease
Specialtyservices
Challenges to Quality Improvement
Ability to Access Needed Services
2937 32
76
52
7682
63
83
0
20
40
60
80
100
Subspecialists Non-emergenthospital admission
Diagnostic imaging
% r
epor
ting
"al
mos
t al
way
s"
IHS Medicare (Black) Medicare (White)
Were you able to obtain access to these services for your patients when necessary?
Sequist, et al. JGIM 2010,, Bach et al. NEJM 2004
Access to Subspecialty Care
0 20 40 60 80 100
Much less than it should be
Somewhat less than it should be
About right
Somewhat greater than it should be
Much greater than it should be
% reporting
Would you say that the complexity of patient conditions you are currently expected to provide care for is…
Sequist, et al. JGIM 2010
Preventiveservices
Chronicdisease
CrossCultural
Specialtyservices
Challenges to Quality Improvement
Some Particular Challenges
▫> 500 tribes and Nations
▫28% of AI/AN speak a language other than English at home
▫IHS Physicians…. 10% report that cross-cultural barriers are
common during encounters As many as 10% of patients challenging to
communicate with due to language 12% report that professional translator
available
Preventiveservices
Chronicdisease
CrossCultural
Specialtyservices
Social inequities
Challenges to Quality Improvement
Socioeconomic Challenges
0
5
10
15
20
25
30
35
Per
cent
CollegeDiploma
Unemployed Income <Poverty Level
AI/AN WhiteBLS 2011; OMH 2010
Preventiveservices
Chronicdisease
CrossCultural
Specialtyservices
Social inequities
Limited finances
Challenges to Quality Improvement
Roubideaux, Y. N Engl J Med 2005
$7,239
$2,741
0
1000
2000
3000
4000
5000
6000
7000
8000
Exp
end
itu
res
Per
Per
son
($)
US Population IHS
IHS is Generally Underfunded
$4.3 billion
(52% of need)
IHS Clinician Shortage
32
19 18
11
0
5
10
15
20
25
30
35
40
Dentist Nurse Physician Pharmacist
Vac
ancy
Rat
e, %
IHS Workforce 2009
Preventiveservices
Chronicdisease
CrossCultural
Specialtyservices
Social inequities
Geographic isolation
Limited finances
Challenges to Quality Improvement
Distribution of AI/AN Population
2010 US Census Bureau
New Mexico AI/AN Population
Sequist et al, HSR 2006
The Importance of Geography
Geographic Isolation
Appropriate Care for Acute MI?
AI/AN with acute myocardial infarction have…
▫Longest duration from symptom onset to arrival at the hospital
▫Increased risk of arriving to hospital without ambulance
▫Lower rates of cardiac catheterization, angioplasty, and coronary bypass surgery
Access To Renal Transplantation
Sequist, et al Am J Kid Dis 2004
Snapshot of IHS Quality
0
20
40
60
80
100
% R
ecei
ving
Ser
vice
US Population (National Healthcare Disparities Report)
Native American (Indian Health Service)Sequist, et al. AJPH 2005
Diabetic Retinopathy Screening
0
20
40
60
80
100
2002 2003 2004 2005 2006
% S
cree
ned
IHS Medicare Medicaid
Tele-Ophthalmology
•AI/AN have low rates of dilated eye exams
•Lack of access to providers
•Tele-ophthalmology program allows remote provision of care
Phoenix Indian Medical Center
0
10
2030
40
50
60
7080
90
100
Before After
% S
cre
en
ed
0
5
1015
20
25
30
3540
45
50
La
se
r T
rea
tme
nt
(pe
r 1
00
0)
Screening Laser Tx
Wilson, Diabetes Care 2005
How Can Academic Centers Contribute?
•Development of physician leaders
•Provision of clinical expertise
Four Directions Summer Research Program
Increase representation of Native Americans among physicians, scientists, and public health officials.
www.fdsrp.org
1) Increase student motivation and confidence2) Individualized mentoring3) Social and professional networking4) Continuous program evaluation
Barriers to Career Advancement
Intrapersonal
• Perceived abilities• Motivation• Fear of isolation
Structural
• Financial• Mentoring• Enrichment programs
Program Results
•Nearly 200 students over 21 years
•“How much did the program increase your motivation to pursue a career in medicine?”▫82% report ‘extreme’
•“Do you feel better prepared to apply to medical or graduate school after participating in the program?”▫65% report ‘extreme’, 30% ‘significant’
Long Term Outcomes
•100% of alumni would recommend program to a colleague
•70% report an ‘extreme’ impact achieving their goals
•63% enrolled in medical or graduate school
BWH Physician Volunteer Program
•Work with IHS clinical staff to expand ability to meet patients’ clinical needs
•To improve the health status of Native American communities
www.brighamandwomens.org/ihs
Navajo Reservation
• 3x the size of Massachusetts with 300,000 members
• 25% unemployment• 43% below federal poverty level• 60% without regular telephone access• 32% lack access to plumbing
Shiprock
Gallup
COUT
NMAZ
Gallup and Shiprock
•Gallup: 99 bed facility, 120 physicians
•Shiprock: 60 bed facility, 75 physicians
Large Service Areas
SHIPROCK
GALLUP
Large Service Areas
ALBUQUERQUE
SHIPROCK
GALLUP
230 miles
Large Service Areas
ALBUQUERQUE
SHIPROCK
GALLUP
230 miles
140 miles
Challenges to Accessing Care
•Concept of “contract care”▫Outside referrals▫Fixed budget▫Rationed according to emergent
need
•Lack of specialty services▫Intermittent (or no) availability
•Many conditions go untreated
Solutions to Accessing Care
•“Clearing” clinical consult backlog
•Increasing capacity of IHS physicians▫Up to date practices▫Expanding ability to provide
specialty care
•Low volume, complex care▫Stabilizing patients▫BWH based experiences
Model of Volunteering
Site Visit• Teaching/ training• Patient care
Distance teaching• Video conferencing
Distance consulting• Email
• Telephone
BWH Shadowing• IHS clinicians travel
Site-specificneeds assessment
Thank You!
