Prevention of foot problems in persons with diabetes.

Lower extremity amputations are increasing among patients with diabetes in the United States. Evidence-based reviews suggest that many of these tragic events may be preventable within the framework of existing health care services. Known benefits for high-risk patients result from the coordination of proven care strategies, such as screening, prophylactic foot care, self-care management education, and protective footwear. Organizational changes in practice settings, including provider education, team coordination, patient registries, appointment systems, flowsheets, and chart reminders, improve both patient and provider participation in the behaviors required to interrupt the cascade of events leading to amputation.

Improving cancer incidence estimates for American Indians in Minnesota.

OBJECTIVES: The purpose of this study was to estimate cancer incidence for American Indians in Minnesota. METHODS: Indian Health Service enrollment data were linked to the Minnesota tumor registry to identify cancers among American Indians in Minnesota. Incidence rates for the 5 most common cancers in this population, estimated after the linkage, were compared with rates estimated before the linkage and with rates for the total population of Minnesota. RESULTS: The linkage identified 302 cancer cases not previously identified as occurring among American Indians in Minnesota. Postlinkage estimates suggested that incidence rates for prostate and colorectal cancer are similar to those for the total population of Minnesota, but that rates of lung and cervical cancer are significantly higher. Breast cancer rates are slightly lower than those for the total population of Minnesota but more than twice as high as previous estimates for American Indians. CONCLUSIONS: The postlinkage estimates suggest different priorities for cancer education, prevention, and control than might be assumed from either prelinkage estimates or previously published data, and underscore the importance of using accurate and specific data for setting these priorities.

Prevalence of diabetes and factors associated with diabetic complications in Oneida Indians.

The study objective was to determine the prevalence of diabetes mellitus among Oneida Indians and to identify factors associated with the development of medical complications. After identifying patients with diabetes (N = 373) treated at the Oneida Community Health Center, their medical records were reviewed to determine age, body mass index (BMI), types of medication used, HbAlc, and the presence of diabetic complications. The age and sex-adjusted prevalence of diabetes was 86.5/1000 population. Where type of diabetes could be determined (N = 345) 96% were non-insulin dependent; 67% were afflicted with diabetic complications. 56% had hypertension. Age, BMI, and HbAlc were significant variables with respect to the presence of certain complications. Although lower than the prevalence for some other groups of Native Americans, diabetes and its complications represent a serious problem for the Oneida Indians. Consistent screening, intensive intervention and culture-sensitive prevention efforts focussing on weight control are needed.

Risk factors for nephropathy and cardiovascular disease in diabetic Northern Minnesota American Indians.

Although complications of diabetes are common among Southwest American Indians, little is known about diabetes and associated risk factors for nephropathy and cardiovascular disease in other genetically distinct tribes. We conducted a retrospective analysis of 665 diabetic patients at two Chippewa Indian reservations in northern Minnesota to evaluate the prevalence of risk factors for diabetic nephropathy and cardiovascular disease. In 79 patients, a more detailed study was carried out, including an assessment of renal function and urinary albumin excretion (UAE). The overall prevalences of proteinuria and hypertension were 47.9% and 62.6%, respectively. Proteinuria was observed more often in hypertensive than in non-hypertensive patients (55.2% vs 44.4%, p < 0.05), and in patients with diabetes for longer than 10 years (57% vs 40% for diabetes less than 10 years, p < 0.05). Although hypercholesterolemia (total cholesterol > or = 200 mg/dl) was observed in 54% of patients, there was no relationship between hypercholesterolemia and proteinuria. In the 79 patients studied in more detail, UAE was greater in hypertensive patients compared to non-hypertensive patients (606 +/- 15600 mg/24h vs 101 +/- 157 mg/24 h, p < 0.05), and in patients with diabetes for 10 years or longer compared to patients in the first decade of disease (748 +/- 1732 mg/24 h vs 96 +/- 171 mg/24 h, p < 0.05). Hypercholesterolemia and elevated LDL-cholesterol (> 130 mg/dl) were observed in 56% and 49% of patients, respectively, but were not associated with increased UAE. In contrast, hypertriglyceridemia (> 250 mg/dl) was associated with an elevated UAE (932 +/- 2150 mg/24 h vs 245 +/- 735 mg/24h, p < 0.05). Increased lipoprotein(a) was found in patients with overt albuminuria. In summary, the prevalence of risk factors for diabetic nephropathy and associated cardiovascular disease is high in Chippewa American Indians in northern Minnesota. Although detecting abnormal UAE may be useful in identifying high-risk patients who may benefit from early intervention, traditional risk factors such as hypercholesterolemia may not explain the risk associated with increased UAE.

Screening and diagnosis for gestational diabetes mellitus among Chippewa women in northern Minnesota.

We reviewed prenatal records of Chippewa women residing on two Minnesota reservations to define the incidence of gestational diabetes mellitus (GDM) and to describe the screening and diagnosis practices for GDM according to National Diabetes Data Group Criteria. Of the 554 pregnancies included in the study, six (1%) involved women with preexisting diabetes mellitus and 32 (5.8%) with GDM. In 24 (4.3%) of the pregnancies, the women were misclassified as having GDM. Women completed screening and/or testing during 450 (82%) of the pregnancies-by 32 weeks gestation for 401 (73%). This is of 548 pregnancies that could potentially have involved GDM. Women with incomplete screening and/or testing were older and of higher parity than those who completed negative screening and/or testing (p<0.05). Chippewa Indian women in northern Minnesota experienced GDM at rates higher than most other U.S. populations. Screening rates for GDM were high, but some high-risk women were not screened. Programs targeting high-risk women for timely and accurate diagnosis of GDM are needed in this primary care setting.

Assessment of diabetes care by medical record review. The Indian Health Service model.

OBJECTIVE: To evaluate the adherence to minimum standards for diabetes care in multiple primary-care facilities using a uniform system of medical record review. RESEARCH DESIGN AND METHODS: In 1986, the Indian Health Service (IHS) developed diabetes care standards and an assessment process to evaluate adherence to those standards using medical record review. We review our assessment method and results for 1992. Charts were selected in a systematic random fashion from 138 participating facilities. Trained professional staff reviewed patient charts, using a uniform set of definitions. A weighted rate of adherence was constructed for each item. RESULTS: Medical record reviews were conducted on 6,959 charts selected from 40,118 diabetic patients. High rates of adherence (> 70%) were noted for blood pressure and weight measurements at each visit, blood sugar determinations at each visit, annual laboratory screening tests, electrocardiogram at baseline, and adult immunizations. Lower rates of adherence (< or = 50%) were noted for annual eye, foot, and dental examinations. CONCLUSIONS: IHS rates of adherence are similar to rates obtained from medical record reviews and computerized billing data, but are less than rates obtained by provider self-report. Medical record review, using uniform definitions and inexpensive software for data entry and reports, can easily be implemented in multiple primary-care settings. Uniformity of data definition and collection facilitates the aggregation of the data and comparison over time and among facilities. This medical record review system, although labor intensive, can be easily adopted in a variety of primary-care settings for quality improvement activities, program planning, and evaluation.

Diabetes in a northern Minnesota Chippewa Tribe. Prevalence and incidence of diabetes and incidence of major complications, 1986-1988.

OBJECTIVE: To determine the prevalence and incidence of diabetes, and the incidence of major diabetic complications, in a Chippewa Indian population. RESEARCH DESIGN AND METHODS: The format was a longitudinal population study that used active community and health center-based surveillance. The setting was a North American Indian reservation community of 4075 residents, served by an IHS clinic from 1986 to 1988. Patients were American Indians of Chippewa descent living on or near the Red Lake Reservation. RESULTS: Midway through the study, 346 people had been diagnosed with diabetes, which yielded an age- and sex-adjusted point prevalence of 148/1000 population. The adjusted rate for individuals > or = 25 yr of age was 252/1000 population, 3.82 times the U.S. rate (CI 2.95-4.93). Some 97 new cases of diabetes were identified for an age- and sex-adjusted average annual incidence of 17/1000 population. The incidence of hospitalization for LEA was 26/1000 diabetic person-yr, 4.3 times the 1978 U.S. rate (95% CI 2.8-6.8). Twelve individuals developed proliferative retinopathy, for an incidence of 12/1000 diabetic person-yr. Newly diagnosed ESRD incidence was 6/1000 diabetic person-yr. Twenty-three acute myocardial infarctions were observed, yielding an incidence of 22/1000 diabetic person-yr. CONCLUSIONS: Diabetes and its complications are prevalent in this Chippewa population, and further surveillance is needed to evaluate the effectiveness of prevention efforts.

Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria.

OBJECTIVE: To evaluate prospectively a risk categorization scheme for lower-extremity problems that incorporates the Semmes-Weinstein 5.07 monofilament and a simple exam to stratify patients who were followed in a primary-care setting into risk groups for plantar ulceration and lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with diabetes in a well-defined American-Indian population were stratified into four risk categories based on sensation status to the 5.07 monofilament, the presence of foot deformity, and a history of lower-extremity events (amputation or ulceration): category 0, sensate; category 1, insensate; category 2, insensate with deformity; and category 3, history of lower extremity events. Patients were followed prospectively for lower extremity events and changes in sensation status. RESULTS: We gave screening exams to 358 (88%) of 406 individuals with diabetes in the community. The distribution of patients for risk categories 0, 1, 2, and 3 was 74.3, 8.4, 4.5, and 13%, respectively. Over a 32-mo follow-up period, 41 patients developed ulcerations, and incidence rates correlated positively with increasing risk category (P less than 0.00001). All 14 amputations occurred in risk groups 2 and 3. CONCLUSIONS: These data suggest that the risk categorization described here may have a role in identifying patients at risk for lower extremity events who are followed in a primary-care setting.