Why the Indian Health Care Improvement Act Has Failed to Effectively Fund Workforce Development for the Indian Health Service.

The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.

Evaluating Disparities in Colon Cancer Survival in American Indian/Alaskan Native Patients Using the National Cancer Database.

BACKGROUND: Studies demonstrate higher mortality rates from colon cancer in American Indian/Alaskan Native (AI/AN) patients compared to non-Hispanic White (nHW). We aim to identify factors that contribute to survival disparities. METHODS: We used the National Cancer Database to identify AI/AN (n = 2127) and nHW (n = 527,045) patients with stage I-IV colon cancer from 2004 to 2016. Overall survival among stage I-IV colon cancer patients was estimated by Kaplan-Meier analysis; Cox proportional hazard ratios were used to identify independent predictors of survival. RESULTS: AI/AN patients with stage I-III disease had significantly shorter median survival than nHW (73 vs 77 months, respectively; p < 0.001); there were no differences in survival for stage IV. Adjusted analyses demonstrated that AI/AN race was an independent predictor of higher overall mortality compared to nHW (HR 1.19, 95% CI 1.01-1.33, p = 0.002). Importantly, compared to nHW, AI/AN were younger, had more comorbidities, had greater rurality, had more left-sided colon cancers, had higher stage but lower grade tumors, were less frequently treated at an academic facility, were more likely to experience a delay in initiation of chemotherapy, and were less likely to receive adjuvant chemotherapy for stage III disease. We found no differences in sex, receipt of surgery, or adequacy of lymph node dissection. CONCLUSION: We found patient, tumor, and treatment factors that potentially contribute to worse survival rates observed in AI/AN colon cancer patients. Limitations include the heterogeneity of AI/AN patients and the use of overall survival as an endpoint. Additional studies are needed to implement strategies to eliminate disparities.

Disparities in post-mastectomy reconstruction use among American Indian and Alaska Native women.

BACKGROUND: American Indian/Alaska Native (AI/AN) breast cancer patients undergo post-mastectomy reconstruction (PMR) infrequently relative to Non-Hispanic White (NHW) patients. Factors associated with low PMR rates among AI/AN are poorly understood. We sought to describe factors associated with this disparity in surgical care. METHODS: A retrospective cohort study of the National Cancer Database (2004 - 2017) identified AI/AN and NHW women, ages 18 - 64, who underwent mastectomy for stage 0 - III breast cancer. Patient characteristics, annual PMR rates, and factors associated with PMR were described with univariable analysis, the Cochran-Armitage test, and multivariable logistical regression. RESULTS: 414,036 NHW and 1,980 AI/AN met inclusion criteria. Relative to NHW, AI/AN had more comorbidities (20% vs 12% Charlson Comorbidity Index ≥ 1, p < 0.001), had non-private insurance (49% vs 20%, p < 0.001), and underwent unilateral mastectomy more frequently (69% vs 61%, p < 0.001). PMR rates increased over the study period, from 13% to 47% for AI/AN and from 29% to 62% for NHW (p <0.001). AI/AN race was independently associated with decreased likelihood of PMR (OR 0.62, 95% CI 0.56-0.69). Among AI/AN, decreased likelihood of PMR was significantly associated with older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size > 5 cm, positive lymph nodes), unilateral mastectomy, non-private insurance, and lower educational attainment in patient's area of residence. CONCLUSION: PMR rates among AI/AN with stage 0 - III breast cancer have increased, yet remain significantly lower than among NHW. Further research should elicit AI/AN perspectives on PMR, and guide early breast cancer detection and treatment.

Weaving pathways: talking with our Elders.

While there exists a relative paucity of completed healthcare directives nationally in the USA, even fewer exist within minority populations. This report describes one model for bringing advance care planning and discussions to American Indian and Alaska Native (AIAN) communities. In 2018, Honoring Choices of Minnesota approached the Center of American Indian and Minority Health (CAIMH), housed in the University of Minnesota Medical School, to collaborate on a project to increase healthcare directives in AIAN communities. CAIMH assembled AIAN students, faculty and community members to identify and address barriers to healthcare directive completion and discussions about end-of-life choices. The project team decided upon a two-pronged approach: culturally informed provider training paralleling culturally relevant community engagement. We aimed to empower AIAN to engage with healthcare providers on decisions impacting their care. To further support AIAN patients and their providers, a toolkit was created and will soon be available for dissemination.

Pain and Functional Limitations Among Midlife and Older Canadians: The Role of Discrimination, Race and Sense of Belonging.

OBJECTIVES: We drew on fundamental cause theory and the weathering hypothesis to examine how discrimination influences aging for midlife and older adults in Canada. METHODS: Using nationally representative data, we assessed the associations between discrimination and pain and functional limitations among adults 45 years of age and older. Discrimination was measured using a modified version of the Everyday Discrimination Scale. Chi-square tests were performed to check for baseline differences in the dependent and key predictor variables by race. Logistic regression was used to estimate the associations of discrimination, race, and sense of belonging with pain and functional limitations, net of sociodemographic characteristics and SES. RESULTS: Indigenous respondents showed a clear health disadvantage, with higher rates of pain and functional limitations compared to Whites and Asians. Self-reported discrimination was also higher for Indigenous midlife and older adults than for their White and Asian age counterparts. Discrimination had a direct and robust association with pain (OR 1.56, 95% CI 1.31, 1.87) and functional limitations (OR 1.55, 95% CI 1.29, 1.87). However, race moderated the impact of discrimination on functional limitations for Blacks. Finally, a strong sense of belonging to one's local community was protective against pain and functional limitations for all racial groups. DISCUSSION: Future research needs to further examine the impact of discrimination on Indigenous peoples' aging process. High rates of discrimination coupled with a greater burden of pain means that Indigenous midlife and older adults may require additional and targeted health and social service resources to age successfully.