Living well with diabetes in Alaska.

Many people with diabetes mellitus experience minimal or no complications. Our objective was to determine the proportion of Alaska Native people who experienced four major complications or mortality and to identify factors that may be associated with these outcomes. We used records in a diabetes registry and clinical and demographic variables in our analyses. We used logistic regression and Cox Proportional Hazards models to evaluate associations of these parameters with death and complications that occurred prior to 2013. The study included 591 Alaska Native people with non-type 1 diabetes mellitus, diagnosed between 1986 and 1992. Over 60% of people in this study remained free of four major diabetes-related complications for the remainder of life or throughout the approximately 20-year study period. Lower BMI, higher age at diagnosis of diabetes, and use of at least one diabetes medication were associated with death and a composite of four complications. A majority of Alaska Native people with DM had none of four major complications over a 20-year period. Lower BMI and use of diabetes medications were associated with higher hazard for some deleterious outcomes. This suggests that goals in care of elders should be carefully individualised. In addition, we discuss several programme factors that we believe contributed to favourable outcomes.

An assessment of cardiovascular disease hospitalizations and disparities by race in patients with rheumatic disease hospitalizations in Alaska, 2015-2018.

BACKGROUND: There is an increased risk of cardiovascular disease in people with many rheumatic diseases. The primary objective of this study was to evaluate cardiovascular disease hospitalizations in Alaska for people with and without a rheumatic disease diagnosis and assess disparities by race, with a focus on Alaska Native and American Indian people. METHODS: This study used the Alaska Health Facilities Data Reporting Program data on inpatient hospitalizations from 2015 to 2018. We identified people with a rheumatic disease diagnosis based on any hospitalization with a set of rheumatic disease diagnoses and compared them to people hospitalized but without a rheumatic disease diagnosis. We determined the odds of cardiovascular disease hospitalization by rheumatic disease diagnosis and assessed the influence of race and other factors, using univariate analyses and multivariable models. RESULTS: People with a rheumatic disease diagnosis other than osteoarthritis had higher odds of cardiovascular disease hospitalization. The odds ratio was highest in people with gout compared to other rheumatic diseases. In multivariable models, there was an interaction between race and rheumatic disease status. Specifically, having gout increased the odds of cardiovascular disease hospitalization for people of all races, while having a rheumatic disease other than gout or osteoarthritis increased the odds of cardiovascular disease hospitalization in Alaska Native/American Indian people but not in people of other races. CONCLUSIONS: The association between rheumatic disease status and cardiovascular disease hospitalization in Alaska varied by type of rheumatic disease and race. This adds substantially to the literature on associations between rheumatic disease and cardiovascular disease in Indigenous North American populations.

Hospitalized Infections in Patients With Rheumatic Disease Hospitalizations in Alaska, 2015-2018.

OBJECTIVE: Rheumatic diseases are associated with increased rates of hospitalized infection, but few studies have included Indigenous North American populations. Our objective was to evaluate the association of rheumatic disease diagnosis during a hospitalization with odds of hospitalized infections in Alaska and assess differences by race. METHODS: We used hospital discharge data from the Alaska Health Facilities Data Reporting Program from 2015 to 2018. We identified people with a rheumatic disease diagnosis based on any hospital discharge diagnosis of a set of rheumatic diseases and compared them to people hospitalized but without a rheumatic disease diagnosis. We determined odds of hospitalized infection by rheumatic disease diagnosis status and type, race, and type of infection. Using multivariable modeling, we determined factors associated with hospitalized infection. RESULTS: Having a rheumatic disease diagnosis other than osteoarthritis was associated with 1.90 higher odds of hospitalized infection overall, whereas people of Alaska Native/American Indian (AN/AI) race with rheumatic disease had 2.44 higher odds. The odds varied by rheumatic disease and were increased in all rheumatic diseases except osteoarthritis (0.73). The most common type of hospitalized infection was sepsis, but opportunistic infections and pneumonia were most associated with a rheumatic disease diagnosis. On multivariable analysis, having a rheumatic disease diagnosis other than osteoarthritis, being of older age, and being of AN/AI race were associated with increased odds of hospitalized infection, with an interaction between race and rheumatic disease status. CONCLUSION: This study confirmed the association of hospitalized infections with rheumatic disease diagnosis (other than osteoarthritis) during hospitalization and identified disparities by race.

Health care utilization in Alaska Native people receiving chronic disease specialty care by videoconsultation compared to propensity-matched controls.

INTRODUCTION: Previous studies have had mixed findings about the effects of telemedicine on health care utilization. We designed this study to assess differences in health care utilization between ever users of telemedicine for chronic disease specialty care compared to propensity-matched controls. METHODS: This observational study of usual care in the Alaska Tribal Health System evaluated telemedicine use (videoconsultation) and healthcare utilization using data from the electronic medical record between 1 January 2015 and 30 June 2019. Eligibility criteria included: age 18 and older, chronic condition diagnosis, and residing in one of four study regions. Cases had ever used telemedicine while controls had not. We used propensity score matching to achieve covariate balance between cases and controls, and then estimated the effect of telemedicine on outcomes using multivariable models. Outcomes included rates of hospitalizations, outpatient visits, and emergency department visits. RESULTS: Cases (ever users of telemedicine) had higher hospitalization rates (rate ratio 1.31, p < 0.01) and higher outpatient visit rates (rate ratio 1.23, p < 0.01). Cases had lower rates of emergency department visits, though non-statistically significant (rate ratio 0.87, p = 0.07). Cases were more likely than controls to have no emergency department visits per follow-up time (49% vs 36%, p < 0.01). DISCUSSION: We found higher rates of inpatient and outpatient health care utilization in people who had ever used telemedicine compared to propensity-matched controls, with potentially lower rates of emergency department visits. These findings contribute to the literature on telemedicine and should be considered in the context of other factors influencing telemedicine use and outcomes.

Hospitalizations Associated With Rheumatic Disease in Alaska, 2015-2018.

OBJECTIVE: Few studies have evaluated hospitalizations associated with rheumatic disease in Indigenous North American populations. The objective of this study was to determine the characteristics of people hospitalized with rheumatic disease in Alaska, including a comparison of hospitalizations for Alaska Native/American Indian (AN/AI) people in Alaska compared with those of other races. METHODS: We used statewide hospital discharge data from the Alaska Health Facilities Data Reporting Program from 2015 to 2018 for this study. Cases were ascertained based on discharge diagnosis (any listed) of a defined set of rheumatic diseases. We determined characteristics associated with rheumatic disease hospitalizations, including age, gender, and race. Using multivariate modeling, we determined risk factors for hospitalization overall, as well as for specific rheumatic diseases. We compared characteristics of hospital encounters for people with or without rheumatic diseases and by race. RESULTS: We identified 15975 people ever hospitalized with rheumatic disease in the study period and 87138 controls hospitalized but without any rheumatic disease diagnosis. Cases were older than controls and more likely to be female. The three most common types of rheumatic disease associated with hospitalization were osteoarthritis, gout, and rheumatoid arthritis. Compared with other races, AN/AI people were more likely to be hospitalized with rheumatic disease, and this association was true for all specific diseases other than gout. CONCLUSION: Hospitalizations associated with rheumatic disease are common in Alaska, with an increased likelihood of hospitalization for AN/AI people. This adds to the literature on health disparities in Indigenous North American populations.

Factors Associated with Telemedicine Use for Chronic Disease Specialty Care in the Alaska Tribal Health System, 2015-2019.

Background:There are disparities in access to specialty care for chronic diseases in rural and minority populations. Telemedicine has been proposed to improve access.Introduction:The objective of this study was to identify predictors of telemedicine use for chronic disease specialty care in the Alaska Tribal Health System (ATHS) in the setting of usual care.Materials and Methods:We utilized data from the electronic health record (EHR) of patients from four regions in the ATHS. We queried the EHR to identify cases (ever users of telemedicine) and controls (never users), both of whom had chronic diseases requiring specialty care. Data were collected from 2015 through mid-2019.Results:We included 3,075 patients (799 ever users and 2,276 never users). In univariate analysis, ever users were older, more likely to be male, had more chronic conditions and higher encounter rates. There were differences by region, community, and type of specialty clinic. In our simple multivariate model, factors associated with telemedicine use included age, male gender, region, and outpatient visit rate per year. Having at least one cardiology clinic visit was also associated with telemedicine use, with the highest estimated odds ratio (5.27, p < 0.01).Discussion:This study describes factors associated with telemedicine use in the ATHS before the COVID-19 pandemic. We anticipate monitoring changes in these predictors over time, as we expect them to evolve.Conclusions:We found among factors associated with telemedicine use were age, gender, region, outpatient visit rate, and visits to a specific specialty clinic.

Environmental Health Consults in Children Hospitalized with Respiratory Infections.

Indoor air pollutants contribute to respiratory infections and asthma exacerbations in children. Rural Alaska Native children experience some of the highest U.S. rates of respiratory hospitalizations, which are associated with lack of in-home running water, household crowding, and woodstove use. In our previous study, in-home education and modifications reduced respiratory symptoms, and medical visits. In this study, we evaluated the feasibility of providing in-hospital environmental health consults for parents/guardians of children < 5 years old hospitalized at the Alaska Native Medical Center with respiratory infections or asthma. Environmental health specialists conducted 92 in-hospital consults and mailed Healthy Homes Toolkits to households. Local housing authorities completed low-cost home modifications in 47 eligible households. Participants reported changes in household behaviors that were specifically addressed in the consult or included in the Toolkit (e.g. allergen-impermeable pillow covers). Reported respiratory symptoms were decreased at the 6-month follow-up. Over a 2 year period the median overall medical costs for respiratory illness in study children were $70,500. Children with in-home piped water had half the daily overall medical costs than children without in-home piped water ($74 compared to $144). In this study, we demonstrate that it is feasible to provide environmental consults, mail Toolkits, and arrange home modifications to the homes of children hospitalized with respiratory illness. These findings, along with the high costs of medical care for these children, suggest in-hospital environmental health consults are a cost-effective intervention.

Ten-year weight gain is not associated with multiple cardiometabolic measures in Alaska EARTH study participants.

BACKGROUND AND AIMS: Alaska Native (AN) traditional lifestyle may be protective against chronic disease risk. Weight gain in adulthood has been linked to increases in chronic disease risk among other populations; yet, its impact among Alaska Native people has never been evaluated. We aimed to evaluate changes in obesity-related metrics over time, and determine associations of changes with cardiometabolic markers of chronic disease risk among AN people. METHODS AND RESULTS: Study participants enrolled in the southcentral Alaska Education and Research Towards Health Study in 2004-2006 were invited to participate in a follow-up study conducted 2015-2017. Of the original 1320 participants, 388 completed follow-up health assessments consisting of multiple health surveys, anthropometric measurements, and cardiometabolic measures including blood sugars, blood lipids, and blood pressure. Differences in measurements between visits were determined and associations of weight change with cardiometabolic measures evaluated. Body mass index increased by 3.7 kg/m2 among men and 4.8 kg/m2 among women. Hip circumference (1.1 cm, p < 0.01) and waist circumference (0.7 cm, p < 0.01) increased among women; only waist circumference increased among men (1.6 cm, p < 0.01). Among men, there were no associations of weight change with cardiometabolic measures. Among women, there was an inverse association between weight gain and high-density lipoprotein cholesterol only (0.17 mg/dL (CI: -3.1, -0.03), p = 0.02). CONCLUSIONS: While weight increase over a 10-year period was not associated with substantive changes in cardiometabolic measures among AN men, there was a decrease in high density lipid cholesterol associated with weight gain among AN women.

Using electronic dental records to establish a surveillance system for dental decay in rural Western Alaska.

OBJECTIVES: Previous surveys have demonstrated high rates of early childhood caries (ECC) in the Alaska Native (AN) population of western Alaska. There are many challenges to providing dental care in this road-less Yukon-Kuskokwim Delta region. The regional Tribal Health Organization implemented an electronic dental record (EDR) system in the late 1990s. We explored use of the EDR to establish an oral health surveillance system in children. METHODS: We contracted with EDR software developers to implement calculation of a summary count of decayed (d), missing (m) or filled (f) primary (dmft) score for each individual. We calculated the yearly average dmft scores for 2011-2019 for children aged 3 and 5 years with a comprehensive exam in a given year. We also assessed the number of children undergoing full mouth dental rehabilitation (FMDR). We used US census data population estimates for these age groups to calculate rates. RESULTS: Over the 9-year period, 2,427 3-year-old children (47 percent of all 3-year olds over this period), received a comprehensive exam; increasing from 24 percent in 2011 to 62 percent in 2019. Their average dmft score over the 9-years was 6.4 with a significant annual decline over this period. Seventy percent of AN children who turned 6 between 2015 and 2019 had received at least one FMDR. CONCLUSIONS: An oral health surveillance system has been established in western Alaska using the Electronic Dental Record. High rates of ECC and FMDR were observed. This surveillance system will allow assessments of ECC prevalence and impact of dental interventions.

Lack of in-home piped water and reported consumption of sugar-sweetened beverages among adults in rural Alaska.

OBJECTIVE: To assess whether a community water service is associated with the frequency of sugar-sweetened beverages (SSB) consumption, obesity, or perceived health status in rural Alaska. DESIGN: We examined the cross-sectional associations between community water access and frequency of SSB consumption, body mass index categories, and perceived health status using data from the 2013 and 2015 Alaska Behavioral Risk Factor Surveillance System (BRFSS). Participants were categorized by zip code to 'in-home piped water service' or 'no in-home piped water service' based on water utility data. We evaluated the univariable and multivariable (adjusting for age, household income and education) associations between water service and outcomes using log-linear survey-weighted generalized linear models. SETTING: Rural Alaska, USA. SUBJECTS: Eight hundred and eighty-seven adults, aged 25 years and older. RESULTS: In unadjusted models, participants without in-home water reported consuming SSB more often than participants with in-home water (1·46, 95 % CI: 1·06, 2·00). After adjustment for potential confounders, the effect decreased but remained borderline significant (1·29, 95 % CI: 1·00, 1·67). Obesity was not significantly associated with water service but self-reported poor health was higher in those communities without in-home water (1·63, 95 % CI: 1·05, 2·54). CONCLUSIONS: Not having access to in-home piped water could affect behaviours surrounding SSB consumption and general perception of health in rural Alaska.

Factors Associated With Use of Telemedicine for Follow-up of Rheumatoid Arthritis.

OBJECTIVE: Telemedicine is increasingly being offered to patients for rheumatology care, but few studies have examined factors associated with telemedicine use or outcomes of telemedicine in rheumatology. The objective of this analysis was to determine factors associated with the use of video telemedicine when offered as part of usual care for follow-up of rheumatoid arthritis (RA). METHODS: Individuals in the Alaska Tribal Health System with a diagnosis of RA were recruited when seeing a rheumatologist either in-person or by video telemedicine, both of which were offered as part of usual care. At the study visit, participants completed the Routine Assessment of Patient Index Data 3 (RAPID3) and a telemedicine perception survey and agreed to a medical record review for demographics and disease characteristics. Data from this visit were analyzed to determine factors associated with using telemedicine for RA, compared to being seen in-person only. RESULTS: Of 122 participants enrolled in the study, 56 (46%) had been seen by telemedicine at least once. Factors associated with telemedicine use in univariate analysis included a higher RAPID3 score, a higher number of rheumatologist visits in the preceding year, more positive perceptions of telemedicine, and seeing a physician who used telemedicine more often. On multivariate analysis, these 4 factors all remained significant. Demographic and other disease-related factors or comorbidities were not associated with telemedicine use. CONCLUSION: When offered as an option for rheumatology care, video telemedicine was more likely to be used by RA patients with higher disease activity and more positive perceptions of telemedicine, and by patients whose physicians used telemedicine more often.

Observed Changes in Natural Killer and T cell Phenotypes with Evaluation of Immune Outcome in a Longitudinal Cohort Following Sofosbuvir-Based Therapy for Chronic Hepatitis C Infection.

BACKGROUND: Chronic hepatitis C virus (HCV) infection diminishes immune function through cell exhaustion and repertoire alteration. Direct acting antiviral (DAA)-based therapy can restore immune cell subset function and reduce exhaustion states. However, the extent of immune modulation following DAA-based therapy and the role that clinical and demographic factors play remain unknown. METHODS: We examined natural killer (NK) cell, CD4+, and CD8+ T cell subsets along with activation and exhaustion phenotypes across an observational study of sofosbuvir-based treatment for chronic HCV infection. Additionally, we examined the ability of clinical variables and duration of infection to predict 12 weeks of sustained virologic response (SVR12) immune marker outcomes. RESULTS: We show that sofosbuvir-based therapy restores NK cell subset distributions and reduces chronic activation by SVR12. Likewise, T cell subsets, including HCV-specific CD8+ T cells, show reductions in chronic exhaustion markers by SVR12. Immunosuppressive CD4+ regulatory T cells decrease at 4-weeks treatment and SVR12. We observe the magnitude and direction of change in immune marker values from pretreatment to SVR12 varies greatly among participants. Although we observed associations between the estimated date of infection, HCV diagnosis date, and extent of immune marker outcome at SVR12, our regression analyses did not indicate any factors as strong SVR12 outcome predictors. CONCLUSION: Our study lends further evidence of immune changes following sofosbuvir-based therapy. Further investigation beyond SVR12 and into factors that may predict posttreatment outcome is warranted.

Disproportionately higher unintentional injury mortality among Alaska Native people, 2006-2015.

We compared rates of unintentional injury (UI) deaths (total and by injury category) among Alaska Native (AN) people to rates of U.S. White (USW) and Alaska White (AKW) populations during 2006-2015. The mortality data for AN and AKW populations were obtained from Alaska Bureau of Vital Statistics and USW mortality data were obtained from WISQARS, the Center for Disease Control and Prevention online injury data program. AN and AKW rates were age-adjusted to the U.S. 2000 Standard Population and rate ratios (RR) were calculated. AN people had higher age-adjusted total UI mortality than the USW (RR = 2.6) and AKW (RR = 2.3) populations. Poisoning was the leading cause of UI death among AN people (35.9 per 100,000), more than twice that of USW (RR = 2.9) and AKW (RR = 2.5). Even greater disparities were found between AN people and USW for: natural environment (RR = 20.7), transport-other land (RR = 12.4), and drowning/submersion (RR = 9.1). Rates of AN UI were markedly higher than rates for either USW or AKW. Identifying all the ways in which alcohol/drugs contribute to UI deaths would aid in prevention efforts. All transportation deaths should be integrated into one fatality rate to provide more consistent comparisons between groups.

Prophylactic Acetaminophen or Ibuprofen Results in Equivalent Acute Mountain Sickness Incidence at High Altitude: A Prospective Randomized Trial.

OBJECTIVE: Recent trials have demonstrated the usefulness of ibuprofen in the prevention of acute mountain sickness (AMS), yet the proposed anti-inflammatory mechanism remains unconfirmed. Acetaminophen and ibuprofen were tested for AMS prevention. We hypothesized that a greater clinical effect would be seen from ibuprofen due to its anti-inflammatory effects compared with acetaminophen's mechanism of possible symptom reduction by predominantly mediating nociception in the brain. METHODS: A double-blind, randomized trial was conducted testing acetaminophen vs ibuprofen for the prevention of AMS. A total of 332 non-Nepali participants were recruited at Pheriche (4371 m) and Dingboche (4410 m) on the Everest Base Camp trek. The participants were randomized to either acetaminophen 1000 mg or ibuprofen 600 mg 3 times a day until they reached Lobuche (4940 m), where they were reassessed. The primary outcome was AMS incidence measured by the Lake Louise Questionnaire score. RESULTS: Data from 225 participants who met inclusion criteria were analyzed. Twenty-five participants (22.1%) in the acetaminophen group and 18 (16.1%) in the ibuprofen group developed AMS (P = .235). The combined AMS incidence was 19.1% (43 participants), 14 percentage points lower than the expected AMS incidence of untreated trekkers in prior studies at this location, suggesting that both interventions reduced the incidence of AMS. CONCLUSIONS: We found little evidence of any difference between acetaminophen and ibuprofen groups in AMS incidence. This suggests that AMS prevention may be multifactorial, affected by anti-inflammatory inhibition of the arachidonic-acid pathway as well as other analgesic mechanisms that mediate nociception. Additional study is needed.

Optic Nerve Sheath Diameter Increase on Ascent to High Altitude: Correlation With Acute Mountain Sickness.

OBJECTIVES: Elevated optic nerve sheath diameter on sonography is known to correlate with increased intracranial pressure and is observed in acute mountain sickness. This study aimed to determine whether optic nerve sheath diameter changes on ascent to high altitude are associated with acute mountain sickness incidence. METHODS: Eighty-six healthy adults enrolled at 1240 m (4100 ft), drove to 3545 m (11,700 ft) and then hiked to and slept at 3810 m (12,500 ft). Lake Louise Questionnaire scores and optic nerve sheath diameter measurements were taken before, the evening of, and the morning after ascent. RESULTS: The incidence of acute mountain sickness was 55.8%, with a mean Lake Louise Questionnaire score ± SD of 3.81 ± 2.5. The mean maximum optic nerve sheath diameter increased on ascent from 5.58 ± 0.79 to 6.13 ± 0.73 mm, a difference of 0.91 ± 0.55 mm (P = .09). Optic nerve sheath diameter increased at high altitude regardless of acute mountain sickness diagnosis; however, compared to baseline values, we observed a significant increase in diameter only in those with a diagnosis of acute mountain sickness (0.57 ± 0.77 versus 0.21 ± 0.76 mm; P = .04). This change from baseline, or Δ optic nerve sheath diameter, was associated with twice the odds of developing acute mountain sickness (95% confidence interval, 1.08-3.93). CONCLUSIONS: The mean optic nerve sheath diameter increased on ascent to high altitude compared to baseline values, but not to a statistically significant degree. The magnitude of the observed Δ optic nerve sheath diameter was positively associated with acute mountain sickness diagnosis. No such significant association was found between acute mountain sickness and diameter elevation above standard cutoff values, limiting the utility of sonography as a diagnostic tool.

Mortality trends among Alaska Native people: successes and challenges.

BACKGROUND: Current mortality rates are essential for monitoring, understanding and developing policy for a population's health. Disease-specific Alaska Native mortality rates have been undergoing change. OBJECTIVE: This article reports recent mortality data (2004-2008) for Alaska Native/American Indian (AN/AI) people, comparing mortality rates to US white rates and examines changes in mortality patterns since 1980. DESIGN: We used death record data from the state of Alaska, Department of Vital Statistics and SEER*Stat software from the National Cancer Institute to calculate age-adjusted mortality rates. RESULTS: Annual age-adjusted mortality from all-causes for AN/AI persons during the period 2004-2008 was 33% higher than the rate for US whites (RR = 1.33, 95% CI 1.29-1.38). Mortality rates were higher among AN/AI males than AN/AI females (1212/100,000 vs. 886/100,000). Cancer remained the leading cause of death among AN/AI people, as it has in recent previous periods, with an age-adjusted rate of 226/100,000, yielding a rate ratio (RR) of 1.24 compared to US whites (95% CI 1.14-1.33). Statistically significant higher mortality compared to US white mortality rates was observed for nine of the ten leading causes of AN/AI mortality (cancer, unintentional injury, suicide, alcohol abuse, chronic obstructive pulmonary disease [COPD], cerebrovascular disease, chronic liver disease, pneumonia/influenza, homicide). Mortality rates were significantly lower among AN/AI people compared to US whites for heart disease (RR = 0.82), the second leading cause of death. Among leading causes of death for AN/AI people, the greatest disparities in mortality rates with US whites were observed in unintentional injuries (RR = 2.45) and suicide (RR = 3.53). All-cause AN/AI mortality has declined 16% since 1980-1983, compared to a 21% decline over a similar period among US whites. CONCLUSION: Mortality rates and trends are essential to understanding the health of a population and guiding policy decisions. The overall AN/AI mortality rate is higher than that of US whites, although encouraging declines in mortality have occurred for many cause specific deaths, as well as for the overall rate. The second leading cause of AN/AI mortality, heart disease, remains lower than that of US whites.