Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems.

OBJECTIVE: To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses. METHODS: We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time. RESULTS: IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases. CONCLUSIONS: This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

Telephone-Based Guideline-Directed Medical Therapy Optimization in Navajo Nation: The Hózhó Randomized Clinical Trial.

Importance: Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy. Objective: To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation. Design, Setting, and Participants: The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024. Intervention: A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff. Main Outcomes and Measures: The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization. Results: Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88. Conclusions and Relevance: In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited. Trial Registration: ClinicalTrials.gov Identifier: NCT05792085.

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.

Neurological Care within the Indian Health Service.

American Indians and Alaska Natives (AI/AN) are the Indigenous peoples of the United States. According to the U.S. Census Bureau, approximately 9.7 million people self-identified as AI/AN (alone or in combination with other races), representing 2.9% of the total U.S. population. These people represent diverse groups of discrete Tribes, each with their language, culture, and geographic home. As part of the conquest and settlement of North America, some Indigenous peoples signed treaties with the U.S. government, surrendering their lands in return for various government commitments, including health care. The Indian Health Service (IHS) was born out of these agreements. The IHS is an agency in the U.S. Department of Health and Human Services under the U.S. Public Health Service. The IHS provides a comprehensive health service delivery system for approximately 2.7 million AI/AN who belong to 574 federally recognized Tribes/nations in 37 states. The aim of this paper is to make recommendations regarding the initiation of sustainable neurology care in marginalized or underserved populations by reviewing 40 years of neurology care provision within the IHS. We will discuss (1) the IHS, (2) neurological care provided within the IHS, including midlevel provider extension of neurology care and traditional medical care, and (3) select neurological diagnoses within AI/AN populations. Marginalized populations, including those in the United States that are rural, remote, or low socioeconomic status, lack access to specialty neurology care. This includes many AI/AN. The IHS has developed novel solutions to promote specialty care, including neurology. Notably, initial IHS investments in full-time neurology providers have led to more robust neurology care, often receiving attention from university programs. This suggests that an initial investment in stable on-site full-time neurology services provides a path to potential sustainable care for marginalized populations.

Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services.

American Indian and Alaska Native (Native) Veterans enrolled in the U.S. Department of Veterans Affairs (VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

Surveillance Methods Used to Detect, Characterize, and Monitor the COVID-19 Pandemic in Rocky Mountain Tribal Communities.

OBJECTIVE: Data were essential to public health decision-making during the COVID-19 pandemic, yet no single data source was adequate for Tribes in Montana and Wyoming. We outlined data access, availability, and limitations for COVID-19 pandemic surveillance response to improve future data exchange. MATERIALS AND METHODS: The Rocky Mountain Tribal Epidemiology Center (RMTEC) used various data sources to deliver data on the number of COVID-19 cases, deaths, and vaccinations at local, state, and regional levels to inform Tribes in Montana and Wyoming. RMTEC reviewed state, federal, and public datasets and then attached a score to each dataset for completeness of demographic information, including race, geographic level, and refresh rate. RESULTS: The RMTEC COVID-19 response team shared data weekly on the number of COVID-19 cases, deaths, and vaccinations distributed and the percentage of the population vaccinated with Tribal health departments in Montana and Wyoming. The Indian Health Service Epidemiology Data Mart dataset scored the highest (24 of 30), followed by datasets from Montana (18 of 30) and Wyoming (22 of 30). Publicly available datasets scored low largely due to data aggregation across larger geographic areas and lack of demographic variables. PRACTICE IMPLICATIONS: The absence of data on race and ethnicity from publicly available data and lack of access to real-time data limited RMTEC's ability to provide Tribal-specific updates on COVID-19 cases, deaths, and vaccinations to Tribal health departments. RMTEC should be fully funded to provide the necessary resources for data management and the capacity to respond to data requests from Tribal health departments and their programs to address current and future pandemics. Federal and state agencies should also be educated on Tribal Epidemiology Centers' public health authority status to improve access to infectious disease data among those agencies.

Health Conditions and Health Care Use Among American Indian and Alaska Native Adults by Tribal Land Residential Status: United States, 2019-2021.

Objective-This report presents estimates for selected health conditions and health care use among American Indian and Alaska Native (AIAN) adults by tribal land residential status.

Incidence and Progression of Diabetic Retinopathy in American Indian and Alaska Native Individuals Served by the Indian Health Service, 2015-2019.

Importance: Estimates of diabetic retinopathy (DR) incidence and progression in American Indian and Alaska Native individuals are based on data from before 1992 and may not be informative for strategizing resources and practice patterns. Objective: To examine incidence and progression of DR in American Indian and Alaska Native individuals. Design, Setting, and Participants: This was a retrospective cohort study conducted from January 1, 2015, to December 31, 2019, and included adults with diabetes and no evidence of DR or mild nonproliferative DR (NPDR) in 2015 who were reexamined at least 1 time during the 2016 to 2019 period. The study setting was the Indian Health Service (IHS) teleophthalmology program for diabetic eye disease. Exposure: Development of new DR or worsening of mild NPDR in American Indian and Alaska Native individuals with diabetes. Main Outcomes and Measures: Outcomes were any increase in DR, 2 or more (2+) step increases, and overall change in DR severity. Patients were evaluated with nonmydriatic ultra-widefield imaging (UWFI) or nonmydriatic fundus photography (NMFP). Standard risk factors were included. Results: The total cohort of 8374 individuals had a mean (SD) age of 53.2 (12.2) years and a mean (SD) hemoglobin A1c level of 8.3% (2.2%) in 2015, and 4775 were female (57.0%). Of patients with no DR in 2015, 18.0% (1280 of 7097) had mild NPDR or worse in 2016 to 2019, and 0.1% (10 of 7097) had PDR. The incidence rate from no DR to any DR was 69.6 cases per 1000 person-years at risk. A total of 6.2% of participants (441 of 7097) progressed from no DR to moderate NPDR or worse (ie, 2+ step increase; 24.0 cases per 1000 person-years at risk). Of patients with mild NPDR in 2015, 27.2% (347 of 1277) progressed to moderate NPDR or worse in 2016 to 2019, and 2.3% (30 of 1277) progressed to severe NPDR or worse (ie, 2+ step progression). Incidence and progression were associated with expected risk factors and evaluation with UWFI. Conclusions and Relevance: In this cohort study, the estimates of DR incidence and progression were lower than those previously reported for American Indian and Alaska Native individuals. The results suggest extending the time between DR re-evaluations for certain patients in this population, if follow-up compliance and visual acuity outcomes are not jeopardized.

Infusing geriatrics in Indian Health Service general primary care clinics: Extending VA workforce development training.

As federal partners, the Veterans Health Administration (VA) and the Indian Health Service (IHS) agreed to share resources, such as education. The VA Geriatric Scholars Program, a workforce development program, provides one of its training programs on team-based primary care of elders to clinicians working in IHS and Tribal Health Programs. The practical impact of that training is described. A mixed methods approach was applied to the course's evaluation survey at five clinics in the Northwestern Plains, Southwest, Pacific Coast, and Alaska. Quantitative approaches assessed participants' self-reported intention to improve recognition and assessment of common geriatric syndromes. A qualitative approach applied to open-ended text responses revealed intensions to improve team-based care. Among the 51 respondents in our sample, we found significant improvements in self-reported ability to recognize previously unfamiliar potential risks to elders' health and safety, t(49) = 8.0233, p < .001, as well as increased comfort with conducting geriatric assessments and increased confidence in interprofessional team-based communication. Improvements to team-based care included enhanced clinical skills, organizational factors and the need to train additional employees. This evaluation demonstrates the value of sharing resources among federal partners and its value for participants in IHS and Tribal Health Programs.

"Treat Me like Your Family": Positive Factors that Influence Patient-Provider Relationships for Native American Women.

Although extensive documentation of the health disparities experienced by Native American peoples exists, little research explores experiences of members of non-federally recognized tribes who receive health care outside of the Indian Health Services (IHS) system. Additionally, positive factors that influence relationships between health care providers and tribal members are understudied and are needed to promote health care access. A qualitative descriptive methodologic approach was used to conduct semi structured life history interviews with 31 women who identified as members of a state-recognized, Gulf South Native American tribe. Results identified the following important themes: Do Participants Have a Regular Provider, Personal Relationship With Provider, Feel Provider Cares, Provider Addresses Concern, and Respect for Traditional or Holistic Medicine. These findings suggest health care providers play an important role in impacting the health care experiences of Native American tribal members. Implications for trainings for health care providers are discussed.

Evaluation of "Catch Up to Get Ahead" efforts on administration of routine childhood vaccinations during COVID-19 pandemic, United States Indian Health Service, 2020.

Routine immunization rates in the United States (US) declined immediately after the US declared COVID-19 a public health emergency in March 2020. Decreases in childhood vaccination place children at risk for vaccine-preventable diseases and communities at risk for outbreaks from these diseases. The US Department of Health and Human Services (HHS) launched "Catch Up to Get Ahead" in August 2020 to promote routine childhood immunization. The decline in mean coverage of the combined 7-vaccine series among children aged 19-35 months was less in Indian Health Service (IHS) federal health centers that implemented "Catch Up to Get Ahead" compared to IHS federal health centers that did not. The effort to promote catch-up vaccination may have showed promise in minimizing the decline in childhood vaccination coverage during the pandemic. However, the effort was not enough to reach pre-pandemic levels, indicating the need for more robust and sustained efforts to catch children up on all delayed immunizations.

Best of ARM: Evaluating engagement in multisector community health networks: The case of tribal organizations.

OBJECTIVE: To quantify variation in public health system engagement with tribal organizations across a national sample of communities and to identify predictors of engagement. DATA SOURCES: We used 2018 National Longitudinal Survey of Public Health Systems data, a nationally representative cohort of the US public health systems. STUDY DESIGN: Social network analysis measures were computed to indicate the extent of tribal organization participation in public health networks and to understand the sectors and social services that engage with tribal organizations in public health activities. Two-part regression models estimated predictors of tribal engagement. DATA COLLECTION: A stratified random sample of local public health agencies was surveyed, yielding 574 respondents. An additional cohort of oversampled respondents was also surveyed to include jurisdictions from the entire state upon the request of their respective state health departments (n = 154). Analyses were restricted to jurisdictions with a nearby American Indian and Alaska Native (AI/AN) serving health facility, yielding a final sample size of 258 local public health systems. PRINCIPAL FINDINGS: When an AI/AN serving health facility was present in the region, tribal organizations participated in 28% of public health networks and 9% of implemented public health activities. Networks with tribal engagement were more comprehensive in terms of the breadth of sectors and social services participating in the network and the scope of public health activities implemented relative to networks without tribal engagement. The likelihood of tribal engagement increased significantly with the size of the AI/AN population, the presence of a tribal facility with Indian Health Service funding in the region, and geographic proximity to reservation land (p < 0.10). CONCLUSIONS: The vast majority of public health networks do not report engagement with tribal organizations. Even when AI/AN serving health facilities are present, reported engagement of tribal organizations remains low.

Mental Illness in Adults With HIV and HCV Infection: Indian Health Service, 2001-2020.

INTRODUCTION: Mental health disorders (MHDs) and substance use disorders (SUDs) in people living with HIV, hepatitis C virus (HCV) infection, and HIV/HCV coinfection are common and result in significant morbidity. However, there are no national prevalence estimates of these comorbidities in American Indian and Alaska Native (AI/AN) adults with HIV, HCV infection, or HIV/HCV coinfection. This study estimates the prevalence of MHD and SUD diagnoses in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection within the Indian Health Service (IHS). METHODS: In 2021, a cross-sectional study using data from the National Patient Information Reporting System was completed to identify MHD or SUD diagnoses in AI/AN adults with HIV, HCV infection, or HIV/HCV coinfection within the IHS during fiscal years 2001‒2020. Logistic regression was used to compare the odds of MHD or SUD diagnoses, adjusting for age and sex. RESULTS: Of AI/AN adults diagnosed with HIV, hepatitis C virus infection, or HIV/HCV coinfection, the period prevalence of MHD or SUD diagnoses ranged from 57.2% to 81.1%. Adjusting for age and sex, individuals with HCV infection had higher odds of receiving a MHD diagnosis (AOR=1.57; 95% CI=1.47, 1.68) or SUD diagnosis (AOR=3.40; 95% CI=3.18, 3.65) than those with HIV, and individuals with HIV/HCV coinfection had higher odds of receiving a MHD diagnosis (AOR=1.60; 95% CI=1.35, 1.89) or SUD diagnosis (AOR=2.81; 95% CI=2.32, 3.41) than those with HIV. CONCLUSIONS: MHD and SUD diagnoses were common in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection, highlighting the need for culturally appropriate screening and treatment programs sensitive to the diverse strengths of AI/AN populations and structural challenges they endure.

American Indian and Alaska Native veterans in the Indian Health Service: Health status, utilization, and cost.

PURPOSE: Many rural American Indian and Alaska Native (AIAN) veterans receive care from the Indian Health Service (IHS). United States Department of Veterans Affairs (VA) has reimbursement agreements with some IHS facilities and tribal programs and seeks to expand community partnerships in tribal areas, but details of how AIAN veterans use IHS are unknown. We aimed to assess the health status, service utilization patterns, and cost of care of veterans who use IHS. METHODS: We used comprehensive and integrated IHS data to compare health status, health service utilization and treatment cost of veterans (n = 12,242) to a matched sample of non-veterans (n = 12,242). We employed logistic, linear, or negative binomial regressions as appropriate, by sex and overall. FINDINGS: Compared to non-veterans, veterans had lower odds of having hypertension, renal disease, all-cause dementia, and alcohol or drug use disorders, but had similar burden of other conditions. In service utilization, veterans had lower hospital inpatient days; patterns were mixed across outpatient services. Unadjusted treatment costs for veterans and non-veterans were $3,923 and $4,145, respectively; veteran adjusted treatment costs were statistically lower. Differences in significance by sex were found for health conditions and service use. CONCLUSIONS: AIAN veterans, compared to AIAN non-veterans, were not less healthy, nor did they require more intensive or more costly care under IHS. Our results indicate the viability and importance of expanding IHS-VA partnerships in community care.