As a family physician and diabetes team lead in Juneau working for the Southeast Alaska Regional Health Consortium, Mary Owen, MD, could audit the care received by all of the diabetes patients served by her tribal clinic. The Special Diabetes Program for Indians (SDPI) funded this population-based approach through the Indian Health Service (IHS), which contracted with the clinic.
The audits allowed Owen, now director of the Center of American Indian and Minority Health at the University of Minnesota Medical School, to assess blood pressure and blood sugar control among patients and to gauge how many patients were receiving guideline-directed care. She could also compare her tribal clinic's results with other clinics in Alaska. If she saw that another community had better results, she could reach out and talk to them about what was working for them. “That has given us power,” said Owen, who is also president of the Association of American Indian Physicians. “The other piece of SDPI that's phenomenal is that we are able to run these systems ourselves.”
The community-driven focus of the SDPI has contributed to its lasting health benefits for Native American communities. Amid rising rates of end stage kidney disease (ESKD) nationally, American Indian and Alaska Native people experienced the lowest increases in the incidence of any racial or ethnic groups between 2000 and 2019, according to the US Centers for Disease Control and Prevention (CDC)'s Morbidity and Mortality Weekly Report (1). Cases of ESKD among American Indian and Alaska Native people increased about 25% during this period compared with a 42% increase in cases in the US overall. Other high-risk groups experienced dramatic escalations in incidence, including Asian (~150% increase), Native Hawaiian and other Pacific Islander (~97% increase), and Hispanic (84% increase) individuals. People of Black race experienced a 30% increase, and those of White race had a 33% increase.
The lead author of the CDC report (1), Nilka Ríos Burrows, MPH, an epidemiologist, recently with the Division of Diabetes Translation and head of the Chronic Kidney Disease (CKD) Initiative at the CDC, noted in an email interview that a variety of factors are contributing to rising rates of ESKD. These include a growing and aging US population; a high prevalence of risk factors, such as diabetes and hypertension; and better ESKD patient survival. However, Burrows and her co-authors attributed the SDPI with helping to slow rates of ESKD among American Indian and Alaska Native people, suggesting the program's population-based approach may be a model for helping to stem rising ESKD rates (Table 1). “The Special Diabetes Program for Indians made access to quality diabetes care and treatment a reality for the communities it served,” said Yvette Roubideaux, MD, MPH, director of the Policy Research Center at the National Congress of American Indians.
The power of population health
Burrows NR, et al. Reported cases of end-stage kidney disease—United States, 2000–2019. MMWR Morb Mortal Wkly Rep 2022; 71:412–415. doi: 10.15585/mmwr.mm7111a3
Indian Health Service. Special Diabetes Program for Indians. October 2016. Accessed May 3, 2022. https://www.ihs.gov/newsroom/factsheets/diabetes/
Bullock A, et al. Vital signs: Decrease in incidence of diabetes-related end-stage renal disease among American Indians/Alaska Natives—United States, 1996–2013. MMWR Morb Mortal Wkly Rep 2017; 66:26–32. doi: 10.15585/mmwr.mm6601e1
Office of the Assistant Secretary for Planning and Evaluation. The Special Diabetes Program for Indians: Estimates of Medicare savings. May 9, 2019. https://aspe.hhs.gov/reports/special-diabetes-program-indians-estimates-medicare-savings
Indian Health Service. Diabetes standards of care and resources for clinicians and educators. Accessed May 3, 2022. https://www.ihs.gov/diabetes/clinician-resources/soc/kidney-care/
Congress renews Special Diabetes Program to address Native health issues. Navajo-Hopi Observer, January 5, 2021. https://www.nhonews.com/news/2021/jan/05/congress-renews-special-diabetes-program-address-n/
Centers for Disease Control and Prevention (CDC). Native Americans with diabetes. Better diabetes care can decrease kidney failure. January 10, 2017. https://www.cdc.gov/vitalsigns/aian-diabetes/index.html