Objective: To conduct a community assessment with the intention of improving glycemic control in members of the target population.
Design: A community assessment utilizing qualitative and quantitative data related to type 2 diabetes was conducted.
Population: The prevalence of type 2 diabetes in American Indians has been estimated at nine percent (MMWR, 2001, v. 50, No. RR-16), nearly a third higher than that seen in the United States general population. The target population of this study consists of members of one southwestern American Indian tribe who have type 2 diabetes. The assessment was conducted within the reservation community and focused on the ambulatory care setting. Data was collected over a two-year period and concluded in September 2000.
Concepts or Variables Studied Together: The level of meeting diabetes standards of care and medication adherence are assessed as independent variables related to glycosilated hemoglobin. Survey and group-generated data provide additional meaning and cultural context.
Methods: A systematic assessment examining indicators of both clinical care of diabetes and community capacity was conducted between May 1999 and September 2000. Quantitative and qualitative data were collected and analyzed. Two annual chart audits (99-2000) were conducted on a sample of patient records using the Indian Health Service audit tool. This tool includes indicators of glycemic control, self-management, diabetes complications, medication regimens, and completion of standards of care. The records sampled (n=220) were retrieved from a registry of diabetic patients receiving care within the previous three years at the two clinic sites on the reservation. Data was trended incorporating audit results from the current study period as well as secondary data from 1995-1998. In addition to the record review, medication adherence and its determinants were examined as an additional measure of the need for a care coordination program. Descriptive statistics were used to aggregate trend data. The Mantel-Haenszel chi-square and ANOVA were used to compare categorical variables and mean values across groups. Qualitative data was collected through survey and group process, which included information obtained through diabetes advisory committee and tribal health board meetings. Qualitative responses were quantified according to content analysis and consensus building protocol.
Findings: Audit results, over time, revealed poor blood sugar control and a low rate of meeting the Tribal health clinic’s standards of care. A combined percentage of patients seen at both clinics revealed that only 23 percent of the sampled population had glycosilated hemoglobin (HbA1c) levels less than 7.0%, the recommendation of both the American Diabetes Association (Diabetes Care 25:S33-S49, 2002) and the Indian Health Service (http://www.ihs.gov/MedicalPrograms/Diabetes/2001soc.pdf). Additionally, it was shown that the time since being out of medication (r=0.40, p=0.008) and the time since the clients’ last diabetes-focused visit (r=0.35, p=0.01) was each positively associated with HbA1c. Qualitative data revealed that transportation, appointment availability and cultural congruency were the major barriers to meeting standards of care.
Conclusions: The successful management of diabetes is determined by a variety of behaviors on the part of both the client and health care provider / health care system. Care coordination, or case management, has been repeatedly shown to improve outcomes in individuals with chronic diseases such as diabetes mellitus. The complexity of self-management may be reduced through the implementation of a care coordination program aimed at assisting the client in making health-supportive decisions.
Implications: Findings from both the health assessment and the care coordination literature have supported the development of an innovative program in this American Indian community. Funding was awarded for the implementation and evaluation of a care-coordination pilot project. Nurses must continue to assist communities in the development of culturally congruent and clinically viable strategies aimed at reducing the many health disparities seen in vulnerable populations.
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