Journal of General Internal Medicine

, Volume 26, Issue 5, pp 480–486

Trends in Quality of Care and Barriers to Improvement in the Indian Health Service

  • Thomas D. Sequist
  • Theresa Cullen
  • Kenneth Bernard
  • Shimon Shaykevich
  • E. John Orav
  • John Z. Ayanian
Original Research

DOI: 10.1007/s11606-010-1594-4

Cite this article as:
Sequist, T.D., Cullen, T., Bernard, K. et al. J GEN INTERN MED (2011) 26: 480. doi:10.1007/s11606-010-1594-4

ABSTRACT

BACKGROUND

Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.

OBJECTIVE

To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).

DESIGN

Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.

PARTICIPANTS

Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.

MAIN MEASURES

Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.

KEY RESULTS

Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.

CONCLUSIONS

Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

KEY WORDS

Indian health service Native American American Indian racial disparities quality of care quality improvement 

Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  • Thomas D. Sequist
    • 1
    • 2
    • 3
  • Theresa Cullen
    • 4
  • Kenneth Bernard
    • 1
  • Shimon Shaykevich
    • 1
  • E. John Orav
    • 1
  • John Z. Ayanian
    • 1
    • 2
  1. 1.Division of General Medicine and Primary CareBrigham and Women’s HospitalBostonUSA
  2. 2.Department of Health Care PolicyHarvard Medical SchoolBostonUSA
  3. 3.Harvard Vanguard Medical AssociatesBostonUSA
  4. 4.Indian Health ServiceRockvilleUSA

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