Journal of General Internal Medicine

, Volume 26, Issue 5, pp 480–486 | Cite as

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

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



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


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


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


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


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.


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.


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


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



Dr. Sequist was funded by the Robert Wood Johnson Foundation through the Harold Amos Minority Faculty Development Program and the Network for Multicultural Research on Health and Healthcare, Department of Family Medicine, David Geffen School of Medicine, U.C.L.A. Dr. Ayanian was supported by the Health Disparities Research Program of Harvard Catalyst | The Harvard Clinical and Translational Science Center (NIH Award #UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic health care centers). The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, the National Center for Research Resources, or the National Institutes of Health. This research was presented at the Annual Research Meetings of the Society of General Internal Medicine (Miami, FL) and Academy Health (Chicago, IL) in 2009. We would like to thank the Indian Health Service physicians and their patients for participating in this study.

Conflict of Interest



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Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  • Thomas D. Sequist
    • 1
    • 2
    • 3
    Email author
  • 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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