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Improving the Quality of Health Care 2004

Measuring Successes and Challenges

Acknowledgements

***Dr. Stephen Jay Mader (1951-2004)***

Data collected by:

**IHS and Tribal Health Program staff**

**IHS Area GPRA Coordinators**

**IHS Headquarters GPRA leads**

**Area GPRA Coordinators:**

  ------------- ------------------ ------------- ----------------------------------
  Aberdeen      Mary Lynne         \(605\)       <Mary.Eaglestaff@ihs.gov>
                Eaglestaff         226-7306      

  Alaska        Bonnie Boedeker    \(907\)       <BBoedeke@akanmc.alaska.ihs.gov>
                                   729-3665      

  Albuquerque   Regina Robertson   \(505\)       <Regina.Robertson@ihs.gov>
                                   248-4773      

  Bemidji       Mary Fairbanks     \(218\)       <Mary.Fairbanks@ihs.gov>
                                   444-0487      

  Billings      Diane Jeanotte     \(406\)       <Diane.Jeanotte@ihs.gov>
                                   247-7125      

  California    Carol Goodin       \(916\)       <Carol.Goodin@ihs.gov>
                                   930-3927      

  Nashville     Byron Jasper       \(615\)       <Byron.Jasper@ihs.gov>
                                   467-1507      

  Navajo        Jenny Notah        \(928\)       <Genevieve.Notah@ihs.gov>
                                   871-5836      

  Oklahoma      Marjorie Rogers    \(405\)       <Marjorie.Rogers@ihs.gov>
                                   951-6020      

  Phoenix       Steve Tetrev       \(602\)       <Steven.Tetrev@ihs.gov>
                                   364-5190      

  Portland      Cheryl Bittle      \(503\)       <Cheryl.Bittle@ihs.gov>
                                   326-3288      

  Tucson        John Kittredge     \(520\)       <John.Kittredge@ihs.gov>
                                   295-2406      
  ------------- ------------------ ------------- ----------------------------------

**Special thanks for data analysis, data format presentation, and report
preparation to:**

**Elaine Brinn, Theresa Cullen, Carol Goodin, and Amy Patterson**

**[IHS Contacts]{.underline}:**

**Theresa Cullen, MD, Timothy Taylor, PhD**

**Phone: (520) 670-4803 Phone: (301) 443-1549**

**<Theresa.Cullen@ihs.gov> <Timothy.Taylor@ihs.gov>**

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Table of Contents

[Executive Summary 1](#executive-summary)

[Detail of Selected Clinical Indicators
4](#detail-of-selected-clinical-indicators)

[Poor Glycemic Control 5](#poor-glycemic-control)

[Ideal Glycemic Control 6](#ideal-glycemic-control)

[Blood Pressure Control 7](#blood-pressure-control)

[Dyslipidemia Assessment 8](#dyslipidemia-assessment)

[Nephropathy Assessment 9](#nephropathy-assessment)

[Diabetic Retinopathy 10](#diabetic-retinopathy)

[Pap Screening 11](#pap-screening)

[Mammography Screening 12](#mammography-screening)

[Alcohol Screening (Fetal Alcohol Syndrome Prevention)
13](#alcohol-screening-fetal-alcohol-syndrome-prevention)

[Dental Access 14](#dental-access)

[Dental Sealants 15](#dental-sealants)

[Diabetic Dental Access 16](#diabetic-dental-access)

[Public Health Nursing 17](#public-health-nursing)

Intimate Partner
Violence............................................................................18

[Childhood Immunizations 19](#__RefHeading___Toc96228149)

[Influenza Immunizations 20](#influenza-immunizations)

[Pneumococcal Immunizations 21](#pneumococcal-immunizations)

[Summary of Other Indicators Met or Not Met
22](#summary-of-other-indicators-met-or-not-met)

[Graphics Credits & References 24](#graphics-credits-references)

## 

## Executive Summary

The Indian Health Service (IHS) is the agency within the Department of
Health and Human Services that carries out the federal government's
trust responsibility to provide health care services to eligible
American Indian and Alaska Native (AI/AN) people. IHS provides these
health services through a network of hospitals, emergency clinics,
health stations, school-based clinics, and numerous Alaskan village
clinics.

These facilities provide direct health care services to over 1.9 million
AI/AN people. Currently, over half of the Indian health system is
operated directly by tribal governments through contracts or compacts.
In addition to these tribally operated programs, IHS contracts with
urban Indian organizations to provide services to eligible AI/AN people
who reside in large metropolitan areas. Together, these sources of care
are known as the IHS/Tribal/Urban (I/T/U) network. When the capability
to provide a particular service is not available through this network,
the IHS Contract Health Services (CHS) appropriation covers the cost of
referring patients to hospitals and specialists. However, most health
programs deplete their funds prior to the end of the year.

Historically, the Indian Health Service has succeeded in substantially
improving the health status of the AI/AN population, primarily by
focusing on preventive and primary care services and developing a
community-based public health system. Examples can be seen in the
dramatic decreases in mortality rates for certain health problems
between 1972-1974 and 1997-1999:

-   Maternal mortality reduced 79% (31.6 to 6.7 per 100,000);

-   Tuberculosis mortality reduced 86% (10.7 to 1.5 per 100,000);

-   Gastrointestinal disease mortality reduced 72% (6.7 to 1.9 per
    100,000);

-   Infant mortality reduced 65% (25.0 to 8.8 per 100,000);

-   Unintentional injuries mortality reduced 54% (206.7 to 95.1 per
    100,000).

The average death rate from all causes for the AI/AN population dropped
a significant 21% between 1972-1974 and 1996-1998.

However, population growth and economic factors are creating pressure on
AI/AN communities and the IHS system. From 1990 to 2000, the AI/AN
population grew at a rate of 26%, while the total U.S. population grew
by only 13%. The Census Bureau projects a 40% increase in the AI/AN
population from 2000 to 2025. In addition, the 1999 unemployment rate
for the AI/AN population was 2.5 times higher than the rate for the rest
of the population;

the percent of the AI/AN population living in poverty was more than
three times that of the non-Hispanic white population in 1999 (25.7%
compared to 8.1%). Educational levels, which influence economic
prospects, also reflect significant differences. The 2000 census
reported that among people aged 25 and older who identified their race
as AI/AN only, 11% had a bachelor's degree or higher compared with 26.7%
of all people aged 25 and older; only 71% of AI/ANs had at least a high
school diploma compared to 84.1 % of all people in the 25 and older age
range.

The AI/AN population suffers disproportionately from a number of health
problems. For example:

-   The 1999-2001 death rate from alcohol abuse was more than 6 times
    higher among AI/ANs than the rate for all races in 2000;

-   In 2001, AI/ANs were 2.6 times more likely to have diagnosed
    diabetes than non-Hispanic whites and the death rate from diabetes
    was 2.9 times higher among AI/ANs than non-Hispanic whites;

-   The death rate from diabetes in the AI/AN community has increased by
    79.9% between 1972-1974 and 1999-2001.

The growth in AI/AN population and chronic disease rates, as well as
socioeconomic constraints, are increasing the challenge of effectively
improving the health status of this population. While the death rates
for both the AI/AN and the U.S. All Races populations dropped according
to the most recent statistics published in January 2005, the rate of
decline among U.S. All Races from 1997 to 2000 was almost twice the rate
of decline among AI/ANs from 1996-1998 to 1999-2001. The 1999-2001
mortality rates for the AI/AN population (adjusted to compensate for
misreporting of AI/AN race on state death certificates) are 21% higher
than the 2000 mortality rate for U.S. All Races. In 2004, the agency
GPRA results reflect the difficulty of maintaining services in light of
increasing demand, as the number of annual GPRA targets that were met
dropped below 70%.

At the same time, it is important to note that the number of patients
actually receiving care has risen. The agency has made significant
progress on some important indicators. For example, in 2004, the
screening rate for diabetic nephropathy rose from 38% last year to 42%.
End stage renal disease or diabetic kidney disease, is a significant and
growing problem in Indian communities. Early identification of patients
at risk for end stage renal disease may help to prevent or delay the
need for costly care such as dialysis or renal transplant.

This year, IHS also made progress in increasing the pneumococcal
vaccination rate for adults over 65 years of age from 65% in 2003 to 69%
in 2004. The improvement in pneumococcal vaccination rates is important
because studies have shown that AI/AN people are at high risk for this
disease; the 1999-2001 AI/AN death rate from pneumonia and influenza was
42% greater than the 2000 U.S. All Races death rate. Vaccination of the
elderly against this disease is one of the few medical interventions
that has been shown to improve health status and save on medical costs.

![](media/image4.wmf){width="3.84375in" height="2.6666666666666665in"}

Clearly, the I/T/U programs have demonstrated the ability to improve
AI/AN health over time. In 2004, IHS continued to maximize health
outcomes. Accountability for GPRA Government Performance Results Act
(GPRA) results is now part of the performance appraisal criteria at all
levels. Clinical Results System software, which provides the capability
for local programs to identify non-compliant patients for follow-up, has
been deployed nationally to interested local facilities. Training for
program staffs is presented in every IHS Area. Area GPRA coordinators
have been actively networking to share information and material on
successful programs, as well as technical assistance to programs to
identify ways of improving clinic operations.

The annual GPRA evaluation is one of a number of measures that assesses
IHS performance. One other important measure is the Performance
Assessment Rating Tool (PART) used by OMB (Office of Management and
Budget). The single IHS program assessed by the PART for this budget
cycle was the Health Care Facilities Construction Program, which
received an overall score of 92%. One of the strengths of this program
is its clear linkage to annual GPRA indicators and ultimately to the
long-term goal of reducing the Years of Potential Life Lost (YPLL). In
essence, this program documents how the construction of health care
facilities contributes to expanding access to critical services as
identified by clinical performance measures documented in the IHS GPRA
plan at specific sites once they are completed and staffed.

This increase in access to critical services over time results in the
reduction of premature deaths as measured by YPLL. The Health Care
Facilities Construction Program's PART assessment required no new
performance measures beyond the existing GPRA indicators (including the
efficient construction of facilities) and the long-term measure of YPLL
from the IHS Strategic Plan. Finally, the contribution of this program
to HHS objectives 3.4 *Eliminate racial and ethnic health disparities*
and 3.6 *Increase access to health services for AI/ANs* is exceptionally
clear.

## Detail of Selected Clinical Indicators {#detail-of-selected-clinical-indicators .Style1}

**Government Performance Results Act**

**2004**

![](media/image5.png){width="1.4666666666666666in"
height="1.4666666666666666in"}

## Poor Glycemic Control

**Indicator:** Assure that the proportion of patients with diagnosed
diabetes that have poor glycemic control does not increase.

**Importance:** *Reducing the number of patients with poor blood sugar
control will reduce the prevalence of diabetes complications. Some
clinical studies have shown that a 1% decrease in the absolute A1c level
translates into: 14% decrease in total mortality, 21% decrease in
diabetes-related deaths, 14% decrease in myocardial infarction, 40%
decrease in eye disease, 12% decrease in strokes, 43% decrease in
amputations, and a 24% decrease in kidney failure. Reducing A1c levels
can also save \$800 per person in annual health care costs.*

![](media/image4.wmf)**2004 Target:** Establish the baseline of patients
with diagnosed diabetes that have poor glycemic control.

**Data source:** GPRA+ electronic examination of 74,408 patient records

IHS diabetic Care and Outcomes Audit

**Results:** IHS met this indicator by setting a baseline.

**Discussion and analysis:** According to GPRA+ results, in 2004, 17% of
diabetic patients had poor glycemic control (\>9.5), as measured by the
Hemoglobin A1c test that measures average blood sugar over the last 1-2
months.

## Ideal Glycemic Control

**Indicator:** Address the proportion of patients with diagnosed
diabetes that have demonstrated ideal glycemic control.

**Importance:** *Keeping Hemoglobin A1c levels below 7 can slow or
prevent the onset and progression of eye, kidney, and nerve disease
caused by diabetes. Good blood sugar control also lowers the risk of
heart attack and stroke.*

**2004 Target:** Increase the proportion of I/T/U clients who have
demonstrated ideal glycemic control by 1%.

![](media/image5.wmf){width="4.1875in" height="2.53125in"}

**Data source:** GPRA+ electronic examination of 74,408 patient records

IHS Diabetic Care and Outcomes Audit

**Results:** IHS met this indicator based on diabetic audit data.

**Discussion and analysis:** The FY 2004 diabetic audit data showed a 3%
increase in the proportion of I/T/U clients with diagnosed diabetes that
have demonstrated ideal glycemic control. These results reflect
meaningful agency accomplishment considering:

-   The prevalence of diabetics in the communities represented in the
    GPRA+ review has increased from 8% in 2000 to 10% in 2004.

-   The number of patients being treated for diabetes in these same
    communities is 7% higher than the number treated in 2003 and 34%
    higher that in 2000.

-   77% of diabetic patients were screened for HbA1c, compared to 67% in
    2000, substantially exceeding the Healthy People 2010 goal of 50%.

-   The number of patients in good control increased from 18,998 in 2003
    to 19,743 in 2004.

## Blood Pressure Control

**Indicator:** Address the proportion of patients with diagnosed
diabetes that have achieved blood pressure control.

**Importance:** *This indicator is directed at reducing complications of
diabetes. A National Heart, Lung, and Blood Institute report indicates
that the risk of heart disease and stroke doubles for every increase of
20 mm in systolic or 10 mm in diastolic pressure. Lower blood pressure
levels in people with diabetes reduce the risk of heart disease and
stroke by 33-50%. Blood pressure control also reduces the risk of eye,
kidney, and nerve disease by one third.*

**2004 Target:** Increase the proportion of I/T/U patients with
diagnosed diabetes that have achieved blood pressure control (\<130/80)
by 1% over the FY 2003 level.

![](media/image6.wmf){width="4.083333333333333in"
height="2.5104166666666665in"}

**Data source:** GPRA+ electronic examination of 74,408 patient records

IHS Diabetic Care and Outcomes Audit

**Results:** IHS met this indicator based on diabetic audit data.

**Discussion and analysis:** The FY 2004 diabetic audit data showed that
the proportion of patients in good control increased from 33% to 34%.
GPRA+ data showed a drop in the percentage of patients who achieved good
control from 37% in 2003 to 35% this year. This drop may be attributable
to tightening the definition of good blood pressure control in GPRA+
software from 2003 to 2004. As a result, some patients who were
considered to be in good control last year are no longer in that
category.

## Dyslipidemia Assessment

**Indicator:** Address the proportion of patients with diagnosed
diabetes assessed for dyslipidemia.

**Importance:** *Low cholesterol levels help to protect diabetic
patients from developing heart disease. Improved control of cholesterol
levels reduces the risk of cardiovascular complications by 20-50%.
National standards recommend that people with diabetes keep their
cholesterol levels below 200 mg/dl, and their LDL cholesterol levels
below 130 mg/dl and ideally below 100 mg/dl. Diabetic patients are
especially prone to develop heart disease and therefore identification
and treatment of elevated lipids in diabetic patients is extremely
important. In addition, because persons with diabetes who experience a
heart attack have an unusually high death rate either immediately or in
the long term, a more intensive prevention strategy is warranted.*

**2004 Target:** Increase the proportion of patients with diagnosed
diabetes assessed for dyslipidemia by 1% over the FY 2003 level.

![](media/image7.wmf){width="4.09375in" height="2.5208333333333335in"}

**Data source:** GPRA+ electronic examination of 74,408 patient records

IHS Diabetic Care and Outcomes Audit

**Results:** IHS met this indicator in 2004.

**Discussion and analysis:** The target of increasing the number of
patients assessed for dyslipidemia was met and substantially exceeded
according to both the diabetic audit data and GPRA+ data.

## Nephropathy Assessment

**Indicator:** Address the proportion of patients with diagnosed
diabetes assessed for nephropathy.

**Importance:** *Diabetes can cause kidney disease by damaging the parts
of the kidneys that filter out wastes. Diabetes is the leading cause of
end stage renal disease (ESRD) and kidney failure, a growing problem in
Indian communities. Early identification of at risk patients may help
prevent or delay the need for costly care such as dialysis or kidney
transplant.*

*Microalbumin (small amounts of protein) in the urine is an early sign
of diabetic kidney disease. Proteinuria (any protein in the urine) is
also an independent predictor of cardiovascular disease, which is the
number one killer of American Indian and Alaska Native adults.*

**2004 Target:** Increase the proportion of patients with diagnosed
diabetes assessed for nephropathy by 1% over the FY 2003 level.

![](media/image8.wmf){width="4.1875in" height="2.7395833333333335in"}

**Data source:** GPRA+ electronic examination of 74,408 patient records

IHS Diabetic Care and Outcomes Audit

**Results:** IHS met this indicator.

**Discussion and analysis:** The target of increasing the number of
patients assessed for nephropathy was met and substantially exceeded,
with a 4% increase in the number of patients assessed based on GPRA+
data and a 2% increase according to the diabetic audit data.

## Diabetic Retinopathy

**Indicator:** Address the proportion of patients with diagnosed
diabetes who receive an annual diabetic retinal examination at
designated sites.

**Importance:** *Diabetes can affect sight by damaging the blood vessels
inside the eye, a condition known as "diabetic retinopathy." Diabetic
eye disease is a leading cause of blindness in the United States. Early
detection of diabetic retinopathy (DR) is a fundamental part of the
effort to reduce visual disability in diabetic patients. Clinical trials
demonstrated that effective laser photocoagulation treatment of DR could
reduce vision loss by 90%. These studies also underscore the need for
early identification of DR at a time when laser photocoagulation is most
effective*

**2004 Target:** During FY 2004, increase the proportion of I/T/U
patients with diagnosed diabetes who receive an annual diabetic retinal
examination at designated sites by 3% over the FY 2003 rate.

![](media/image9.wmf){width="5.0625in" height="2.5625in"}

**Data source:** GPRA+ data from RPMS databases at selected pilot sites
as well as all other facilities.

**Results:** IHS did not meet this indicator.

**Discussion and analysis:** In FY 2003, the examination rate for pilot
sites was 58%; in FY 2004, the rate dropped to 55%. Reasons for this
drop include an increase in the size of the diabetic population as well
as eye department staff decreases, or lack of staff increases. Adjusting
for these variables, increases can be shown at all pilot sites except
one, where the "Tmed-DR" telemedicine program was minimally operational
in 2004 due to staffing issues. Compared with the results of all sites
providing GPRA+ data in FY 2004, the results at pilot sites are
impressive. The rates for all sites dropped from 49% in FY 2003 to 47%
in FY 2004.

## Pap Screening

**Indicator:** Address the proportion of eligible women patients (ages
18 through 64) who have had a Pap screen within the previous three
years.

**Importance:** *American Indian women have a cervical cancer mortality
rate of 3.8 (1999-2001) exceeding the 2000 rate of 2.8 for U.S. All
Races. More than any other racial or ethnic group, American Indian women
report having never had a Pap screen. Regular screening with a Pap
screen lowers the risk of invasive cervical cancer. If cervical cancer
is detected early, the survival rate is almost 100 percent with
appropriate treatment and follow- up.*

![](media/image10.wmf){width="3.875in" height="2.4895833333333335in"}

**2004 Target:** Maintain the proportion of eligible women patients who
have had a Pap screen within the previous three years at the FY 2003
levels.

![](media/image11.wmf){width="4.48125in" height="2.209722222222222in"}

**Data source:** GPRA+ electronic examination of 227,904 patient records

**Results:** IHS did not meet this indicator, partly because
gynecological examinations are no longer counted unless the patient
record explicitly states a Pap screen has been done.

**Discussion and analysis:** In 2004 the Pap screen rate was 58%, a drop
of 3% from the 61% rate reported in 2003.

## Mammography Screening

**Indicator:** Address the proportion of eligible women (ages 50 through
64) who have had mammography screening within the last 2 years.

**Importance:** *Screening women every two years between the ages of 50
and 69 has been shown to be a cost effective way to decrease the breast
cancer mortality rate. Breast cancer is the second leading cause of
cancer death among U.S. women (lung cancer is first). Regular
mammography screening can reduce breast cancer mortality by 20-30%.
AI/AN women diagnosed with breast cancer have lower 5-year survival
rates in comparison to whites, mainly because their cancers are less
likely to be found in earlier stages.*

**2004 Target:** During FY 2004, maintain the proportion of eligible
women patients who have had mammography screening within the last 2
years at the FY 2003 level.

![](media/image12.wmf){width="4.5625in" height="3.0729166666666665in"}

**Data source:** GPRA+ electronic examination of 39,780 patient records.

**Results:** IHS met this indicator

**Discussion and analysis:** The 2004 mammogram rate remained unchanged
from the 2003 rate of 40%. Experience with mobile mammography
demonstrates that lack of equipment to perform screenings on site is one
reason this rate is difficult to increase. For example, one site
offering mobile mammogram service had a 56% screening rate in 2003; the
rate dropped to 47% in 2004 when the service was not available.
Similarly, another site with a 48% screening rate in 2003 dropped to a
20% rate in 2004 when its grant for mobile mammography ended. A second
factor is that Contract Health Service funding, used to purchase care
not available at the local operating unit, is often spent on emergency
care.

##   {#section-1 .unnumbered}

## 

## Alcohol Screening (Fetal Alcohol Syndrome Prevention)

**Indicator:** Address screening for alcohol use in appropriate female
patients.

**Importance:** *Heavy drinking during pregnancy can cause significant
birth defects, including Fetal Alcohol Syndrome (FAS). FAS is the
leading known, and preventable, cause of mental retardation. Rates of
FAS are higher among AA/ANs than the general population. The US
Preventative Services Task Force recommends screening and behavioral
counseling interventions to reduce alcohol misuse by adults, including
pregnant women, in primary care settings. Screening with intervention
has been shown to be effective in reducing alcohol misuse in pregnancy
and to reduce the incidence of FAS.*

**2004 Target:** During FY 2004, establish a baseline screening rate for
alcohol use in women of childbearing age.

![](media/image13.wmf){width="3.9895833333333335in"
height="2.8020833333333335in"}

**Data source:** GPRA+ electronic examination of 217,255 patient records

**Results:** IHS met this indicator and established a baseline screening
rate of seven percent.

**Discussion and analysis:** The intermediate goal of this indicator is
to increase the screening rate for women of childbearing age. The long
term goal is a reduction in the incidence of Fetal Alcohol Syndrome.

## Dental Access

**Indicator:** Address the proportion of AI/AN patients who obtain
access to dental services.

**Importance:** *This indicator is directed at improving the oral health
status of the American Indian and Alaska Native population. Untreated
tooth decay can cause abscesses and infections, pain, dysfunction and
weight loss. Dental problems result in the loss of almost 2.5 million
workdays each year. Access to dental care improves oral health as well
as the overall health of AI/AN people.*

**2004 Target:** Maintain the proportion of patients that obtain access
to dental services at the 2003 level.

![](media/image14.wmf){width="3.8229166666666665in"
height="2.2916666666666665in"}

**Data source:** GPRA+ electronic extraction of 1,168,311 patient
records

**Results:** IHS did not meet this indicator.

**Discussion and analysis:** The target of increasing the percent of
patients who accessed dental services in 2004 was not met, as the
percentage of patients obtaining access dropped by 1% to 24%. The key
national factor contributing to this drop is the continued high vacancy
rate in the dental program, which remains around 23%. Access to care,
over recent years, seems closely tied to vacancy rates. A second factor
is a substantial drop (9%) in the percentage of patients reported as
accessing dental service in one Area. In all other reporting areas, the
percentage of patients reported as accessing dental services remained
static or varied by either one percent higher or lower. An investigation
into this discrepancy showed that two reporting facilities had
substantial data entry problems. These two facilities did have manual
tallies available. If we take these into account, the indicator is met.

## Dental Sealants

**Indicator:** Address the number of sealants placed in AI/AN patients
per year.

**Importance:** *Surveys of American Indian and Alaska Native children
have consistently identified them as having significantly higher dental
decay rates than the general U.S. population. Dental sealants, a
recognized standard in preventive dental care, are an effective measure
for reducing dental decay rates and can be effectively applied by dental
auxiliaries at relatively low cost. Sealants reduce both the ravages and
costs of treating dental decay.*

**2004 Target:** During FY 2004, maintain the number of dental sealants
placed per year in American Indian and Alaska Native patients at the FY
2003 level.

![](media/image15.wmf){width="5.5in" height="2.8229166666666665in"}

**Data source:** The National Patient Data Information Reporting System
(NPIRS). In 2005, sealant data will be reported based on data collected
at local facilities using CRS software.

**Results:** IHS met this indicator.

**Discussion and analysis:** The intent of this indicator is to reduce
dental decay by increasing both the number of patients with dental
sealants and the number of sealants per patient, and the 2004 target was
met. As measured by NPIRS, the total number of sealants increased from
243,499 in 2003 to 287,158 in 2004.

## Diabetic Dental Access

**Indicator:** Address that the proportion of patients diagnosed with
diabetes who obtain access to dental services.

**Importance:** *The purpose of this indicator is to improve both oral
health status and diabetic control for American Indian and Alaska Native
diabetics. All diabetic patients should receive a complete dental exam
on an annual basis. Diabetics are at increased risk for destructive
periodontal disease and subsequent tooth loss.*

*In addition, untreated periodontitis (inflammation of the gums) in
diabetics may complicate glycemic control. Access to both primary and
secondary treatment and preventive services for diabetics can lessen
periodontal disease progression and the subsequent effects on diabetes
and overall health. Regular visits provide opportunities for prevention,
early detection, and treatment.*

**2004 Target:** Increase the proportion of patients with diagnosed
diabetes who obtain access to dental services by 1% over the 2003 level.

![](media/image16.wmf){width="4.572916666666667in" height="2.875in"}

**Data source:** GPRA+ examination of 74,408 patient records

IHS Diabetes Care and Outcomes Audit

**Results:** IHS met this indicator.

**Discussion and analysis:** The percentage of patients diagnosed with
diabetes that accessed dental care increased by 1% over the previous
year. The diabetic audit data showed a 2% increase.

## Public Health Nursing

**Indicator:** Address the number of public health nursing services
provided by public health nurses.

**Importance:** *Public health nursing is a method of delivering
services to patients outside of the clinic or hospital setting. Public
health nurses usually treat very young children, pregnant women,
patients with chronic or acute diseases, the elderly, and the medically
under-served. Public health nurses provide health assessment, health
promotion, disease prevention, and infectious disease management. The
public health nurse has intimate knowledge of the local community and
family structures; this knowledge is essential in improving health
status. Public health nursing in the community and homes helps reduce
health care cost through early detection and prevention of health
problems and reaches patients who might not receive care if they were
required to travel to a doctor's office.*

**2004 Target:** Maintain the total number of public health nursing
services provided to individuals in all settings and the total number of
home visits at the 2003 workload levels.

![](media/image17.wmf){width="4.65625in" height="2.8854166666666665in"}

**Data source**: GPRA+ electronic examination of 1,168,311 patient
records

**Results:** IHS met this indicator.

**Discussion and analysis:** The total number of home visits reported in
2004 was 192,121 compared to 160,650 visits reported in 2003. The total
number of visits in all settings was 423,379 in 2004, compared to
359,089 visits reported in 2003. It is important to note that the number
of facilities reporting in 2004 increased significantly.

**Domestic Violence - Intimate Partner Violence**

**Indicator:** Address the proportion of women who are screened for
domestic violence at health care facilities.

**Importance:** *This indicator is designed to ascertain, evaluate and
reduce the prevalence of family violence, abuse and neglect in American
Indian and Alaska Native communities. Rates of intimate partner violence
are double for American Indian and Alaska Native people compared to
whites, and 1½ times greater than U.S. all races. The health
consequences of intimate partner violence are numerous. Women who
experience domestic violence are more often victims of nonconsensual
sex, have higher levels of smoking, chronic pain syndromes, depression,
generalized anxiety, substance abuse, and Post-Traumatic Stress
Disorder. Screening and appropriate referrals should help decrease the
morbidity and mortality associated with intimate partner violence.*

**2004 Target:** During FY 2004, the IHS will screen at least 15% of
female patients ages 16-24 for domestic violence at health care
facilities.

![](media/image18.wmf){width="5.197916666666667in"
height="2.9270833333333335in"}

**Data source:** GPRA+ electronic examination of 78,917 patient records.

**Results:** IHS did not meet this indicator with only 4% of eligible
patients screened.

**Discussion and analysis:** IHS is working with the Family Violence
Prevention Fund and Administration for Children and Families to fund
domestic violence prevention projects in over 10 communities during FY
2005.

[]{#__RefHeading___Toc96228149 .anchor}**Childhood Immunizations**

**Indicator:** Address rates for recommended immunizations for AI/AN
children patients 19-35 months.

**Importance** *Routine immunizations (vaccines) represent a
cost-effective public health measure that significantly improves the
health of children. Among all US children aged 19-35 months, vaccine
coverage in 2003 reached an all-time high. National coverage levels are
now over 90 percent for each vaccine recommended through age 35 months,
except the Varicella and Pneumococcal vaccines, and the fourth dose of
DTaP. National Immunization Survey statistics show that AI/AN children
have vaccination rates that are below the national averages. The Healthy
People 2010 goal is 90% coverage for all routine immunizations for
children aged 19-35 months.*

**2004 Target:** During FY 2004, establish baseline rates for
recommended immunizations for American Indian and Alaska Native children
19-35 months and increase 3-27 month rates by 2% over FY 2003.

![](media/image19.jpeg){width="4.259722222222222in"
height="2.839583333333333in"}

**Data source:** Quarterly immunization reports on children 3-27 months
old and an annual 2- year old immunization report based on IHS patient
care records and public health nursing records of children who receive
immunizations at an IHS facility. GPRA+ data will be used in future
years.

**Results:** IHS did not meet this indicator.

Discussion and analysis: Although a baseline rate was established for
children 19-35 months, the coverage rate for 3-27 month old children was
raised only by 1%, from 80% to 81%. After 2004, the IHS will track
immunization rates for children ages 19-35 months only.

## Influenza Immunizations

**Indicator:** Address influenza rates among adult patients aged 65
years and older.

**Importance:** *Influenza (flu) is a highly contagious respiratory
disease that can cause potentially life-threatening secondary
infections. Elders who get influenza are also at increased risk of
hospitalization and death from heart disease and stroke, and vaccination
reduces that risk. In one study comparing vaccinated to non-vaccinated
persons aged 65 and older over two influenza seasons, researchers found
a 20% reduction in hospitalization for cardiovascular and
cerebrovascular events in addition to a 30% reduction in hospitalization
for influenza and a 50% reduction in death from all causes.*

**2004 Target:** In FY 2004, maintain FY 2003 rate for influenza
vaccination levels among adult patients aged 65 years and older.

![](media/image20.wmf){width="3.7395833333333335in"
height="2.6458333333333335in"}

**Data source:** GPRA+ electronic examination of 46,647 patient records

**Results:** IHS met this indicator.

**Discussion and analysis:** The target of maintaining the influenza
vaccination rate was met and exceeded, with the percentage of eligible
patients receiving influenza vaccine at 54%. This rate is 3% higher than
the percentage reported last year and more than 20% higher than the
percentage reported in 2000. Continued efforts must be made in order to
reach the Healthy People 2010 goal of a 90% immunization rate. Studies
show that system interventions such as standing orders to administer
vaccine increased rates by 39%, more than any other type of
intervention.

##  Pneumococcal Immunizations

**Indicator:** Address Pneumococcal vaccination rates among adult
patients aged 65 years and older.

**Importance:** *The purpose of this indicator is to reduce illnesses
and deaths due to pneumococcal disease among older adults. Elder health
is an increasingly important issue as more and more of the population
survives beyond the age of 65. Pneumococcal disease includes pneumonia,
bacteremia, and meningitis. Pneumococcal disease has the highest death
toll from a vaccine-preventable bacterial disease and patients over the
age of 65 account for more than 51% of the deaths. Vaccination of the
elderly against pneumococcal disease is one of the few medical
interventions that has been found to improve health and save on medical
costs.*

**2004 Target:** In FY 2004, maintain the FY 2003 rate for pneumococcal
vaccination levels among adult patients age 65 years and older.

![](media/image21.wmf){width="4.385416666666667in"
height="2.7736111111111112in"}

**Data source:** GPRA+ electronic examination of 46,647 patient records

**Results:** IHS met this indicator.

**Discussion and analysis:** The target of maintaining the 2003 rate for
pneumococcal vaccination was met and exceeded. In 2004 the percentage of
patients receiving pneumococcal vaccinations rose 4% compared to the
percentage reported in 2003.

## Summary of Other Indicators Met or Not Met

**Government Performance Results Act**

**2004 Results**

![](media/image22.png){width="1.625in" height="1.625in"}

**The following page shows results for those 2004 GPRA indicators not
highlighted on the previous pages. A comprehensive GPRA indicator list
for FY04-FY06, including complete definitions, is located at**
www.ihs.gov/cio/crs

  ------------------------------------------ ----- -----------------------
  [2004 GPRA Indicator]{.underline}                [Met/Not Met/Data
                                                   Pending]{.underline}

  Youth Regional Treatment Centers                 Met

  Fluoridated water                                Not met

  Data quality improvement                         Met

  Behavioral health                                Not met

  Urban improvement                                Met

  IHS hospital and clinic accreditation            Met

  Medication error reporting                       Met

  Customer satisfaction                            Not met

  Injury prevention                                Met

  Injury deaths                                    Data available 2005

  Suicide prevention surveillance                  Met

  Cardiovascular disease prevention (pilot         Met
  sites)                                           

  Obesity assessment                               Met

  Tobacco use assessment                           Met

  HIV risk reduction counseling                    Not met

  Environmental health web-based system            Met

  Sanitation facilities to Indian homes            Met

  Construction of new health facilities            Met

  I/T/U satisfaction with consultation             Not met

  CHS procurements by contracts and rate           Not met
  quotes                                           

  Assessment of public health infrastructure       Met

  Placement of scholarship recipients              Met

                                                   

                                                   

                                                   

                                                   
  ------------------------------------------ ----- -----------------------

##  Graphics Credits & References

**GRAPHICS CREDITS**

© Poison\'s Icons (<http://members.aol.com/poison64/nagifs/gifs.html>)

© THE GREASY GRASS 2000-2004
(<http://www.thegreasygrass.com/ggtrail.html>)

Cover Photo Courtesy of Nora Cata

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height="1.6236111111111111in"}