Indian Health Service Research Articles

Longitudinal associations of depression and diabetes with Alzheimer’s disease and related dementias risk among American Indian and Alaska Native people

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) research worldwide indicate that it is more common in indigenous than in non‐indigenous populations. The increased risk for ADRD among indigenous people may be partially due to the population’s high rates of depression and diabetes. Thus, we examined the relationship of depression and diabetes, alone and together, with incident ADRD in a large sample of American Indian and Alaska Native people (AI/ANs).MethodWe used data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project with a sample of 65,801 AI/ANs aged ≥ 45 years. The IHS Data Project includes data for a purposeful sample of AI/ANs who lived in 15 IHS service units, which are IHS geographic classifications located throughout the United States. We used Cox proportional hazard models to estimate associations between ADRD risk and baseline depression and diabetes.ResultWe found that 2.3% of our sample received an ADRD diagnosis during FY2010‐13. Compared to persons with neither depression nor diabetes, unadjusted models indicated that those who had both depression and diabetes had twice the risk of developing ADRD (Hazard Ratio (HR) = 2.02, 95% CI = 1.72‐2.37). The unadjusted risk among those with depression only was 77% higher (HR = 1.77, 95% CI = 1.50‐2.08). Adjusted analyses showed that the HR for those with depression and diabetes was 1.82 (95% CI = 1.53‐2.16) and those with depression only had a hazard ratio of 1.70 (95% CI = 1.44‐2.00) for ADRD. The association between depression and diabetes and depression only with ADRD risk was stronger for persons aged 45 to 64 years compared to persons aged ≥ 65 years. In the adjusted models, we did not find a relationship between only having diabetes and ADRD risk.ConclusionOur findings suggest that depression by itself and depression with diabetes increases the risk of ADRD in AI/ANs aged ≥ 45 years. In the future, ensuring clinical and behavioral services for AI/ANs include regular mental health screening and depression treatment might help decrease ADRD risk. Such efforts may also focus on middle‐aged persons.

Abstract C110: Mobile low dose computerized tomographic (LDCT) scanning program identifies pre-malignant lung cancer lesions in a Native American population: A study of Indian Health Service and Levine Cancer Institute

Abstract BACKGROUND: Native Americans (NA) are an under-served population for healthcare, including lung cancer screening. Randomized trials have shown LDCT screening for lung cancer improves survival but with severe under-representation of NA due to financial and insurance constraints, geography and lack of access. They are over-represented in national statistics of presentation with advanced disease and lung cancer deaths. In our region, the Indian Health Service (IHS) has recorded less than 5% of eligible heavy smokers from the Catawba and other tribes have undergone LDCT lung screening. We previously reported that a free, mobile LDCT unit achieved a shift to earlier diagnosis in African Americans (AAs) and other under-served groups with improved 4 year survival and reduced costs of care (1).We adapted our initial trial to include a structured evaluation of efficacy and utility of mobile LDCT in heavy smokers in our NA population. We hypothesized that mobile LDCT would overcome key obstructions to lung cancer screening in NA. METHODS: We used a coach fitted with a portable 32 slice low-dose CT scanner; all films were reviewed by a central panel via the LUNGRADS protocol (1). Eligible subjects were invited to participate by IHS staff. Levine Cancer Institute committed to treat any identified cancers, irrespective of insurance status to avoid delay. Technical details of the unit have been reported (1). RESULTS: 91 heavy smokers have been screened, representing 60% participation rate, with the following characteristics: M:F=1:1; median age 61 years (44-77 years); 68% had some form of health insurance which did not cover lung cancer screening (termed "under-insured") and 32% were uninsured; 73% still smoking; median pack year history 48 (range 22-98). No lung cancers were identified but 10% had LUNGRADS 3-4 (moderate-high risk) lesions, 36% had LUNGRADS 2 lesions and 20% had scattered, non-diagnostic lung lesions; patients with LUNGRADS 4 lesions were offered biopsy to define whether cancer was present. All subjects have been recruited into ongoing follow up LDCT and smoking cessation programs. DISCUSSION: NA traditionally have had the highest level of advanced lung cancer at presentation with high mortality rate from lung cancer. We have increased participation in LDCT lung cancer screening from 5% to 60% of eligible heavy smokers, and have identified a unique sub-population of 10% with potentially premalignant disease that will require meticulous follow-up to achieve early diagnosis of lung cancer. Our previous studies in impoverished AAs and other under-served groups have identified a shift from 20% to 60% early stage cancer at diagnosis; similar benefits are expected in NAs. This is the first such study in NAs and suggests mobile LDCT should be considered by health services responsible for their care. Studies of the science of cancer in the under-served should also focus on pragmatic solutions with potential for early improvement in outcome. REFERENCES: 1. Raghavan D et al, The Oncologist, 2020, 25: e777-e781. Citation Format: Kia Dungan, Hollis Reed, Darcy Doege, Daniel Carrizosa, Melissa Wheeler, Derek Raghavan. Mobile low dose computerized tomographic (LDCT) scanning program identifies pre-malignant lung cancer lesions in a Native American population: A study of Indian Health Service and Levine Cancer Institute [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C110.

Abstract IA009: Curios case of cancer among American Indians and Alaska Natives

Abstract Cancer incidence data published in 2008, and cancer mortality data published in 2014, both paint a picture of profound geographic variation in these rates among American Indians/Alaska Natives. Non-Hispanic whites (NHWs) living across six large geographic regions upon which both datasets were analyzed rarely exhibited geographic variation greater than 25%, with an upper limit approaching 30%. This is in distinct contrast to the AIAN population living in the same regions, who routinely exhibited geographic variation in cancer incidence rates ranging over 100% and from some cancer types in excess of 500%. These data will be shown, and subsequent consequences future priorities discussed. By the conclusion of this presentation, attendees will Gain more valuable insight about the federal Indian Health Service Be delighted to see that they can understand raw cancer data including multiple lessons regarding the profound geographic variation in AIAN cancer incidence rates Identify how they may get involved with those of us who are focused on these AIAN cancer disparities. Citation Format: Jeffrey A. Henderson. Curios case of cancer among American Indians and Alaska Natives [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA009.

Self-Determination to Better Health Outcomes: A Study of Diabetes in the Native American Community

Increased self-determination in health care by the Native American community may help combat preventable diseases like diabetes. The racial stereotyping of Native Americans in medical clinics has been found to directly correlate to health disparities such as poor care and poor medical outcomes (Solomon et al.). However, since 1975, the ISDEAA, or Indian Self-Determination and Education Assistance Act, provides three major avenues by which Native Americans may receive health care: directly from the federal government through the Indian Health Service, through a Title I contract to administer part of their own health care programs, or through a Title V compact to take over all of their own health care (Marley, “Ambiguous Jurisdiction” 433). Longitudinal research into the diabetes prevalence rates across time for each of the 574 federally recognized tribes should be juxtaposed against the timeline of when each individual tribe evolved from Indian Health Service dependent to Title I, and then finally to Title V. I had sought to prove that diabetes prevalence rates for Native Americans show a lagging decline as self-determination of health care increases. Further collection of specific, tribal, micro-level data is necessary to prove or disprove this point. Ultimately, this conceptual paper is a proposal for further data collection by the United States Department of Health and Human Services, which is in charge of the Indian Health Service.

Incidence of Stomach, Liver, and Colorectal Cancers by Geography and Social Vulnerability Among American Indian and Alaska Native Populations, 2010-2019.

Social determinants of health and associated systems, policies, and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared with other racial/ethnic groups. In this study, we examined incidence rates of 3 types of gastrointestinal cancer among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and Social Vulnerability Index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000 population) for stomach, liver, and colorectal cancers were compared within NH-AI/AN populations and between the NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate- and high-SVI-score counties in Alaska, the Southern Plains, and the East than in low-SVI counties. Incidence rates among NH-AI/AN populations were elevated when compared with NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations.

Early-Career Compensation Trends Among Family Physicians.

Family medicine incomes are often cited as a key reason for shortages of family physicians. The purpose of this study was to identify family physician income trends and to test how income varies among early-career family physicians. We used data from the 2016 to 2020 American Board of Family Medicine National Graduate Survey (NGS) collected from early-career family physicians (n = 9566; response rate = 63.9%). The NGS asked practice income, practice activities, practice site, and setting. We performed an income trend analysis and conducted multivariate regression to test for associations of personal and workplace characteristics with income. Average income across the full sample of early-career family physicians (after inflation adjustments) was $224,292. Overall, income growth outpaced inflation from 2016 to 2020. There are significant differences in income based on personal and work characteristics, and income growth varied dramatically. Notably, women respondents reported earnings of $33,522 below those of men respondents in adjusted models. In addition, the incomes of several groups lagged behind inflation, including those practicing geriatrics (-0.67%), employed by the Indian Health Service (-1.72%), and respondents who identified as Black or African American (-0.85%). Greatest increases in inflation-adjusted incomes were observed among those in palliative care (4.61%) and at nonfederal government clinics (4.46%). Though income is only one factor physicians consider in deciding where and how to work, it is concerning to see lower incomes among groups that traditionally experience shortages (eg, geriatrics and government-associated practice sites). Differences in expected income among family physicians choosing different work may exacerbate workforce challenges.

Surveillance Methods Used to Detect, Characterize, and Monitor the COVID-19 Pandemic in Rocky Mountain Tribal Communities.

Data were essential to public health decision-making during the COVID-19 pandemic, yet no single data source was adequate for Tribes in Montana and Wyoming. We outlined data access, availability, and limitations for COVID-19 pandemic surveillance response to improve future data exchange. The Rocky Mountain Tribal Epidemiology Center (RMTEC) used various data sources to deliver data on the number of COVID-19 cases, deaths, and vaccinations at local, state, and regional levels to inform Tribes in Montana and Wyoming. RMTEC reviewed state, federal, and public datasets and then attached a score to each dataset for completeness of demographic information, including race, geographic level, and refresh rate. The RMTEC COVID-19 response team shared data weekly on the number of COVID-19 cases, deaths, and vaccinations distributed and the percentage of the population vaccinated with Tribal health departments in Montana and Wyoming. The Indian Health Service Epidemiology Data Mart dataset scored the highest (24 of 30), followed by datasets from Montana (18 of 30) and Wyoming (22 of 30). Publicly available datasets scored low largely due to data aggregation across larger geographic areas and lack of demographic variables. The absence of data on race and ethnicity from publicly available data and lack of access to real-time data limited RMTEC's ability to provide Tribal-specific updates on COVID-19 cases, deaths, and vaccinations to Tribal health departments. RMTEC should be fully funded to provide the necessary resources for data management and the capacity to respond to data requests from Tribal health departments and their programs to address current and future pandemics. Federal and state agencies should also be educated on Tribal Epidemiology Centers' public health authority status to improve access to infectious disease data among those agencies.

1391-P: National Retrospective Cohort Study of COVID-19 Infection and Incident Diabetes in American-Indian/Alaska-Native People

Background: Studies report increased risk of incident diabetes following COVID-19 illness. American Indian/Alaska Native (AI/AN) people have had more frequent and severe COVID-19 illness and historically higher diabetes incidence than other racial/ethnic groups in the US. We examined the association between COVID-19 illness and incident diabetes in AI/AN people. Methods: Using de-identified data from the Indian Health Service, we created three cohorts spanning two periods: COVID-19 cohort and no-COVID-19 cohort (no indication of COVID-19 infection) both from 3/1/2020-12/31/2021 and pre-COVID-19 cohort from 1/1/2018-2/28/2020. We used data from the year prior to cohort entry to exclude prevalent cases of diagnosed diabetes (diagnosis codes, labs, or diabetes medications) and assess baseline characteristics. During the study period we ascertained COVID-19 infection (diagnosis codes, labs) and incident diabetes. We calculated age-adjusted diabetes incidence rates and rate ratios comparing the COVID-19 cohort to the no-COVID-19 and pre-COVID-19 cohorts. Results: Across cohorts, age, sex, and healthcare utilization differed. Age-adjusted diabetes incidence rates and rate ratios were significantly higher in the COVID-19 cohort (Table 1). Conclusions: Clinically confirmed COVID-19 infection was associated with increased incident diabetes rates in AI/AN people. Disclosure J.Keck: None. S.Bressler: None. M.Bruce: None. U.Chukwuma: None. M.E.Lacy: None. Funding National Institutes of Health (R34DK132548-01S1)

American Indian and Alaska Native substance use treatment: Barriers and facilitators according to an implementation framework

IntroductionSubstance use disorder (SUD) and overdose deaths are higher in the American Indian and Alaska Native (AIAN) population than in other racial/ethnic groups. Multi-level gaps hinder SUD treatment for AIAN patients. Few studies have engaged front-line clinicians and administrators of SUD treatment programs serving AIAN patients to identify barriers and facilitators to improve the implementation of effective treatment. MethodsWe conducted key informant interviews with a diverse sample of providers and administrators of SUD treatment programs across California regarding barriers and facilitators to treatment for AIAN patients. An AIAN-majority community advisory board (CAB) guided the development of an interview guide and helped to recruit respondents from five types of SUD programs statewide. Using ATLAS.ti, the research team coded interviews and classified emergent themes as barriers and facilitators related to Outer, Inner, and Individual domains of the Consolidated Framework for Implementation Research (CFIR). ResultsRepresentatives of 13 of 15 invited SUD treatment programs participated and 9 of the 13 interviewed self-identified as AIAN. Related to Outer Setting barriers from coded interviews, a dominant barrier was policies that defund or underfund SUD treatment, especially detoxification centers. Outer Setting facilitators included consistent Indian Health Service (IHS) eligibility criteria, judicial system connections for direct treatment access, and community programs advocating SUD treatment. Key themes related to barriers for the Inner Setting were limited bed capacity, poor coordination of intake and care, and lack of telehealth technology. Facilitators integrated mental health, linkage to external resources, and culturally centered care. Individual-level barriers were negative attitudes such as SUD stigma, distrust of governmental programs, and lack of transportation while individual engagement was facilitated by programs addressing negative attitudes and providing telemedicine for remote care. ConclusionThe public health threat of SUD for the AIAN population mandates the implementation of interventions and policies that facilitate care. This qualitative study with primarily AIAN clinical leaders of SUD treatment highlights opportunities to improve care at multiple CFIR levels, focusing on capacity, coordination, culturally congruent care, and community initiatives to promote engagement.

The relationship between social determinants of health and hospitalization among American Indian and Alaska native older adults with and without dementia

AbstractBackgroundAlthough American Indian and Alaska Native (AI/AN) adults are at high risk for dementia, little is known about their hospital inpatient utilization. AI/ANs who access health services through the Indian Health Service and Tribal health programs experience disparities in income, education, and health care access. The aim of this study is to examine patient characteristics, including social determinations of health (SDOH), that are associated with having one or more hospital admissions among AI/AN adults aged 65+ years, and to understand how dementia influences their risk of hospitalization.MethodWe analyzed fiscal year 2013 hospital utilization data from Indian Health Service and Tribal health programs for 19,025 AI/AN adults aged ≥65 years who lived in 31 counties across 12 project sites. Among these adults, 1,464 had dementia. We estimated a logistic regression model, with project site fixed‐effects and county‐level random effects, to examine associations between health status, health coverage, and 3 SDOH (educational attainment, household income, and geographical access to hospital facilities) with being hospitalized 1+ times during the year.ResultThe odds of hospitalization were higher for patients with dementia (Odds Ratio (OR) = 2.56; 95% CI: 2.19‐3.01, p<0.01), than those without dementia. Having cardiovascular disease (OR = 3.46; 95% CI: 3.05‐3.92, p< 0.01) and liver disease (OR = 3.74; 95% CI: 3.15‐4.43, p<0.01) also increased the odds of hospitalization. Adults with Medicaid coverage, compared to those without, had higher odds of hospitalization (OR = 1.36; 95% CI: 1.16‐1.59, p<0.01). While living in a county with lower educational attainment increased the odds of hospitalization (OR = 1.03; 95% CI: 1.01‐1.05, p< 0.05), living in a county with a lower household income had no association. Patients with travel time >45 minutes from their community to a hospital, compared to 15 minutes or less, had lower odds of hospitalization (OR = 0.63; 95% CI: 0.55‐0.72, p< 0.01).ConclusionUnderstanding and addressing SDOH associated with hospitalizations among AI/AN older adults, with and without dementia, may aid in the development of strategies that reduce preventable hospitalization. In‐depth studies are needed to understand the health risks of AI/AN with dementia who have Medicaid coverage and who live far from hospital services.

The costs of treating dementia among American Indians with diabetes within the Indian Health Service and Tribal health programs

AbstractBackgroundAmerican Indian and Alaska Native (AI/AN) adults have one of the highest prevalence of diabetes (14.7%) in the United States, nearly double that of the White population. As AI/ANs age, they are at high risk for chronic diseases that have diabetes as a well‐established risk factor, such as cardiovascular complications and dementia. Approximately half of AI adults with dementia have diabetes, but little is known about their treatment costs. Our aims were to profile treatment costs of AI adults with diabetes, with and without dementia, and to understand how dementia influences costs by type of service.MethodWe analyzed fiscal year 2013 treatment cost data from the Indian Health Service and Tribal health programs for American Indian (AI) adults aged ≥65 years with diabetes. Using data for 921 adults with dementia and a matched sample without dementia (n = 921), matched by age, sex, and location, we report actual and adjusted total treatment costs and costs by service type. Adjusted costs were estimated using a generalized linear model with a log link function and gamma distribution.ResultsThe morbidity burden of AI adults with both diabetes and dementia was high. Over seventy percent (71.4%) had cardiovascular disease (CVD) and 39.4% had renal disease. The prevalence of these conditions was lower (57.8% and 30.6%, respectively) among adults with diabetes without dementia. Mean total treatment cost was higher for adults with dementia ($15,978) than for adults without dementia ($8,857), a difference of $7,121. The difference in adjusted total treatment costs between adults with and without dementia was $3,891 (95% confidence interval [CI]: $2,122‐$5,659), most of which was due to the difference in hospital inpatient costs ($3,754; 95% CI: $2,221‐$5,286). Furthermore, among adults with both dementia and CVD, adjusted hospital inpatient costs were $8,114 (95% CI: $6,018‐$10,211), significantly higher than that among adults with dementia only ($2,075; 95% CI: $992‐$3,158) and among adults with CVD only ($3,050; 95% CI: $2,399‐$3,701) (Figure 1).ConclusionKnowing CVD is strongly associated with high inpatient costs among AI adults with both diabetes and dementia may inform enhancements to outpatient and home‐based services that address their CVD health risks.

A Health Equity Fellowship Based in Experiential Learning Through a Rural Academic-Community Partnership

While rural communities continue to experience significant health disparities, investment in graduate medical education (GME) focused on rural health remains uneven.1 Investing in rural GME could allow early-career physicians to address health disparities by providing leadership training and mentored experience generating systems change. Leadership skills and systems change are especially important when physicians work in communities they are not from. There is a steep learning curve to understanding a community's priorities, governance structures, and building their trust. Despite best intentions, unprepared physicians may fail to make lasting beneficial change for the community, and communities risk losing physicians to burnout and turnover.The Massachusetts General Hospital Fellowship Program in Rural Health Leadership teaches skills in leadership and health systems change to early-career primary care physicians through a rural-based experiential learning model based on Kolb's Learning Styles Inventory.2 Fellows develop attitudes, knowledge, and skills in leadership and health equity by moving through 4 stages of learning: (1) experiencing and reflecting on the rural experience; (2) acquiring new knowledge and concepts; (3) practicing new ideas through discussion; and (4) taking action and learning from the result.Fellows spend a quarter per year of the 2-year program at the rural community partner site in Rosebud, South Dakota, working clinically as independent attending-level physicians. Rosebud is the home of the Sicangu Lakota Oyate and Indian Health Service Rosebud Service Unit and has long experienced some of the worst health outcomes in the country due to sustained historical, systemic, and infrastructure challenges. As the Rosebud community experiences many of the same challenges facing rural communities across the United States, fellows learn skills in leadership and health equity that can be translated in their future careers to other sites with challenged infrastructure.Faculty support is provided by a network of academic teaching physicians experienced in rural health through a combination of asynchronous/synchronous and remote/on-site forums, including weekly meetings where difficult clinical cases and systems improvement work is discussed, a de-identified encrypted group chat, monthly discussion exchanges with other global and rural fellowships, weekly fellow seminars, and shared reading lists. These teaching interactions provide fellows with new concepts to apply to their experiences, as well as opportunities to articulate their reflections and test their new ideas through discussion.A key aspect of the fellowship is the completion of a mentored capstone project in any aspect of systems change—research, policy, advocacy, quality improvement, or education are a few examples. Focused mentorship and a program-funded Master of Public Health are pillars of the capstone project support. These capstone projects allow fellows to apply their lessons learned to new practice and to observe the results.The key values of the program are imbued in the structure of experiential learning and are seen in the fellows' activities during the program and beyond (Table).In a 2021 GME survey of fellows, the clinical breadth and intense experiential learning in clinical and leadership roles was consistently named as a major strength of the program.Successful graduates from the program should be prepared to move directly into a leadership position in rural and community health. Since the first fellowship class graduated in 2017, the fellowship has produced 7 graduates. Since graduation, fellows have gone on to positions in medical education leadership, policy, and leading innovative clinical programs with rural and underserved populations.

Patterns of Health Care Access and Use in an Urban American Indian and Alaska Native Population.

Studies of health care access and use among historically resilient populations, while common, often field a limited sample size and rarely ask the groups most impacted by health inequities to weigh in. This is especially so for research and programs that focus on the American Indian and Alaska Native (AIAN) population. The present study addresses this gap by examining data from a cross-sectional survey of AIANs in Los Angeles County. To better interpret project findings and generate culturally relevant contexts, qualitative feedback was gathered at a community forum held in Spring 2018. Because recruitment of AIANs has historically been challenging, purposive sampling was employed to strategically identify a larger eligible pool. Among those who were eligible, 94% completed the survey (n = 496). AIANs who were enrolled in a tribe were 32% more likely to use the Indian Health Service (IHS), compared with those who were not enrolled (95% CI: 20.4%, 43.2%; p < .0001). In multivariable modeling, the strongest factors influencing IHS access and use were: tribal enrollment, preference for culturally-specific health care, proximity of the services to home or work, having Medicaid, and having less than a high school education. Feedback from the community forum indicated cost and trust (of a provider) were important considerations for most AIANs. Study findings reveal heterogeneous patterns of health care access and use in this population, suggesting a need to further improve the continuity, stability, and the image of AIANs' usual sources of care (e.g., IHS, community clinics).

Underutilization of Transcatheter Aortic Valve Replacement in Northern Plains American Indians with Severe Aortic Stenosis

IntroductionTranscatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement and revolutionized the treatment strategy for aortic valve replacement. Little is known on the disparities among minorities, especially American Indians (AI), undergoing this procedure. We explore TAVR outcomes to identify disparities at our institution.MethodsRetrospective chart review was completed on patients who underwent TAVR at a North Dakota community hospital between 2012 and 2021. There were 1133 non-AI and 20 AI patients identified (n = 1153). AI patients were identified by enrollment in nationally recognized tribes, Indian Health Service (IHS), or who self-identified as AI. Patient demographics, preoperative characteristics, procedural information, and outcomes were collected. United States 2020 census data was used for state-wide population racial percentages. Unpaired two tail t test assuming unequal variance and chi-squared tests were used to evaluate data and identify disparities between AI and non-AI.ResultsAI presented at an earlier age (71 vs. 79; p = .001) with higher rates of diabetes (60% vs. 35%; p = .018) and history of smoking (100% vs. 60%; p ≤ .001) than Caucasian/white (C/W). The Society of Thoracic Surgery (STS) risk scores (3.2% vs. 4.6%; p = .054) and aortic valve mean gradients were lower among AI (42.8 mmHg vs. 47.5 mmHg; p = .010). For those deceased, AI had significantly shorter lifespans post-TAVR compared to C/W (374 days vs. 755 days; p = .004). AI from North Dakota had fewer TAVR procedures performed than expected (4 actual vs. 32 expected; p < .001).ConclusionsAI undergoing TAVR presented earlier, with higher rates of diabetes and smoking, lower STS risk scores, and lesser aortic valve gradients than C/W. The number of TAVR procedures performed on AI from North Dakota was lower than anticipated despite a nearly 10-year period and the disparities experienced by AI who could have otherwise benefited from TAVR.

Insight of a headache medicine provider in Indian Health Service: A personal and professional observation

Dr. Larry Charleston IV has received personal compensation for serving as a consultant for Allergan/AbbVie, Alder/Lundbeck, Amneal, Biohaven, Haleon, LinPharma, Satsuma, and Teva; was on the advisory panel for Ctrl M Health (stock); received grant support from the Disparities in Headache Advisory Council; served as an Expert Witness for Vaccine Injury Compensation Program. He is a non-compensated associate editor for Headache: The Journal of Head and Face Pain and serves as a non-compensated Board Member-at-Large for the Clinical Neurological Society of America. Mary Michelle Herne serves as a non-compensated member of the Advanced Practice Provider Committee for Association of Migraine Disorders.

"Prescriptive authority for psychologists: The next step": Correction.

Reports an error in "Prescriptive authority for psychologists: The next step" by Steven Eric Curtis, Samantha Hoffmann and Maeve O'Leary Sloan (Psychological Services, Advanced Online Publication, May 05, 2022, np). In the original article, changes were needed to clarify the timeline of state legalizations of prescriptive authority for psychologists (RxP) and the current status of RxP with regard to the Federal Bureau of Prisons (BOP). In the second paragraph of the "RxP From 2011 to Present" section, the citations relating to legalization in Idaho and Iowa were corrected, and the year in the Prescribing Psychologist reference was corrected in the References section and in text citations throughout. Additionally, in the last paragraph of the "RxP From 2011 to Present" section, the text was updated to clarify that at the present time, prescribing psychologists are not able to prescribe for the BOP. All versions of this article have been corrected. (The following abstract of the original article appeared in record 2022-58802-001). Since the endorsement of prescriptive authority for psychologists (RxP) by the American Psychological Association (APA) in 1995, it has become legal in five states (Idaho, Illinois, Iowa, Louisiana, and New Mexico). The Department of Defense, including the U.S. Air Force, U.S. Army, and U.S. Navy, as well as the Public Health Service, and the Indian Health Service, continue to utilize prescribing psychologists as well. There are now over 200 prescribing psychologists in the United States. Five APA-designated RxP training programs offer a pathway to attain prescription privileges and future board certification when approved. The purpose of this article is to provide information for those with minimal exposure to RxP, updates for those more informed, and recommendations for the next phase of RxP. This article examines scholarship related to RxP as well as newsletter columns, state legislative efforts, current RxP laws, policies, training programs, and critical events in the RxP history. Public access to quality and comprehensive mental health services can be expected to improve as more psychologists complete the necessary RxP training and licensure requirements. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prescriptive authority for psychologists: The next step.

[Correction Notice: An Erratum for this article was reported online in Psychological Services on Jul 11 2022 (see record 2022-79840-001). In the original article, changes were needed to clarify the timeline of state legalizations of prescriptive authority for psychologists (RxP) and the current status of RxP with regard to the Federal Bureau of Prisons (BOP). In the second paragraph of the "RxP From 2011 to Present" section, the citations relating to legalization in Idaho and Iowa were corrected, and the year in the Prescribing Psychologist reference was corrected in the References section and in text citations throughout. Additionally, in the last paragraph of the "RxP From 2011 to Present" section, the text was updated to clarify that at the present time, prescribing psychologists are not able to prescribe for the BOP. All versions of this article have been corrected.] Since the endorsement of prescriptive authority for psychologists (RxP) by the American Psychological Association (APA) in 1995, it has become legal in five states (Idaho, Illinois, Iowa, Louisiana, and New Mexico). The Department of Defense, including the U.S. Air Force, U.S. Army, and U.S. Navy, as well as the Public Health Service, and the Indian Health Service, continue to utilize prescribing psychologists as well. There are now over 200 prescribing psychologists in the United States. Five APA-designated RxP training programs offer a pathway to attain prescription privileges and future board certification when approved. The purpose of this article is to provide information for those with minimal exposure to RxP, updates for those more informed, and recommendations for the next phase of RxP. This article examines scholarship related to RxP as well as newsletter columns, state legislative efforts, current RxP laws, policies, training programs, and critical events in the RxP history. Public access to quality and comprehensive mental health services can be expected to improve as more psychologists complete the necessary RxP training and licensure requirements. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

An initial reliability analysis of a patient counseling rubric to objectively measure student pharmacist performance

Current literature outlines the documented need for improved communication during patient medication counseling. Although many tools exist, there needs to be a national standardized tool that complies with federal and state law, to objectively measure student pharmacist performance during patient counseling in the community pharmacy setting. The primary objective of this study is to perform an initial analysis of the internal consistency reliability of a patient medication counseling rubric designed with an Indian Health Services theoretical framework. Secondary objectives include measuring changes in student performance over the time of the study. The 18-item rubric was developed to objectively measure student pharmacist performance during patient medication counseling sessions in a 21-h Introductory Pharmacy Practice Experience (IPPE) course. The community-pharmacy-based IPPE patient counseling course evaluates students' communication skills and patient-centered counseling techniques in live and simulated patient counseling sessions. Three pharmacist evaluators assessed a total of 247 student counseling sessions. The rubric's internal consistency reliability was analyzed, and student performance improvement was observed within the course. Students' performance was evaluated as “meets expectations” in most live and simulated sessions. However, an independent groups t-test showed that the mean performance score for the live counseling sessions (2.59, SD = 0.29) was higher (p < 0.001) than that for the simulated counseling sessions (2.35, SD = 0.35). Students' performance in the course improved over three weeks [Week 1: mean (SD) = 2.29 (0.32), Week 2: mean (SD) = 2.44 (0.33), Week 3: mean (SD) = 2.62 (0.29); p < 0.001]. A Tukey-Kramer comparison post hoc test found a significant increase in the mean performance scores between weeks (p < 0.05). The overall internal consistency reliability of the counseling rubric was determined acceptable, with a Cronbach's alpha of 0.75. Further study is required, including the assessment of inter-rater reliability, factor analysis, variable analysis, and use in other states with patient confirmation testing necessary to validate the rubric for use with student pharmacists in the community pharmacy setting.

Great Plains American Indians' Perspectives on Patient and Family Needs Throughout the Cancer Journey.

To explore the perspectives on patient and family needs during cancer treatment and survivorship of American Indian (AI) cancer survivors, caregivers, Tribal leaders, and healers. 36 AI cancer survivors from three reservations in the Great Plains region. A community-based participatory research design was employed. Postcolonial Indigenous research techniques of talking circles and semistructured interviews were used to gather qualitative data. Data were analyzed using content analysis to identify themes. The overarching theme of accompaniment was identified. The following themes were intertwined with this theme: (a) the need for home health care, with the subthemes of family support and symptom management; and (b) patient and family education. To provide high-quality cancer care to AI patients in their home communities, oncology clinicians should collaborate with local care providers, relevant organizations, and the Indian Health Service to identify and develop essential services. Future efforts must emphasize culturally responsive interventions in which Tribal community health workers serve as navigators to accompany patients and families during treatment and in survivorship.

"Know Your Children, Who They Are, Their Weakness, and Their Strongest Point": A Qualitative Study on Diné Parent Experiences Accessing Autism Services for Their Children.

Marked inequities in access to autism services and related health outcomes persist for U.S. children, undermining broader initiatives to advance the population's health. At the intersection of culture, poverty, and ruralness little remains known about autism in many Indigenous communities. This qualitative study on the lived experiences of Navajo (Diné) parents raising a child with autism sought to identify factors affecting access to services. A Diné researcher conducted in-depth interviews with 15 Diné parents of children with autism living in or around the Navajo Nation. A directed content analysis approach was used to identify themes, subthemes, and connections between themes. Twelve overarching themes emerged on Diné parents' experiences accessing autism diagnostic and treatment services, as well as ways access to autism services can be improved. The following themes were related to diagnosis: the diagnostic process was often emotionally fraught; long wait times of up to years for diagnostic services were commonplace; limited clinician training and cultural humility impeded access to diagnostic services; and adequate health insurance, Indian Health Service referrals, care coordination, financial aid for travel, and efficient evaluation facilitated diagnosis. Themes on treatment access were as follows: parent perceptions of the extent to which an autism service helped their child affected access; social support helped parents to access treatment; obtaining referrals and care coordination influenced treatment access; treatment costs affected access; and service availability and geographic proximity impacted treatment access. Themes on ways to improve access to autism services were as follows: greater autism awareness is needed; autism-focused support groups may be helpful; and increased availability and quality of autism services across and around the Navajo Nation is paramount. Diné parents' access to autism services was dynamically affected by sociocultural factors that must be addressed in future health equity-oriented initiatives.