Virtually unheard of in the Native American and Native Alaskan populations until the 1950s, type 2 diabetes is now one of the largest medical problems faced by indigenous peoples in the United States. Native peoples have a diagnosis rate of about 16 percent, almost double the national average.
Left unchecked, diabetes often leads to other serious medical complications, including end-stage renal disease (ESRD), for which it is the most common cause.
As sobering as these statistics are, some good news on the ESRD front has emerged. Over the past two decades, the Indian Health Service (IHS), an agency of the US Public Health Service that serves a population of more than 2 million from more than 550 tribes, has instituted a public health model of care that resulted in a 54 percent decline in kidney failure due to diabetes over a 17-year period.
It is a model of care that can be replicated on a wider scale, said Andrew S. Narva, MD, director of the National Kidney Disease Education Program at the National Institutes of Health (NIH). He was instrumental in implementing the model during his 25-year tenure at the IHS, where he served as a chief clinical consultant for nephrology and director of the Kidney Disease Program until 2006.
The sharp decline in ESRD among Native Americans is “quite significant,” he said. “It’s really an example of how the Indian Health Service has turned around a problem.” By 2013, the rate of ESRD diagnosis among people with diabetes was virtually the same in Native Americans as among whites.
Dr. Narva attributed the IHS’ success to education—of patients with diabetes and the health professionals who provide their care.
The training of physicians, registered nurses, pharmacists, dietitians, behavioral health specialists and community health workers has taken place at the hundreds of hospitals, health centers, clinics and health stations run by the IHS or the tribes themselves. During his time at the IHS in New Mexico, Dr. Narva said, he clocked about 25,000 miles a year in his car to oversee care of patients with kidney disease and to offer workshops about identifying Native Americans at risk for ESRD and putting in place early intervention techniques that have proven effective in preventing diabetic patients from developing kidney problems. The workshops touched on:
Periodic monitoring of kidney function (eGFR) and kidney damage (albuminuria).
Continued management of blood pressure and glucose levels.
Use of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) to slow progression.
Use of statins to bring down and control elevated lipid levels.
Prudent use of nonsteroidal medications.
Medical management of cardiovascular risk factors.
Patient education about the need for dietary modifications, regular exercise, and other lifestyle changes.
“”The organization of Indian Health Service facilitates quality improvement in a chronic disease like diabetes,” Dr. Narva told AMA Wire®. “It’s a matter of delivering simple interventions in a systematic and consistent manner.”
Indian Health Service has a history of welcoming innovative approaches such as telemedicine to care which improve outcomes for American Indian people. Dr. Narva has conducted a telenephrology clinic remotely with the IHS Zuni Comprehensive Health Center in New Mexico since 2007, a year after he left his full-time job at IHS to work at NIH.
In a recent article published in Advances in Chronic Kidney Disease, Dr. Narva and his colleagues documented their experiences conducting the twice-monthly clinic at which he has consulted with more than 1,800 patients and their direct health care providers over the past decade. Dr. Narva and his colleagues wrote that “a collaborative approach engaging a nurse case manager, nephrologist, primary clinicians, pharmacists and community health nurses” was essential to the team’s efforts in ESRD prevention, with the nurse manager “the most critical factor in successfully conducting a referral clinic by telemedicine.”
Although the kidney disease-control effort was instituted within IHS, a unique healthcare organization, Dr. Narva added that there was nothing so specialized about it so as to deter clinicians and health care administrators from adapting it to other, larger settings and patient groups.
The AMA has a policy supporting IHS programs that benefit Native American health and opposing cuts to the program.
Brian P. McDonough, MD, FAAFPPeer
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