Foot care practices, services and perceptions of risk among medicare beneficiaries with diabetes at high and low risk for future foot complications.

A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient claims data and their risk for foot complications was estimated based on claims reflecting services for recent foot problems. A telephone survey of a random sample from this cohort was conducted to assess their foot care practices, barriers, and perceptions of risk. Eight percent of respondents reported a history of foot ulcers and 7% a history of lower extremity amputation. Based on claims data, 30% of respondents were at high risk for future foot complications. Compared to those at low risk, those at high risk were more likely to report having an annual foot exam, using protective footwear, and perceiving themselves to be high risk for future foot complications. However, 50% of those with claims indicating a high risk perceived themselves to be at low risk for future foot complications. Overall, 20% of respondents seldom checked their feet daily for sores or irritations. Among this group, 60% felt that it was unimportant and 9% reported they were limited by poor vision or physical problems. Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes. Additionally, emphasis is needed to help individuals understand their risk and seek and perform appropriate preventive foot care.

Establishing surveillance for diabetes in American Indian youth.

OBJECTIVE: To determine prevalence estimates in order to monitor diabetes, particularly type 2 diabetes, in American Indian youth. RESEARCH DESIGN AND METHODS: To explore the feasibility of developing a case definition using information from primary care records, all youth aged <20 years with an outpatient visit or hospitalization for diabetes were identified from the Billings Area Indian Health Service database in Montana and Wyoming from 1997 to 1999, and the medical records were reviewed. Classification for probable type 1 diabetes was based on age < or =5 years, weight per age < or =15th percentile at diagnosis, or positive results of islet cell antibody test. Classification for probable type 2 diabetes was based on weight per age > or =85th percentile or presence of acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history for type 2 diabetes, or use of oral hypoglycemic agents with or without insulin or absence of current treatment 1 year after diagnosis. RESULTS: A total of 52 case subjects with diabetes were identified, 3 of whom had diabetes secondary to other conditions. Of the remaining 49 case subjects, 25 (51%) were categorized as having probable type 2 diabetes, 14 (29%) as having probable type 1 diabetes, and 10 (20%) could not be categorized because of missing or negative information. Prevalence estimates for diabetes of all types, type 1 diabetes, and type 2 diabetes were 2.3, 0.6, and 1.1, respectively, per 1,000 youth aged <20 years. CONCLUSIONS: Our definitions may be useful for surveillance in primary care settings until further studies develop feasible case definitions for monitoring trends in diabetes among youth.

Cardiovascular disease and risk factors in Montana American Indians and non-Indians.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death for both American Indian and non-Indian adults. Few published studies have compared the prevalence of CVD and related risk factors in Indians to that in non-Indians in the same geographic area. OBJECTIVE: To compare CVD and risk factors in American Indian and non-Indian populations in Montana. METHODS: Adult American Indians (n=1000) living on or near Montana's seven reservations and non-Indian (n=905) Montanans statewide were interviewed through the 1999 Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS: Indians aged > or =45 years reported a significantly higher prevalence of CVD compared to non-Indians (18% vs 10%). In persons aged 18-44 years, Indians were more likely to report hypertension (15% vs 10%), obesity (29% vs 12%), and smoking (42% vs 24%) compared to non-Indians. For persons aged > or =45 years, Indians reported higher rates of diabetes (24% vs 9%), obesity (38% vs 16%), and smoking (32% vs 13%) compared to non-Indians. Non-Indians aged > or =45 years reported having been diagnosed with high cholesterol more frequently than did Indians (32% vs 24%). CONCLUSIONS: Both Indians and non-Indians in Montana reported a substantial burden of CVD. The CVD risk patterns differ in the two populations. Prevention programs should be tailored to the risk burdens in these communities with particular emphasis on smoking cessation and the prevention of obesity.

Comparing self-reported measures of diabetes care with similar measures from a chart audit in a well-defined population.

The objective of this study was to compare self-reported measures of diabetes care with measures derived from medical records in a well-defined population. Diabetes measures were collected through a 1997 Behavioral Risk Factor Surveillance System telephone survey of American Indians living on or near 7 Montana reservations (N = 398) and were compared with data collected from charts of a systematic sample of American Indians with diabetes seen in 1997 at Indian Health Service (IHS) facilities. Survey respondents were more likely to report a duration of diabetes > or = 10 years (44 vs 31%), annual dilated retinal exam (75 vs 59%), and an influenza immunization in the past year (73 vs 57%) compared with estimates from the chart audit. Estimates of pneumococcal immunization (88 vs 42%), annual cholesterol screening (86 vs 69%), and overweight, based on body mass index (67 vs 50%), were significantly higher from the chart audit. No significant differences were found between the survey respondents and the chart audit data for annual foot exams (65 vs 61%), annual blood pressure checks (98 vs 93%), high cholesterol (35 vs 41%), and high blood pressure (54 vs 64%). These findings suggest that self-reported data may over and underestimate specific measures of diabetes care.

Applying the diabetes quality improvement project indicators in the Indian Health Service primary care setting.

OBJECTIVE: With publication of the Diabetes Quality Improvement Project (DQIP) measures, the Indian Health Service National Diabetes Program applied the DQIP format to its IHS Diabetes Care and Outcomes Audit for comparison and benchmarks. RESEARCH DESIGN AND METHODS: Since 1986 the IHS Diabetes Care and Outcomes Audit has been conducted by medical record review in >75% of IHS and tribal facilities. Each year systematic random sample of charts is drawn from local diabetes registries. Chart reviews are conducted by, trained professionals according to standard definitions and instructions. Abstracted data are entered into a microcomputer-based epidemiologic software package. Local, regional, and national rates are constructed for each item. During the period 1995-1997, 150 facilities submitted data for compilation, representing participation from all 12 IHS administrative regions. The IHS Diabetes Care and Outcomes Audit collected virtually all of the DQIP measures, with the exception of LDL cholesterol (which was added to the record review in 1998). RESULTS: In 1995, 1996, and 1997, a total of 9,557, 9,985, and 9,626 individuals, respectively, were included in the total IHS audit sample. The reviews for 1995, 1996, and 1997 revealed that of all subjects: 55, 65, and 80%, respectively, had more than one HbA1c test during the year (P < 0.001); 42, 38, and 34%, respectively; had a high-risk HbA1c (>9.5%) (P < 0.001); 83, 81, and 84%, respectively, were tested for macroproteinuria (P < 0.11) and 16, 17, and 23%, respectively were tested for microproteinuria (P < 0.001); total cholesterol was assessed in 80, 81, and 85%, respectively (P < 0.001), and corresponding proportions of those with values <5.17 mmol/l were 48, 50, and 52%, respectively; triglyceride values were measured for 75,75, and 80%, respectively (P < 0.001), and the corresponding median triglyceride levels were 199, 198, and 193 mg/dl, respectively (P < 0.001); the proportion of clients with a blood pressure <140/90 mmHg was 64, 64, and 66%, respectively (P < 0.05); 55, 56, and 55%, respectively, had a dilated eye exam (P < 0.053); and the proportion of clients who had a comprehensive foot exam were 59, 59, and 61%, respectively (P < 0.05). CONCLUSIONS: The DQIP accountability and quality improvement measures could be easily applied to the IHS Diabetes Care and Outcomes Audit, and the process can prove to be practical. However, data alone are not sufficient to effect change. Use of the measures to ensure that the quality of care improves must also be stressed, because measuring alone will not guarantee such improvement.

Nontraumatic lower extremity amputations in the Medicare end-stage renal disease population.

BACKGROUND: Nontraumatic lower limb amputation is a serious complication of both diabetic neuropathy and peripheral vascular disease. Many people with end-stage renal disease (ESRD) suffer from advanced progression of these diseases. This study presents descriptive information on the rate of lower limb amputation among people with ESRD who are covered by the Medicare program. METHODS: Using hospital bill data for the years 1991 through 1994 from the Health Care Financing Administration's ESRD program management and medical information system (PMMIS), amputations were based on ICD9 coding. These hospitalizations were then linked back to the PMMIS enrollment database for calculation of rates. RESULTS: The rate of lower limb amputation increased during the four-year period from 4.8 per 100 person years in 1991 to 6.2 in 1994. Among persons whose renal failure was attributed to diabetic nephropathy, the rates in 1991 and 1994 were 11.8 and 13.8, respectively. The rate among diabetic persons with ESRD was 10 times as great as among the diabetic population at large. Two thirds died within two years following the first amputation. CONCLUSIONS: The ESRD population is at an extremely high risk of lower limb amputation. Coordinated programs to screen for high-risk feet and to provide regular foot care for those at high risk combined with guidelines for treatment and referral of ulceration are needed.

Measures of disease control in Medicare beneficiaries with diabetes mellitus.

OBJECTIVE: To investigate measures of disease control for Medicare beneficiaries with diabetes and their outpatient care in the fee-for-service setting. DESIGN: Retrospective cohort study. SETTINGS: Office practices in Alabama, Iowa, and Maryland of 293 primary care physicians (PCPs) who volunteered to participate in the Ambulatory Care Quality Improvement Project. PARTICIPANTS: A total of 5980 patients with an average age of 75.2 years. MEASUREMENTS: For an 18-month period (1/1/94-6/30/95), medical records were abstracted for clinical parameters, including up to four blood glucose values; two blood pressure measurements; one total cholesterol value; two serum creatinine values; medication use, including antihypertensives, angiotensin-converting enzyme (ACE) inhibitors, and lipid-lowering agents; and frequency of glycosylated hemoglobin (GHb) determinations. RESULTS: During the study, 44% of patients received at least one GHb determination, 94% received at least one blood glucose, 68% at least one total serum cholesterol, 74% at least one serum creatinine test, and 97% at least one blood pressure measurement. Ten percent of patients had mean blood glucose levels > or = 250 mg/dL. Eighty-five percent had evidence of hypertension. Of this group of hypertensive patients with blood pressure readings available, 70% had blood pressure readings > or = 140/90 mm Hg, even though there were on medication that could have been prescribed for hypertension. Thirty-six percent of those who had evidence of hypertension were taking an ACE inhibitor. Thirty-two percent of those taking lipid-lowering medication had a total serum cholesterol value > or = 240 mg/dL. Statistically significant differences were noted for age and gender, with men and patients more than 85 years old generally having better measures of disease control. CONCLUSIONS: Many older Medicare patients with diabetes did not achieve recommended target levels of blood glucose, blood pressure, and lipids. GHb and serum cholesterol are not being monitored at recommended intervals. Significant opportunities exist to improve diabetes care for this population.

Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting.

BACKGROUND: While lower-extremity amputation (LEA) is a frequent complication of diabetes, effective strategies for the prevention of LEA in primary care settings have not been extensively studied. METHODS: This prospective study of American Indians with diabetes in a rural primary care clinic was divided into three periods: the standard care period (1986 to 1989), during which patients received foot care at the discretion of the primary care provider; the public health period (1990 to 1993), during which patients were screened for foot problems and high-risk individuals received foot care education and protective footwear; and the Staged Diabetes Management (SDM) period (1994 to 1996), during which comprehensive guidelines for diabetic foot management were adapted by the primary care clinicians to their practices and were systematically implemented. RESULTS: A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation. Patient sex distribution, mean age, and mean duration of diabetes were similar i the three periods. The average annual LEA incidence was 29/1000 diabetic person-years for the standard care period (n = 42), 21/1000 for the public health period (n = 33), and 15/1000 for the SDM period (n = 20), an overall 48% reduction (P = .016). Overall, the incidence of a first amputation declined from 21/1000 to 6/1000 (P < .0001). CONCLUSIONS: The customization and systematic implementation of practice guidelines by local primary care providers was associated with improved diabetic foot care outcomes. SDM has relevance to primary care organizations seeking to improve outcomes for patients with diabetes.

Ketoacidosis in Apache Indians with non-insulin-dependent diabetes mellitus.

BACKGROUND: Although more classically associated with insulin-dependent diabetes mellitus, diabetic ketoacidosis (DKA) can occur in some patients with non-insulin-dependent diabetes mellitus (NIDDM). To better define the clinical features that may be associated with ketoacidosis in patients with NIDDM, we reviewed the medical histories of Apache Indians with NIDDM who had been treated for an episode of DKA. METHODS: Cases of ketoacidosis among patients with NIDDM were identified at 2 separate Apache Indian reservations. Chart data were used to confirm and characterize the diagnosis of NIDDM, the metabolic disturbances associated with DKA, and the historical features of the patients. RESULTS: Among 724 patients with NIDDM, 17 patients experiencing at least 1 episode of DKA were identified. The mean (+/-SD) age at the time of the episode was 40.8 +/- 13.9 years. The patients were predominantly male (15[88%]), with a mean (+/-SD) body mass index (calculated as the weight in kilograms divided by the square of the height in meters) of 24.9 +/- 4.4 kg/m2. Causes of DKA included infections (8[47%]) and omission of treatment (3/15[20%]). Concurrent abuse of alcohol was noted in 4 (27%) of the patients. In addition, a lifetime history of alcohol abuse was noted in 15 (94%) of 16 patients. CONCLUSIONS: This report confirms the growing recognition that DKA occurs in some patients with NIDDM. The present study also adds male sex, alcohol abuse, and relatively low body mass index as clinical factors that may play a role in the development of DKA in this setting.

The Tripler Army Medical Center LEAN Program: a healthy lifestyle model for the treatment of obesity.

This paper provides an overview of the Tripler Army Medical Center LEAN Program for the treatment of obesity, hypercholesterolemia, and essential hypertension. The LEAN Program, a multi-disciplinary prevention program, emphasizes healthy Lifestyles, Exercise and Emotions, Attitudes, and Nutrition for active duty service members. The treatment model offers a medically healthy, emotionally safe, and reasonable, low-intensity exercise program to facilitate weight loss. We will discuss the philosophy behind the LEAN Program and the major components. Thereafter, we will briefly discuss the preliminary results.

Diabetes prevention in American Indians and Alaska Natives: where are we in 1994?

American Indians and Alaska Natives have experienced rapidly increasing rates of non-insulin-dependent diabetes (NIDDM). To address this epidemic Indian Health Service (IHS) and tribal communities have developed primary, second and tertiary intervention strategies. The scientific basis for secondary and tertiary prevention supports well-defined care practices, and the surveillance of the implementation of these practices and their impact on metabolic and hypertension control is now standard. Community interventions for the primary prevention of diabetes are underway and reflect the priorities of individual communities.

Screening and diagnosis for gestational diabetes mellitus among Chippewa women in northern Minnesota.

We reviewed prenatal records of Chippewa women residing on two Minnesota reservations to define the incidence of gestational diabetes mellitus (GDM) and to describe the screening and diagnosis practices for GDM according to National Diabetes Data Group Criteria. Of the 554 pregnancies included in the study, six (1%) involved women with preexisting diabetes mellitus and 32 (5.8%) with GDM. In 24 (4.3%) of the pregnancies, the women were misclassified as having GDM. Women completed screening and/or testing during 450 (82%) of the pregnancies-by 32 weeks gestation for 401 (73%). This is of 548 pregnancies that could potentially have involved GDM. Women with incomplete screening and/or testing were older and of higher parity than those who completed negative screening and/or testing (p<0.05). Chippewa Indian women in northern Minnesota experienced GDM at rates higher than most other U.S. populations. Screening rates for GDM were high, but some high-risk women were not screened. Programs targeting high-risk women for timely and accurate diagnosis of GDM are needed in this primary care setting.

Improving diabetes care in the primary health setting. The Indian Health Service experience.

PURPOSE: To identify key systems issues from the Indian Health Service (IHS) experience that must be addressed to improve metabolic control among patients with non-insulin-dependent diabetes mellitus (NIDDM) who were followed in primary care settings. DATA SOURCES: Records of diabetic patients seen in IHS facilities in specific geographic regions from 1987 to 1994. STUDY SELECTION: A representative sample of charts from each facility was reviewed yearly to measure key variables. The sampling frame was the number of diabetic patients currently active on the registry and the sample size calculated to measure a 10% change in selected practices at each facility. EXTRACTION: Regional diabetes coordinators reviewed charts or trained local providers to sample and extract data in a standard format. RESULTS: Regional data were examined to show trends in the performance of immunizations and foot examinations and in other variables such as hypertension and metabolic control. The percentage of diabetic patients who received a single dose of pneumococcal vaccine improved from 24% in 1987 to 1988 to 57% in 1994 (P < 0.01 for trend) among diabetic patients in Minnesota, Wisconsin, and Michigan. Rates of yearly comprehensive foot examination increased from 36% to 58% (P < 0.01 for trend) over the same period. In Montana and Wyoming, the percentage of diabetic patients with uncontrolled hypertension (defined as the mean of three systolic blood pressure measurements of > or = 140 mm Hg or diastolic pressure measurements > or = 90 mm Hg, or both, during the previous year) decreased from 36% in 1992 to 25% in 1993 after the regional diabetes coordinator emphasized hypertension control. In 1994, when less emphasis was placed on hypertension, 33% of the diabetic patients had uncontrolled hypertension. Estimates of metabolic control from records of diabetic patients in Washington, Oregon, and Idaho in 1994 showed that 29% of patients had excellent metabolic control (a hemoglobin A1c [HbA1c] level < or = 7.5% or mean blood glucose level < or = 9.2 mmol/L) within the past year; only 9% experienced poor control (a HbA1c level > 12% or mean blood glucose level > 18.9 mmol/L). CONCLUSIONS: The IHS experience shows that standard, ongoing monitoring of key variables allows facilities to improve diabetes care. Simple, reliable methods of defining metabolic control combined with a feedback system in the primary care setting are needed to improve metabolic control in patients with NIDDM.

Toward comprehensive obesity prevention programs in Native American communities.

Obesity is a particularly important challenge to the health status of Native Americans. This challenge is manifest in the increasing rates of non-insulin-dependent diabetes mellitus among Native Americans. Most studies of Native American infants, preschool children, schoolchildren, and adults have confirmed a high prevalence of overweight. Historical studies suggest that for many Native American communities the high rates of obesity are a relatively recent phenomenon. The specific reasons for the increase in obesity among Native Americans have not been determined, although it has been hypothesized that Native Americans have a genetic predisposition to overweight in a "westernized" environment of abundant food and decreased energy expenditure. Few detailed studies of diet or of physical activity levels of contemporary Native Americans have been published. Community-based interventions to modify diet and activity levels to prevent obesity in Native American communities are needed. Preliminary evidence from two formative school-based programs in the Southwest suggest that Native American communities are receptive to school-based interventions, and that such programs may be able to slow the rate of excess weight gain and to improve fitness in school children. Because of the cultural diversity among Native Americans, future studies should focus on collecting community- and region-specific data, and should emphasize the need for obesity prevention through culturally appropriate community- and school-based behavioral interventions.

Assessment of diabetes care by medical record review. The Indian Health Service model.

OBJECTIVE: To evaluate the adherence to minimum standards for diabetes care in multiple primary-care facilities using a uniform system of medical record review. RESEARCH DESIGN AND METHODS: In 1986, the Indian Health Service (IHS) developed diabetes care standards and an assessment process to evaluate adherence to those standards using medical record review. We review our assessment method and results for 1992. Charts were selected in a systematic random fashion from 138 participating facilities. Trained professional staff reviewed patient charts, using a uniform set of definitions. A weighted rate of adherence was constructed for each item. RESULTS: Medical record reviews were conducted on 6,959 charts selected from 40,118 diabetic patients. High rates of adherence (> 70%) were noted for blood pressure and weight measurements at each visit, blood sugar determinations at each visit, annual laboratory screening tests, electrocardiogram at baseline, and adult immunizations. Lower rates of adherence (< or = 50%) were noted for annual eye, foot, and dental examinations. CONCLUSIONS: IHS rates of adherence are similar to rates obtained from medical record reviews and computerized billing data, but are less than rates obtained by provider self-report. Medical record review, using uniform definitions and inexpensive software for data entry and reports, can easily be implemented in multiple primary-care settings. Uniformity of data definition and collection facilitates the aggregation of the data and comparison over time and among facilities. This medical record review system, although labor intensive, can be easily adopted in a variety of primary-care settings for quality improvement activities, program planning, and evaluation.