Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems.

OBJECTIVE: To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses. METHODS: We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time. RESULTS: IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases. CONCLUSIONS: This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

COVID-19 Pandemic and Indigenous Representation in Public Health Data.

Public Health 3.0 calls for the inclusion of new partners and novel data to bring systemic change to the US public health landscape. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has illuminated significant data gaps influenced by ongoing colonial legacies of racism and erasure. American Indian and Alaska Native (AI/AN) populations and communities have been disproportionately affected by incomplete public health data and by the COVID-19 pandemic itself. Our findings indicate that only 26 US states were able to calculate COVID-19‒related death rates for AI/AN populations. Given that 37 states have Indian Health Service locations, we argue that public health researchers and practitioners should have a far larger data set of aggregated public health information on AI/AN populations. Despite enormous obstacles, local Tribal facilities have created effective community responses to COVID-19 testing, tracking, and vaccine administration. Their knowledge can lead the way to a healthier nation. Federal and state governments and health agencies must learn to responsibly support Tribal efforts, collect data from AI/AN persons in partnership with Indian Health Service and Tribal governments, and communicate effectively with Tribal authorities to ensure Indigenous data sovereignty. (Am J Public Health. 2021;111(S3): S208-S214. https://doi.org/10.2105/AJPH.2021.306415).

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries.

BACKGROUND: Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data. OBJECTIVE: The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years. SUBJECTS: A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%). RESULTS: Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs. CONCLUSIONS: Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

Trends in Indicators of Injection Drug Use, Indian Health Service, 2010-2014 : A Study of Health Care Encounter Data.

OBJECTIVES: Hepatitis C virus (HCV) and HIV transmission in the United States may increase as a result of increasing rates of opioid use disorder (OUD) and associated injection drug use (IDU). Epidemiologic trends among American Indian/Alaska Native (AI/AN) persons are not well known. METHODS: We analyzed 2010-2014 Indian Health Service data on health care encounters to assess regional and temporal trends in IDU indicators among adults aged ≥18 years. IDU indicators included acute or chronic HCV infection (only among adults aged 18-35 years), arm cellulitis and abscess, OUD, and opioid-related overdose. We calculated rates per 10 000 AI/AN adults for each IDU indicator overall and stratified by sex, age group, and region and evaluated rate ratios and trends by using Poisson regression analysis. RESULTS: Rates of HCV infection among adults aged 18-35 increased 9.4% per year, and rates of OUD among all adults increased 13.3% per year from 2010 to 2014. The rate of HCV infection among young women was approximately 1.3 times that among young men. Rates of opioid-related overdose among adults aged <50 years were approximately 1.4 times the rates among adults aged ≥50 years. Among young adults with HCV infection, 25.6% had concurrent OUD. Among all adults with arm cellulitis and abscess, 5.6% had concurrent OUD. CONCLUSIONS: Rates of HCV infection and OUD increased significantly in the AI/AN population. Strengthened public health efforts could ensure that AI/AN communities can address increasing needs for culturally appropriate interventions, including comprehensive syringe services programs, medication-assisted treatment, and opioid-related overdose prevention and can meet the growing need for treatment of HCV infection.

Using Indian Health Service (IHS) counseling techniques in an independent community pharmacy to improve adherence rates among patients with diabetes, hypertension, or hyperlipidemia.

OBJECTIVES: To 1) identify barriers to medication adherence and 2) examine the relationship between the Indian Health Service (IHS) 3 prime questions and medication adherence in patients with diabetes, hypertension, or hyperlipidemia before and 6 months after intervention. METHODS: This quasi-experimental study evaluated the effectiveness of an adherence program at an independent community pharmacy. Patients who met inclusion criteria were telephoned monthly to answer questions related to their medications. Patients served as their own controls to show comparison between pre- and postintervention adherence rates calculated according to proportion of days covered over the previous 6 months. Mean medication adherences before and after intervention were assessed via paired t test. Linear regression was used to analyze predictors of average medication adherence. The Charlson Comorbidity Index was used to measure the impact of comorbid conditions on medication adherence. RESULTS: Fifty-six of 354 patients met inclusion criteria, consented, and completed the study. The percentage of patients achieving an adherence rate of 80% or more increased from 9% initially to 59% at study completion. Each medication class showed improvement in adherence rates: diabetes from 66.24% to 80.06% (P = 0.0153), hypertension from 72.33% to 81.34% (P = 0.0192), and hyperlipidemia from 64.45% to 74.66% (P = 0.0103). Overall, average medication adherence increased by 11% (P < 0.0001). The top patient-reported barrier to adherence was convenience/forgetfulness (46.43%). CONCLUSION: Pharmacist-led counseling sessions with the use of the 3 prime questions showed short-term improvement in adherence rates among patients participating in a medication adherence program. Future studies should assess if improved adherence is sustained long-term following active intervention.

Assessing New Diagnoses of HIV Among American Indian/Alaska Natives Served by the Indian Health Service, 2005-2014.

OBJECTIVES: The objectives of this study were to use Indian Health Service (IHS) data from electronic health records to analyze human immunodeficiency virus (HIV) diagnoses among American Indian/Alaska Natives (AI/ANs) and to identify current rates and trends that can support data-driven policy implementation and resource allocation for this population. METHODS: We analyzed provider visit data from IHS to capture all AI/AN patients who met a definition of a new HIV diagnosis from 2005 through 2014 by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We calculated rates and trends of new HIV diagnoses by age, sex, region, and year per 100 000 AI/ANs in the IHS user population. RESULTS: A total of 2273 AI/ANs met the definition of newly diagnosed with HIV from 2005 through 2014, an average annual rate of 15.1 per 100 000 AI/ANs. Most (356/391) IHS health facilities recorded at least 1 new HIV diagnosis. The rate of new HIV diagnoses among males (21.3 per 100 000 AI/ANs) was twice as high as that among females (9.5 per 100 000 AI/ANs; rate ratio = 2.2; 95% confidence interval, 2.1-2.4); by age, rates were highest among those aged 20-54 for males and females. By region, the Southwest region had the highest number (n = 1016) and rate (19.9 per 100 000 AI/ANs) of new HIV diagnoses. Overall annual rates of new HIV diagnoses were stable from 2010 through 2014, although diagnosis rates increased among males ( P < .001) and those aged 15-19 ( P < .001), 45-59 ( P < .001), and 50-54 ( P = .01). CONCLUSIONS: New HIV diagnoses, derived from provider visit data, among AI/ANs were stable from 2010 through 2014. AI/ANs aged 20-54, particularly men, may benefit from increased HIV prevention and screening efforts. Additional services may benefit patients in regions with higher rates of new diagnoses and in remote settings in which reported HIV numbers are low.

Indian Health Service Care System and Cancer Stage in American Indians and Alaska Natives.

PURPOSE: We aimed to determine whether the association between late-stage cancer and American Indian/Alaska Native (AI/AN) race differed by enrollment in the Indian Health Service Care System (IHSCS). METHODS: We used Surveillance, Epidemiology, and End Results (SEER) data linked to Medicare files to compare the odds of late-stage breast, colorectal, lung, or prostate cancer between non-Hispanic Whites (NHWs) (n=285,993) and AI/ANs with (n=581) and without (n=543) IHSCS enrollment. RESULTS: For AI/ANs without IHSCS enrollment, the odds of late-stage disease were higher in AI/ANs compared with NHWs for breast (OR=3.17, 95%CI: 1.82-5.53) and for prostate (OR=2.59, 95%CI:1.55-4.32) cancer, but not for colorectal or lung cancers. Among AI/ANs with IHSCS enrollment, there was not a significant association between late-stage disease and AI/AN race for any of the four cancers evaluated. CONCLUSION: Our results suggest that enrollment in the IHSCS reduced the disparity between AI/ANs and NHWs with respect to late-stage cancer diagnoses.

Vaccine-preventable, hospitalizations among American Indian/Alaska Native children using the 2012 Kid's Inpatient Database.

Our aim was to assess the odds of hospitalization for a vaccine-preventable, infectious disease (VP-ID) in American Indian/Alaska Native (AI/AN) children compared to other racial and ethnic groups using the 2012 Kid's Inpatient Database (KID) The KID is a nationally representative sample, which allows for evaluation of VP-ID in a non-federal, non-Indian Health Service setting. In a cross-sectional analysis, we evaluated the association of race/ethnicity and a composite outcome of hospitalization due to vaccine-preventable infection using multivariate logistic regression. AI/AN children were more likely (OR=1.81, 95% CI=1.34, 2.45) to be admitted to the hospital in 2012 for a VP-ID compared to Non-Hispanic white children after adjusting for age, sex, chronic disease status, metropolitan location, and median household income. This disparity highlights the necessity for a more comprehensive understanding of immunization and infectious disease exposure among American Indian children, especially those not covered or evaluated by Indian Health Service.

Behavioral health services in urban American Indian health organizations: A descriptive portrait.

The federal Indian Health Service (IHS) is the primary funding source for health services designated for American Indians (AIs; Gone & Trimble, 2012). Urban Indian health organizations (UIHOs), funded in part by IHS, are typically the only sites in large metropolitan settings offering treatments tailored to AI health needs. This is a first look at how mental health treatment is structured at UIHOs. UIHO staff at 17 of 34 UIHOs responded to our request to participate (50%), 14 employed behavioral health program directors who could complete the survey on behalf of their programs, and 11 of these submitted complete data regarding their current treatment practices and personal attitudes toward empirically supported treatments. Reported treatment profiles differed less than expected from available data on national outpatient clinics from the National Mental Health Services Survey (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014), and program director attitudes toward empirically supported treatments were similar to national norms reported by Aarons et al. (2010). One way in which treatment differed was in the reported use of traditional AI healing services. All program directors indicated that traditional AI healing services were available within their behavioral health programs in some form. These findings seem promising for the development of new empirically supported treatments for AI clients, but also raise concerns, given what is known about AI treatment preferences and mental health disparities. For example, traditional healing services are often considered "alternative medicine," outside the purview of evidence-based practice as typically construed by mental health services researchers. This potential conflict is a subject for future research. (PsycINFO Database Record

Human Papillomavirus Vaccine Uptake: Increase for American Indian Adolescents, 2013-2015.

INTRODUCTION: Although Indian Health Service, tribally-operated, and urban Indian (I/T/U) healthcare facilities have higher human papillomavirus (HPV) vaccine series initiation and completion rates among adolescent patients aged 13-17 years than the general U.S. population, challenges remain. I/T/U facilities have lower coverage for HPV vaccine first dose compared with coverage for other adolescent vaccines, and HPV vaccine series completion rates are lower than initiation rates. Researchers aimed to assist I/T/U facilities in identifying interventions to increase HPV vaccination series initiation and completion rates. STUDY DESIGN: Best practice and intervention I/T/U healthcare facilities were identified based on baseline adolescent HPV vaccine coverage data. Healthcare professionals were interviewed about barriers and facilitators to HPV vaccination. Researchers used responses and evidence-based practices to identify and assist facilities in implementing interventions to increase adolescent HPV vaccine series initiation and completion. Coverage and interview data were collected from June 2013 to June 2015; data were analyzed in 2015. SETTING/PARTICIPANTS: I/T/U healthcare facilities located within five Indian Health Service regions. INTERVENTION: Interventions included analyzing and providing feedback on facility vaccine coverage data, educating providers about HPV vaccine, expanding access to HPV vaccine, and establishing or expanding reminder recall and education efforts. MAIN OUTCOME MEASURES: Impact of evidence-based strategies and best practices to support HPV vaccination. RESULTS: Mean baseline first dose coverage with HPV vaccine at best practice facilities was 78% compared with 46% at intervention facilities. Mean third dose coverage was 48% at best practice facilities versus 19% at intervention facilities. Intervention facilities implemented multiple low-cost, evidence-based strategies and best practices to increase vaccine coverage. At baseline, most facilities used electronic provider reminders, had standing orders in place for administering HPV vaccine, and administered tetanus, diphtheria, and acellular pertussis and HPV vaccines during the same visit. At intervention sites, mean coverage for HPV initiation and completion increased by 24% and 22%, respectively. CONCLUSIONS: A tailored multifaceted approach addressing vaccine delivery processes and patient and provider education may increase HPV vaccine coverage.

Cancer Treatment Delays in American Indians and Alaska Natives Enrolled in Medicare.

To assess whether timing of initial post-diagnosis cancer care differs between American Indian and Alaska Native (AI/AN) and non-Hispanic White (NHW) patients, we accessed SEER-Medicare data for breast, colorectal, lung, and prostate cancers (2001-2007). Medicare claims data were examined for initiation of cancer-directed treatment. Overall, AI/ANs experienced longer median times to starting treatment than NHWs (45 and 39 days, p < .001) and lower rates of treatment initiation (HR[95%CI]: 0.86[0.79-0.93]). Differences were largest for prostate (HR: 0.80[0.71-0.89]) and smallest for breast cancer (HR: 0.96[0.83-1.11]). American Indians / Alaska Natives also had elevated odds of greater than 10 weeks between diagnosis and treatment compared with NHWs (OR[95% CI]: 1.37[1.16-1.63]), especially for prostate cancer (OR: 1.41[1.14-1.76]). Adjustment for comorbidity and socio-demographic factors attenuated associations except for prostate cancer. In this insured population, we observed evidence that AI/ANs start cancer therapy later than NHWs. The modest magnitude of delays suggests that they are unlikely to be a determinant of survival disparities.

Pediatric Readiness in Indian Health Service and Tribal Emergency Departments: Results from the National Pediatric Readiness Project.

INTRODUCTION: In 2014, 45 Indian Health Service (IHS)/Tribal emergency departments serving American Indian and Alaskan Native communities treated approximately 650,000 patients of which, 185,000 (28%) were children and youth younger than 19 years. This study presents the results of the National Pediatric Readiness Project (NPRP) assessment of the 45 IHS/Tribal emergency departments. METHODS: Data were obtained from the 2013 NPRP national assessment, which is a 55-question Web-based questionnaire based on previously published 2009 national consensus guidelines. The main measure of readiness is the weighted pediatric readiness score (WPRS), with the highest score being 100. RESULTS: The overall mean WPRS for all emergency departments is 60.9. Of the IHS/Tribal emergency departments that had pediatric emergency care coordinators, scores across all domains were higher than those of emergency departments without pediatric emergency care coordinators. All 45 emergency departments have readily available a pediatric medication dosing chart, length-based tape, medical software, or other system to ensure proper sizing of resuscitation equipment and proper dosing of medication. Of the 45 IHS/Tribal 37% report having 100% of the equipment items, and 78% report having at least 80% of these items. DISCUSSION: This article reports the results of the NPRP assessment in IHS/Tribal emergency departments that, despite serving a historically vulnerable population, scored favorably when compared with national data. The survey identified areas for improvement, including implementation of QI processes, stocking of pediatric specific equipment, implementation of policies and procedures on interfacility transport, and maintaining staff pediatric competencies.

Causes and Disparities in Death Rates Among Urban American Indian and Alaska Native Populations, 1999-2009.

OBJECTIVES: To characterize the leading causes of death for the urban American Indian/Alaska Native (AI/AN) population and compare with urban White and rural AI/AN populations. METHODS: We linked Indian Health Service patient registration records with the National Death Index to reduce racial misclassification in death certificate data. We calculated age-adjusted urban AI/AN death rates for the period 1999-2009 and compared those with corresponding urban White and rural AI/AN death rates. RESULTS: The top-5 leading causes of death among urban AI/AN persons were heart disease, cancer, unintentional injury, diabetes, and chronic liver disease and cirrhosis. Compared with urban White persons, urban AI/AN persons experienced significantly higher death rates for all top-5 leading causes. The largest disparities were for diabetes and chronic liver disease and cirrhosis. In general, urban and rural AI/AN persons had the same leading causes of death, although urban AI/AN persons had lower death rates for most conditions. CONCLUSIONS: Urban AI/AN persons experience significant disparities in death rates compared with their White counterparts. Public health and clinical interventions should target urban AI/AN persons to address behaviors and conditions contributing to health disparities.

Stool DNA Testing for Screening Detection of Colorectal Neoplasia in Alaska Native People.

OBJECTIVE: To assess the accuracy of a multitarget stool DNA test (MT-sDNA) compared with fecal immunochemical testing for hemoglobin (FIT) for detection of screening-relevant colorectal neoplasia (SRN) in Alaska Native people, who have among the world's highest rates of colorectal cancer (CRC) and limited access to conventional screening approaches. PATIENTS AND METHODS: We performed a prospective, cross-sectional study of asymptomatic Alaska Native adults aged 40-85 years and older undergoing screening or surveillance colonoscopy between February 6, 2012, and August 7, 2014. RESULTS: Among 868 enrolled participants, 661 completed the study (403 [61%] women). Overall, SRN detection by MT-sDNA (49%) was superior to that by FIT (28%; P<.001); in the screening group, SRN detection rates were 50% and 31%, respectively (P=.01). Multitarget stool DNA testing detected 62% of adenomas 2 cm or larger vs 29% by FIT (P=.05). Sensitivity by MT-sDNA increased with adenoma size (to 80% for lesions ≥3 cm; P=.01 for trend) and substantially exceeded FIT sensitivity at all adenoma sizes. For sessile serrated polyps larger than 1 cm (n=9), detection was 67% by MT-sDNA vs 11% by FIT (P=.07). For CRC (n=10), detection was 100% by MT-sDNA vs 80% by FIT (P=.48). Specificities were 93% and 96%, respectively (P=.03). CONCLUSION: The sensitivity of MT-sDNA for cancer and larger polyps was high and significantly greater than that of FIT for polyps of any size, while specificity was slightly higher with FIT. These findings could translate into high cumulative neoplasm detection rates on serial testing within a screening program. The MT-sDNA represents a potential strategy to expand CRC screening and reduce CRC incidence and mortality, especially where access to endoscopy is limited.

Lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general United States child population.

BACKGROUND: The lower respiratory tract infection (LRTI)-associated hospitalization rate in American Indian and Alaska Native (AI/AN) children aged <5 years declined during 1998-2008, yet remained 1.6 times higher than the general US child population in 2006-2008. PURPOSE: Describe the change in LRTI-associated hospitalization rates for AI/AN children and for the general US child population aged <5 years. METHODS: A retrospective analysis of hospitalizations with discharge ICD-9-CM codes for LRTI for AI/AN children and for the general US child population <5 years during 2009-2011 was conducted using Indian Health Service direct and contract care inpatient data and the Nationwide Inpatient Sample, respectively. We calculated hospitalization rates and made comparisons to previously published 1998-1999 rates prior to pneumococcal conjugate vaccine introduction. RESULTS: The average annual LRTI-associated hospitalization rate declined from 1998-1999 to 2009-2011 in AI/AN (35%, p<0.01) and the general US child population (19%, SE: 4.5%, p<0.01). The 2009-2011 AI/AN child average annual LRTI-associated hospitalization rate was 20.7 per 1,000, 1.5 times higher than the US child rate (13.7 95% CI: 12.6-14.8). The Alaska (38.9) and Southwest regions (27.3) had the highest rates. The disparity was greatest for infant (<1 year) pneumonia-associated and 2009-2010 H1N1 influenza-associated hospitalizations. CONCLUSIONS: Although the LRTI-associated hospitalization rate declined, the 2009-2011 AI/AN child rate remained higher than the US child rate, especially in the Alaska and Southwest regions. The residual disparity is likely multi-factorial and partly related to household crowding, indoor smoke exposure, lack of piped water and poverty. Implementation of interventions proven to reduce LRTI is needed among AI/AN children.

Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

OBJECTIVE: To compare compensatory sweating after lowering or restricting the level of sympathectomy. METHOD: A systematic review and meta-analysis were conducted of all randomized controlled trials published in English that compared compensatory sweating after lowering or restricting the level of sympathectomy. The Cochrane collaboration tool was used to assess the risk of bias, and the Mantel-Haenszel odds ratio method was used for the meta-analysis. RESULTS: A total of 11 randomized controlled trials were included, including a total of 1079 patients. Five of the randomized controlled trials studied restricting the level of sympathectomy, and the remaining six studied lowering the level of sympathectomy. CONCLUSIONS: The compiled randomized controlled trial results published so far in the literature do not support the claims that lowering or restricting the level of sympathetic ablation results in less compensatory sweating. .

HIV, Chlamydia, Gonorrhea, and Primary and Secondary Syphilis among American Indians and Alaska Natives Within Indian Health Service Areas in the United States, 2007-2010.

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

Ectopic pregnancy among American Indian and Alaska Native women, 2002-2009.

To examine rates of ectopic pregnancy (EP) among American Indian and Alaska Native (AI/AN) women aged 15-44 years seeking care at Indian Health Service (IHS), Tribal, and urban Indian health facilities during 2002-2009. We used 2002-2009 inpatient and outpatient data from the IHS National Patient Information Reporting System to identify EP-associated visits and obtain the number of pregnancies among AI/AN women. Repeat visits for the same EP were determined by calculating the interval between visits; if more than 90 days between visits, the visit was considered related to a new EP. We identified 229,986 pregnancies among AI/AN women 15-44 years receiving care at IHS-affiliated facilities during 2002-2009. Of these, 2,406 (1.05 %) were coded as EPs, corresponding to an average annual rate of 10.5 per 1,000 pregnancies. The EP rate among AI/AN women was lowest in the 15-19 years age group (5.5 EPs per 1,000 pregnancies) and highest among 35-39 year olds (18.7 EPs per 1,000 pregnancies). EP rates varied by geographic region, ranging between 6.9 and 24.4 per 1,000 pregnancies in the Northern Plains East and the East region, respectively. The percentage of ectopic pregnancies found among AI/AN women is within the national 1-2 % range. We found relatively stable annual rates of EP among AI/AN women receiving care at IHS-affiliated facilities during 2002-2009, but considerable variation by age group and geographic region. Coupling timely diagnosis and management with public health interventions focused on tobacco use and sexually transmitted diseases may provide opportunities for reducing EP and EP-associated complications among AI/AN women.