Clinical characteristics of non-insulin-dependent diabetes mellitus among southwestern American Indian youths.

The clinical characteristics and presentation of non-insulin-dependent diabetes mellitus (NIDDM) among 22 youths, aged less than 20 years, of an American Indian tribe Tohono O'odham Nation in the southwestern United States were studied. Ten males and 12 females (7-20 years old) were identified with a 13.7-year mean age of onset of diabetes. Over 80% (18/22) of the patients were obese at diagnosis having a body mass index greater than the 95th percentile for their age and sex, and there was a strong family history of NIDDM; eight patients were born to mothers who had gestational diabetes, and 19 patients had at least one parent with NIDDM. At the time of diagnosis, plasma glucose levels ranged from 10.3 mmol/L to 33 mmol/L, with nearly 60% (13/22) of the patients having a glucose reading greater than 16.8 mmol/L. C-peptide levels were done on 10 patients, and these were in the normal to elevated range. Clinical management of the 22 patients varied. To control hyperglycaemia and symptoms, such as nocturia and polyuria, 14 patients were on oral hypoglycaemic medication, and five were on insulin therapy. Compliance with dietary management was very difficult for these patients as evidenced by the fact that only three patients were on dietary control for their diabetes. The cases described in this series demonstrate NIDDM in childhood and illustrate the importance of accurate classification of diabetes during childhood, particularly in children from populations at high risk for NIDDM.

Midline congenital anomalies: the estimated occurrence among American Indian and Alaska Native infants.

While congenital anomalies have been identified as the second leading cause of infant mortality among American Indians and Alaska Natives, limited information exists concerning the morbidity of such malformations. This study was undertaken to address this concern. Using data from the national hospital discharge database of the Indian Health Service, for the years 1980-1988, morbidity rates of seven, relatively common and easily identifiable midline malformations among liveborn infants in this minority population were estimated. The seven congenital anomalies and the estimated rates per 10000 births were: neural tube defects 8.09; oral clefts 29.03; abdominal wall defects 2.99; tracheoesophageal fistula 1.86; conotruncal heart defects 5.90; rectal atresia 3.15; and diaphragmatic hernia 3.24. Seven cases (1.1%) had two midline defects reported.

Measuring human betterment through avoidable mortality: a case for universal health care in the USA.

The USA system of health care has begun a monumental change that will affect everyone, irrespective of their socioeconomic status, professional status or pre-existing health insurance status. Whatever type of plan is finally implemented through the legislative process, there will need to be a way to evaluate its success (or failure). One way to evaluate the plan's effectiveness is through its impact on human betterment as viewed by a reduction in 'avoidable mortality' for those most in need of health care; the poor and uninsured. For one USA minority population, universal health care has improved human betterment by reducing avoidable mortality, even in the face of a severe burden of poverty.

Changes over time in the ADL status of elderly US veterans.

The ageing of the US veteran population has greatly out-paced that of the general US population in the last decade and the demographics of this subgroup have changed relative to the US general population. To address the concerns of policy makers within the US Department of Veterans' Affairs (VA), data on elderly US male veterans and non-veterans from the Longitudinal Survey on Aging in 1984, 1986, 1988, and 1990 were used in a prospective study. Health status or well-being was assessed through changes over time in ADL status, according to the following five categories; (I) the presence of no ADL dependence and not developing a dependence between survey periods, (II) no change in ADL dependence between survey periods, (III) an increase in ADL dependence status between survey periods, (IV) a decrease in ADL dependence between survey periods, and (V) the occurrence of death between survey periods. Using a polytomous logistic regression model, these five categories were assessed in relation to a set of variables representing social, health-care utilization, and socioeconomic characteristics. The estimated coefficients from the model indicate that family income, having worked in the last 12 months, having an increase or no change in levels of physical activity in the past 12 months and the presence of Medicare coverage are inversely associated with moving, over time, into a lower state of health status or well-being. The prior existence of an ADL limitation, the number of doctor and hospital visits in the past 12 months, level of education, having been widowed in the past 12 months and veteran status were all proportionally associated with the likelihood of moving into a lower state of health status or well-being. These findings lead to the conclusion that being a veteran in the US does make a difference in regard to moving into various states of health status or well-being. This difference is supported by the estimated coefficient for veteran status being significant at a p value of 0.01 and through an evaluation of the estimated transition likelihood, controlling for veteran status. Veterans are less likely to die than their non-veteran counterparts, but have a greater likelihood of transition into levels of ADL dependence. Similarly, given the existence of a prior ADL limitation, over time, veterans are less likely to die, but more likely to move into a state of increased ADL limitations.

Trends in asthma-related admissions among American Indian and Alaskan native children from 1979 to 1989. Universal health care in the face of poverty.

OBJECTIVE: To describe changes in asthma-related hospitalizations in Indian Health Service facilities and compare with national trends. DESIGN: Trend analysis. PATIENTS AND SETTING: Hospital discharge records of patients aged 17 years and younger treated by the Indian Health Service between 1979 and 1989. MAIN OUTCOME MEASURES: Patients discharged with asthma as the first listed diagnosis. RESULTS: The rates of asthma-related hospitalizations increased an average of 2.6% (95% confidence interval [CI], 0.1 to 5.2) per year between 1979 and 1989 among American Indian and Alaskan Native children aged 0 to 17 years. The increase was 3.7% among the 0- to 4-year age group (95% CI, 2.0 to 5.5) and 0.3% (95% CI, 0.26 to 0.3) among the 5- to 17-year age group. Boys tended to have a higher rate of increase (4.3% [95% CI, -0.1 to 8.7]) compared with girls (2.6% [95% CI, -0.2 to 5.4]). The rates for any hospitalization decreased during this period for 0- to 4-year-olds (-7.5% [95% CI, -10.5 to -4.5]). Little change was noted in hospitalization rates for lower respiratory tract diseases. Diagnostic transfer from bronchitis/bronchiolitis to asthma could not explain the increase. Both first admission and readmission for treatment of asthma contributed to the increase. Compared with previously published data, 0- to 4-year-old American Indian and Alaskan Native children more closely approximate white children than black children in both rates of hospitalization (1979-1987) and annual percentage increase in hospitalization (1979-1989 for American Indian and Alaskan Native children and 1979-1987 for white and black children) for the treatment of asthma. CONCLUSIONS: American Indian and Alaskan Native children who are cared for by the Indian Health Service have asthma-related hospitalization patterns that are similar to those seen in white children despite having socioeconomic characteristics more similar to those of black children.

Forecasting the demand for inpatient services for specific chronic conditions.

While the proposed forecasting methodology has a well-established record in evaluating economic time-series, there is minimal, if any, use of this technique in projecting hospitalizations for specific chronic conditions. Using an established taxonomy of disease codes for alcoholism and alcohol abuse in a national inpatient database, a monthly time-series of hospitalizations was modeled. The model derived in both statistically adequate and accurate in forecasting future monthly demand for inpatient hospitalizations. This type of model specifications could be used by hospital planners and policy makers in evaluating monthly resources for specific chronic conditions.

Comparative analysis of violent deaths in American Indians and Alaska Natives.

Accidents, injuries, and outcomes from adverse effects have been identified as the second leading cause of death for American Indians and Alaska Natives (AI/AN). However, no studies have been done which analyze violent deaths (homicides, suicides, and other accidents) for this population with a focus on time trends. For this study, overall and gender-specific mortality rates due to violent deaths were computed for 1973-88. The results indicate that overall and gender-specific mortality rates for violent deaths in AI/AN have been decreasing on average per year: homicide, 4.3%; suicide, 2.7%; other accidents, 5.6%. Similarly, age-adjusted rates have been declining, and at faster rates than those of the U.S. general population: homicide, 4.5% vs. 1.4%; suicide, 2.5% vs. 0.6%; other accidents, 6.2% vs. 2.6%. However, the male-female ratio for homicides and other accidents has remained unchanged, and the ratio for suicide has been increasing. While the gap between age-adjusted rates have been narrowing, the age-adjusted rates for AI/AN have remained consistently above those of the U.S. general population.

Hospital resource utilization by American Indians/Alaska Natives for alcoholism and alcohol abuse.

Previous work examining the issue of alcoholism and alcohol abuse among American Indians and Alaska Natives can be broadly categorized as either descriptions of the consumption patterns and behaviors of specific tribes or mortality studies, focusing on deaths due to alcoholism, alcohol abuse, chronic liver disease, or cirrhosis. A major shortcoming of previous studies has been that they have not looked at the burden this problem has imposed upon the system of health care delivery for this minority population. By using an International Classification of Diseases, Ninth Revision, Clinical Modification taxonomy of diagnostic codes developed by the National Institute on Alcoholism and Alcohol Abuse (NIAAA) and the national Indian Health Service (IHS) inpatient database for direct and contract admissions, utilization patterns for 43 IHS facilities were investigated. The period of study was 1980-1988, and our case definition included any individual 14 years and older who had any mention upon discharge of an alcohol-related diagnosis (ARD). For the 9-year period under investigation, 43,302 adult inpatient admissions occurred at the 43 IHS facilities for ARD. These admissions accounted for an overall estimated per annum rate of 13.7% of the adult inpatient days. In addition, age and gender specific discharge rates for ARD were estimated and compared to reported ARD discharge rates of the United States civilian population prepared by the NIAAA using the National Hospital Discharge Survey over the period 1979-1988. In contrast, the IHS discharge rates for ARD were three times greater than reported ARD discharge rates for the United States civilian population.