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 noninsulin-dependent diabetes mellitus (NIDDM) who were followed in primary care settings. Data Sources: Records of diab etic patients seen in IHS facilities in specific geographic regions fr om 1987 to 1994. Study Selection: A representative-sample of charts fr om each facility was reviewed yearly to measure key variables. The sam pling frame was the number of diabetic patients currently active on th e registry and the sample size calculated to measure a 10% change in s elected practices at each facility. Extraction: Regional diabetes coor dinators reviewed charts or trained local providers to sample and extr act 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. Th e percentage of diabetic patients who received a single dose of pneumo coccal vaccine improved from 24% in 1987 to 1988 to 57% in 1994 (P < 0 .01 for trend) among diabetic patients in Minnesota, Wisconsin, and Mi chigan. Rates of yearly comprehensive foot examination increased from 36% to 58% (P < 0.01 for trend) over the same period. In Montana and W yoming, the percentage of diabetic patients with uncontrolled hyperten sion (defined as the mean of three systolic blood pressure measurement s of greater than or equal to 140 mm Hg or diastolic pressure measurem ents greater than or equal to 90 mm Hg, or both, during the previous y ear) decreased from 36% in 1992 to 25% in 1993 after the regional diab etes coordinator emphasized hypertension control. In 1994, when less e mphasis was placed on hypertension, 33% of the diabetic patients had u ncontrolled hypertension. Estimates of metabolic control from records of diabetic patients in Washington, Oregon, and Idaho in 1994 showed t hat 29% of patients had excellent metabolic control (a hemoglobin A(1c ) [HbA(1c)] level less than or equal to 7.5% or mean blood glucose lev el less than or equal to 9.2 mmol/L) within the past year; only 9% exp erienced poor control (a HbA(1c) level > 12% or mean blood glucose lev el > 18.9 mmol/L). Conclusions: The IHS experience shows that standard , ongoing monitoring of key variables allows facilities to improve dia betes care. Simple, reliable methods of defining metabolic control com bined with a feedback system in the primary care setting are needed to improve metabolic control in patients with NIDDM.