ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure

The goal of the Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure project, also referred to as the IHS Improving Health Care Delivery Data Project,^a was to create an Indian Health Service (IHS) data infrastructure to provide information on health status, utilization, and treatment costs to inform the identification and prioritization of effective strategies for chronic disease management and to improve health outcomes among American Indians and Alaska Native peoples (AI/ANs). The project data were used specifically to assess strategies for providing health services for AI/ANs with diabetes or cardiovascular disease (CVD) through two objectives:

1. Develop a longitudinal data infrastructure from existing electronic data stored on multiple platforms to provide information about AI/AN health status and IHS health service utilization and treatment costs.
2. Conduct a comparative effectiveness research (CER) study on strategies implemented to reduce CVD risk among AI/ANs with diabetes or CVD using the data infrastructure.

The project was funded by the Agency for Healthcare Research and Quality (AHRQ) with in-kind support provided by IHS and Tribal health organizations. The Centers for American Indian and Alaska Native Health (CAIANH) at the Colorado School of Public Health, University of Colorado Denver implemented the project.^b The primary source of data for the infrastructure was the IHS National Data Warehouse.

IHS funds health services for approximately two million AI/ANs. Similar to other health systems, IHS and Tribes have implemented many initiatives to address chronic disease. For example, IHS is incorporating patient-centered, medical home concepts throughout its system, using a model referred to as the Improving Patient Care (IPC) Program.¹ IPC sites are improving the quality of, access to, and coordination of services by focusing on patient- and family-centered care; ensuring access to primary care by health care teams; acting on the guidance of the community and of Tribal leadership; and making positive, sustainable, and measurable improvements in care.¹ Additionally, the congressionally funded Special Diabetes Program for Indians (SDPI) provides resources to IHS and Tribes to prevent and treat diabetes, and to monitor health outcomes for those with diabetes.² SDPI provides grants to over 400 IHS, Tribal, and Urban Indian health programs.² Using current scientific research and evidence-based best practices, SDPI grant programs have made tremendous improvements in diabetes treatment and prevention in both clinical settings and community-based programs. Since SDPI was implemented in 1998, access to education and case management (ECM) services by those with diabetes has increased dramatically.² At the same time, there have been documented improvements in glycemic control (HbA1c) and low-density lipoprotein (LDL) cholesterol levels among AI/ANs with diabetes, as well as decreases in the incidence of end stage renal disease (ESRD).²

The data infrastructure includes data for a purposeful sample of approximately 540,000 AI/ANs who obtained health services through IHS and lived in 14 Service Units. At least one of the 14 project sites (i.e., Service Units) is located in each of the 12 IHS Areas: Aberdeen, Alaska, Albuquerque, Bemidji, Billings, California, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson. Because of the large number of AI/ANs living in the Navajo and Oklahoma City Areas, two project sites were selected from these areas, for a total of 14 project sites. In nine of the project sites, IHS provides services; the remaining five project sites were Tribally operated.

The data mart includes 4 consecutive years of data (fiscal years [FY] 2007-2010) from three primary sources:

1. IHS National Data Warehouse (NDW): Information on utilization IHS and Tribally operated (I/T) inpatient, outpatient, and pharmacy services.
2. Contract Health Services (CHS): Utilization and payment information for services obtained at non-IHS providers^c yet paid for by IHS.
3. Centers for Medicare and Medicaid Services Cost Reports: Information on the costs of providing I/T services within the IHS Service Units.

In Chapter 2 we describe project implementation. Project implementation required close collaboration between the Centers for American Indian and Alaska Native Health (CAIANH), IHS Headquarters, and personnel from the 14 project sites involved in the project. In this chapter we describe the collaboration and important project milestones that facilitated project implementation.

We provide an overview of the data infrastructure development process, specific data files, and data measures in Chapter 3. In Chapter 4, differences among the project sites are described for consideration when reviewing and interpreting findings. Once the data mart was created, the data were used to conduct analyses for each project goal. Goal 1 and Goal 2 findings are provided in Chapters 5 and 6, respectively. Chapter 7 includes a discussion of the project’s key findings. Lessons learned and suggestions for data enhancements and potential future uses of the data are addressed in Chapters 8 and 9.

^aDue to the length of the project's contract title, IHS assigned this working project title to facilitate communication.
^bThe AHRQ contract was awarded to Denver Health. Denver Health subcontracted with CAIANH to implement the project and provided administrative project support.
^cNon-IHS providers are providers that are not I/T providers.