Trends in quality of care and barriers to improvement in the Indian Health Service

Abstract

Background: Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.

Objective: To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).

Design: Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.

Participants: Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.

Main measures: Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.

Key results: Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.

Conclusions: Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

Figure 1

National trends in clinical performance among Indian Health Service, Medicare, and Medicaid from 2002 through 2006. Five year trends in clinical performance for four selected ambulatory services, including cancer screening, flu shots for adults, and diabetes care. Medicare and medicaid data derived from the national committee for quality assurance State of Health Care Quality Report.