Results Summary
What was the research about?
Diabetes is a long-term illness that causes blood sugar levels to rise. It can cause health problems that affect the heart, brain, eyes, limbs, and kidneys. American Indian and Alaska Native, or AI/AN, peoples are more likely to have diabetes than people from other ethnic groups.
The Indian Health Service and Tribal health programs offer health care to members of AI/AN Tribes. In addition to usual care, some people with diabetes receive education, case management, and pharmacy, or ECP, services. Nurses, case managers, and advanced practice pharmacists deliver these services, which include:
- Information about diet, exercise, and regularly checking blood sugar
- Support getting the healthcare services people need
- Help managing medicines
In this study, the research team wanted to learn if ECP services helped people with diabetes improve their health. Using health data, the team compared a group of people who used ECP services with a group who didn’t.
What were the results?
Compared with the people who didn’t use ECP services, those who did:
- Were less likely to have high blood pressure or high cholesterol
- Were less likely to be admitted to the hospital or have one or more avoidable hospital stays
- Spent fewer days in the hospital and had fewer emergency room visits
The two groups didn’t differ in blood sugar levels.
Also, compared with people who had one or two ECP visits, those with three or more visits:
- Were less likely to have high blood pressure or high cholesterol
- Spent fewer days in the hospital
- Were less likely to have avoidable hospital stays
Who was in the study?
The research team looked at health data from 28,578 AI/AN people with diabetes who lived throughout the United States. Of these, 57 percent were women. During the study, 41 percent went to at least one ECP visit. People who used any ECP services averaged about three visits in one year.
What did the research team do?
The research team looked at health data for three fiscal years. The team looked at health outcomes in fiscal year 2013. The team looked at use of ECP services in fiscal year 2012. The team used data from fiscal year 2011 to account for differences between the two groups, such as age or gender.
AI/AN people, caregivers, and staff from the Indian Health Service, Tribal health programs, Tribal Councils, and Tribal Authorities gave input on the study.
What were the limits of the study?
The study didn’t assign people to each group by chance. The team can’t be sure that the results were entirely because of ECP services.
Future studies could look at whether the benefits of ECP services last more than one year.
How can people use the results?
Clinics can use the results to support AI/AN people with diabetes.
Professional Abstract
Objective
To examine the effectiveness of education, case management, and advanced practice pharmacy (ECP) services on health outcomes and hospital admissions among American Indian and Alaska Native (AI/AN) peoples with diabetes
Study Design
| Design Element | Description |
|---|---|
| Design | Observational: cohort study |
| Population | 28,578 AI/AN adults with diabetes who used Indian Health Service and Tribal health services in fiscal years 2011 to 2013 |
| Interventions/ Comparators |
|
| Outcomes |
Blood glucose, blood pressure, blood cholesterol, any hospital admission, any potentially preventable hospital admission, average number of days spent in the hospital, average number of ED visits |
| Timeframe | 1-year follow-up for study outcomes |
This retrospective cohort study compared the impact of receiving versus not receiving ECP services on health outcomes and hospital admissions among AI/AN adults with diabetes. Diabetes is more prevalent among AI/AN adults than other ethnic groups.
Researchers analyzed data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project for AI/AN adults with diabetes who used IHS or Tribal services during the study period and lived throughout the United States. They compared health outcomes and hospital utilization by those who used ECP services with those who did not. ECP services include diabetes, nutrition, and other types of health education; support to coordinate health care; and advanced-practice pharmacy services, including medication management. Multiple professionals including nurses, case managers, and advanced-practice pharmacists delivered these services.
The study included data for 28,578 AI/AN adults. Of these, 57% were female, and 41% had at least one ECP visit. People who used ECP services averaged 2.7 visits in one year. Researchers examined study outcomes in fiscal year 2013 for patients who used ECP services in fiscal year 2012, controlling for baseline characteristics in fiscal year 2011. They used inverse probability of treatment weighting to control for differences between ECP users and non-users in observed characteristics, such as age, gender, and comorbidities, that might influence ECP use.
AI/AN people, caregivers, and representatives from the IHS, Tribal health programs, Tribal Councils, and Tribal Authorities helped design the study and interpret findings.
Results
Compared with the group that did not use ECP services, the group that did:
- Was less likely to have high blood pressure (odds ratio [OR]=0.85; 95% confidence interval [CI]: 0.79, 0.93)
- Was less likely to have high cholesterol (OR=0.89; 95% CI: 0.84, 0.98)
- Was less likely to have any hospital admissions (OR=0.80; 95% CI: 0.71, 0.89) or potentially preventable hospital admissions (OR=0.79; 95% CI: 0.64, 0.91)
- Had 0.13 fewer inpatient days (95% CI: -0.21, -0.04) and 0.8 fewer emergency department (ED) visits (95% CI: -0.12, -0.05)
The two groups did not differ significantly in blood glucose levels.
Compared with people who had one or two visits, those with three or more ECP visits:
- Were less likely to have high blood pressure (OR=0.82; 95% CI: 0.70, 0.97) or high cholesterol (OR=0.83; 95% CI: 0.71, 0.97)
- Were less likely to have potentially preventable hospital admissions (OR=0.72; 95% CI: 0.53, 0.98)
- Had 0.14 fewer inpatient days (95% CI: -0.26, -0.01)
Limitations
Because the study did not randomly assign people to ECP service use, it is not possible to attribute, with certainty, changes in health outcomes and hospital admissions to the intervention.
Conclusions and Relevance
ECP services may improve health outcomes and reduce hospital admissions for AI/AN people with diabetes.
Future Research Needs
Future studies could examine whether the effects of ECP services for AI/AN people with diabetes last longer than one year.
Final Research Report
View this project's final research report.
More to Explore...
Blogs
In the Navajo Nation, a Focus on Health Data
Native Americans have disproportionately high rates of diabetes. Two PCORI studies, including this study, are searching for answers in the Navajo Nation and its health data. Challenges abound—including far-flung geography, low health resources, and language barriers—but together Navajo researchers and community health workers are meeting them. This blog was co-authored by Joan O'Connell, PhD, this study's principal investigator.
Journal Citations
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Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked the researchers to add information regarding treatment costs, one of the study goals, or to add an explanation for why costs were not explicitly addressed. The researchers explained that their stakeholder network requested many additional analyses that used up available resources, so they were not able to complete the original cost analyses. With supplemental funding from other sources, the researchers said they are planning to review their treatment cost findings and publish those results separately.
- The reviewers asked for more explanation for how missing data were handled for participants who had some missing data in sites that were included in the analyses. The researchers provided more detail in the text and in an appendix on how they handled missing data. In general, their analyses included participants missing baseline data but with outcome data. However, the researchers excluded participants missing data on a particular outcome from analyses of that outcome.