End-Stage Renal Disease Rates Slashed Among Native Americans

Miriam E Tucker

January 11, 2017

Diabetes-related end-stage renal disease (ESRD) rates among American Indians and Alaska Natives were cut in half over the past 2 decades, thanks in large measure to a federally funded program, according to a new report from the Centers for Disease Control and Prevention (CDC).

The findings, from several US databases, were published January 10 as a "Vital Signs" item in the CDC's Morbidity and Mortality Weekly Report by Ann Bullock, MD, director of the US Indian Health Service, division of diabetes treatment and prevention, Rockville, Maryland, and colleagues.

The American Indian and Alaskan Native population has the highest diabetes prevalence of all US racial groups, but the 54% drop from 1996 to 2013 in that group brought their diabetes ESRD rate down to the same as that of whites with diabetes, despite large disparities in income and healthcare resources, as well as disease burden.

Much of the progress is attributed to the US Indian Health Service's implementation of systematic approaches to diabetes care, beginning in the 1980s, that included multidisciplinary team-based, coordinated clinical action and education, community outreach, and tracking of both clinical process and outcomes data at local, regional, and national levels.

The program is "a superb example of how public health can save both lives and money," CDC Director Tom Frieden, MD, said during a telebriefing for journalists.

And the results are relevant to all Americans, Dr Frieden said, because "although diabetes is our leading cause of kidney failure…it can be prevented. The approaches implemented by the Indian Health Service are applicable and scalable for all people with diabetes."

Indeed, Dr Bullock told Medscape Medical News, "Preventing diabetes complications, such as kidney failure, is really about good diabetes care, which includes routine screening for chronic kidney disease and use of kidney-protective medicines."

She added: "Providing comprehensive, team-based care over the lifespan of people with diabetes may be more expensive in the short term but, as this Vital Signs report shows, can make a tremendous difference in rates of complications over the long run."

Improvements in Both Process and Outcome Measures

The data were taken from the US Renal Data System, the Indian Health Service, the National Health Interview Survey, and the US Census. Incidence rates for diabetes-related ESRD were calculated by race/ethnicity for all US adults during from 1996 to 2013 and for those with diabetes from 2006 to 2013.

After increasing slightly from 1996 to 1999, the age-adjusted diabetes-related ESRD incidence per 100,000 of all American Indian/Alaskan Native adults dropped from 63.5 to 26.5 in 2013.

Among those with diabetes, the decline was about 7% per year, and by 2013 the figure was 152.7 per 100,000, very similar to the 159 per 100,000 among whites with diabetes. (Those rates also dropped among blacks with diabetes but not Asians during that time.)

Contributing to this was an increase in ACE-inhibitor prescriptions for American Indian/Alaskan Native adults with diabetes from 42% in 1997 to 74% in 2002 (remaining steady after that through 2015), in contrast to just 56% of adults with diabetes in the general US population who were prescribed ACE inhibitors during 2009–2014.

In 2015, average blood pressure among more than 101,000 American Indian/Alaskan Native adults with both diabetes and hypertension was 133/76 mm Hg, below the target of <140/90.

And from 1996 to 2014, average HbA1c levels in American Indian/Alaskan Native adults with diabetes decreased from 9.0% to 8.1%

Urine albumin-to-creatinine ratio testing was performed in 50% of American Indian/Alaskan Natives aged 65 years and older with diabetes in 2013, increasing to 62% by 2016. In contrast, the rate of such testing in the general Medicare diabetes population was 40% in 2013.

According to Dr Bullock, "Reducing complications from diabetes, such as kidney failure, requires years of partnership between patients and their diabetes care team.

"In addition to good clinical care, it's important to work with patients to address the obstacles they may face in taking their medications and keeping their blood sugars and blood pressures in control. These can include poverty, food insecurity, lack of transportation, health insurance, child care, or sick leave, and other chronic stresses," she emphasized.

Clinic staff can assess these needs and connect patients to local resources, she noted, adding, "Often the patients at highest risk for diabetes complications are the ones who aren't able to get to the clinic regularly for care, so outreach using nurses and community health workers may be needed."

Dr Frieden and Dr Bullock have no relevant financial relationships.

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MMWR Morb Mortal Wkly Rep. Published online January 10, 2017. Article


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