Population Health for CKD and Diabetes: Lessons From the Indian Health Service

Abstract

Despite extensive clinical guidelines, innovative efforts to improve care, and well-funded efforts to raise awareness, limited progress has been made in reducing the burden of kidney disease in the United States, and the prevalence continues to increase worldwide. The Indian Health Service and the Centers for Disease Control and Prevention recently reported a 54% decrease in the incidence of kidney failure among American Indian and Alaska Native people with diabetes. This decrease in end-stage renal disease incidence was associated with a population health approach to diabetes care based in the community and the primary clinical setting. The effort focused on integrating better care for kidney disease within the context of routine diabetes care. Although the American Indian population and the Indian Health Service may be unfamiliar to many clinicians and health system administrators, the demonstration that simple evidence-based interventions implemented in a comprehensive and consistent way can reduce the burden of end-stage renal disease suggests that population-based approaches to chronic disease offer significant potential benefits. Large pragmatic trials may offer the best way to rigorously test this hypothesis.

Keywords: AI/AN; Alaska Natives; American Indians; Native Americans; Population health; chronic disease management; chronic kidney disease (CKD); diabetes; disease progression; end-stage renal disease (ESRD); health care delivery; indigenous people; prevention.

Figure 1

Incidence of diabetes-related end-stage renal disease among adults aged =18 years, by race and ethnicity — United States, 1996–2013. Incidence is shown as rate per 100,000 population and is age-adjusted based on the 2000 US standard population. AI/AN=American Indians and Alaska Natives. Racial groups include persons of Hispanic and non-Hispanic origin; Hispanics may be of any race. Adapted from Bullock et al.