Transcript for CDC Telebriefing: Vital Signs - Diabetes

OPERATOR: To ask a question press star one on your touch tone phone, unmute your phone, state your name clearly and I will introduce you.  This call is being recorded.  If you have any objections you may disconnect at this time.  I'd like to turn the call over to Michelle Bonds.  Ma'am, you may begin. 

MICHELLE BONDS: Thank you for joining us today for the release of the new CDC Vital Signs. This one is on progress made on diabetes related kidney failure among Native Americans. We are joined today by the Director of the CDC Dr. Tom Frieden and Mary Smith, principal deputy director of the Indian Health Service.  I'd like to turn the call over now to Dr. Frieden. 

TOM FRIEDEN: Thank you very much, and thank you all for joining us for today's Vital Sign report.  CDC works 24/7 to protect the health, safety and security of all Americans.  One of the ways we do this is by identifying health threats and working to address them.  This Vital Signs report has important information on reducing kidney failure that results from diabetes.  The report focuses on the American Indian/Alaska Native population and it is a superb example of how public health can save both lives and money.  For today, I will refer to this combined population as Native Americans. But the implication of these findings are not just important for all American Indians, Alaska Natives and Native Americans, they are important for all Americans. The bottom line is this.  Although diabetes is our leading cause of kidney failure, something increasing rapidly across the U.S. - It can be prevented.  Untreated or poorly controlled diabetes may result in kidney disease that progresses to kidney failure that requires either dialysis or kidney transplant.  The approaches implemented by the Indian Health Services, IHS, are applicable and scalable for all people with diabetes.  When an approach uses a population-wide team-based methodology, even and especially in those disproportionately affected by diabetes, kidney failure can be delayed or prevented.  Good diabetes care includes controlling blood pressure and blood sugar, involving patients in their own care, ensuring that patients get kidney protective medicine, and regular testing and monitoring.  Today, the report outlines a population group where this has been done with remarkable success.  Native Americans have more diabetes than any other group in the U.S., and they used to have more kidney failure.  But with this effective program, kidney failure from diabetes dropped by more than half between 1996 and 2013 among Native Americans.  Native Americans are much more likely than other Americans to have diabetes and about two out of three Native Americans who develop kidney failure got it from diabetes.  The Indian Health Service applied population health and team-based approaches to diabetes and kidney care, which reduced kidney failure rates much faster among Native Americans than among any other race or ethnic group in this country.  The approaches aren't unique for diabetes management, but they were applied to the Native American population earlier and more comprehensively.  Here are some of the important improvements since the IHS began this approach to diabetes care.  First, use of medicine to protect the kidneys nearly doubled from 42% to 74% in just five years.  Second, blood pressure is well controlled overall.  About 68% of Native Americans with diabetes meet the target blood pressure of lower than at least 140/90 in 2016.  Third, blood pressure improved with a 10% decrease in blood sugar levels between 1996 and 2014.  Fourth, more than 60% of those 65 and older had the recommended urine tests for kidney damage in 2015.  That's much higher than other groups in other systems of care in this country.  And finally, among people aged 65 and older with diabetes, two-thirds were -- I'm sorry, three-quarters, 76%, were prescribed medicines in 2014 to protect the kidneys.  That compares with about 56% in the U.S. population outside of this special effort.  Beyond its devastating effects for individuals and their families, kidney failure is very expensive.  In 2013, the medical costs for kidney failure from diabetes were about $82,000 per person in the U.S. and Medicare spent $14 billion to treat people with kidney failure from diabetes in the U.S., - a remarkable annual expenditure for something that can be prevented and which the IHS program shows has been prevented in this very important and sometimes challenging population.  I'm now going to turn this over to Mary Smith, principal deputy director of Indian Health Service, to tell us about the meaning to Native Americans.  Before, I’d like to say I’ll come back and talk a little bit in the next section about how this happened and how it's relevant for other groups.  Ms. Smith. 

MARY SMITH: Thank you so much, Dr.  Frieden.  At the Indian Health Service, we provide comprehensive health care to approximately 2.2 million Native Americans across the country.  Our mission is to raise the physical, mental, social, and spiritual health of Native Americans to the highest level.  I'm so thrilled today that we're partnering with CDC and you to announce these important findings.  As Dr. Frieden mentioned, Native Americans are twice as likely to have diabetes as other populations.  Native Americans’ dramatic drop in kidney failure due to diabetes, is due to our comprehensive diabetes program. Success shows how to prevent or delay this costly disabling complication of diabetes.  Kidney failure from diabetes dropped 54% in Native Americans between 1996 and 2013, more than in any other racial or ethnic group.  This is a dramatic drop.  This steep decline in diabetes-related kidney failure is good news for the population we serve, and the Indian Health Service team-based coordinated diabetes care model can be used to reduce kidney failure in other populations as well.  We can attribute this decline in diabetes- related kidney failure to public health and population management approaches to diabetes, accompanied by improvements in clinical care that have been implemented by the Indian Health Service.  Long ago, the Indian Health Service recognized the developing epidemic of diabetes in Native Americans, and we responded by establishing the National Diabetes Program in 1979.  Through this program, IHS developed its first diabetes standards of care in 1986.  These standards promoted evidence-based treatment practices.  These standards were updated to include kidney care disease in the 1990s.  I will just say that coordination and resources have been key.  Also in 1986, IHS began collecting data on diabetes care processes and clinical outcomes, which became the Diabetes Care and Outcome Audit in 1997.  Our special diabetes program, which is our current program, is coordinated by our division of diabetes and is led by Dr. Ann Bullock, lead author of this Vital Signs report we are releasing today.  So compared with 1997, there have been successes in IHS efforts to improve diabetes care.  For instance, between 1997 and 2013, the number of grantees from our special diabetes program who have reported the availability of diabetes clinical teams had jumped from 30% to 96%, and adult weight management program increased from 19% to 78%.  Other positive efforts include time off for tribal employees for diabetes education and exercise, better access to healthier foods, transportation to clinic visits, and health education and exercise classes.  Although some of IHS successes began before the special diabetes program initiative, the SDPI Program has made it possible for American Indian communities to sustain quality diabetes programs and care practices and has helped the Indian health system make tremendous improvements.  Management of risk factors for kidney failure have improved, including use of medicine to protected kidneys, controlling high blood pressure and controlling blood sugar.  Also, this remarkable decline followed implementation by the Indian Health Service of public health and population management approaches to diabetes.  The recommendations in this study, which are already being implemented, allow IHS to catch at-risk patients earlier and provide them the treatment they need before the onset of diabetes.  This results in better health for our patients and a significant cost savings as compared to long-term diabetes treatment.  A public health problem such as diabetes requires years of sustained effort and intervention.  In partnership with tribes, IHS will continue to implement and expand its successful approaches to diabetes prevention and treatment.  Thank you again, Dr. Frieden, for bringing attention to this important public health issue, and for partnering on the innovative approaches we have implemented at IHS to treat and prevent diabetes in American Indian and Alaska Natives.  I will now hand it back over to you. 

TOM FRIEDEN: Thank you very much and thanks to the Indian Health Service for demonstrating how effective a community wide program can be.  When health systems, public health professionals, policymakers, patients in the communities work together, these results show there can be substantial improvements.  Some of the key components that enabled that success were standards of care for improving diabetes care, including integrating kidney disease screening, prevention and education into routine management.  Team-based approaches that are increasingly important include patient education, community outreach, care coordination among various providers, access to dietitians, pharmacists, community health workers, behavioral health specialists.  Also addressing health barriers that patients face.  Critically important - measuring outcomes, tracking both diabetes care processes and long-term outcomes and using these data to continuously improve the implementation of programs.  In all health systems, health care policy leaders and insurers can help by ensuring that health plans assess members with diabetes, including and especially those who don't regularly visit their health care provider. They are the ones at greatest risk of progressing to complications such as amputation, kidney failure or blindness.  Promoting kidney disease screening and monitoring and appropriate use of medicine that protect the kidneys in people with diabetes and chronic kidney disease. Also, implementing and supporting team-based care, case management, patient education, home visits, and community outreach.  The federal government will continue to work on this issue by funding diabetes treatment and prevention services in Native American communities through this special diabetes program for Indians, working to improve diabetes outcomes for those who receive direct health care from federal agencies including U.S.  veterans as well as Native Americans, helping community health centers throughout the U.S. provide comprehensive diabetes care and developing a national system to track chronic kidney disease and its complications.  I'll now turn it over to the moderator to open for questions. 

OPERATOR: Thank you.  Again, if you would like to ask a question, please press star one on your touch-tone phone, unmute your phone and record your name clearly at the prompt.  If you need to withdraw your question, you may press star two.  Please stand by for the first question. 

PAUSE  PAUSE PAUSE

The first question comes from Mike Stobbe, Associated Press.  Your line is open.  Mike Stobbe, your line is open.  Please check your mute button. 

PAUSE  PAUSE PAUSE

TOM FRIEDEN: Let's go to the next question, please. 

MIKE STOBBE, ASSOCIATED PRESS: Hello?  Hello? 

TOM FRIEDEN: We've got you now, Mike.  Go ahead. 

MIKE STOBBE, ASSOCIATED PRESS: I'm sorry.  I don't know what was going on.  Thanks.  Just a couple of quick questions.  I understand that this findings this is specific to Native Americans treated through IHS system.  What proportion of U.S. Native Americans fall into that group?  Then I was also wondering, I believe Mary Smith said something about a program with IHS since 1979.  I think that, you know, when we talk about diabetes often there's an assumption that we're talking mainly about type 2 diabetes, obesity related diabetes.  I don't think type 2 was recognized as a big issue in the U.S. until after 1979.  So I was wondering, the breakdown of diabetes related -- how much type 1 diabetes is there in that population versus type 2?  And then the final question would be aside from the programs that you all talked about, are there other possible explanations for this remarkable reduction? 

TOM FRIEDEN: Thank you.  I'll turn it over to Mary Smith.  If she would like to turn it over to Ann Bullock, lead author. Then I’ll make some comments at the end. 

MARY SMITH:  Well, thank you so much for the question.  I think I will turn most of the question over to Dr. Bullock, but I believe that of the Native Americans who have diabetes, about 99% have type 2 diabetes and 1% have type 1 diabetes.  And that's according to IHS diabetes care and outcomes audit.  I will turn over the remainder of the question to Dr. Bullock, the author of the study. 

ANN BULLOCK: Thank you, Ms. Smith.  There's a bit of a difference between self-defined Native Americans in the census versus how Indian Health Service and tribes in urban organizations define that.  Roughly approximately 2.2 million people are eligible for care through Indian health system and 4.5 million define themselves as Native American in the census.  So it's roughly half those that define themselves as Native Americans in the census are eligible for care through the Indian health system.  Your second question Ms. Smith answered absolutely correctly.  According to our diabetes audit, 99% of Native Americans who have diabetes have type 2 diabetes.  We don't have exact figures for the percent of people with kidney failure in diabetes if they have type 2, but there is no reason to think it is not a similar type of ratio, about 99% type 2.  What are other things that could be responsible for these changes? We never want to forget to acknowledge the efforts of our patients.  Partly through all the patient education that our Indian Health Service, tribal and urban partners have been doing so many years but also from their understanding in hearing these things from other places our patients made remarkable efforts overcoming huge obstacles and barriers of care to get in for their appointments, to exercise, eat healthfully as their budgets will allow, to take their medications as prescribed.  We want to give lots of credit to our patients as well as to the system in which they received their care.  Thank you. 

OPERATOR: The next question comes from…

TOM FRIEDEN: Before we go to the next question, I'd like to draw your attention to figure one with this dramatic 54 percent reduction in diabetes.  This is not just among patients treated in the Indian Health Service, this is among American Indian and Alaskan Natives.  I think it's hard to think of any explanation other than much better care, including in particular the better control of blood pressure and the widespread use of kidney protective medications such as angiotensin-converting enzyme inhibitors.  Would anyone else like to comment on the question of whether IHS versus broader care? 

MICHELLE BONDS: Next question, please? 

OPERATOR:  The next question comes from Rob Capriccioso, Indian Country Today.  Your line is open. 

ROB CAPRICCIOSO, INDIAN COUNTRY TODAY: Thank you.  Kidney failure findings suggests the interventions you're mentioning are having a very positive impact for American Indians.  Yet you noted type 2 diabetes rates are still high in the Indian population.  I'm curious, why do American Indians have the highest rate of diabetes over any group in the U.S. today?  Second, is kidney failure and disease a whole lot easier to curb than type 2 diabetes is to prevent? 

MARY SMITH:  Dr. Bullock, do you want to take that? 

TOM FRIEDEN: Maybe before Dr. Bullock comments I will also and then Dr. Bullock can comment further.  First to say I think your point is very well taken.  It is somewhat less difficult to control the complications of diabetes than to prevent diabetes in the first place.  We're not clear - There's no definitive evidence as to why diabetes is more common in some groups than others.  We know that the rates are so much higher in Native Americans.  We also know programs like diabetes prevention program work and can greatly reduce the progression from prediabetes to diabetes.  In addition, to better care of people with diabetes, we're also working not just with Indian Health Service but with providers throughout the U.S. to scale up the diabetes prevention program.  We're encouraged that an increasing number of insurers and payment systems, including Medicare, will be paying for the diabetes prevention program.  Over to Dr. Bullock. 

ANN BULLOCK: Thank you.  So rates of type 2 diabetes still are highest among Native Americans, among U.S. racial groups.  However, our rates have actually flattened out and the beginning of suggestion of a decrease is starting to be seen. We hope this is a trend develops over the next few years.  At the very least we know that it has flattened out.  Unfortunately for other groups it appears to still be increasing.  While we're slowing down, even leveling off, some of them are continuing to increase.  I don't know for how many more years we'll have the highest rates.  We don't wish that for other groups for sure.  It is a difficult thing.  We know many things contribute to risks for type 2 diabetes across populations. Many social determinates of health, poverty, food insecurity, which includes lack of consistent access to healthful nutritious food and chronic stress itself is a contributing factor across populations.  We don't have all the reasons as Dr. Frieden said why our population has the highest prevalence of diabetes, it's a complex disease but we are seeing things turn around there just as we are seeing it for kidney failure.  As Dr. Frieden says, it can be in some way easier to treat diabetes as hard as that is versus preventing it in the first place. Again, because of how complex the factors, we're working on both aspects, prevention of diabetes and complications once they have diabetes in Indian health system.  Thank you. 

MICHELLE BONDS: Next question, please. 

OPERATPOR: The next comes from Eileen Fuller, Seminole Tribune.  Your line is open. 

EILEEN FULLER, SEMINOLE TRIBUNE: Hi, thanks so much for taking my questions.  A couple of them have already been answered, thank you very much.  I’m curious to find out if there is information available on specific tribes or about specific populations within regions throughout the United States.  Also, I’m curious to find out what the cost of the program and how it was paid for?

MARY SMITH: Sorry, Dr. Frieden, did I interrupt you? 

TOM FRIEDEN: No, I was turning it over to you.  Thank you. 

MARY SMITH: Okay.  Well, our special diabetes program for Indians was established by congress in 1997, and it's funded at $150 million a year.  We provide grant funding to over 300 Indian, tribal and urban programs across the country.  So that answers, I think, part of your question.  In terms of tribal and area specific data, I will turn it over to Dr. Bullock. 

ANN BULLOCK: Thank you, Miss Smith.  We do not release data by specific tribes.  That's considered data for the tribes themselves.  If they wish to release that, that is their choice. But the Indian Health Service does not release that data. There are some things we release by area like GPRA by IHS area.  Many diabetes measures are available through GPRA and available on the IHS website now.  As Ms. Smith said, the cost of the program, you have to look at SDPI as part of it.  Certainly that $150 million a year is a tremendous help in scaling and making more widespread these wonderful practices which we know are reducing complications like kidney failure.  But other types of clinical care that IHS tribes, Indian program funds are important, too.  We're trying to improve care not just through SDPI but clinical systems. Whether SDPI funds are part of those funds or not.  Improving clinical care is something we're trying to do across the board.  That's a hard thing to cost out relative to other costs that I just had for providing general clinical care to Native American people. 

OPERATOR: Thank you.  That's all the time we have for questions.  Dr. Frieden? 

TOM FRIEDEN: Thank you very much.  Thanks for joining us today.  Today's information shows that preventing or delaying kidney failure is possible.  The striking decrease in kidney failure among Native Americans is remarkable, particularly given the health and socioeconomic disparities in this population, including poverty, limited health care resources, and the burden of so many health problems.  The Indian Health Service has shown that kidney failure can be delayed or prevented by better controlling blood pressure and blood sugar, providing medicines that protect the kidneys, and involving a team with rigorous accountability for progress. Reducing kidney failure requires long-term, consistent and comprehensive approaches to diabetes care but these approaches pay off in greatly reduced human suffering, illness and in reduced health care costs.  Thank you very much for joining us. 

OPERATOR:  This concludes today's conference.  Thank you for your attendance.  You may disconnect your lines.  

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES