Kidney failure from diabetes among American Indian/Alaskan Native (AI/AN) adults decreased 54% between 1996 and 2013, according to a recently released Vital Signs report from the Centers for Disease Control and Prevention (CDC).1 The authors point out that this remarkable decrease follows population-based approaches to diabetes management and improvements in clinical care begun by the Indian Health Service (IHS) in the mid-1980s. Furthermore, the authors suggest that these approaches might be a useful model for diabetes management in other health care systems, especially those serving populations at high risk.

Data from the U.S. Renal Data System, the Indian Health Service, the National Health Interview Survey, and the U.S. Census were used to calculate rates of diabetes-related ESRD by race/ethnicity among US adults aged 18 years or older during 1996–2013. In addition, IHS clinical data from the Diabetes Care and Outcomes Audit (the Audit) were analyzed for diabetes management measures in AI/ANs, including prescription of ACE inhibitors and angiotensin II receptor blockers (ARBs); blood pressure; hemoglobin A1C (A1C) to assess glucose control; and urine albumin-to-creatinine ratio testing for identifying and monitoring diabetic kidney disease.

First implemented in 1986, the Audit is an annual process for assessing diabetes care and health outcomes for AI/ANs with diagnosed diabetes who receive care at IHS facilities, tribally operated health programs, and urban Indian (I/T/U) health systems.2

Among AI/AN adults, age-adjusted rates of diabetes-related ESRD per 100,000 population decreased significantly by 54%, from 57.3 in 1996 to 26.5 in 2013 (see Figure 1).1 Although rates for adults in other racial/ethnic groups also decreased during this period, AI/AN adults had the steepest decline.1

Diabetes-related ESRD is delayed or prevented by controlling blood pressure and blood sugar, using kidney-protective medicines, and conducting regular kidney testing.3–5 The decrease of diabetes-related ESRD in AI/ANs was likely the result of improvements in both process and outcome measures, as documented in the Audit. Data from the Audit show that prescription of ACE inhibitors or ARBs in AI/ANs with diabetes increased 76% from 1997 to 2002 (from 42% to 74%) and then remained steady through 2015 (see Figure 2).2,6 Among AI/AN patients with diabetes and hypertension or chronic kidney disease (CKD), prescription of ACE inhibitors or ARBs was greater than 77% for each year studied (see Figure 2).2

Furthermore, measures related to the assessment and treatment of risk factors for diabetes-related ESRD showed more improvement in AI/ANs than in the general population. Compared with the overall US population with diabetes, in 2014, prescription of ACE or ARBs among AI/AN with diabetes was 36% higher (76% vs 56%).2,6,7

Similarly, among persons with diabetes aged 65 years or older, the rate of urine albumin-to-creatinine ratio testing was 55% higher in AI/AN compared with Medicare beneficiaries (62% vs 39%).2,8 Outcome measures were also positive, including blood pressure control in AI/ANs with diabetes and hypertension (average blood pressure of 133/76 in 2015) and improved glycemic control overall (10% drop in A1C between 1996 and 2014).2,9 These favorable trends in diabetes management and prevention of diabetes-related ESRD followed population and team-based approaches to diabetes care undertaken by the IHS.10,11

Commitment to a multidisciplinary approach

Starting in the mid-1980s, IHS implemented systematic approaches to diabetes care that include multidisciplinary team-based, coordinated clinical care and education, community outreach, and tracking of clinical process and outcomes data at the local, regional, and national levels.10,11 These approaches were informed by public health and population management principles, which focus not just on short-term outcomes for individual patients who seek care but also on long-term outcomes, costs, disparities, and wellness of the entire community.12

An organized approach to assessing CKD risks

The IHS system of diabetes care enabled I/T/U sites to successfully and consistently deliver evidence-based interventions that reduce risk factors for diabetes-related ESRD. In 1986, IHS developed its first Diabetes Standards of Care to disseminate evidence-based recommendations aimed at improving diabetes care for AI/ANs.10 These standards were revised in the early 1990s to include assessment and treatment of CKD13 about 10 years before the release of the Kidney Disease Outcomes Quality Initiative guidelines for the evaluation and classification of CKD.14

 IHS was one of the first health care systems to establish routine reporting of the estimated glomerular filtration rate, yearly monitoring of urine albumin excretion, and prescription of angiotensin converting enzyme inhibitors (ACE) inhibitors and ARBs.11 Both of these classes of therapeutic agents have been shown to prevent or delay diabetes-related ESRD in patients with albuminuria, independent of their effects in reducing blood pressure.3,4

Successful implementation of evidence-based clinical interventions as documented by the Audit might explain in part the decline in the rate of new cases of diabetes-related ESRD in AI/AN adults. IHS has made other improvements in diabetes care by developing clinical education programs and tools, culturally relevant patient education materials, and population-based management tools in the IHS electronic health record.9,11,15 I/T/U case managers help coordinate in-house care as well as referrals for specialty services in order to facilitate greater care continuity than in more fragmented systems.6 I/T/U facilities also support diabetes care and education by using public health nurses and community health workers to provide outreach and education to the community.16

In 1997, Congress established the Special Diabetes Program for Indians (SDPI).9 SDPI provides much-needed funding to 301 I/T/U sites to implement interventions that reduce risk factors for diabetes and its complications, including diabetes-related ESRD. In addition, SDPI funds have been used by IHS to improve its national program for disseminating evidence-based interventions and providing training, tools for data collection and analysis, and support to diabetes programs in AI/AN communities across the country. Because of SDPI, the partnership of IHS and I/T/U programs is stronger. Together they provide a comprehensive public health-oriented national program that demonstrates success in addressing the diabetes epidemic in AI/ANs and in reducing ESRD.9


ESRD is a disabling and costly complication of diabetes. In 2014, total Medicare spending for diabetes-related ESRD was $15 billion, about half (45%) of the $33 billion in Medicare spending for ESRD overall, with estimated costs of $84,000 per person.8 The response of IHS, a direct care agency organized around a public health model, might be a useful model for other health care systems, especially those serving populations at high risk. Integrating public health, clinical, and community-based approaches to deliver evidence-based interventions that reduce risk factors for diabetes-related complications can sustain and improve declines in the rate of complications such as diabetes-related ESRD.1

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. To read the entire Vital Signs report, visit For more information on the IHS’s and CDC’s work, visit and


  1. Bullock A, Burrows NR, Narva AS, Sheff K, Hora I, Lekiachvili A, Cain H, Espey D. Vital Signs: Decrease in incidence of diabetes-related end-stage renal disease among American Indians/Alaska Natives—United States, 1996–2013. MMWR Morb Mortal Wkly Rep.66(1):26–32, 2017
  2. Indian Health Service. The IHS Diabetes Care and Outcomes Audit.
  3. Patel A, MacMahon S, Chalmers J, et al.; ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 370:829–840, 2007
  4. Brenner BM, Cooper ME, de Zeeuw D, et al.; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 345:861–869, 2001
  5. Zoungas S, de Galan BE, Ninomiya T, et al.; ADVANCE Collaborative Group. Combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes: new results from the ADVANCE trial. Diabetes Care 32:2068–2074, 2009
  6. Indian Health Service. Special Diabetes Program for Indians—2011 report to Congress, 2011.
  7. Afkarian M, Zelnick LR, Hall YN, et al. Clinical manifestations of kidney disease among US adults with diabetes, 1988–2014. JAMA 316:602–610, 2016
  8. United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016
  9. Indian Health Service. Special Diabetes Program for Indians—2014 report to Congress. Rockville, Maryland: Indian Health Service; 2014
  10. Acton K, Valway S, Helgerson S, et al. Improving diabetes care for American Indians. Diabetes Care 16:372–375, 1993
  11. Narva AS. Reducing the burden of chronic kidney disease among American Indians. Adv Chronic Kidney Dis 15:168–173, 2008
  12. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 100:590–595, 2010
  13. Narva AS. Caring for the patient with progressive renal disease. IHS Prim Care Provid 15:101–104, 1990
  14. Kidney Disease Outcomes Quality Initiative (NKF). Clinical Practice Guidelines for CKD: Evaluation, Classification, and Stratification.
  15. Sequist TD, Cullen T, Acton KJ. Indian health service innovations have helped reduce health disparities affecting American Indian and Alaska native people. Health Aff (Millwood) 30:1965–1973, 2011.
  16. Indian Health Service. Community Health.