Quality of care for First Nations and non-First Nations People with diabetes.
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ABSTRACT: Background and objectives
Compared with non-First Nations, First Nations People with diabetes experience higher rates of kidney failure and death, which may be related to disparities in care. This study examined First Nations and non-First Nations People with diabetes for differences in quality indicators and their association with kidney failure and death.Design, setting, participants, & measurements
Adults with diabetes and an outpatient creatinine in Alberta from 2005 to 2008 were identified. Logistic regression was used to determine the likelihood of process of care indicators (measurement of urine albumin/creatinine ratio [ACR], LDL, and hemoglobin A1C [A1C]) and surrogate outcome indicators (achievement of LDL and A1C targets). Cox regression was used to determine the association between lack of achievement of indicator targets and each of kidney failure and death.Results
This study identified 140,709 non-First Nations and 6574 First Nations People with diabetes. There was a significant interaction between First Nations status and CKD for the outcomes (P<0.01); therefore, results are stratified by CKD. Among participants without CKD, First Nations People were less likely to receive process of care indicators and achieve target A1C compared with non-First Nations People. For those with CKD, First Nations People were as likely to receive these indicators (other than LDL) and achieve LDL and A1C targets. Lack of LDL and A1C assessment and achievement of targets were associated with increased risk of kidney failure and death similarly for both groups.Conclusions
Compared with non-First Nations, First Nations People with diabetes but without CKD experience disparities in assessment of quality indicators and achievement of A1C target.
SUBMITTER: Deved V
PROVIDER: S-EPMC3700698 | biostudies-literature | 2013 Jul
REPOSITORIES: biostudies-literature
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Project description:BackgroundFirst Nations people in Ontario have an increased prevalence of diabetes compared to other people in the province. This study examined use of health care services by First Nations people with diabetes and other people with diabetes in Ontario.MethodsUsing linked health administrative databases, we identified all people in Ontario with diabetes as of Apr. 1, 2014. We identified First Nations people using the Indian Register. We looked at outcomes from Apr. 1, 2014, to Mar. 31, 2015. We determined the proportion of people with a regular family physician and their continuity of care with that physician. We also examined visits with specialists for diabetes care, hospital admissions for ambulatory-care-sensitive conditions, and emergency department visits for hypo- or hyperglycemia.ResultsThere were 1 380 529 people diagnosed with diabetes in Ontario as of Apr. 1, 2014, of whom 22 952 (1.7%) were First Nations people. First Nations people were less likely to have a regular family physician (85.3% v. 97.7%) and had lower continuity of care with that physician (mean score for continuity of care 74.6 v. 77.7) than other people in Ontario. They were also less likely to see specialists. First Nations people were more likely to be admitted to hospital for ambulatory-care-sensitive conditions (2.4% v. 1.2%) and to have an emergency department visit for hypo- or hyperglycemia (1.5% v. 0.8%). Disparities were particularly marked for those living in First Nations communities.InterpretationFirst Nations people with diabetes in Ontario had poorer access to and use of primary care than other people with diabetes in the province. These findings may help explain continued disparities in the rates of complications related to diabetes.
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Project description:BACKGROUND:End-stage kidney disease is a serious complication of diabetes. We describe the prevalence of chronic kidney disease, prevalence and incidence of end-stage kidney disease and quality of care of early-stage chronic kidney disease for First Nations people with diabetes compared to other Ontarians with diabetes. METHODS:We conducted a retrospective cohort study in Ontario using linked administrative data at ICES. We included adults with incident diabetes between 1994 and 2014, and used laboratory values to identify kidney disease and quality indicators for care for early-stage disease. We compared measures in First Nations people to those in other people in Ontario, and used direct age and sex standardization. We used Cox proportional hazards regression to compare the incidence of end-stage kidney disease between groups. RESULTS:Our study included 21 968 First Nations people with diabetes. The age- and sex-standardized prevalence of chronic kidney disease was higher for First Nations people than for other Ontarians (20.7% v. 18.4%), as was the prevalence of end-stage kidney disease (2.9% v. 1.0%). The incidence of end-stage kidney disease was higher among First Nations people than among other people in Ontario (9.3 v. 4.7 events per 10 000 person-years; age- and sex-adjusted hazard ratio 2.23, 95% confidence interval 1.72-2.89). The 2 groups were similarly likely to receive recommended medications, but First Nations people were less likely to receive laboratory tests for their kidney disease. INTERPRETATION:Despite receiving similar quality of care for early-stage kidney disease, First Nations people with diabetes had higher rates of end-stage kidney disease than other Ontarians. Further research is needed to better understand contributing factors to help inform future interventions.
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Project description:ImportanceType 2 diabetes is increasing worldwide, disproportionately affecting First Nations (FN) people. Identifying early-life determinants of type 2 diabetes is important to address the intergenerational burden of illness.ObjectiveTo investigate the association of in utero exposure to gestational diabetes and type 2 diabetes, stratified by FN status, with the development of type 2 diabetes in offspring.Design, setting, and participantsThis cohort study was derived from the linkage of a pediatric diabetes clinical database and a population-based research data repository in Manitoba, Canada. Mother-infant dyads with a hospital birth or midwifery report in the data repository between April 1, 1984, and April 1, 2008, were identified. The dates of analysis were August through December 2017. Children identified with type 1 diabetes, monogenic diabetes, or secondary diabetes were excluded.ExposuresPrimary exposures included maternal gestational diabetes or type 2 diabetes and FN status.Main outcomes and measuresThe primary outcome was incident type 2 diabetes in offspring by age 30 years.ResultsIn this cohort study of 467 850 offspring (mean follow-up, 17.7 years; 51.2% male), FN status and diabetes exposure were associated with incident type 2 diabetes in offspring after adjustment for sex, maternal age, socioeconomic status, birth size, and gestational age. Type 2 diabetes exposure conferred a greater risk to offspring compared with gestational diabetes exposure (3.19 vs 0.80 cases per 1000 person-years, P < .001). Compared with no diabetes exposure, any diabetes exposure accelerated the time to the development of type 2 diabetes in offspring by a factor of 0.74 (95% CI, 0.62-0.90) for gestational diabetes and a factor of 0.50 (95% CI, 0.45-0.57) for type 2 diabetes. First Nations offspring had a higher risk compared with non-FN offspring (0.96 vs 0.14 cases per 1000 person-years, P < .001). First Nations offspring had accelerated type 2 diabetes onset by a factor of 0.52 (95% CI, 0.49-0.55) compared with non-FN offspring. Neither interaction between FN and type 2 diabetes (0.92; 95% CI, 0.80-1.05) nor interaction between FN and gestational diabetes (0.97; 95% CI, 0.77-1.20) was significant (P = .21 and P = .75, respectively).Conclusions and relevanceImportant differences exist in offspring risk based on type of diabetes exposure in utero. These findings have implications for future research and clinical practice guidelines, including early pregnancy screening and follow-up of the offspring.
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Project description:BACKGROUND:To improve diabetes care, First Nations leaders and others need access to population-level health data. We provide details of the collaborative methods we used to describe the prevalence and incidence of diabetes in First Nations people in Ontario and present demographic data for this population compared to the rest of the Ontario population. METHODS:To identify the population of First Nations people and other people in Ontario, we created annual cohorts of the Ontario population for each year between Apr. 1, 1995, and Mar. 31, 2015. Through a partnership between First Nations and academic researchers, we linked provincial population-based health administrative data stored at ICES with the Indian Register, which identifies all Status First Nations people. Our collaborative process was guided by the First Nations principles of ownership, control, access and possession (OCAP). RESULTS:Demographic characteristics for the 2014/15 cohort (n = 13 406 684) are presented here. The cohort includes 158 241 Status First Nations people and 13 248 443 other people living in Ontario. Using postal codes, we were able to identify virtually all (99.9%) First Nations people in Ontario as living in (n = 55 311) or outside (n =102 889) a First Nations community. First Nations people were younger and more likely to live in semiurban or rural areas than the rest of Ontario's population. INTERPRETATION:The collaborative methodology used in this study is applicable to many jurisdictions working with Indigenous groups who have access to similar data. The Ontario cohort defined here is being used to conduct analyses of health outcomes and use of health care services among First Nations people with diabetes in Ontario.
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Project description:BACKGROUND:Population-based planning tools are important for informing diabetes-prevention efforts in First Nations communities. We used the Diabetes Population Risk Tool (DPoRT) to predict 10-year diabetes risk and describe the factors that contribute to diabetes risk in First Nations adults living in Ontario First Nations communities. METHODS:We examined population data from adult (? 20 yr) respondents to the First Nations Regional Health Survey (RHS) phase 3, a representative cohort of First Nations people living in Ontario First Nations communities. We applied the DPoRT to risk factor information in the survey to predict the distribution of 10-year type 2 diabetes incidence and number of new diabetes cases from 2015/16 to 2025/26. RESULTS:There were 993 respondents to the RHS phase 3 adult survey, of whom 936 (708 without diabetes and 228 with a diagnosis of type 2 diabetes) were eligible for inclusion. The DPoRT predicted a type 2 diabetes risk of 9.6% (confidence interval [CI] 8.3-10.8) between 2015/16 and 2025/26, corresponding to 3501 (95% CI 2653-4348) new diabetes cases. Diabetes cases were predicted to occur disproportionately among those experiencing food insecurity, low income, overweight, obesity and physical inactivity. Reduced diabetes risk was predicted among those who reported connections to Indigenous culture, as measured by eating traditional vegetative foods a few times or often in the previous 12 months. INTERPRETATION:Socioeconomic conditions and known risk factors for type 2 diabetes are important determinants of diabetes risk in First Nations communities. Culturally appropriate policies, programming and services that address socioeconomic disadvantage and other diabetes risk factors in First Nations communities likely have an important role for diabetes prevention in First Nations adults.
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Project description:BACKGROUND:In Canada, First Nations populations experience a higher incidence of diabetes and diabetes-related complications than other people. Given the paucity of information on use of preventive eye examinations and the need for interventional care for severe retinopathy among First Nations people, we carried out a population-based study to compare rates of eye examinations and interventional therapies to treat vision-threatening stages of diabetic retinopathy among First Nations people and other people with diabetes in Ontario. METHODS:In collaboration with the Chiefs of Ontario, we carried out a population-based study to identify cohorts of First Nations people and other people with diabetes in Ontario from 1995/96 to 2014/15. We used linked health administrative databases to evaluate rates of eye examination (2005/06-2014/15) and severe diabetic retinopathy treatment and compared them between the 2 populations, and between First Nations people living in and outside of First Nations communities. RESULTS:We identified 23 013 First Nations people and 1 364 222 other people diagnosed with diabetes from 1995/96 to 2014/15, of whom 49.8% (95% confidence interval [CI] 48.9%-50.7%) and 53.8% (95% CI 53.7%-54.0%), respectively, received an eye examination in 2014/15. Eye examination rates were similar for First Nations people regardless of whether they lived in or outside a First Nations community. First Nations people developed severe diabetic retinopathy at a faster rate than other people (hazard ratio 1.19, 95% CI 1.02-1.38). The gap between First Nations people and other people in the proportion requiring therapy for severe diabetic retinopathy was especially prominent among younger people. There were no significant differences in rates of diabetic retinopathy treatment in First Nations people stratified by place of residence. INTERPRETATION:Eye examination rates remain suboptimal among people with diabetes in Ontario and were lower among First Nations people. This is particularly concerning in light of our other findings showing an increased risk of requiring treatment for advanced diabetic retinopathy and the accelerated rate of diabetic retinopathy progression among First Nations people with diabetes.
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Project description:BACKGROUND:Peripheral arterial disease is an important vascular complication of diabetes that may lead to lower-extremity amputation. We aimed to compare the treatment and complications of peripheral arterial disease between First Nations people and other people in Ontario with diabetes. METHODS:Using health care administrative databases, we identified annual cohorts, from 1995/96 to 2014/15, of all people aged 20-105 years in Ontario with a diagnosis of diabetes. We used the Indian Register to identify those who were First Nations people and compared them to all other people in Ontario. We identified revascularization procedures (angioplasty or bypass surgery) and lower-extremity amputation procedures in the 2 populations and determined the mortality rate among those who had had lower-extremity amputation. RESULTS:First Nations people received revascularization procedures at a rate comparable to that for other people in Ontario. However, they had lower-extremity amputation procedures at 3-5 times the frequency for other Ontario residents. First Nations people had higher mortality than other people in Ontario after lower-extremity amputation (adjusted hazard ratio 1.15, 95% confidence interval 1.05-1.26), with median survival of 3.5 years versus 4.1 years. INTERPRETATION:First Nations people in Ontario had a markedly increased risk for lower-extremity amputation compared to other people in Ontario, and their mortality rate after amputation was 15% higher. Future research is needed to understand what barriers First Nations people face to receive adequate peripheral arterial disease care and what interventions are necessary to achieve equitable outcomes of peripheral arterial disease for First Nations people in Ontario.
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Project description:Studies about the health of Indigenous (i.e., original inhabitants) populations often focus on chronic diseases and risk behaviors, emphasizing physical aspects of health. Our objective was to test for differences in self-reported health-related quality of life (HRQOL), which provides a multidimensional and holistic perspective on health, between First Nations (one group of Indigenous peoples) and Caucasian women. Data were from the First Nations Bone Health Study, conducted in the Canadian province of Manitoba. HRQOL was measured using the validated Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). It captures respondent's perceptions of eight health domains, as well as overall mental and physical health components.Analyses were conducted for 707 participants of which 47.4% were of First Nations origin. First Nations respondents had significantly lower unadjusted scores (p < 0.05) than Caucasian respondents on all SF-36 dimensions, except bodily pain and vitality. They also had significantly lower overall mental health scores. After adjusting for multiple determinants of health (e.g., age, education, substance use), differences were no longer statistically significant, except for the social functioning and role emotional domains and overall mental health component. Complex cultural factors are likely responsible for the persistent mental health inequalities experienced by First Nations women.
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Project description:BackgroundFirst Nations people in Canada are overrepresented among those who have undergone nontraumatic lower extremity amputation, and are more likely to be younger, have diabetic foot infections and have no previous revascularization procedures than non-First Nations populations who have undergone lower extremity amputations. We sought to identify access barriers for high-risk First Nations patients, explore patients' experiences with health care systems and identify solutions.MethodsEmploying a community participatory research design, we engaged representatives from 2 communities. They assisted with research design and data analysis, and approved the final manuscript. Using a hermeneutic phenomenological approach and purposeful sampling, we conducted 5 semistructured focus groups between August and December 2021 with community health care teams and patients at risk for, or who had previously undergone, a nontraumatic lower extremity amputation.ResultsPatients' (n = 10) and community health care providers' (n = 18) perspectives indicated that barriers to health care access led to delayed care and increased complications and risk for lower extremity amputations, leading to aggressive procedures upon receiving care. Barriers to care led to negative experiences at urban centres and aggressive procedures created further distrust, leading to care disengagement and poor outcomes. Patients and providers both suggested building stronger partnerships between urban and rural health care providers, improving education for patients and health care providers and identifying innovative strategies to improve patients' overall health.InterpretationSystemic changes, health promotional program and reliable on-reserve primary care are needed to create equitable access for First Nation patients at risk for lower extremity amputations. The study results imply that health care delivery for First Nations patients at risk for lower extremity amputations can be improved through stronger partnership and communication between urban and community providers, and continued education and cultural competency training for urban health care providers.
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