COVID-19 diagnostic testing and vaccinations among First Nations in Manitoba: A nations-based retrospective cohort study using linked administrative data, 2020-2021.

BACKGROUND: Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). METHODS AND FINDINGS: In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. CONCLUSION: In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada.

Geographic Comparison of Dietary Intake and Quality in Manitoba Adolescents.

Purpose: The Food and Nutrition for Manitoba Youth (FANS) study examined dietary intakes, food behaviours, food security status, health indicators, and body mass index of a cohort of grade 9 students. This paper describes regional differences and similarities in dietary intake (food and nutrients) and quality of youth participants in the FANS study.Methods: Grade 9 students completed a web-based survey on dietary intakes (24-hour recall), food behaviours, self-reported health indicators, and sociodemographic variables. Nutrient intakes were compared with national guidelines and diet quality was assessed using a modified Healthy Eating Index.Results: A total of 1587 students participated from northern, rural, and urban regions in Manitoba. Northern and rural students had higher intakes of sugar, sodium, and saturated fat compared with urban. Northern students consumed fewer grain products compared to urban, and more servings of "other" foods compared with rural and urban. While most participants were classified into the "needs improvement" or "poor" Healthy Eating Index categories, significantly more northern participants were in the "poor" category.Conclusions: Most adolescents in the study are at nutritional risk; however, there are additional vulnerabilities for those in rural and northern communities. Dietitians can use results to advocate for and plan interventions to improve adolescent nutrition.

Adherence to Psychotropic Medication Before and During COVID-19: A Population-Wide Retrospective Observational Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and associated public health measures have shifted the way people access health care. We aimed to study the effects of the COVID-19 pandemic on psychotropic medication adherence. METHODS: A retrospective cohort study using administrative data from the Manitoba Centre for Health Policy Manitoba Population Research Data Repository was conducted. Outpatients who received at least 1 prescription for an antidepressant, antipsychotic, anxiolytic/sedative-hypnotic, cannabinoid, lithium, or stimulants from 2015 to 2020 in Manitoba, Canada, were included. Adherence was measured using the proportion of individuals with a mean possession ratio of ≥0.8 over each quarter. Each quarter of 2020 after COVID-19-related health measures were implemented was compared with the expected trend using autoregression models for time series data plus indicator variables. Odds ratio of drug discontinuation among those previously adherent in 2020 was compared with each respective quarter of 2019. RESULTS: There were 1,394,885 individuals in the study population in the first quarter of 2020 (mean [SD] age, 38.9 [23.4] years; 50.3% female), with 36.1% having a psychiatric diagnosis in the preceding 5 years. Compared with the expected trend, increases in the proportions of individuals adherent to antidepressants and stimulants were observed in the fourth quarter (October-December) of 2020 (both P < 0.001). Increases in the proportions of individuals with anxiolytic and cannabinoid adherence were observed in the third quarter (July-September) of 2020 (both P < 0.05), whereas a decrease was seen with stimulants in the same quarter ( P < 0.0001). No significant changes were observed for antipsychotics. All drug classes except lithium had decreases in drug discontinuation in previously adherent patients during the pandemic compared with 2019. CONCLUSIONS: Improved adherence to most psychotropic medications in the 9 months after public health restrictions were enacted was observed. Patients who were already adherent to their psychotropic medications were less likely to discontinue them during the pandemic.

Changes in health indicator gaps between First Nations and other residents of Manitoba.

BACKGROUND: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades. METHODS: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods. RESULTS: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations. INTERPRETATION: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations.

Regional variation in the potentially inappropriate first-line use of fluoroquinolones in Canada as a key to antibiotic stewardship? A drug utilization review study.

BACKGROUND: Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada. METHODS: Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit. RESULTS: We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD. CONCLUSIONS: Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones.

Impact of consultation recordings on patient-reported outcomes in patients with brain tumors: a parallel randomized controlled trial.

OBJECTIVE: We aimed to determine the impact of a primary treatment consultation recording on perception of being informed, satisfaction with cancer care, satisfaction with the oncologist, and psychological distress in patients with brain tumors. METHODS: This was a prospective, double-blind, parallel, randomized controlled trial conducted in 3 Canadian cities, in which patients who had their initial treatment consultation recorded were assigned to either receive their digital recording or not. It was hypothesized that patients who received their recording would realize statistically significant benefit on the outcomes of interest at 1 week, 3 months, and 6 months post-consultation in comparison to patients who did not receive their recording. Outcome measures included the following: Patient Satisfaction with Cancer Scale, Hospital Anxiety and Depression Scale, PrestMan Satisfaction with Doctor Scale, and Perception of Being Informed Scale. RESULTS: Of the 246 eligible patients, 133 participated (60.9% male; age M=52.4 years; 53.4% grade IV disease). Of these, 63 received their consultation recording and 70 did not. Intention-to-treat analysis showed that, compared to baseline, patients who received their consultation recording reported being more fully informed about their disease and treatment at 1 week post-consultation than patients who did not receive their recording (p = 0.007), but this finding was no longer significant at 3 and 6 months. There were no statistically significant differences observed between the two groups on the measures of satisfaction with cancer care, satisfaction with the doctor, and depression or anxiety at any assessment time point, though the study was under-powered. CONCLUSION: The study findings show that primary treatment consultation recordings may provide limited benefit beyond brain tumor patients' perception of being informed, despite being highly valued by these patients, and high listening rates among their significant others. The lack of statistical power should be considered when interpreting the findings. TRIAL REGISTRATION: ClinicalTrials.gov - NCT01866228.

Prevalence and clinical, social, and health care predictors of miscarriage.

BACKGROUND: Pregnancy loss is common and several factors (e.g. chromosomal anomalies, parental age) are known to increase the risk of occurrence. However, much existing research focuses on recurrent loss; comparatively little is known about the predictors of a first miscarriage. Our objective was to estimate the population-level prevalence of miscarriages and to assess the contributions of clinical, social, and health care use factors as predictors of the first detected occurrence of these losses. METHODS: In this population-based cohort study, we used linked administrative health data to estimate annual rates of miscarriage in the Manitoba population from 2003 to 2014, as a share of identified pregnancies. We compared the unadjusted associations between clinical, social, and health care use factors and first detected miscarriage compared with a live birth. We estimated multivariable generalized linear models to assess whether risk factors were associated with first detected miscarriage controlling for other predictors. RESULTS: We estimated an average annual miscarriage rate of 11.3%. In our final sample (n = 79,978 women), the fully-adjusted model indicated that use of infertility drugs was associated with a 4 percentage point higher risk of miscarriage (95% CI 0.02, 0.06) and a past suicide attempt with a 3 percentage point higher risk (95% CI -0.002, 0.07). Women with high morbidity were twice as likely to experience a miscarriage compared to women with low morbidity (RD = 0.12, 95% CI 0.09, 0.15). Women on income assistance had a 3 percentage point lower risk (95% CI -0.04, -0.02). CONCLUSIONS: We estimate that 1 in 9 pregnant women in Manitoba experience and seek care for a miscarriage. After adjusting for clinical factors, past health care use and morbidity contribute important additional information about the risk of first detected miscarriage. Social factors may also be informative.

An unconditional prenatal income supplement is associated with improved birth and early childhood outcomes among First Nations children in Manitoba, Canada: a population-based cohort study.

BACKGROUND: In Manitoba, Canada, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit, an unconditional income supplement of up to CAD $81/month, during their latter two trimesters. Our objective was to determine the impact of the Healthy Baby Prenatal Benefit on birth and early childhood outcomes among Manitoba First Nations women and their children. METHODS: We used administrative data to identify low-income First Nations women who gave birth 2003-2011 (n = 8209), adjusting for differences between women who received (n = 6103) and did not receive the Healthy Baby Prenatal Benefit (n = 2106) with using propensity score weighting. Using multi-variable regressions, we compared rates of low birth weight, preterm, and small- and large-for-gestational-age births, 5-min Apgar scores, breastfeeding initiation, birth hospitalization length of stay, hospital readmissions, complete vaccination at age one and two, and developmental vulnerability in Kindergarten. RESULTS: Women who received the benefit had lower risk of low birth weight (adjusted relative risk [aRR] 0.74; 95% CI 0.62-0.88) and preterm (aRR 0.77; 0.68-0.88) births, and were more likely to initiate breastfeeding (aRR 1.05; 1.01-1.09). Receipt of the Healthy Baby Prenatal Benefit was also associated with higher rates of child vaccination at age one (aRR 1.10; 1.06-1.14) and two (aRR 1.19; 1.13-1.25), and a lower risk that children would be vulnerable in the developmental domains of language and cognitive development (aRR 0.88; 0.79-0.98) and general knowledge/communication skills (aRR 0.87; 0.77-0.98) in Kindergarten. CONCLUSIONS: A modest unconditional income supplement of CAD $81/month during pregnancy was associated with improved birth outcomes, increased vaccination rates, and better developmental health outcomes for First Nations children from low-income families.

Complete physical examinations in Manitoba adults with an intellectual or developmental disability: A retrospective cohort study.

BACKGROUND: Complete physical examinations (CPE) can identify health disparities in persons with intellectual or developmental disabilities. The objective of this study was to determine and compare rates of CPE among Manitoba adults with and without intellectual or developmental disabilities over time and to identify factors that were associated with receiving a CPE. METHOD: A retrospective cohort study using linked administrative health and non-health data from 1995 to 2015 was conducted. Poisson and logistic regression were used to calculate CPE rates and examine factors associated with CPE. RESULTS: The rates of CPE are decreasing over time and are higher among Manitobans with an intellectual or developmental disability. Characteristics such as being male, living rurally, low socioeconomic status, and high continuity of care led to lower odds of receiving a CPE. CONCLUSIONS: The current state of CPE provision to adults with intellectual or developmental disabilities in Manitoba is encouraging but needs improvement.

Differential effects of a school-based obesity prevention program: A cluster randomized trial.

School-based healthy living interventions are widely promoted as strategies for preventing obesity. The peer-led Healthy Buddies™ curriculum has been shown to improve obesity-related outcomes in school-aged children. We examined whether these improvements existed among subgroups of children stratified by sex, income level and urban/rural geography. In a cluster-randomized controlled trial, elementary schools in Manitoba, Canada, were randomly allocated to Healthy Buddies™ (10 schools, 340 students) or standard curriculum (10 schools, 347 students). Healthy Buddies™ participants had 21weekly lessons on healthy eating, physical activity and self-efficacy, delivered by children age 9-12 to children age 6-8. We assessed pre- and post-intervention body mass index (BMI) z-scores, waist circumference, healthy living knowledge, dietary intake and self-efficacy among the younger children. Compared to standard curriculum (n = 154), Healthy Buddies™ participants (n = 157) experienced a greater reduction in waist circumference (-1.7 cm; 95% confidence interval [CI][-2.8, -0.5 cm]) and improved dietary intake (4.6; 95% CI [0.9, 8.3]), healthy living knowledge (5.9; 95% CI [2.3, 9.5]) and self-efficacy (5.3; 95% CI [1.0, 9.5]) scores. In subgroup analyses, effects for waist circumference (-2.0 cm; 95% CI [-3.6, -0.5]), healthy living knowledge (9.1; 95% CI [4.4, 13.8]) and self-efficacy (8.3; 95% CI [3.3, 13.3]) were significant among boys. Dietary intake (10.5; 95% CI [5.5, 15.4]), healthy living knowledge (9.8; 95% CI [4.5, 15.0]) and self-efficacy (6.7; 95% CI [0.7, 12.7]) improved among urban-dwelling but not rural-dwelling children. Healthy Buddies™ was effective for boys and children living in urban settings. Enhanced curricula may be needed to improve program effectiveness for select subgroups of school-aged children.

The 5-Year Incidence of Mental Disorders in a Population-Based ICU Survivor Cohort.

OBJECTIVE: To estimate incidence of newly diagnosed mental disorders among ICU patients. DESIGN: Retrospective-matched cohort study using a population-based administrative database. SETTING: Manitoba, Canada. PARTICIPANTS: A total of 49,439 ICU patients admitted between 2000 and 2012 were compared with two control groups (hospitalized: n = 146,968 and general population: n = 141,937), matched on age (± 2 yr), sex, region of residence, and hospitalization year. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Incident mental disorders (mood, anxiety, substance use, personality, posttraumatic stress disorder, schizophrenia, and psychotic disorders) not diagnosed during the 5-year period before the index ICU or hospital admission date (including matched general population group), but diagnosed during the subsequent 5-year period. Multivariable survival models adjusted for sociodemographic variables, Charlson comorbidity index, admission diagnostic category, and number of ICU and non-ICU exposures. ICU cohort had a 14.5% (95% CI, 14.0-15.0) and 42.7% (95% CI, 42.0-43.5) age- and sex-standardized incidence of any diagnosed mental disorder at 1 and 5 years post-ICU exposure, respectively. In multivariable analysis, ICU cohort had increased risk of any diagnosed mental disorder at all time points versus the hospitalized cohort (year 5: adjusted hazard ratio, 2.00; 95% CI, 1.80-2.23) and the general population cohort (year 5: adjusted hazard ratio, 3.52; 95% CI, 3.23-3.83). A newly diagnosed mental disorder was associated with younger age, female sex, more recent admitting years, presence of preexisting comorbidities, and repeat ICU admission. CONCLUSIONS: ICU admission is associated with an increased incidence of mood, anxiety, substance use, and personality disorders over a 5-year period.

Assessing childhood health outcome inequalities with area-based socioeconomic measures: a retrospective cross-sectional study using Manitoba population data.

BACKGROUND: Socioeconomic gradients in health exist in Canada. Although multiple Canadian area-based socioeconomic measures (ABSM) have been developed, none have been specifically validated against pediatric outcomes. Our objective was to compare the strength of association between key pediatric health outcomes and a number of ABSM, including income quintile. METHODS: This was a retrospective cross-sectional assessment of the association between socioeconomic status (SES) measured by ABSM and 20 specific pediatric health outcomes. Data from the Manitoba Population Research Data Repository were used for residents aged 0-19 years from 2010 to 2015. Outcomes included birth-related events (e.g. mortality), vaccination uptake, hospitalizations, and teen pregnancy. Regression goodness of fit was used to assess the strength of individual associations. Inequality was measured by slope index of inequality (SII) and relative index of inequality (RII). RESULTS: Overall, 19 of 20 outcomes had socioeconomic gradients identified by SII and RII. The multidimensional CAN-Marg indices had the best explanatory power in standard regression models. The simplest ABSM-income quintile-detected 16 of 19 confirmed inequalities, more than any other single measure. CONCLUSIONS: At all ages, many pediatric health outcomes in Manitoba were associated with significant socioeconomic inequalities; while income quintile detected most, CAN-Marg composite indices had the best explanatory power.

Intrauterine exposure to diabetes and risk of cardiovascular disease in adolescence and early adulthood: a population-based birth cohort study.

BACKGROUND: It is unclear whether intrauterine exposure to maternal diabetes is associated with risk factors for cardiovascular disease and related end points in adulthood. We examined this potential association in a population-based birth cohort followed up to age 35 years. METHODS: We performed a cohort study of offspring born between 1979 and 2005 (n = 293 546) and followed until March 2015 in Manitoba, Canada, using registry-based administrative data. The primary exposures were intrauterine exposure to gestational diabetes and type 2 diabetes mellitus. The primary outcome was a composite measure of incident cardiovascular disease events, and the secondary outcome was a composite of risk factors for cardiovascular disease in offspring followed up to age 35 years. RESULTS: The cohort provided 3 628 576 person-years of data (mean age at latest follow-up 20.5 [standard deviation 6.4] years, 49.3% female); 2765 (0.9%) of the offspring experienced a cardiovascular disease end point, and 12 673 (4.3%) experienced a cardiovascular disease risk factor. After propensity score matching, the hazard for cardiovascular disease end points was elevated in offspring exposed to gestational diabetes (adjusted hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12-1.79) but not type 2 diabetes (adjusted HR 1.40, 95% CI 0.98-2.01). A similar association was observed for cardiovascular disease risk factors (gestational diabetes: adjusted HR 1.92, 95% CI 1.75-2.11; type 2 diabetes: adjusted HR 3.40, 95% CI 3.00-3.85). INTERPRETATION: Intrauterine exposure to maternal diabetes was associated with higher morbidity and risk related to cardiovascular disease among offspring up to 35 years of age.

Extreme restriction design as a method for reducing confounding by indication in pharmacoepidemiologic research.

PURPOSE: Confounding by indication is a concern in observational pharmacoepidemiologic studies, including those that use active comparator, new user (ACNU) designs. Here, we present a method of restriction to an indication, which we call "extreme restriction," to reduce confounding in such studies. METHODS: As a case study, we evaluated the effect of proton pump inhibitors (PPIs) on hospitalization for community-acquired pneumonia (HCAP). PPI use has been associated with increased HCAP risk, but this association likely results from confounding by indication due to gastroesophageal reflux disease (GERD). Using the UK's Clinical Practice Research Datalink, we compared the risk of HCAP within 180 days between PPI users and histamine-2 receptor antagonist (H2RA) users in an ACNU cohort using Cox proportional hazard models with a time-fixed exposure definition adjusted for high-dimensional propensity score deciles. We then performed the same analysis on an "extremely-restricted" cohort of incident nonsteroidal anti-inflammatory drug (NSAID) users, some of whom received PPIs for prophylaxis. Because PPIs were given as prophylaxis in this population, confounding due to GERD should be limited. We compared effect estimates between ACNU and restricted cohorts to evaluate confounding in both analyses. RESULTS: In the ACNU cohort, PPIs were associated with an increased risk of HCAP (hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 1.05, 1.47), but this association was not present in the restricted cohort (HR: 1.06; 95% CI: 0.75, 1.49). CONCLUSIONS: Restriction to a single indication for treatment may reduce confounding by indication in studies conducted in distributed data networks and other large databases.

Fixed Nodes of Transience: Narratives of Homelessness and Emergency Department Use.

Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed.

Assessing perceptions of professionalism in medical learners by the level of training and sex.

Background: Canadian medical student and residents' severity ratings of professionalism vignettes were examined to identify the differences in ratings by the level of training and by sex. Methods: Eight hundred and thirty-five medical learners (400 medical students and 435 residents) were invited to participate in an online survey measuring medical professionalism. The survey was composed of questions about descriptive information and professionalism vignettes. The tool consists of 16 vignettes examining respondent's ability to recognize the professional and unprofessional behaviors. For each vignette, participants were asked to rate the severity of the infraction as "not a problem" to "severe." Wilcoxon rank sum tests and Fischer's Chi-square tests were used to examine the differences in perceptions of professionalism by the level of training and sex, and logistic regression models were created with the level of training and sex to examine their association with binary vignette responses (not a severe infraction and severe infraction); controlling for the effect of the other variable. Results: Overall response rate for the completed survey was 30% (n = 253). Significant differences between males and females were found for lapse in excellence (P ≤ 0.039), inappropriate dress (P ≤ 0.003), lack of altruism (P ≤ 0.033), disrespect (P ≤ 0.013), shirking duty (P ≤ 0.028), and abuse of power (P ≤ 0.006). Females rated all six vignettes as more severe as compared to males. Shirking duty (P ≤ 0.002) was found to have the differences between learner responses. Regressions found sex to be associated with severity of professionalism infractions on seven vignettes. Discussion: Future work is needed in the area of professionalism and sex to understand why female and male learners may perceive professionalism differently.

The Incidence of Diabetic Ketoacidosis During "Emerging Adulthood" in the USA and Canada: a Population-Based Study.

BACKGROUND: As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication. OBJECTIVE: To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood." DESIGN: Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013). PARTICIPANTS: Individuals aged 12-30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba). MAIN MEASURES: DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization. KEY RESULTS: The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba. CONCLUSIONS: In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.

Health, Social, Education, and Justice Outcomes of Manitoba First Nations Children Diagnosed with Fetal Alcohol Spectrum Disorder: A Population-Based Cohort Study of Linked Administrative Data.

OBJECTIVE: To examine health services, social services, education, and justice system outcomes among First Nations children and youth with fetal alcohol spectrum disorder (FASD). METHODS: In this retrospective cohort study, health and social services, education, and justice data were linked with clinical records on First Nations (FN) individuals aged 1 to 25 and diagnosed with FASD between 1999 and 2010 (n = 743). We compared the FN FASD group to non-FN individuals with FASD (non-FN FASD; n = 315) and to First Nations individuals (matched on age, sex, and income) not diagnosed with FASD (FN non-FASD; n = 2229). Rates and relative risks (RRs) were calculated using generalized linear models. RESULTS: FN FASD individuals had similar health services use to non-FN FASD individuals but had greater involvement with child welfare (RR, 1.20; 95% confidence interval [CI], 1.02 to 1.41) and the justice system (RR, 1.37; 95% CI, 1.07 to 1.74) and were more likely to be charged with a crime (RR, 1.40; 95% CI, 1.05 to 1.86). There were no suicides/suicide attempts among the non-FN FASD individuals during the study, but the crude rate/100 person-years of suicides among FN FASD individuals (0.22 for females; 1.06 for males) was substantially higher than for FN non-FASD individuals (0.08 for females; 0.32 for males). There were no significant differences between groups in the education outcomes we measured. CONCLUSIONS: Young people with FASD are at risk for poor health, education, and social outcomes, but First Nations young people with FASD face comparably higher risks, particularly with child welfare and justice system involvement. The study emphasizes a critical need for appropriate resources for First Nations children with FASD.

Mortality Among Mothers Whose Children Were Taken Into Care by Child Protection Services: A Discordant Sibling Analysis.

This study examines whether mothers who had a child taken into care by child protection services have higher mortality rates compared with rates seen in their biological sisters who did not have a child taken into care. We conducted this retrospective cohort study using linkable administrative data from 3,948 mothers whose oldest child was born in Manitoba, Canada, between April 1, 1992, and March 31, 2015. These mothers were from 1,974 families in which one sister had a child taken into care and one sister did not. We computed rate differences and hazard ratios of all-cause, avoidable, and unavoidable mortality. There were an additional 24 deaths per 10,000 person-years among mothers who had had a child taken into care. Mothers who had a child taken into care had higher rates of mortality due to avoidable causes (hazard ratio = 3.46; 95% confidence interval: 1.41, 8.48) and unavoidable causes (hazard ratio = 2.92; 95% confidence interval: 1.01, 8.44). The number of children taken into care did not affect mortality rates among mothers with at least 1 child taken into care. The higher mortality rates-particularly avoidable mortality-among mothers who had a child taken into care indicate a need for more specific interventions for these mothers.

Association of the Social Determinants of Health With Quality of Primary Care.

PURPOSE: In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings. METHODS: Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors. RESULTS: Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09). CONCLUSIONS: Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care.