Monitoring, treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes.

BACKGROUND: Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario. METHODS: We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A1c and LDL targets and use of glucose-lowering medications. RESULTS: The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%-50% for A1c and 30%-70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%). INTERPRETATION: As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Diabetes prevalence, incidence and mortality in First Nations and other people in Ontario, 1995-2014: a population-based study using linked administrative data.

BACKGROUND: Diabetes mellitus is an established health concern in First Nations communities and is associated with complex influences of colonization. This study, a partnership between First Nations and academic researchers, was undertaken to determine patterns of diabetes prevalence, incidence and mortality in Ontario. METHODS: Using health services and population data from Ontario for 1995 to 2014, linked with the federal Indian Register, we calculated age- and sex-adjusted annual estimates of diabetes prevalence, incidence and mortality for First Nations people (living within and outside First Nations communities) and other people in Ontario. We also examined age- and sex-specific crude diabetes prevalence. RESULTS: Between 1995 and 2014, the prevalence of diabetes increased and the incidence decreased somewhat in all populations. Both prevalence and incidence were substantially higher among First Nations people than among other people in Ontario. In particular, First Nations women had higher prevalence than other women (4.2% v. 1.6% for ages 20-34 yr and 17.6% v. 6.0% for ages 35-49 yr). The lifetime risk of diabetes was higher among First Nations people than among other people in Ontario (57.0%, 95% confidence interval [CI] 56.3%-57.6% v. 44.5%, 95% CI 44.4%-44.6%). Over time, all-cause mortality for those with diabetes declined but remained consistently higher for First Nations people than for other people in Ontario. INTERPRETATION: Diabetes is more common among First Nations people than among other people in Ontario, particularly at younger ages and in women. First Nations-led approaches to address the high prevalence of diabetes in younger First Nations women have the potential to improve metabolic health across generations.

Peripheral arterial disease in Ontario First Nations people with diabetes: a longitudinal population-based cohort study.

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.

Kidney disease and care among First Nations people with diabetes in Ontario: a population-based cohort study.

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.

First Nations people with diabetes in Ontario: methods for a longitudinal population-based cohort study.

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.

Unlocking First Nations health information through data linkage.

INTRODUCTION: The importance of Indigenous data sovereignty and Indigenous-led research processes is increasingly being recognized in Canada and internationally. For First Nations in Ontario, Canada, access to routinely-collected demographic and health systems data is critical to planning and measuring health status and outcomes in their populations. Linkage of this data with the Indian Register (IR), under First Nations data governance, has unlocked data for use by First Nations organizations and communities. OBJECTIVES: To describe the linkage of the IR database to the Ontario Registered Persons Database (RPDB) within the context of Indigenous data sovereignty principles. METHODS: Deterministic and probabilistic record linkage methods were used to link the IR to the RPDB. There is no established population of First Nations people living in Ontario with which we could establish a linkage rate. Accordingly, several approaches were taken to determine a denominator that would represent the total population of First Nations we would hope to link to the RPDB. RESULTS: Overall, 201,678 individuals in the national IR database matched to Ontario health records by way of the RPDB, of which 98,562 were female and 103,116 were male. Of those First Nations individuals linked to the RPDB, 90.2% (n=181,915) lived in Ontario when they first registered with IR, or were affiliated with an Ontario First Nation Community. The proportion of registered First Nations people linking to the RPDB improved across time, from 62.8% in the 1960s to 94.5% in 2012. CONCLUSION: This linkage of the IR and RPDB has resulted in the creation of the largest First Nations health research study cohort in Canada. The linked data are being used by First Nations communities to answer questions that ultimately promote wellbeing, effective policy, and healing.

Cancer risk factors and screening in First Nations in Ontario. / Facteurs de risque et dépistage du cancer chez les Premières Nations en Ontario.

INTRODUCTION: A lack of identifiers in health administrative databases limits our understanding of the cancer burden in First Nations. This study compares cancer risk factors and screening between First Nations in Ontario (on and off reserve) and non-Aboriginal Ontarians using two unique health surveys. METHODS: We measured age-standardized prevalence estimates using the First Nations Regional Health Survey (RHS) Phase 2, 2008/10 (for First Nations on reserve) and the Canadian Community Health Survey (CCHS), 2007-2013 (for First Nations off reserve and non-Aboriginal Ontarians). We used prevalence rate ratios (RR) and Pearson's chisquare tests for differences in proportions to compare estimates between First Nations (on and off reserve) and non-Aboriginal Ontarians. RESULTS: A higher proportion of First Nation men, women and adolescents on reserve smoked (RR = 1.97, 2.78 and 7.21 respectively) and were obese (RR = 1.73, 2.33 and 3.29 respectively) compared to their non-Aboriginal counterparts. Similar patterns were observed for First Nations off reserve. Frequent binge drinking was also more prevalent among First Nation men and women living on reserve (RR = 1.28 and 2.22, respectively) and off reserve (RR = 1.70 and 1.45, respectively) than non-Aboriginal Ontarians. First Nation men and women on reserve were about half as likely to consume fruit at least twice per day and vegetables at least twice per day compared to non-Aboriginal men and women (RR = 0.53 and 0.54, respectively). Pap test uptake was similar across all groups, while First Nation women on reserve were less likely to have had a mammogram in the last five years than non-Aboriginal women (RR = 0.85). CONCLUSION: First Nations, especially those living on reserve, have an increased risk for cancer and other chronic diseases compared to non-Aboriginal Ontarians. These results provide evidence to support policies and programs to reduce the future burden of cancer and other chronic diseases in First Nations in Ontario.

INTRODUCTION: L'absence d'identificateurs, dans les bases de données administratives sur la santé, nous empêche de bien comprendre le fardeau du cancer chez les Premières Nations. Notre étude compare les facteurs de risque et le dépistage du cancer chez les membres des Premières Nations en Ontario (vivant dans des réserves et hors réserves) et chez les Ontariens non autochtones, en s'appuyant sur deux enquêtes sur la santé. MÉTHODOLOGIE: L'absence d'identificateurs, dans les bases de données administratives sur la santé, nous empêche de bien comprendre le fardeau du cancer chez les Premières Nations. Notre étude compare les facteurs de risque et le dépistage du cancer chez les membres des Premières Nations en Ontario (vivant dans des réserves et hors réserves) et chez les Ontariens non autochtones, en s'appuyant sur deux enquêtes sur la santé. RÉSULTATS: Une proportion plus élevée d'hommes, de femmes et d'adolescents des Premières Nations vivant dans des réserves fumaient (RT = 1,97, 2,78 et 7,21 respectivement) et souffraient d'obésité (RT = 1,73, 2,33 et 3,29 respectivement), comparativement à leurs homologues non autochtones. Des tendances similaires ont été observées chez les membres des Premières Nations vivant hors réserves. La consommation excessive ponctuelle d'alcool fréquente était également plus répandue chez les hommes et les femmes des Premières Nations vivant dans des réserves (RT = 1,28 et 2,22, respectivement) et hors réserves (RT = 1,70 et 1,45, respectivement) que chez les Ontariens non autochtones. Les hommes et les femmes des Premières Nations vivant dans des réserves étaient deux fois moins susceptibles de consommer des fruits au moins deux fois par jour et des légumes au moins deux fois par jour que les hommes et les femmes non autochtones (RT = 0,53 et 0,54, respectivement). La participation au test de Pap était similaire dans tous les groupes, mais les femmes des Premières Nations étaient moins susceptibles que les femmes non autochtones (RT = 0,85) d'avoir subi une mammographie au cours des cinq années précédant l'enquête. CONCLUSION: Comparativement aux Ontariens non autochtones, les membres des Premières Nations, en particulier ceux qui vivent dans une réserve, présentent un risque accru de cancer et d'autres maladies chroniques. Ces résultats fournissent des éléments probants à l'appui de politiques et de programmes visant à réduire le fardeau futur du cancer et d'autres maladies chroniques chez les Premières Nations en Ontario.