Quality of Care for First Nations and Non-First Nations People with Diabetes

Abstract

SummaryBackground 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. 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.

Differential mortality and the excess burden of end-stage renal disease among First Nations people with diabetes mellitus: a competing-risks analysis

“…Known contributing factors include genetic 3 and other prenatal determinants, 23 envi- ronmental factors such as glycemic and blood pressure control 8,24 and social determinants such as quality of and access to health care. 18,19 We have now confirmed that an age-related survival advantage after diabetes diagnosis also contributes to the elevated risk for diabetes-related end-stage renal disease among First Nations individuals. End-stage renal disease and death without endstage renal disease are competing risks among people with diabetes, because each precludes the other.…”

“…15 This phenomenon occurs in the formerly perplexing context of higher age-adjusted mortality among First Nations individuals with diabetes. 8,16,17 It also explains our earlier observation that the time from diabetes diagnosis to end-stage renal disease is significantly longer among First Nations individuals, 2 despite evidence for poorer quality of diabetes care 18,19 and a larger proportion of patients with early diabetic nephropathy. 8,20 These findings are notable because they reveal an important mechanism underlying ethnicity-based disparities in endstage renal disease that has serious long-term implications for First Nations and other indigenous populations.…”

“…6 Second, strategies to postpone type 2 diabetes should be considered: if the occurrence of diabetes can be delayed, it seems plausible that the risk of chronic complications and premature deaths will be reduced. Finally, addressing disparities in both accessibility and quality of diabetes care 8,19 is imperative to achieve therapeutic targets for glycemic, blood pressure and lipid control. 18,19 Although the reasons underlying these disparities are complicated, they are also modifiable, and substantial improvements are likely during even the early stages of resolution.…”

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study

“…Similarly, the association between First Nations status and poor glycaemic control has been previously documented. In prior studies, First Nations people with diabetes were less likely to achieve an HbA 1c target of < 53 mmol/mol (7%) and had higher mean HbA 1c levels . Although the reasons underlying this disparity are likely to be complex, important determinants may include rural/remote geographical location affecting access to and quality of care , provider‐perceived challenges with patient engagement , as well as cultural continuity and community autonomy .…”

Exploring Canadian Physicians' Experiences With Type 2 Diabetes Care for Adult Indigenous Patients

“…Such studies indicate that high-quality clinical care is one facet of a broad systemic approach needed to address the worrisome trend of increasing rates of diabetes and its complications in Indigenous populations (12,13). Unfortunately, gaps in the quality of diabetes care for Indigenous patients exist (14,15); approximately one-third of patients achieve targets for control of glycated hemoglobin (A1C) levels, and very few achieve control of lipids, blood sugars and blood pressure (16). This article describes experiences of diabetes care by physicians with significant numbers of Indigenous patients and pays particular attention to contextual factors to be learned from health professionals experienced in adapting care to address Indigenous health inequities.…”