National Survey of Indigenous primary healthcare capacity and delivery models in Canada: the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) community profile survey

The TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD): economic analysis

BACKGROUND

Indigenous populations have increased risk of developing diabetes and experience poorer treatment outcomes than the general population. The FORGE AHEAD program partnered with First Nations communities across Canada to improve access to resources by developing community-driven primary healthcare models.

METHODS

This was an economic assessment of FORGE AHEAD using a payer perspective. Costs of diabetes management and complications during the 18-month intervention were compared to the costs prior to intervention implementation. Cost-effectiveness of the program assessed incremental differences in cost and number of resources utilization events (pre and post). Primary outcome was all-cause hospitalizations. Secondary outcomes were specialist visits, clinic visits and community resource use. Data were obtained from a diabetes registry and published literature. Costs are expressed in 2023 Can$.

RESULTS

Study population was ~ 60.5 years old; 57.2% female; median duration of diabetes of 8 years; 87.5% residing in non-isolated communities; 75% residing in communities < 5000 members. Total cost of implementation was $1,221,413.60 and cost/person $27.89. There was increase in the number and cost of hospitalizations visits from 8/$68,765.85 (pre period) to 243/$2,735,612.37. Specialist visits, clinic visits and community resource use followed this trend.

CONCLUSION

Considering the low cost of intervention and increased care access, FORGE AHEAD represents a successful community-driven partnership resulting in improved access to resources.

First Nations status and emergency department triage scores in Alberta: a retrospective cohort study

BACKGROUND

Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores.

METHODS

We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non-First Nations patients.

RESULTS

First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92-0.94) compared with non-First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76-0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84-0.98) and anxiety disorder (OR 0.67, 95% CI 0.60-0.74).

INTERPRETATION

First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.

Regional variation in multimorbidity prevalence in British Columbia, Canada: a cross-sectional analysis of Canadian Community Health Survey data, 2015/16

INTRODUCTION

Multimorbidity represents a major concern for population health and service delivery planners. Information about the population prevalence (absolute numbers and proportions) of multimorbidity among regional health service delivery populations is needed for planning for multimorbidity care. In Canada, health region-specific estimates of multimorbidity prevalence are not routinely presented. The Canadian Community Health Survey (CCHS) is a potentially valuable source of data for these estimates.

METHODS

Data from the 2015/16 cycle of the CCHS for British Columbia (BC) were used to estimate and compare multimorbidity prevalence (3+ chronic conditions) through survey-weighted analyses. Crude frequencies and proportions of multimorbidity prevalence were calculated by BC Health Service Delivery Area (HSDA). Logistic regression was used to estimate differences in multimorbidity prevalence by HSDA, adjusting for known confounders. Multiple imputation using chained equations was performed for missing covariate values as a sensitivity analysis. The definition of multimorbidity was also altered as an additional sensitivity analysis.

RESULTS

A total of 681 921 people were estimated to have multimorbidity in BC (16.9% of the population) in 2015/16. Vancouver (adj-OR = 0.65; 95% CI: 0.44-0.97) and Richmond (adj-OR = 0.55; 95% CI: 0.37-0.82) had much lower prevalence of multimorbidity than Fraser South (reference HSDA). Missing data analysis and sensitivity analysis showed results consistent with the main analysis.

CONCLUSION

Multimorbidity prevalence estimates varied across BC health regions, and were lowest in Vancouver and Richmond after controlling for multiple potential confounders. There is a need for provincial and regional multimorbidity care policy development and priority setting. In this context, the CCHS represents a valuable source of information for regional multimorbidity analyses in Canada.

Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review

The objective of this review is to document contemporary barriers to accessing healthcare faced by Indigenous people of Canada and approaches taken to mitigate these concerns. A narrative review of the literature was conducted. Barriers to healthcare access and mitigating strategies were aligned into three categories: proximal, intermediate, and distal barriers. Proximal barriers include geography, education attainment, and negative bias among healthcare professionals resulting in a lack of or inadequate immediate care in Indigenous communities. Intermediate barriers comprise of employment and income inequities and health education systems that are not accessible to Indigenous people. Distal barriers include colonialism, racism and social exclusion, resulting in limited involvement of Indigenous people in policy making and planning to address community healthcare needs. Several mitigation strategies initiated across Canada to address the inequitable health concerns include allocation of financial support for infrastructure development in Indigenous communities, increases in Indigenous education and employment, development of culturally sensitive education and medical systems and involvement of Indigenous communities and elders in the policy-making system. Indigenous people in Canada face systemic/policy barriers to equitable healthcare access. Addressing these barriers by strengthening services and building capacity within communities while integrating input from Indigenous communities is essential to improve accessibility.

Closing the indigenous health gap in Canada: Results from the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) program

AIMS

TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM.

METHODS

Pre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics.

RESULTS

No significant change in HbA1c orsBP, but a small reduction indBP(-0.75 mmHg, p < 0.05) and LDL (-0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): -0.40 (95%CI:-0·55,-0·24),sBP (N = 561): -7·67 mmHg (95%CI:-9·23, -5·72),dBP (N = 291): -7·46 mmHg (95%CI:-8·69, -6·26), LDL (N = 450): -0·37mmo/l (95%CI:-0·44, -0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80).

CONCLUSIONS

FORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements.

What do indigenous communities want from their surgeons and surgical services: A systematic review

BACKGROUND

This investigation was undertaken to define the factors determining the optimal and most productive relationship among indigenous communities, surgeons, and providers of surgical services.

METHODS

A systematic literature review was conducted to identify studies reporting on the experience of indigenous communities with surgeons, medical practitioners, and the providers of surgical and other health services. The databases searched were MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar, including all literature available until the search date of April 3, 2019. The reference lists of all included articles and related review articles were searched manually to identify further relevant studies. An inductive approach was used to identify common themes.

RESULTS

Thirty-three publications discussed the experiences of New Zealand Māori (n = 2), Aboriginal and Torres Strait Islanders (n = 20), North American First Nation (n = 10), and Indigenous Latin Americans (n = 1). Across all indigenous peoples, 6 themes emerged: accessible health services, community participation and community governance, continuous quality improvement, a culturally appropriate and clinically skilled workforce, a flexible approach to care, and holistic healthcare.

CONCLUSION

To provide medical and surgical services in indigenous communities successfully requires a diverse range of skills and core technical and academic competencies. Many skills lie within the definition of professionalism and advocacy as well as the ability to undertake and operationalize community consultation and empowerment. If surgical services serving Indigenous communities are to be successful in addressing health disparity, specific training in these skills will need to be developed and made available.